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Chief complaint :
Recurrent UTI since April 2022
Burning micturition accompanied by fever with chills and vomiting
Left flank pain
History of present illness :
Patient was apparently asymptomatic 3days ago when she developed UTI along with radiating left flank pain accompanied by burning micturition with frothy urine.
The patient has been experiencing recurrent vomiting accompanied by UTI on having solid food and liquid food.
She was experiencing burning micturition with frothy urine and greenish tinge to urine without gross hematuria.
The patient is experiencing continuous fever accompanied by chills which subsided on taking medication.
History of past illness :
1. HTN since 11 years for which medications were used (TAXIM 40mg, AMLODIPINE 5mg)
2. DM since 10years, for which medication was used (insulin injections)
3. Known case of hypothyroidism since 6 years for which medication was used (THYRONORM 25mcg)
4. History of recurrent UTI since past 6 months.
5. UTI accompanied by fever chills and burning micturition, with radiating flank pain nad vomiting.
Personal history :
Appetite - normal
Sleep - normal
Bowel movements - Normal
Micturition - burning micturition
Diet - mixed diet
Drugs :
Insulin BD - 15 units in the morning, 20 units at night
Taxim 40 mg
Amlodipine 5 mg since last 2 months
Thyronorm 25mcg
Diagnosis :
Early pyelonephritis with hydronephrosis
Treatment :
Inj PIPTAZ 2.25 mg
Inj PAN 40
Inj HAI S/C
Inj INSULIN
Tab Thyronorm 25 mcg
GRBS monitors 6 hrly
Inj OPTINEURON
Fever chart
Lab report :
Serum electrolyte
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