Mrs. Faiza, a 29-year-old married garment worker, was admitted to the hospital with a chief complaint of fever for 5 days, burning during urination for 5 days, and vomiting for 3 days. On examination, she was ill-looking and anxious with a temperature of 102°F, pulse of 120 beats/min, and blood pressure of 120/70 mmHg. Laboratory tests found anemia, elevated white blood cell count, and urine culture grew Klebsiella bacteria. She was diagnosed with acute pyelonephritis with renal impairment and mild hyponatremia. She was treated with intravenous antibiotics and discharged with advice on hydration and preventing future urinary tract infections.

1. WELCOME TO MORNING SESSION
Dr. Shahadat Hossain Rubel
Intern Doctor
Department of Medicine
Tairunnessa Memorial Medical College

2. PARTICULAR’S OF THE PATIENT :
Name : Mrs. Faiza
Age :29 years
Sex : Female
Religion : Islam
Marrital Status : Married
Occupation : Garments worker
Present Address : Sharifpur ,Gazipur
Permanent Address : Sorisa bari , Jamal pur
Date of Admission : 09/june/18 (5:30 pm)
Date of Examination :09/june/18(8:30 am)

3. CHIEF COMPLAINTS :
1. Fever for 5 days .
2. Burning sensation during micturation
for same duration .
3. Vomiting for 2 to 3 times for 3 days .

4. HISTORY OF PRESENT ILLNESS :
According to the statement of the patient she was
reasonably well 5 days back then she developed
fever which was high grade Intermittent in nature
associated with chills and rigor the fever usually
sub sides by taking medication (Ace 500 mg) .fever
is not associated with cough, breathlessness , rash
and There is no traveling history .

5. She also complained burning sensation during
micturation and increased frequency of
micturation for same duration . Urine volume Is
scanty in amount and not Associated with blood
. She also complained nausia and vomiting for 3
days and she vomited 2 to 3 times and the
vomitus was non projectile slight in amount ,
containing undigested food material and not
blood or bile stained . Her bowel havit is normal .
Now she admitted in the hospital for batter
managemment .

6. HISTORY OF PAST ILLNESS:
She has no history of DM , HTN , Bronchia
Asthma ,TB , and there is no history of same
kind of disease Previously
FAMILY HISTORY :
Her all family members are healthy .
PERSONAL HISTORY :
She is non Smoker , not beetle nut chewer .

7. DRUG HISTORY:
She takes Tab . Napa 500 mg (paracetamol ) 1+1+1+1
She takes Omeprazole occationaly and she started
taking inject able contraceptives from feb 2018
SOCIOECONOMIC HOSTORY :
her husband is a Rickshaw puller and her socio
economic condition is poor.

8. IMMUNIZATION HISTORY :
She is immunized as per EPI schedule
Menstrual history :
MP / MC : 5day / regular
LMP : 24/04/18
Obstetrical history :
MF : 10 years
Para : 1 (nvd ) + 0(ab)
ALC : 3 Years
0+

9. GENERAL EXAMINATION :
Appearance : Ill looking and anxious
Body build : Average
Co-operation :Co-operative
Decubitus :On choice
Nutrition :Well nourished
Anaemia : Present
Cyanosis : Absent
Jaundice : Absent
Clubbing : Absent
Koilonychia :Absent
Leuconychia :Absent

10. CONT……
Pulse : 120 beats/min
BP :120/70 mm of Hg
Temperature :102 F
Respiratory rate :18 breaths /min
Urine output : Reduced
Oedema : Absent
Thyroid gland : Not enlarged
Lymph node : Not palpable
Skin condition : normal
0

11. Systemic examination
Alimentary system
Oral cavity examination :
lips ,teeth, gums are normal
Examination of Abdomen proper :
Inspection:
Shape of abdomen: Normal
Movement of abdomen: Moves with respiration
Visible pulsation: Absent
Visible peristalsis: Absent
Umbilicus: Inverted .
Scar mark: Absent.

12. Palpation:
Superficial Palpation :
Temperature: Raised
Tenderness: Absent
Any mass: Absent
Deep palpation:
Liver: not enlarged
Spleen: not enlarged
Kidney: not palpable, not ballotable
Renal angel tenderness :Absent

13. Percussion:
Percussion note: Tympanic
Upper border of liver dullness: Right 5th intercostalspce
in the mid-clavicular line .
Fluid thril: Absent
Shifting dullness: Absent
Auscultation:
Bowel sound: Present
No Hepatic bruit and splenic rub

14. CARDIOVUSCULAR SYSTEM :
Pulse :120 beats/min ,Regular
BP :120/70 mm of Hg
JVP :Not raised
PRECORDIAM EXAMINATION :
Inspection :
There is no chest deformity ,no visible cardiac
impulse or any other scar mark .

15. PALPATION :
Apex beat: It is palpable at left fifth intercostal space,9
cm from mid sternal line, normal in character.
Thrill :Absent
Left para sternal heave:Absent
Palpable P2 :Absent
Epigastric palsation :Absent .
AUSCALTATION :
1st and 2nd heart sound is audible in all ascultatory area
but 1st heart sound is more audible in mitral & tricuspid
area and 2nd heart sound is more audible in aortic &
pulmonary area ,there is no murmur or added sound .

