40yr old female with pain abdomen and fever with chills
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Blood pressure: 150/90mmhg
CASE PRESENTATION:
A 40yr old female with pain abdomen and fever and chills
CHIEF COMPLAINTS;
Pain abdomen since 1week
Fever and chills since 1 week
Nausea and vomitings since 3days
Increased frequency of stools since 3days
Decreased urine output since 3days
Facial puffiness, pedal edema and abdominal distention since 2days
HISTORY OF PRESENTING ILLNESS;
Patient was apparently asymptomatic 1week back then she developed Pain in the lower abdominal region Which is insidious in onset and gradually progressive with diffuse type of pain since 1week
•She also had low grade fever which is continuous and associated with chills and subsided on medication
•She had history of nausea and vomitings since 3days 3-4episodes/day, non bilious and non projectile with food particles as content.
•She had history of loose stools since 3days 8-10 episodes/day small quantity,greenish colour, mucoid and non foul smelling
•She had history of decreased urine output since 3days
•She also had history of facial puffiness, pedal edema and abdominal distention since 2days.
•History of similar complaints 1month ago associated with burning micturition.
No history of burning micturition now and no history of cough, sputum
No history of trauma.
PAST HISTORY:
●She is a known case of DM2 since 5years and on medication
-TAB.METFORMIN 500mg+
-TAB.GLIMIPERIDE 2mg+
-TAB.VOGLIBOSE 0.3mg 1/2 tab OD
●She is a known case of peptic ulcer disease since 5years and on medication
●Not a known case of HTN, CAD, CVA, TB, epilepsy and asthma.
DRUG HISTORY:
History of usage of antacids since 2yrs For recurrent peptic ulcer disease.
History of usage of TAB.NAXDOM 250mg 3days ago given by local RMP.
SURGICAL HISTORY:
She underwent hysterectomy 10yrs back
FAMILY HISTORY:
No significant family history
PERSONAL HISTORY:
Occupation:Housewife
Diet:mixed
Appetite: Decreased
Sleep: Decreased due to severe abdominal pain
Bowel and bladder movements:
Decreased urine output and increased frequency of stools
No addictions
GENERAL EXAMINATION:
Patient is conscious coherent and cooperative
Moderately built and moderately nourished
Pallor-absent
Icterus-absent
Cyanosis-absent
Clubbing-absent
Lymphadenopathy-absent
Pedal edema-present
VITALS:
Temp:98.2°F
Pulse rate: 98bpm
Respiratory rate: 22cpm
Spo2: 98% on room air
GRBS: 362mg/dl
SYSTEMIC EXAMINATION:
•Cardiovascular system:S1 S2 heard and no murmurs.
•Respiratory system:BAE+, NVBS heard and no added breath sounds
•Central nervous system: no focal neurological deficit
•GIT:Soft and Tenderness present in left hypochondrium and no organomegaly
INVESTIGATIONS:
On 12/11/22
LAB REPORTS:
CBC-Normocytic normochromic anemia with leucocytosis