UMANAND PRASAD SCHOOL OF

MEDICINE AND HEALTH SCIENCES

INTERNAL MEDICINE 501

2022

LOGBOOK CASE 3

NAME: SHAKSHI RAINA

ID: 20170017
MBBS 5
 Patient Information

Name: R.K
Age: 42
Gender: Female
DOB: 5/11/1980
NHN: 3267*****
Ethnicity: Fijian of Indian Decent
Residential Address: Olosara, Sigatoka
Occupation: Hotel worker
Date of Admission: 31/10/2022

PRESENTINGCOMPLAINT

 Dysuria
 Right lower Quadrant pain
 Productive cough X 2/7
 Body pain
 Headache

HISTORYOFPRESENTINGCOMPLAINT

The patient was previously well until 2 days prior to admission when she started having complains of Right
lower Quadrant back which was radiating to her back. Patient also complained of painful urination. The
pain was moderate, burning in nature, worse during the first morning void. She said she feels she is
urinating more than usual as she keeps going to the washroom more often. There was however no
accompanying hematuria or pyuria. She mentioned that just drank a lot of water but this did not relief the
burning micturition.

Two days prior to admission, above symptom worsened,she could not bear the pain in the right lower
abdomen which was radiating to her back. She then started having associated productive cough, fever,
chills, and headache together with body pains.

Hence presented to A&E in the early hours of 31 st October 2022. Where she was given 1g paracetamol for
symptomatic relief, after which Urine Dip stick was conducted and it was found that her Urine ketones had
traces of glucose 4+ and her CGB was done which was 12.3 mmol/L. She was taken for ultrasound
abdominal scan. She was cannulated and bloods were taken for Full blood count (FBC), Urea electrolytes
creatinine (UECr). Patient was asked to do a pregnancy test which came out to be negative

Plan
  Keep under observation
 Give Intravenous (IV) Chloramphenicol 1g Stat
 Soluble insulin 10 Units Subcutaneously STAT IMI
 Intravenous Fluid 1 Litre over 2hours
 Review Post hydration with investigations

PASTMEDICALHISTORY

 Known case of Diabetes Mellitus 2

 No history of previous admissions
 Not hypertensive

ALLERGIES --- No known allergies to penicillin or foods.

MEDICATION HISTORY
 Paracetamol 1g
 Diabetes medication Glipizide 5mg (non-compliant)

FAMILY HISTORY
 Strong family history of Hypertension & Diabetes in parents and siblings.
 Mother (Aged 78) has Hypertension and diabetes for 20 years now.

SOCIAL HISTORY
 Stays with an extended family, youngest daughter (aged 18) in a 4 bedroom house. Has 2 children.
 Sexually active, last sexual contact 2 months ago
 Financially stable
 Consumes alcohol occasionally
 No smoking
 Consumes foods cooked at home and occasionally eats at restaurants
 Psychologically quiet stressed about current health condition.
 Has access to tap water and proper flush toilet facilities.

REVIEW OF SYSTEMS

General Status:
 (+) Fatigue
 (+) Fever
 (+) Febrile

Cardiovascular:
 (-) Chest pains
  (+) Tachycardia
 (-) Palpitations
 (-) Syncope
 (-) Leg swelling

 Respiratory:
 (+) productive cough
 (-) Hemoptysis
 (-)Wheeze

GIT:
 (-) Vomiting
 (-) Bloating
 (-) Hematemesis
 (-) Hematochezia
 (-) Diarrhea
 (-) Constipation
 (-) Tenesmas
 (-) Dysphagia
 (-) Heartburn
 (-) Fecal Incontinence
 Normal bowel movements
 (+) right lower Quadrant pain

Genitourinary:
 (+) Decreased Urine Output
 (+) Dysuria
 (+) frequent urination
 (+) burning sensation upon urination
 (-) Hematuria
 (-) Urethral Discharge

Endocrine:
 (-) Diaphoresis
 (-) Cold Intolerance
 (+) Polydipsia / (+) Polyphagia / (+) Polyuria(known Diabetes Mellitus 2)

PHYSICAL EXAMINATION
Upon examination: The patient is middle aged female lying on bed conversing, oriented to time, place,
person, and in no cardiorespiratory distress. Complains of slight pain in the right lower quadrant.

VITALS:

BP:110/73 mm Hg
PR: 87 beats/min
RR: 18 breaths/min
Temp:37.5
SPO2 : 98%
CBG (on admission)= 15.6mmol/L

HEENT

 Pupils Equal and Reactive to Light

 conjunctiva pink
 Dry oral mucosa

CHEST
 S1S2 regular with no murmurs heard
 Lung Fields Clear bilaterally, Equal & good Air entrance bilaterally

ABDOMEN
 Slight right Abdominal Tenderness
 (-) Guarding
 (-) Rebound tenderness
 Abdomen soft

EXTREMITIES
 Good volume pulses
 No Edema
 Capillary refill <2 secs

Investigations
 1. Perform Labs
 FBC / RBS / Blood Culture
 Urea, Creatinine & Electrolytes
 LFTs
 Lipid Profile
 Urine Analysis
 Renal Function Test
2. Clean catch, Midstream Urine specimen in the morning– For Gram Staining
3. Catheterize if unable to void or urinary retention.
4. Perform ECG / Chest X-Ray/ Echocardiogram

Plan
1. Medications
 Chloramphenicol 1g IV Q6H
 Paracetamol 1g PO Q6H
 Increased Glipizide dose to 20mg PO BD
2. Request for Medical Review in the morning (After ECG / CXR)
3. Monitor vitals Q4H hourly.
4. No IVF as yet.
5. Oral fluid intake to a minimum.
6. Dietician and physiotherapist to see
7. Patient counseled on diagnosis & management.
8. Follow up all the Lab results (MSU & Urinalysis results)

ASSESSMENT

1) Urinary Tract Infection (UTI)

2) Known Case Of Diabetes Mellitus
3) Urinary tract Infection (UTI) Vs Pyelonephritis

Discharge medications

1. Septrin 960mg PO Q12H x 5/7

2. Glipizide dose was increased to 20 mg PO BD
3. ORS (Oral Rehydration Salts)