3RD APRIL, 2023
MEDICAL REPORT/DISCHARGE SUMMARY
E.M, 26YEARS, FEMALE
WCA/6107/2023
Background information : A 26yr old lady with complain of right flank pain noticed 2weeks ago sudden in onset, progressively becomes worst. Severe enough to prevent physical activity and brathing excursions associated with fever, nausea,anorexia. However, no LUT, no history of passage of stone by urethra, Hematuria or change in urinary habbit. No GI symptoms. She was initially seen in a private facility were she’s given medications with temporary relieve. However, symptoms have remain persistence.
Previous abdominal images reveal right solitary kidney. No known co- morbidities
Smoking- 0, Alcohol- 0
Single, 4th out of 7 children, all alive and well. Public servant.
Diagnosis; Acute
pylonephritis ina solitary Right Kidney
.
Management plan;
·
Patient
counseled
·
Admit
·
I.V
levofloxacin 500mg daily (tavanic)
·
I.V Rocephin 1g 12hrly
·
I.V
fluid N/saline alternating with Dextrose water 1L 12hrly
·
Meanwhile
do FBC,ESR,EUCR,LFTs, all were within
the normal range. Urine MCS yielded no growth.
·
KIV
CT Urography
Presentation and Neurology;
O/E: a young girl, in some painful distress, afebrile, well hydrated,
not pale, anicteric, acyanosed
CVS: PR- 98bpm, BP- 110/70mmHg
Abdomen: Full. Moves with respiration, right flank fullness, severely
tender, +ve renal angle punch test, no other appreciable organomegaly, other
systems ISQ
UPDATE ( 3/4/2023)
3Days on I.V Antibiotics as recommended by the urologist.
Symptoms have improved. She is awaiting review by urologist for further management plan.
Urologist Review
Plan: To do CT-IVU
Continue I.V Antibiotics
· 2 more shots of Rocephine
· 2 more shots of levoflaxacin
For discharge on tabs levofloxacin 500mg daily x 10/7
UPDATE (4/4/2023)
She is awaiting CT IVU and being treated for malaria.
1:51am
CT IVU is ready and the urologist requested for her to be discharge and he would come later to view the CT IVU
Plan: discharge patient home on; tabs Levofloxacin 500mg daily x 10/7
Discharge instructions:
· Continue antimalarials and complete the dose
· To be seen after the urologist view the CT IVU
Discharge Medications:
· I.M Emal 150mg daily x 3/7
· Tabs ACT 80/480mg at 0, 8hr, 12hrly x 3/7
· Tabs Levofloxacin 500mg daily x 10/7
Kindly
revert to us for clarifications where necessary.
Yours Sincerely,
Dr.
Halima Ibrahim
For Team Wellington
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