Fever projr unclassified 29/F
date of admission 3/5/2024
date of discharge 16/5/2024
Diagnosis
RADIATION ENTERITIS WITH RIGHT HYDROURETERO NEPHROSIS
KNOWN CASE OF CARCINOMA CERVIX POSTHYSTERECTOMY STATUS
Case History and Clinical Findings
C/O PAIN ABDOMEN SINCE 10 DAYS
LOOSE STOOLS SINCE 6 DAYS
HOPI:PATIENT WAS APPARENTLY ASYMPTOMATIC 10 DAYS BACK, THEN HE DEVELOPED PAIN PAIN ABDOMEN DIFFUSE INSIDUOUS ONSET GRADUALLY PROGRESSIVE AND SUBSIDED YESTERDAY EVENING .SQUEEZING IN NATURE AGGRAVATED ON TAKING FOOD AND RELIEVED ON PASSING TOOLS
H/OLOOSE STOOLS SINCE 6 DAYS FOOD AS CONTENT10-12 EPISODES PER DAY
H/O FEVER LOW GRADE INTERMITTENT DURING NIGHT RELIEVED ON TAKINGMEDICATION NOT ASSOCIATED WITH CHILLS AND RIGOR
NO H/O VOMITING .
PAST HISTORY:
K/C/O HYPOTHYROIDISM AND ON CARBIMAZOLE 2.5 MG OD
NO H/O SIMILAR COMPLAINTS IN THE PAST.
N/K/C/O DM, HTN, TB , CKD ,CVA , ASTHMA,EPILEPSY ,THYROID.
H/O OF CARCINOMA CERVIX 1 YEAR AGO FOR WHICH HYSTERECTOMY WAS DONE F/B RADIOTHERATY AND CHEMOTHERAPY FOR 3 MONTHS
PATIENT IS CONSCIOUS , COHERENT AND COOPERATIVE.
NO PALLOR , ICTERUS , CYANOSIS , CLUBBING , LYMPHADENOPATHY , EDEMA
VITALS :
TEMPERATURE - AFEBRILE , PULSE RATE - 90 BPM, RESPIRATORY RATE - 120CPM , BP- 110/70 MMHG, SPO2 - 99% AT RA,
SYSTEMIC EXAMINATION:
CVS :S1S2+ , NO MURMURS
RS : BAE+, NVBS+
CNS : NFND
P/A -SOFT,NT BS+
LOCAL EXAMINATION
ON INPECTION
ABDOMEN IS DISTENDED
UMBLICUS CENTRAL AND INVERTED
NO VISIBLE LUMPS
NO ENGORGED VEINS
VERTICAL HYSTERECTOMY SCAR PRESENT
NO VISIBLE PULSATIONS AND PERISTALSIS
ALL QUADRANTS OF ABDOMEN ARE MOVING ACCORDINGLY WITH RESPIRATION
HERNIAL ORIFICE NORMAL
ON PALPATION
ABDOMEN IS SOFT AND DISTENDED
NO LOCAL RISE OF TEMPERATURE
NO TENDERNESS
NO PALPABLE LUMPS
NO GUARDING OR RIGIDITY
NO ORGANOMEGALY
ON PERCUSSION
NORMAL LIVER DULLNESS
REST OF ABDOMEN RESONANT
UROLOGY REFERAL WAS TAKEN I/V/O RIGHT SIDED HYDRO URETERO NEPHROSIS AND NEEDFOR STENTING AND THEY ADVISED SURGERY ONCOLOGY OPINION AND RADIATION ONCOLOGY OPINION
SURGICAL ONCOLOGY REFERAL WAS DONE AND ADVISED TAB RIFAGUT 400MG PO BD X 10 DAYS ,GENERAL MEDICINE REFERAL TO RULE OUT MEDICAL CAUSES OF FEVER,UROLOGY REFERAAL FOR HYDROURETERONEPHROSIS
GENERAL MEDICINE REFERAL WAS TAKEN FOR UNCONTROLLED FEVER SPIKES AND LOOSE STOOLS AND ADVISED FEVER PROFILE ,PRBC TRANSFUSION ,INJ FCM INFUSION ,TAB OROFER-XT PO BD AND
TAB NITROFURANTOIN 100MG PO BD
TAB SPOROLAC -DS 2 TABS PO TID
TAB REDOTIL 100 MG PO BD
TAB PCM 650 MG PO SOS
