40 year old female with acute pyelonephritis

** This is an ongoing case. I am in the process of updating and editing this ELOG as and when required.

Note: This is an online E Log book recorded to discuss and comprehend our patient's  de-identified health data shared, AFTER taking his/her/guardian's signed informed consent.


Here, in this series of blogs, we discuss our various patients' problems through series of inputs from available global online community of experts with an aim to solve those patients' clinical problems, with collective current best evidence based inputs.


This E-log book also reflects my patient-centered online learning portfolio and of course, your valuable inputs and feedbacks are most welcome through the comments box provided at the very end.

 
I have been given the following case to solve, in an attempt to understand  the concept of "Patient clinical analysis data" to develop my own competence in reading and comprehending clinical data, including Clinical history, Clinical findings,  Investigations and come up with the most compatible diagnosis and treatment plan tailored exclusively for the patient in question.


CASE SHEET

Chief complaint: Pain and burning sensation on micturition. Itching over the genital area. Recurrent urinary tract infections

History of presenting illness:  Patient was apparently asymptomatic 6 months back. 
She developed very high fever and burning and itching on micturition. 
She went to a physician who prescribed her medication upon which the episode ceased. 
She developed similar symptoms after a month and again took same medication upon which episode subsided. 
The infection kept recurring every one to two months due to which she was referred to our hospital
Now since past 3 days patient has developed left abdominal pain 

History of past illness:  
Patient has had no similar episodes in the past. 
She is a known diabetic since 10 years for which she takes medication. It was diagnosed when patient complained of blurred vision
She developed hypertension during her last pregnancy which was in 2008 and has had hypertension ever since and is taking medication for the same
Patient has hypothyroidism since 6 years and is on regular medication for the same. 


Drug history  
Metformin for 8 years
Insulin since last 2 years twice a day
Thronorm once a day 25 ug

Personal history:   
Mixed diet. Appetite reduced during period of high fever
Burning micturition, itching
No sleep disturbances
No addictions

Family history: Mother was hypertensive and diabetic. She also had hypothyroidism

General examination:

Pallor: 


Icterus: 


Cyanosis: 



Clubbing: 



Koilonychia: 

Lymphadenopathy: 

Edema: 


Vitals:

Temperature: 

Respiratory rate: 

Pulse : 

Blood pressure: 






CVS examination: 





Respiratory system examination:
 

CNS examination:
Higher functions: 

Speech: 

Gait 

Cranial nerves: 

Laboratory investigations:


Blood sugar



 Hemogram:




Urine analysis:


LFT



RFT


BLOOD UREA


Creatinine


HIV


HBC


HEPATITIS B



ECG

IMAGING:



Provisional Diagnosis: 

Treatment:
Day1

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