CLINICAL CASES REPORT | URINARY TRACT INFECTION (UTI) | INTERNAL MEDICINE HISTORY

PATIENT’S IDENTIFICATION

NAME;    Victoria Mushi

AGE;       23 years

SEX;        Female

ADDRESS;    Magomeni

RELIGION;    Christian

OCCUPATION; Jobless

DATE OF ADMISION;   2 days post admission

DATE OF HISTORY TAKING; 07/08/2016

 

MAIN COMPLAINT(S):

Abdominal pain  3/7

Painful during micturation 2/7

 

HISTORY OF PRESENTING ILLNES

A patient was apparently well until 3 days ago when she experienced an acute onset of lower abdominal pain that was radiating from the suprapubic area toward the back. The pain had no periodicity but it is aggravated by bending forward and is relieved when she sleep. The pain was associated with mild fever, loss of appetite mild lower back pain and general body weakness. But no diarrhoea, no constipation, no vomiting.

The second day she noted painful during mituraton that was also acute onset increasing in severity as time goes. The pain was burning in nature with no periodicity other than during urination. The pain has unknown aggravating and relieving factors. But no haematuria, no urine retention.

 

REVIEW OF OTHER SYSTEM

Central nervous system;

Ø No head ache,

Ø No conversion,

Ø No dizziness,

Cardiovascular system;

Ø No swelling of lower limb,

Ø No palpitation,

Ø No chest pain

 

Respiratory system;

Ø No cough,

Ø No difficult in breathing,

Ø No chest tightness,

Musculoskeletal system;

Ø No joint pain,

Ø No muscle pain,

Ø No joint swelling

 

PAST MEDICAL HISTORY 

The patient had  no history of previous admission but she had history of the same symptoms as she have now. She used flagily from pharmacy for one week and she recovered. This is the first admission. She had no surgical history and any previous pelvic inflammatory diseases.

 

FAMILLY & SOCIAL HISTORY.

She is not marred, she live with her parents, she is not doing any job, her level of education is form four. She not using any alcohol drinks also she not using a cigarette. Her father is a watcher man but her mother is house wife. There is no any inherited diseases to their family such as; sickle cell, Diabete mellitus, epilepsy, except hypertension where by her mother is suffering for about six years and she is on regular medication.

 

PHYSICAL EXAMINATION

GENERAL EXAMINATION;

She is alert, she have normal hair colour  distribution and texture. Her eyes have no signs of anaemia and jaundice. No angular stomatitis, Her skin is normal with no rashes, no cyanosis no pustules No discharge or redness from the ears, no oral thrash, No enlargement of lymph nodes , no lower limb swelling  her palm are not pale, no finger clubbing, the capillary refill also is good.

 

VITAL SIGNS    

Temperature:    37.6 c

Blood pressure:   110/85mmHg

Pulse rate:    70b/m

Respiration rate:  18b/m

 

 

SYSTEMIC EXAMINATION

Abdominal examination.

Ø The stomach moves with respiration,

Ø The umbilicus is inverted ,

Ø No engorgement of vein ,

Ø No visible peristalsis,

Ø No visible mass.

Palpation

Ø No palpable mass,

Ø No tenderness ,

Ø No enlargements of abdominal organ such as liver, kidney, spleen and pancreas but she experience a mild lower abdominal pain during deep palpation.

Percussion

Ø On percussion tympanic sound was heard ,

Ø No dull sound,

Ø No shifting dullness.

Auscultation

Ø On auscultation a bowel sound was heard

 

Central nevous system

Ø She is alert,

Ø oriented to people,place and time

Ø The short and long memory is good.

Ø She can speak , can hear, can move, and she can swallow.

Ø Also she can see,can shrug her shoulder,her muscle tone,muscle buck and muscle power are good

Ø Generally no abnormality detected.

 

Respiratory system

Inspection

Ø The chest is symetry,

Ø Move with respiration,

Ø Have no any mark such as surgical mark or traditional mark ,

Ø No any visible mass and scars.


Palpation

Ø Trachea is centrally located,

Ø No palpable mass,

Ø No tenderness,

Ø The tactile vocal fremitus is normal (is not increased or decreased).

Percussion

Ø On percussion resonance sound was heard

Auscultation

Ø The vesicular sound was head with no any added sound  like crackles sound.

 

Cardiovascular system

Inspection  

Ø No any protruded blood vessel such as deep and superficial jugular vein

Ø No swelling of lower limbs

Palpation  

Ø The apex beat is located at 5th intercostal muscles of left clavicular line.

Auscultation

Ø Heart sound 1 and 2 heard normal

Ø No added sound such as murmurs.

 

SAMMARY

Victoria Mushi 23years old from Magomeni have 3 days post admission with a main complaints of lower abdominal pin for 2/7 and painful during urination for 1/7 which are associated with general body malaise, mild lower back pain plus loss of appetite and mild fever.

 

PROVISSION DIAGNOSIS

The provisional diagnosis is Urinary Tract Infection (U.T.I).

This is because of these features; Painful during urination, mild fever, lower abdominal pain.

 

DIFFERENTIAL DIAGNOSIS.

Ø Pelvic Inflammatory Diseases (P.I.Ds)

Ø Trichomoniasis and Interstitial cystitis and Vaginitis due to candida

 

INVESTIGATIONS.

Ø Urine dipstick

Ø Full blood picture

Ø Urine for cuture and sensitivity

 

PATIENT CARE PLAN

Ø Intravenous(IV) antimicrobial therapy with third generation cephalosporin eg. Ceftriaxone, ceftazidime, ciprofloxacin or an amino glycoside eg, Gentamiacine.  

Ø IV fluid resuscitation to restore appropriate circulatory volume and promote adequate urinary flow.

Ø Also she can use antibiotic such as Amoxicillin 500mg PO 12hr, or 250mg PO 8hr, or  ampicillin 250mg PO 8hr, or trimethoprine 100mg PO 12hr or Doxycycline.

Ø Antipyretics is needed to relieve fever

Ø Should be given also analgesics such as paracetamol or panadol

 

FOLOW UP

Routine supervision and review a patient for a new complait(s). If a new complaint(s) arise, treat them in early stage to prevent complication and deformities.

 

PROGNOSIS

The prognosis will be good if she will adhere to the medication given and if she will follow the prevention ways here under.

 

PREVENTION

Ø Proper personal hygiene

Ø To seek medical help when she experience any abnormal signs and symptoms at early stage to prevent development of disease

Ø Health education is also more important for people to protect themselves against squaring diseases.

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