33 year old female with severe back pain
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Bunni Sadhguna
Roll no. 25
33 year old female with severe back pain
A 33 year old female, sales woman by occupation, bought to the opd with chief complaints of
Patient came with pain from loin to groin since 3 months
- dragging type of pain
-vomitings ,fever +
- no burning micturition
TB since 3 months on medication
HISTORY OF PRESENT ILLNESS
patient was apparently asymptomatic 3 months ago. Patient developed pain from loin to groin, gradually progressive dragging, type of pain. Vomiting present since 4 days containing food particles, no burning micturition and decreased urine output ,high fever since morning.
HISTORY OF PAST ILLNESS
Similar complaints in past was with renal abscess ,TB since 3 months (on ATT since march)
Epilepsy, CAD,CVD
No surgery
TREATMENT HISTORY
no diabetes
no hypertension
no CAD
No asthma
Tuberculosis since March 2022
No radiation
No hormones
No antibiotics
No blood transfusions
No surgeries
PERSONAL HISTORY
married
Non vegetarian with normal appetite and normal bowl.
Normal micturition
No allergies
No drugs ,alcohol or smoke consumption
FAMILY HISTORY
No diabetes
No hypertension
No heart disease
No stroke
No cancer
No tuberculosis
No asthma
No hereditary disease
MENSTRUAL HISTORY
age of menarche: 13
Menstrual cycle: duration of cycle/no days of bleeding: 4/4-5( past)
LMP: 1-05-2022
PHYSICAL EXAMINATION
A. General
Pallor: yes
Icterus: no
Cyanosis:no
Clubbing of fingers/toes: no
Lymphadenopathy: no
Oedema of feet: no
Malnutrition : no
Dehydration : no
VITAL EXAMINATION
Temp: 102 F
Pulse: 124/ min
Respiration (count for a full min) Rate: 16/ min
SYSTEMATIC EXAMINATION:
CARDIOVASCULAR SYSTEM
No thrills
Cardiac sounds s1 s2 +
No cardiac murmurs
RESPIRATORY SYSTEM
No dyspnoea and wheeze
Central position of trachea with vesicular breath sounds and no adventitious sounds.
ABDOMEN
Scaphoid abdomen, no tenderness ,no palpable mass,normal hernial orifices, no free fluid and bruits, not palpable liver and spleen, bowel sounds present.
CENTRAL NERVOUS SYSTEM
Normal speech ,conscious, no signs of meningeal irritation
CEREBRAL SIGNS
Normal finger nose coordination and knee heel in coordination.
TREATMENT
Ethambutol hydrochloride isoniazid tab
Dolo 650
Rifampicin capsules I.P
Ranitidine tablets
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