16. Respiratory system
Inspection
Shape of the chest: Normal
Movement of chest: Normal
Respiratory rate: 18 breaths/min
Visible impulse: Absent
Any scar marks: Absent

17. Palpation
Position of trachea: Centrally placed
Apex beat: In the left 5th intercostal space just medial
to the mid clavicular line and 9 cm from the mid line.
Vocal fremitus : normal
Chest expansibility: normal

18. Percussion
Percussion note: Resonant
Upper border of liver dullness: in right 5th intercostal
space in mid-clavicular line
Auscultation
Breath sounds: Vesicular .
Added sounds: no added sounds .
Vocal Resonance: Normal.

19. NERVOUS SYSTEM:
Higher psychic function: Intact
Cranial nerve examination: All cranial nerves are intact.
Signs of meningial irritation:
Neck rigidity: Absent
Kernig’s sign: Negative
Brudzinski’s sign: Negative
Sensory function: Normal
Cerebeller function: Intact
Motor Function : Intact

20. SALIENT FEATURE :
Mrs. Faiza 29 years old Married muslim garments
worker hailing from Borobari, Gazipur admitted in
this hospital With the complaints of fever for 5
days which was high grade Intermittent in nature
associated with chills and rigor the fever usually
sub sides by taking medication (Ace
500mg)(paracetamol) . Fever is not associated with
cough, breathlessness and rash . There is no traveling
history .

21. She also complained burning sensation during
micturation and increased frequency of
micturation for same duration. Urine volume Is
scanty in amount and not Associated with blood .
She also complained nausea and vomiting for 3
days and she vomited 2 to 3 times and the
vomitus was non projectile slight in amount ,
containing undigested food material and not
blood or bile stained . Her bowel habit is normal .

22. She has no history of DM , HTN , Bronchial Asthma
.Her family members are healthy . She takes
injectable contraceptives .On general examination
patient was anxious and ill-looking , anemic , pulse
120b/min , BP 120/70 mmHg , RR 18 / min ,Temp
102 F jaundice , oedema , cyanosis , dehydration ,
Koilonychia ,Leuconychia are absent . Lymph nodes
and thyroid gland are not enlarged . Skin condition
is normal.

23. On systemic examination alimentary system
revealed lips , gums teeth are normal .On
abdominal proper examination the Shape of
abdomen is normal , moves with respiration, no
visible pulsation , peristalsis or Scar mark
umbilicus is Inverted. On palpation of abdomen is
nontender , Liver ,spleen, kidney are not palpable
. Others systems revels no abnormality .

24. PROVISIONAL DIAGNOSIS :
???

25. Provisional diagnosis :
Urinary Tract Infection

26. Differential Diagnoses
Early pregnancy .

27. Investigation with findings :
1. CBC : HB% : 8.7 gm/dl
ESR : 135 mm in 1st hr
Total WBC count : 17.0 X 10 /ul
Differential count
Neutrophil 78%
Lymphocyte 12%
Monocyte 7%
T.Platlet count : 190 X 10 /ul
MCV : 80 fl
MCH : 27 pg
MCHC : 34 g/dl
3
3

28. 2. RBS : 4.92 mmol/l
3 . S.electrolyte : Na 130 mml/l
K 4 .8 mmol/l
Cl 100 mmol/l
4. S. CREATININE : 2.16 mg/dl
5. Urine R/E :
Pus cells : 15-18/HPF
RBC : 1-3 / HPF
6. USG OF KUB :
.
7. Blood Culture : No growth
urine for

29. 8. Urine Culture
Growth of Klebisella at 37 C in aerobic condition after
48 hours incubation
Colony count : 10 cfu/ml
Sensitivity
Sensitive Resistant
Ciprofloxacin Amoxiclav
Cifixime Levofloxacin
Ceftriaxone Cefuroxime
Nitrofurantoin Co-Trimoxazol
Gentamicin Azithromycin
Amikacin Linezolid
Imipenem
5
0

30. CONFIRMATORY DIAGNOSIS
Acute pyelonephritis with renal impairment
with mild hyponatraemia with anaemia

31. Treatment :
1 .Bed rest .
2 .Diet :Normal
3 . Inj . Ceftron (2g) [ceftriaxone]
1 vial I/V ----------- 12 hourly
4.Inj. Maxpro (40 mg ) [Esomeperazole ]
1 vial I/V ----------- 12 hourly B/M
5.Inj. Emistat (8mg) [Ondansteron ]
1 amp I/V ---------- 8 hourly B/M
6. Inj. Algin (5mg) [Tiemonium methysulphate]
1 amp I/V ---------- 8 hourly

32. Tab . Napa (500 mg) [paracetamol]
1+1+1+1 ----------- After meal
Cap . Zif CI [ carbonyl Iron+ Folic acid and zinc ]
1+0+1
Supp . Napa (500 mg)
1 stick P/R if temp > 102 Fo

33. Discharge
Patient is discharged on risk bond .

34. Advice
1. Drink planty of water at least 4l/day .
2. Do not hold urine for long time .
3. Wipe front to back after defication with toilet
paper .
4. Pass urine before sleep .
5. Pass urine after sexual intercourse .
6. Take iron containing food like kochu shak , lal
shak , Green banana , Apple , liver etc .

35. THANK YOU ALL