sapthagiri Super Speciality Hospital
Creating Healthcare
~
G O Grou p
Miss Bh11vya MR No: SH0002811435
22 YIF Visit 10: IP2504020044
IAggeree Adml11lon Date: 02-04-2025 10:54
B~NGALORE. KARNATAKA Discharge Date: 08-04-2025 11 :20
Or. Jayachandr a • Ward/Bed: GENERAL MEDICINE
GENERAL MEDICINE FEMALE UNIT
ABRK 3/GENERAUIP9
I\KS Referred By: Walk In
Dlacharga Summary
OR ~YACHANORA
OR RAVEENORA
OR RAGHAVENORA
ORHARITHA
URINARY TRACT INFECTION (CULTURE POSITIVE
- E.COLI)
ure Done
C/0 BURNING MICTURITION SINCE 2 DAYS
C/0 FEVER SINCE 2 DAYS
C/0 PAIN ABDOMEN SINCE 1 DAY
C/OVOMITING SINCE 1 DAY
tory
THE PATIENT WAS APPARENTLY NORMAL 2 DAYS
AGO WHEN SHE DEVELOPED BURNING
MICTURITION, ACUTE IN ONSET, PROGRESSIVE,
NO AGGRAVATING OR RELIEVING FACTORS.
THE PATIENT ALSO C/0 FEVER SINCE 2 DAYS,
ACUTE IN ONSET, CONTINUOUS, HIGH GRADE
ASSOCIATED WITH CHILLS AND RIGORS. THE FEVE FEVER,
R IS RELIEVED WITH MEDICATION.
THE PATIENT ALSO C/0 PAIN ABDOMEN SINCE
1DAY,
ABDOMEN, INTERMITTENT COLICKY TYPE OF PAIN, ACUTE IN ONSET, IN RIGHT LOWER PART OF
NON RADIATING PAIN. NO AGGRAVATING OR
RELIEVING FACTORS.
THE PATIENT ALSO C/0 VOMITING SINCE 1 DAY,
ACUTE IN ONSET, 3 EPISODES IN A DAY, NON
PROJECTILE, NON BILIOUS, CONTAINED FOOD
PARTICLES .
NO H/0 LOOSE STOOLS, INCREASED FREQUENC
Y OF MICTURITION
NO H/0 COUGH, RUNNY NOSE, THROAT PAIN.
NO H/0 CHEST PAIN, BREATHLESSNESS, PALP
ITATIONS, HEADACHE.
PATIENT ALSO GIVES H/0 WHITE DISCHARGE
PV 2 DAYS AGO, LASTING FOR 1 DAY, MINIMAL
AMOUNT, WHITE CURDY DISCHARGE, ASSOCIATE
D WITH ITCHING
t Medical History
.,
No. 15, chlkkasandra, Hesaraghatta Main Road,
Bengaluru - 560 090.
Tel: 080-22188999, Fax: 080-22188900 Email: hospl
talsapthaalrl@amall.com
www.sapthaglrlhospltal.com Page loft
HISTORY OF SIMILAR COMPLAINTS 2 WEEKS AGO, ADMITTED AND GIVEN INJ POSIBAC 4.5G
1-1-1-1 FOR 3 DAYS, AND TAB NIFTAS 100MG 1-0-1 FOR 5DAYS, URINE CULTURE POSITIVE FO
CONS, RESISTANT TO NITROFURANTOIN THE SYMPTOMS RESOLVED WITHIN 1 WEEK OF
TREATMENT. .
)
NOT A K/C/0 DIABETES MELLITUS, HYPERTENSION, THYROID DISORDERS, TB, ASTHMA, EPIL
Personal History
DIET-MIXED
APPETITE- NORMAL
SLEEP- ADEQUATE
BOWEL- REGULAR
BLADDER- BURNING MICTURITION PRESENT, REGULAR
NO HABITS
Menstrual Examination
AGE OF MENARCHE-12YEARS
LMP- 2103/25
CYCLES ARE IRREGULAR, 30 TO 40DAYS CYCLE, 3 DAYS FLOW, NO CLOTS, NO DYSMENORRH
Physical Examination
A YOUNG FEMALE, MODERATELY BUILT AND NOURISHED, CONSCIOUS, COHERENT, COOPEM
WELL ORIENTED TO TIME, PLACE, AND PERSON
VITALS:
PULSE-110BPM, REGULAR
BP- 96/70MMHG
SPO2- 97% AT ROOM AIR
RR-18CPM
TEMP-101F
Local Examination
NO SIGNS OF PALLOR, ICTERUS, CYANOSIS, CLUBBING, LYMPHADENOPATHY, OR EDEMA.
