61M WITH FEVER AND PAIN ABDOMEN
Case History and Clinical Findings
C/O FEVER SINCE 10 DAYS C/O PAIN ABDOEN 10 DAYS
HOPI
PT WAS APPARANTLY ALRIGHT 10 DAYS BACK THEN HE HAD HIGH GRADE ASSOCIATED WITH CHILLS,INTERMITTENT , RELIEVED BY TAKING MEDICATION PAIN ABDOMEN SINCE 10 DAYS , DRAGGING TYPE OF PAIN , NON RADIATING , ASSOCIATED WITH VOMITING ONE EPISODE ,BILIOUS , NON BLOOD TINGED , NON PROJECTILE , NON FOUL SMELLING BINGE OF ALCOHOL 10 DAYS BACK NO PEDAL EDEMA NOP COUGH , COLD
PAST H/O
N/K/C/O DM II , HTN , CVA , CAD , EPILEPSY ,
K/C/CO B/L RENAL CALCULI S/P L URTSL + DJ STENTING 4 MONTHS BACK VARICOSE VEINS PRESENT
PERSONAL HISTORY :
DIET :MIXED APPETITE : GOOD SLEEP : ADEQUATE BOWEL:REGULAR
GENERAL EXAMINATION :
PATIENT IS CONSCIOUS , COHERENT , COOPERATIVE PALOR PEDAL EDEMA NO SIGNS OF CLUBBING , ICTERUS , CYANOSIS , LYMPHEDNOPATHY VITALS : TEMP : 98.3 F PR : 76 BPM BP : 110/70 MMHG GRBS : 118 MG / DL SPO2 : 94% RR : 15 CPM
SYSTEMIC EXAMINATION :
CVS : S1 , S2 HEARD , NO MURMURS
RS : BAE + , NVBSHEARD
PA :SOFT,NT, NO ORGANOMEGALY
CNS : NFAD
USG ABDOMEN PELVISGRADE 1 FATTY LIVER B/L RENAL CALCULI
URINE C/S
PSEUDOMONAS AERUGINOSA GREATER THEN 10 X10X10 CFU /ML OF URINE ISOLATED
Diagnosis
ACUTE PYLEONEPHRITIS WITH PSOAS ABSCESS (RESOLVING) WITH RENAL AKI ON CKD (STAGE V) RESOLVING WITH RENAL CALCULI (12 MM IN LOWER POLE OF KIDNEY) S/P L URSL +DJ STENTING WITH ANEMIA OF CHRONIC DISEASE
Treatment Given
1.IVF NS @ 75 ML/HR 2. INJ PIPTAZ 2.25 GM/IV/TID 3.INJ PAN 40 MG / IV / OD 4.INJ NEOMOL 14 ML /IV /SOS /IF TEMP GREATER 101 F 5.INJ TRAMADOL IN 100ML NS /IV/ SOS 6.TAB DOLO 650 MG /PO /SOS IF TEMP GREATER THAN 100 F
Advice at Discharge
1.TAB AUGMENTIN 625MG/PO/BD X 5 DAYS
2.TAB NODOSIS 1GM/PO/BD
3.TAB SHELCAL CT PO/OD
4.TAB OROFER XT PO/OD