ALLOW PLENTY OF FLUIDS
TAB CEFIXIME 400 MG BD
TAB AZITHRO 1GM OD
Investigation
COMPLETE BLOOD PICTURE (11/5/24)
HAEMOGLOBIN :5.8gm/dl
TOTAL COUNT 18000 cells/cumm
NEUTROPHILS 81 %
LYMPHOCYTES 10 %
EOSINOPHILS 07%
MONOCYTES 02%
BASOPHILS 00 %
PLATELET COUNT 7.0 lakhs/cu.mm
SMEAR MICROCYTIC HYPOCHROMIC ANEMIA WITH NEUTROPHILIC LEUCOCYTOSIS AND THROMBOCYTOSIS
COMPLETE BLOOD PICTURE (15/5/24)
HAEMOGLOBIN :5.1gm/dl
TOTAL COUNT 17800 cells/cumm
NEUTROPHILS 83 %
LYMPHOCYTES 10 %
EOSINOPHILS 03%
MONOCYTES 04%
BASOPHILS 00 %
PLATELET COUNT 7.7 lakhs/cu.mm
RBC:2.4 MILLIONS/CUMM
SMEAR MICROCYTIC HYPOCHROMIC ANEMIA WITH NEUTROPHILIC LEUCOCYTOSIS AND THROMBOCYTOSIS
WIDAL TEST ON 9/5/24
S TYPHI O AB:1:20
S TYPHI H AB:1:20
S PARA TYPHI AH AB:NO AGGLUTINATION SEEN
S PARATYPHI NH AB: NO AGGLUTINATION SEEN
STOOL FOR OCCULT BLOOD : NEGATIVE
SERUM CREATININE (13/5/24) : 0.8 MG/DL
SERUM ELECTROLYTES:(13/5/24)
SODIUM:135 MMOL/L
POTASSIUM:4.5 MMOL/L
CHLORIDE:98 MMOL/L
CRP:POSITIVE(2.4MG/DL)
SERUM IRON:28 MICRO GRAM/DL
24 HOUR UP:CREATINE ---)81MG/DAY
24 URINARY CREATINE:1.2GM/DAY
RATIO:0.06
USG:
RIGHT GROSS HYDROURETERO NEPHROSIS
LEFT MILD HYDROURETERONEPHROSIS
LEFT TINY RENAL CALCULI
MINIMAL PERIHEPATIC FLUID
CECT:
K/C/O CA CERVIX -POST HYSTERECTOMY PLUS RT/CT
ENHANCING SHEET OF PRESACRAL SOFT TISSUE THICKENING WITH FEW AREAS OF NODULARITY
F/S/O RADIATION INDUCED RETROPERITONEAL FIBROSIS
SOFT TISSUE NODULE IN SPACE BETWEEN RECTUM AND BLADDER
PRESACRAL SOFT TISSUE CAUSING ENTRAPMENT PF RIGHT URETER RESULTING IN MODERATE RIGHT HYDROURETERONEPHROSIS
URINARY BLADDER SHOWS WALL THICKENING INVOLVING RIGHT LATERAL AND POSTERIOR WALL-RADIATION CYSTITIS
DILATED TRANSVERSE COLON AND PROXIMAL DESCENDIG COLON
5 CM SEGMENT OF SIGMOID/PROXIMAL RECTUM SHOWS CIRCUMFERENTIAL WALL THICKENING WITH LUMINAL NARROWING-F/S/O RADIATION COLITIS
Treatment Given(Enter only Generic Name)
TAB.NITROFURANTOIN 100MG PO/BD
SOFT DIET
TAB OFLOX -OZ PO BD
TAB RIFAGUT 400 MG PO BD
TAB PCM 650 MG PO TID
TAB SPOROLAC -DS 2 TABS PO TID
TAB REDOTIL 100 MG PO BD
TAB OROFER -XT PO BD
TAB ZOFER 4 MG PO SOS
TEPID SPONGING
Advice at Discharge
SOFT DIET
TAB NITROFURANTOIN 100MG PO BD X3 DAYS
TAB DAROLAC PO BD X 5 DAYS
TAB REFAGUT 400 MG PO BD X1 DAY
TAB PCM 650 MG PO TID X 5 DAYS
ORS
PLENTY OF FLUIDS
TAB CEFIXIME 400 MG BD X5 DAYS
TAB AZITHRO 1GM PO OD X 1 WEEK
TAB OROFER XT PO BD X 5 DAYS
TAB ZOFER SOS
TEPID SPONGING
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