Systemic ExamlnatJon
PA - SOFT, TENDERNESS PRESENT IN RIGHT LUMBAR REGION
RS - B/L NVBS HEARD, NO ADDED SOUNDS
CVS - S1S2 HEARD. NO MURMURS
CNS- CONSCIOUS, ORIENTED
Investigations
URINE ROUTINE
VOLUME 10ml
COLOUR Yellow
APPEARENCE Turbid Protein-error of pH
indicators (strip)
Page
-. -:.c1p1nc19m ~uper :tpeciality Hos . .
WV Creating Hea1tp1ta1
care
~
Go~
I
Gro11p
.. '0, SUIIJlfiAARV
~ SUGAR Nill Double Sequential
~IBA.c 4 5 UR matic/GOD-POD
\'~~Ii/Ve ~6~ ~~iE PROTIEN Nill
K OF URINE WBC 10-12 0 - 5 /hpf
URINE RBC NIL O - 2 / hpf
EPITHELIAL CELLS Plenty O - 5 /hpf
j
THMA., EP/Le CASTS NIL
CRYSTALS NIL
OTHERS Bacteria
present
J 1
LIVER FUNCTION TEST
TOTAL BILIRUBIN 1.5 Jendrassic-GR OF/Diazo
Method DPD
mg/dL 0.2 - 1.3
DIRECT BILIRUBIN 0.2 Calculated mg/dL 0.0 - 0.3
INDIRECT BILIRUBIN 1.3 mg/dL
TOTAL PROTEIN 8.4 Biuret g/dL 6.3- 8.2
SERUM ALBUMIN 4.6 Bromocresol Green g/dL 3.5 - 5.0 '
GLOBULIN 3.8 Calculated g/dL 2.0 - 3.5
IENORRHC AJG RATIO 1.2 Calculated 1: 1 - 1:7
AST OR SGOT {ASPARTATE AMINO ... 17 Enzymatic U/L < 36
ALT OR SGPT (ALANINE TRANSAM ... 13 IFCC Kinetic U/L < 35
ALKALINE PHOSPHATAS E (ALP) 95 IFCC Kinetic U/L 6-10 yr: 153-367
Male
11 -15 yr: 113-438
16-21 yr: 56-167
22 - 79 yr : 50 - 116
Female
11 - 15 yr : 64 - 359
16 - 29 yr : 44 -107
30 - 79 yr : 46 -122
RENAL FUNCTION TEST
UREA (SERUM) 10 Urease GLDH mg/dL 10 - 40
SERUM CREATININE 0.6 Enzymatic mg/dl 0.5-1.2
SERUM SODIUM 138 ISE DIRECT mmol/L 136-144
A. SERUM POTASSIUM 4.0 ISE DIRECT mmol/L 3.6 - 5.1 ,
SERUM CHLORIDE 105 ISE DIRECT mmol/L 93-105
COMPLETE HAEMOGRAM
l
HAEMOGLOB IN 12.6 SLS-HB METHOD g/~L 12.0-16.0
RBC COUNT 3.85 Electrical lmpendence M111ion/cumm 3.8 - 5.0
HAEMATOCR IT or PCV 39.3 Calculated 0Yo 36.0 -47.0
MCV 102.1 Calculated % 80 - 100
MCH 32.7 Calculated% 26 - 34
MCHC 32 · 1 Calculated %
T 88 Electrical lmpendence Lakhs/cumm 1.5 - 4.5
PLATELET COUN T· 2
Flow Cytometry cells/cumm 4000-11000
TOTAL WBC COUN 15310 .
