female patient with recurrent pyelonephritis (case 4)

June 24th, 2023

General medicine blog 

Hi , I Ebrahim Badshah , a 5th semester student.  This is an online elog book to discuss our patients health data after taking his consent. This also reflects my patient centered online learning portfolio.

The patient’s consent was taken prior to history taking and examination of his condition.

I've been given this case to solve in an attempt to understand the topic of "patient clinical data analysis" to develop my competency in reading and comprehending clinical data including history, clinical findings, investigations and come up with a diagnosis and treatment plan. 


CHIEF COMPLAINT:
A 50 year old female patient, from narayanpur,came to the hospital with chief complaints of fever and left loin pain since 1 week . Patient also suffers from recurrent pyelonephritis since 1 year 

HISTORY OF PRESENT ILLNESS


 she presented with similar complaints of left loin pain and sever abdominal pain 1 year ago . No diurnal variation .
Intermittent dragging type of pain felt in left loin since 1 week , relieved on medication.
C/O 2 episodes of vomiting 1 week ago containing food particles.
No cold , cough , burning micturition , rash , loose stools.

PAST HISTORY : 
Type 2 diabetes mellitus since 12 years
 No HTN 
No Tb
No asthma


PERSONAL HISTORY :
Hysterectomy done
Mixed diet 

PHYSICAL EXAMINATION:
Patient is conscious and coherent
pallor present 
No icterus
No clubbing 
No pedal oedema 
No lymphadenopathy 
No malnourishment
No cyanosis

VITALS:
Temperature:Afebrile 
BP:130/70 mm Hg
RR:13/min
Pulse rate:78/min
SpO2:98%
S1 and S2 present, no murmurs

FAMILY HISTORY:
None

ALLERGY HISTORY:
None
Investigations:
PROVISIONAL DIAGNOSIS:
Recurrent pyelonephritis 






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