23/M with ?pyelonephritis (resolving)
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A 23 yr old male patient who is a mason by occupation came to the casualty with
C/O fever 8 days back
C/O low back ache since 8 days
H/O Present illness :
Patient was apparently asymptomatic 8 days ago then he developed high grade fever which was associated with chills and subsided with medication.
Low back ache was gradually progressive in nature.
No H/O headache,vomitings,altered sensorium
No H/O pedal edema, decreased urine output.
No H/O chest pain, palpitations.
Past History :
Not a K/C/O HTN,DM,Epilepsy,Asthma,CAD.
Drug history :
Patient was kept on antibiotic treatment ( Meropenem)in the past when he visited a local hospital for the similar complaints.
Personal History :
Diet : Mixed
Appetite : Normal
Bowel and bladder movements : Regular
Sleep : Adequate
No addictions
General examination :
Patient is conscious, coherent and cooperative.Moderately built and nourished.
No pallor, icterus, clubbing, lymphadenopathy, edema.
Vitals :
Temp : 98.5 degrees F
BP : 130/80 mm Hg
PR : 62 bpm
RR : 16 cpm
SpO2 : 99% @ Room air
Systemic examination :
CVS : S1S2 + , No murmurs
RS : B/L Air Entry + , NVBS +
P/A : Soft , Non tender
CNS : NAD
Provisional diagnosis :
? Pyelonephritis ( resolving )
SOAP NOTES 02-01-2021
S : C/O severe low back ache
O :
Temp : 98 degrees F
BP : 120/80 mm Hg
PR : 92 bpm
RR : 18 cpm
A :
Pyelonephritis (resolving)
P :
1. Inj Ceftriaxone 1gm IV/BD
2. IVF NS,RL @ 75ml/hr
3. Inj Optineuron 1 amp in 100ml NS IV over 30 min/OD
4. Inj PAN 40 mg IV/OD
5. Tab Ultracet 1/2 tab PO/QID
6. Inj Tramadol 1 amp in 100 ml NS
SOAP NOTES 03-01-2021
S : C/O low back ache
No fever spikes
O :
Temp : 98 degrees F
BP : 110/70 mm Hg
PR : 92 bpm
RR : 18 cpm
A :
Pyelonephritis (resolving)
P :
1. Inj Ceftriaxone 1gm IV/BD
2. IVF NS,RL @ 75ml/hr
3. Inj Optineuron 1 amp in 100ml NS IV over 30 min/OD
4. Inj PAN 40 mg IV/OD
5. Tab Ultracet 1/2 tab PO/QID
6. Inj Tramadol 1 amp in 100 ml NS
SOAP NOTES 04-01-2021
S : C/O low back ache reduced,
No fever spikes
O :
Temp : 98 degrees F
BP : 110/70 mm Hg
PR : 82 bpm
RR : 18 cpm
A :
Pyelonephritis (resolving)
P :
1. Inj Ceftriaxone 1gm IV/BD
2. Tab Hifenac P PO/BD
3. Tab MVT PO/OD
4. Tab PAN 40 mg PO/OD
SOAP NOTES 05-01-2021
S :
Patient is subjectively feeling better,
No fever spikes.
O :
Temp : 97.5 degrees F
BP : 120/80 mm Hg
PR : 86 bpm
RR : 18 cpm
A :
Pyelonephritis (resolving)
P :
1. Inj Ceftriaxone 1gm IV/BD - Day 5
2. Tab Hifenac P PO/BD
3. Tab MVT PO/OD
4. Tab PAN 40 mg PO / OD