ESR 85 Photometric Capillary
stopped flowkinetic
analysis
mm/hr C) 00 Flow Cytometry %
EOSINOPHIL (D
N 15 chlkkasandra, Hesaraghatta Main Road, Bengaluru - 560 090. .(
page: 3 ot
Tel . o:0-22,188999, Fax: 080-22188900 Email: hospltalsapthaglri@qmail.com
· www.sapthaglrlhospltal.com
?age 2
ry % 25 - 40
L YMP HOC YTE {DC ) 06 Flow Cyto met
M ONO CYT E 09 Flow Cyto met ry %
NEU TRO PHI L 85 Flow Cyto met ry %
PER IPH ERA L SME AR
I pre d omlnantly Normocytlc Norm ochr omic RBCs. Also seen
are few
RBC 's: Are norm al in num ber w'th
Mac rocy tic RBC s. '
trophlls .
normal morphology and increased Neu
WBC 's: Are incr ease in num ber with
seen as single.
Platelets: A~ ade qua te In num ber and
Hemoparas1tes: Are not seen .
tosis .
Blood Picture With Neutrophilic Leucocy
Imp ress ion: Nor moc ytic Norm ochr omic
URI NE CUL TUR E & SEN SITI VITY
ple: Urine
Met hod :Aer obic met hod Natu re Of Sam
Org anis m Isola ted: E.coli
Colo ny Cou nt:1 00,0 00 cfu/ml
ity
Anti biot ic Sen sitiv ity Anti biot ic Sensitiv
AMIKACIN S FOS FOM YCI N S
GENTAMICIN S LEV OFL OXA CIN S
CEF AZO LIN R CEF EPI ME S
COL S
AZIT HRO MYC IN S CHL ORA MPH ENI
AZT ERO NAM S TET RAC YCL INE S
AMP ICIL LIN R IMIP ENE M S
CEF URO XIM E R CEF TRI AXO NE R
VS
NIT ROF URO ANT OIN S AMO XY - CLA
ZOB ACT AM S
NOR FLO XAC IN S PIPE RAC ILLI N/TA
S
MER OPE NEM S CIP ROF LOX ACI N
OXA ZOL E S AMP ICIL LIN/ SUL BACTAM S
COT RIM
CULTURE
BAC T ALE RT AUT OMA TED - BLO OD
Method: Aero bic met hod
Specimen: Blood els
r 48hrs of aerobic incubation.
Report: Culture yields no growth afte
CBC g/dL 12.0 -15. 0
HAEMOGLOBIN 10.7 SLS -HB METHOD
trica l lmpe nden ce Million/cumm 3.8 - 4.8
RBC COU NT 3.29 Elec
d % 36.0 - 46.0
HAE MAT OCR IT or PCV 33.1 Calculate
Elec trica l lmpe ndence Lakhs/cumm 1.5 - 4.1
PLA TEL ET COU NT 2.21
metry cells/cumm 400 0-10 000
TOTAL WBC COU NT 9330 Flow Cyto
40 - 75
NEUTROPHILS 71 Flow Cytometry %
19 Flow Cyto met ry % 20 - 40
LYMPHOCYTES
Flow Cyto met ry % 2 - 10
MONOCYTES 10
S 00 Flow Cyto met ry % 1-6
EOSINOPHIL
-1
BASOPHILS 00 Flow Cytometry % 0
_ 4. 2
(TSH) 2.968 CLIA mlU /L 22 - 54 yr : 0.4
THYROID STIMULATING HOR MON E
55 - 87 yr : 0.5 - 8.9
Pregnancy
First Trimester : 0.1 - 2.5
Second Trimester: 0.2 -3.0
w - - uroup
tD• surt .,1,~,·,y
~mester: 0.3 -3.0
ROTEIN 115.74 mg/L New born:< 0.6
c-REACTI VE P
1day:< 3.2
1week: < 1.6
