A 35 year old female came with burning micturition,pain abdomen ,left sided loin pain since 5 days

 

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A 35 year old female who is labourer by occupatio came with c/o burning micturition since 5 days C/o pain abdomen since 5 days

C/o left sided loin pain since 5 days

Hopi : pt was apparently asymptomatic 5 days back then she developed c/o burning micturition since 5 days

C/o pain abdomen since 5 days at epigastric region which is intermittent type and increased after intake of food associated with nausea

C/o left sides loin pain since 5 days

C/o no passage of stools since 3 days (passing flatus)

C/o B/L swelling at lower limb since 2 days which is up to knee (pitting type) 

No H/o decreased urine output ,Sob , palpitations,giddiness,jaundice

Past history :

No H/o similar complaints in the past

denovo  T2 DM present

Not a k/c/o HTN,cAD,asthma ,tb ,epilepsy.

Personal history : 

There is decreased appetite

Mixed appetite

Constipation since 3 days

Burning micturition present 

Occasionally toddy drinker 

No H/o similar complaints in the past 

O/E : pt is c/c/c

No pallor,icterus,clubbing,lymphadenopathy

B/L pitting type of oedema present

Vitals : pt is afebrile 

Bp: 110/70mmhg

PR: 86bpm

RR: 20c/m

S/E:

Cvs :s1s2 heard.no murmurs

Rs: BAE +, NVBS 

P/A: 

PER ABDOMEN:

INSPECTION : Abdomen bilaterally symmetrical.

All quadrants moving equally with respiration.

Umbilicus is central and inverted.

No scars,sinuses,striae,pigmentation,echymosis,dilated veins and visible pulsations.

PALPATION: on palpation abdomen is soft and  tenderness present at epigastric region

Deep tenderness present at renal angle

No Guarding and rigidity. 

No palpable mass

PERCUSSION : No fluid thrill.no shifting dullness

AUSCULTATION : Bowel sounds are sluggish

Cns : 

CNS: Higher mental function normal

Cranial nerves intact 

       Motor system: intact

       Sensory system: intact 

INVESTIGATIONS :

Rx :

Ivf NS and RL @75ml /hr

Inj magnex forte 1.5gm /iv/bd 

Inj lasix 20 mg iv bd

Inj pantop 40mg iv od

Temp charting 4th hourly 

Strict i/o charting

GRBS charting 6th hourly

Bp ,pr,spo2 4th hourly

Inj HAI sc after checking GRBS

Inj zofer 4mg iv bd 

Syp  lactulos 15ml po hs

Day 1 

No fresh complaints

Vitals 

Bp :130/90mmhg

Pr:81bpm

Rr:20c/m

Cvs :s1s2 heard

Rs :BAE +,NVBS

CNS :Normal

INVESTIGATIONS 

Treatment

Ivf NS and RL @75ml /hr

Inj magnex forte 1.5gm /iv/bd 

Inj lasix 20 mg iv bd

Inj pantop 40mg iv od

Temp charting 4th hourly 

Strict i/o charting

GRBS charting 6th hourly

Bp ,pr,spo2 4th hourly

Inj HAI sc after checking GRBS

Syp lactulose 15ml po hs

Day 2

No fresh complaints

Vitals 

Bp :110/70mmhg

Pr:80bpm

Rr:21c/m

Cvs :s1s2 heard

Rs :BAE +,NVBS

CNS :Normal

INVESTIGATIONS:

Treatment:

Ivf NS and RL @75ml /hr

Inj magnex forte 1.5gm /iv/bd 

Inj lasix 20 mg iv bd

Inj pantop 40mg iv od

Temp charting 4th hourly 

Strict i/o charting

GRBS charting 6th hourly

Bp ,pr,spo2 4th hourly

Inj HAI sc after checking GRBS

Syp lactulose 15ml po hs

Day 3

No fresh complaints

Vitals 

Bp :110/70mmhg

Pr:86bpm

Rr:22c/m

Cvs :s1s2 heard

Rs :BAE +,NVBS

CNS :Normal

 INVESTIGATIONS 

Treatment:

Ivf NS and RL @75ml /hr

Inj magnex forte 1.5gm /iv/bd 

Inj lasix 20 mg iv bd

Inj pantop 40mg iv od

Temp charting 4th hourly 

Strict i/o charting

GRBS charting 6th hourly

Bp ,pr,spo2 4th hourly

Inj HAI sc after checking GRBS

Syp lactulose 15ml po hs

Diagnosis : left sides pyelonephritis with AKI with denovo T2 DM