33 year old female with severe back pain

 This is online e log book to discuss our patient's de - identified health data shared

after taking  her guardian's signed informed consent .

Here we discuss our individual patient's problems through series of inputs from available global online community of experts with aim to solve those patients clinical problems with collective current best evidence based inputs.

This E log book reflects my patient-centered  online learning portfolio and your valuable inputs on the comment.

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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