Adults< 6.0
CB~MOGLOBIN 11.3 SLS-HB METHOD g/dl 12.0 - 15.0
!:c COUNT 3.49 Electrical lmpendence Milllon/cumm 3.8 - 4.8
HAEMATOCRIT or PCV 34.4 Calculated % 36.0 - 46.0
PLATELET COUNT 2.76 Electrical lmpendence Lakhs/cumm 1.5 - 4.1
TOTAL wee COUNT 5490 Flow Cytometry cells/cumm 4000 -10000
NEUTROPHILS 58 Flow Cytometry % 40 - 75
LYMPHOCYTES 30 Flow Cytometry % 20 - 40
MONOCYTES 09 Flow Cytometry % 2 - 10
EOSINOPHILS 03 Flow Cytometry % 1-6
BASOPHILS 00 Flow Cytometry % 0 - 1
RENAL FUNCTION TEST
UREA (SERUM) 5.0 Urease GLDH mg/dL 10 - 40
SERUM CREAT\NINE 0.6 Enzymatic mg/dL 0.5-1.2
SERUM SODIUM 138 \SE DIRECT mmol/L 136-144
SERUM POTASSIUM 3.9 ISE DIRECT mmol/L 3.6- 5.1
SERUM CHLORIDE 108 ISE DIRECT mmol/L 93-105
Course In The Hospital
THE PATIENT CAME TO OPD WITH ABOVE MENTIONED COMPLAINTS. VITALS ASSESSED WERE
PULSE-110BPM, BP-96/70MMHG, SPO2-97% AT ROOM AIR, RR-18CPM, TEMP-101F. ALL RELEVANT
INVESTIGATIONS WERE SENT AND PATIENT WAS SHIFTED TO WARD FOR FURTHER MANAGEMENT.
COMPLETE HEMOGRAM REVEALED ELEVATED TLC -15310 WITH NEUTROPHILIC PREDOMINANCE.
URINE ROUTINE SHOWED PUS CELLS 10 TO 12, WITH BACTERIA PRESENT. PERIPHERAL SMEAR
SHOWED NORMOCYTIC NORMOCHROMIC PICTURE WITH NEUTROPHILIC LEUCOCYTOSIS. USG
ABDOMEN AND PELVIS REVEALED CYSTITIS AND NO OTHER ABNORMALITIES. THE PATIENT WAS
TREATED WITH IV ANTIBIOTICS, IV FLUIDS AND OTHER SUPPORTIVE MANAGEMENT. THE TOTAL
COUNTS IMPROVED TO 9330 OVER 1 DAY, FEVER SPIKES REDUCED AFTER 1 DAY OF ADMISSION
AND VOMITING IMPROVED. BLOOD C/S YIELDED NO GROWTH AFTER 48HRS OF AEROBIC
INCUBATION. URINE CULTURE WAS POSITIVE FORE- COLI, RESISTANT TO CEFTRIAXONE,
AMPICILLIN, CEFUROXIME. GYNECOLOGY OPINION WAS SOUGHT IN/O WHITE DISCHARGE PV, AND
WAS ADVISED TAB FLUCONAZOLE 150MG STAT, AND ADVICE WAS FOLLOWED. DAILY VITALS AND
1/0 MONITORING DONE. REPEAT CBC AT TIME OF DISCHARGE SHOWED REDUCED TOTAL
COUNTS(5490). NO C/O FEVER SPIKES FOR >48HRS. THE PATIENT IS NOW SYMPTOMATICALLY
BETTER AND CLINICALLY STABLE AND HENCE BEING DISCHARGED WITH FOLLOWING ADVICE.
Treatment Given
IVF NS AT 100MUHR
INJ XONE 1G IV 1-0-1 FOR 2 DAYS, STOPPED ACCORING TO C/S REPORTS
INJ PIPTAZ 4.5G IV 1-1-1-1 X 5 DAYS
INJ METROGYL 500MG IV 1-1-1 X 5 DAYS
INJ PANTOCID 40MG IV 1-0-0 (B/F)
INJ EMESET 4MG IV 1-1-1 FOR 3 DAYS F/B SOS
No. 15, chlkkasandra, Hesaraghatta Main Road, Bengaluru - 560 090.
