uretro peritoneal fistula with h/o hysterectomy

Welcome and greetings to every one who are visiting my blog. This is an online E log platform to discuss our patient's de-identified health data shared after taking his/her/guardian's signed informed consent. I have been given this case in order to solve in an attempt to understand the topic of patient's clinical data analysis to develop my competency in reading and comprehending clinical data and come up with a diagnosis and treatment plan.

CHEIF COMPLAINT

36 yrs /F daily farmer by occupation came to OPD with c/o Pain in abdomen and vomitings, fever
And hysterectomy before 22days

HOPI(History of present illness):
Patient was apparently asymptomatic 1month back.
Then one day she developed non-radiating pain in abdomen
And there is history of Vomitings on and off
 and nausea ,fever,
No history of pyuria
No history of hematuria

PAST HISTORY:
Not a K/c/o DM , HTN , BA , Thyroid disorder and Epilepsy.
No history of hyperthyroidism since 6 months since eltoxin surgery
History of hysterectomy 22days back


PERSONAL HISTORY:
Diet - mixed
Appetite - normal
Sleep - adequate
Bowel and bladder movements - regular
She have no habit of drinking alcohol 

FAMILY HISTORY:
No similar history in the family

GENERAL EXAMINATION:
-Patient is conscious,coherent and cooperative at the time of joining 

-No pallor 

-No icterus

-No lymphadenopathy 

-No cyanosis 

-No clubbing of fingers

-No edema of feet

-No malnutrition

-No dehydration 

 ▪️VITALS:
Temperature - 98F
Pulse rate - 83 bpm
Respiration rate - 12cpm
BP - 110/70 mmhg
Spo - 99%

SYSTEMIC EXAMINATION:

▪️CVS

-no thrills 

-no cardiac murmurs

S1&S2 sounds are heard

▪️RESPIRATORY SYSTEM 
No Dysponea
No Wheeze 
Vesicular beath sounds

Abdomen
Shape of abdomen': obese
Tenderness: no
Palpable mass': no
Hernial orifices :no
Free fluids: no
Bruits: no
Liver: no
Spleen: no 
Bowel sounds: yes



▪️CNS
Level of consciousness :consious
Speech: normal
Signs of meningial inflammation
Neck stiffness: no
Kerning sign :no

Provisional diagnosis
Uretro peritoneal fistula
Investigation
Surgical profile
Uretric reimplantation

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