32 year old female came with back pain

June7 ,2022

This is an online e log book to discuss our patient deidentified health data shared after taking her /guardian signed informed consent .here we discuss our individual patient problem through series of input from available global online community of expert with an aim to solve those patient clinical problem with collective current best evident based input
 
 This e log book also reflect my patient centered online learning portfolio and your valuable input on the comment box also welcome 
 I have been given these case to solve in an attempt to understand the topic of patient clinical data analysis to develop my competency in reading and comprehending clinical data including history , clinical findings , investigation and comeup with diagnosis and treatment plan 
 
Chief complaints

A 32 year old female patient ,works in shopping mall by occupation came with complaints of severe back pain since 3 months , vomiting  ,
TB since 3 months on medication 

HOPI
Patient was asymptomatic before covid vaccine ,in November  ,after that  developed back pain and on medication ,but the pain  progressive increased from March  dragging type of pain . vomiting present since May  with in 30 min after intake of food which contains food particles ., difficulty during swallowing ,no history of burning micturition ,

Past history
Diagnosied with left renal abscess and TB since 3 months and on medication (ATT March ) 
No history of any surgery 
Personal history 
,no diabetes ,no hypertension,no asthma no CAD, no blood transfusion 
Non-vegetarian diet ,no known allergies 
Family history 
No TB
General examination
No pallor, icterus , clubbing of fingers/toes ,oedemaof feet lymphadenopathy 
Temp :98.5 C/F 
PR :96/ min
RR: 20 /min 
BP : 100/60 
Spo2:98%
GRBS:109mg/dl
Systemic examination
CNS patient is conscious , coherent , cooperative
Speech is normal 
Respiratory system 
No dyspnea 
No wheeze 
Position of trachea is central
CVS 
Cardiac sounds present 
No cardiac murmur 
Abdomen
Schapoid abdomen ,no tenderness ,no palpable mass,no free fluid andbruits,not palpable liver and spleen bowel sounds present

Diagnosis
Left renal abscess
Pottis spine 
Investigation 
USG KUB
NCCT KUB
Treatment
June 8 2022
Similar complaint,
Back pain
Difficulty in swallowing 
Vomiting 
USG KUB 
NCCT KUB 

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