Pain in abdomen with fever since 7 days
Name : Suresh
Age/Sex : 40 yrs/M
Add : Muzaffarnagar, U.P
Occupation: Carpenter
Marital Status : Married since 18 yrs
Date Of Admission :19.08.11
PRESENTING COMPLAINTS
Pain in abdomen with fever since 7days
HISTORY OF PRESENTING COMPLAINT
Patient was apparently well 7 days back when he suddenly developed fever in night and same morning he developed pricking type of pain in right lumbar region n hypogastrium.
< lying on opposite side,night ,before and during micturition
>After micturition, pressure on opposite side
Fever: temp.101 deg F with severe chills which persisted for 4-5 hours aqnd heat stage for 2-3 hours and no sweat stage. During all stages the thirst was increased n there was desire for luke warm water.
<evening till midnight
Past History: No history of any major illness
Family History: nothing significant
Personal history: Addiction :nil,diet: non veg,nothing significant
Physical Generals
Thermal Reaction: chilly
Appetite: normal
Thirst : 3 L/day,increased during fever for luke warm water
Stool: D1 N0,not satisfactory
Urine:D5-6, N5-6,burning before urination n patients screams during micturition,difficulty in beginning of urination
Sleep: disturbed due to pain
Desires: sweet
Aversion:pumpkin
Perspiration-very scanty
Mental Generals
General Physical Examination
Built:ectomorphic
Nutrition: poor
Pallor: present
Jaundice,cyanosis,clubbing,oedema: not present
Pigmentation: N
B.P.: 110/70 mm of Hg
Pulse: 82/min
Temp: 101 deg F
Tongue: furrowed and yellow coated
Systemic Examination: tenderness in hypogastrium and right lumbar region
Rest :NAD
Investigation done
Hb:12gm/dl, TLC:6700,DLC: P58 L38 E2 M2,ESR:56
Urine:protein :1+,WBC:50-80, Epithelial cells: 7-10, other cells: 0-1
Usg(16/8/11) :right renal cyst,sized 21 x 16.1mm
Usg KUB.Prostrate(20/8/11):NAD
Treatment
19-20 Aug: Cantharis 30/Qid,Chimaphilla Q/TDS
21/8: Bell 30/1dose stat,mag phos 6X
22/8:Bryonia 200/3doses/stat
23-28/8: Berb.vulgaris 30/Qid,Chimaphila Q and on 27th Bell 30/3 doses stat at 11 pm
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