Tel: 080-22188999, Fax: 080-22188900 Email: hospitalsapthaglrl@gmaU.com Pag~ 5 oft
www.sapthaglrlhospltal.com
"
INJ PCT 1G IV SOS
TAB DOLO 650MG 1-1-1-1 FOR 2DAYS F/8 SOS
SYP CITRALKA 10ML IN A GLASS OF WATER 1-1-1
Condition On Discharge
IMPROVED
Advice On Discharge
SYP CITRALKA 10ML IN A GLASS OF WATER 1-1-1 FOR 3 DAYS
TAB DOLO 650MG SOS
PLENTY OF ORAL FLUIDS
How to Obtain Urgent Care
CONTACT: 080-28393392/93, 080-22188777, 8884439132
Remarks
TO REVIEW IN MEDICINE OPD SOS
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SURGERY
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• SAPTHAGIRI INSTITUTE OF MEDICAL ICIENCEI & IEIWCN OlfTI
A.GE f GENDER :
No.1S,Cttin1 oa.Hturagt\lltlllinRold,Blllgllorl·seOOIO·
Tel : ~ 2 I 13 I Wlb: www.~t11.C0ffl
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NameendR~
UHIO No I MRO No. HillofYrec;o,dedbY
IPNO : Date and Tlme
Oas,t. l Unl / w.d : Addrell:
Dae. & rme d AIHSSi,,@114. :
IN PATIENT - INITIAL ASSESSMENT FORM
_ Med. Surg, ortho, Ent, Opthal, Tb & Chest, Psychiatry, Dermatology
~THISTOR
(
• HYPERTENSION YES/~ SINCE
• DIABETES MELLITUS YES/@) SINCE
• IHD · YES/~ SINCE
l• BRONCHIAL ASTHMA/ COP~ YES/ · SINCE
1• THYROID DISORDERS SINCE
• EPILEPSY SINCE
I• PULMONARY T.B YES SINCE
- • ALLERGIES YES/ 0 SINCE
- • ON BLOOD THINNERS YES/@) SINCE
• BLOOD TRANSFUSION YES~ DURATION
\ YES/~ DURATION
• SURGERY
• OTHER- SPECIFY YES/NO SINCE
-I
lM!LY HISTORY
(y
EASED / DECREASED
:RSONAL HISTORY : APPETITE : ~I...LINCR
SLEEP : sollli9JJllSTURBED
ET : VEG/ NONVEG tN...J .
OTHER HABITS :
-----.___>WEL MOVEMENTS : kO...Qg, SMOKING: YEsQ!O'IF YES: SINCE
HISTORY' OF DRUG AlllRGY:
ADDER HABITS: ll,, r -
ALCOHOLIC: y~')I°) IF yes: SINC!
OTHERS SPECIFY.
'R FEMALE PATIENTS :
:NSTRUAL HISTORY: MENSTRUAL CYCLES 'J ,~.Av 'lc."'14.--lo,c!
IEDICATIOI IIISTORr: 1 E OF MENARCHE: 1J r YES/NO IF YES : SINCE
YESIN...9,.
I. .J.
IP:
TAINED MENOPAUSE
STORY OF:
l-- (01jis DYSMENORRHOEA :
POLYMENORRHOEA ;
MENORRHAGIA :
YE8/NO
YE8/NO-
l\l} ,Q.ol1 .
STORY OF ALLERGY:
,I ENERAL PHYSICAL EXAMINATION :
CONBCIOUBNEBB: ORIENTATION :
I , • ·..11 JILT AND NOURISHMENT:
_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __:__:__ __ WEIGHT: BMI: TEMP:
_ _ _:IGHT:
ICTERUS: C:) CLUBBING: (:) CYAN0818: 8 EDEMA: c:'C) LYMPHIDINOP~V:
-.-.rPIEWIUIIM:ITIMIIOIIIIS'OITI: /;'' II.LOR: 8
JLSE: I ID ~r. BP: 'H /·,o ,,.,_ IIJ RESPIRATORY RATE: I e, I'·8P02: r 17"/- ~ (I} QRBI:
q:
N4YMURMUR:
YITEMIC EXAMINATION :
I
ARDIOVASCULAR SYSTEM: HEART SOUNDS (81, 82):
VY OTHER FINDINGS:
I £8PIRTORY SYSTEM:
IN&PECTIOH: N,~
PALPATION: 6/ L Vf ~~
PERCU88ION: r~C>-'-'.., ~M ~- Jo 0,....,, f "',t
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