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Southern Luzon State University

College of Allied Medicine

Lucban, Quezon

NCM 107

A Case Analysis

Submitted to:
Clinical Instructor

Submitted by:
Rebutar, Mariel R.
Patient’s Data

Name Patient RM
Age 48 years old
Sex Male
Date of Birth 11/12/1970
Civil Status Married
Religion RC
Date of Admission 02/20/19
Time Admitted 07:51
Attending Physician Dr. Letargo
Chief Complaint Right Lower Quadrant Pain
Admitting Diagnosis t/c SBO / t/c AP

Physical Assessment

Vital Signs

Blood Pressure 100/60 mmHg 100/80 mmHg

Temperature 36.3 C 36.4 C

Pulse Rate 82 bmp 80 bpm

Respiratory Rate 21 bpm 22 bpm

General Condition
 Patient is awake, conscious and coherent.
 Speech is adequate and converses are well oriented.
 Patient is responsive to questions both verbally and physically
 Patient has on and off fever

 The patient’s skin is brown in complexion
 Skin on the right arm is punctured due to intravenous fluid infusion. No redness nor
swelling noted
 Body hair is evenly distributed
 Skin is warm to touch
 With good skin turgor
 The tissues surrounding the nails of the patient are intact. 1-2 seconds upon blanching

 Symmetrical
 The patient’s scalp is lighter than the color of his skin and has no areas of tenderness
 The hair is evenly distributed
 With symmetrical facial movements

 External ear canal is dry
 No pus nor blood
 Normal voice tones are audible to patient
 Without masses

 Has evenly distributed hair
 Symmetrically aligned and has equal movement.
 Sclera is white and clear, conjunctiva is pinkish

 The patient has no tenderness on sinuses
 The nose is in the midline, has no discharges, no nasal flaring

 Mucosa (buccal) is pink in color, moist and has no lesions
 Teeth are white to yellowish in color
 Gums are pink, moist and no bleeding
 No discharges

 No masses palpated
 No jugular distension

Chest and Lungs

 Breathing pattern is quiet, rhythmic and effortless
 Chest is symmetric upon expansion

 Soft and tender abdomen
 Abdominal skin color is uniform, no tenderness noted
 With scar on lower right abdomen caused by stab wound
 With midabdominal scar caused by post explore laparotomy last December 2018
 With palpable mass on RLQ

 With straw colored urine, moderate in amount
 Hematuria
 Nocturia
 Dysuria

Upper/ Lower Extremities

 Extremities are equal in size
 No involuntary movements
 No edema; color is even
 Warm to touch
 Can perform complete range of motion

History of Present Illness

On February 15, 2019, Mr. RM experienced to have a right lower quadrant pain that is
radiating to his back. He describes the pain as a prickling pain. He has no bowel movements but
positive flatus for three days. He had an on and off fever.
He has a palpable mass on his right lower quadrant that was already present for a year
now. He can feel the mass to move sometimes.
For the early weeks of February, he suffered from nocturia, dysuria and hematuria.

Past Medical History

The patient is alcoholic. He does not smoke, and he loves to drink energy drinks as well
as eat salty foods.
The patient had history of abdominal trauma from a stab wound that happened last
December 27, 2018. His stab wound was located on his right lower quadrant.

Family Health History

The patient has a history of hypertension in both his mother and father’s side.

Personal and Social History

The patient lives in Calauag, Quezon. He works as a tricycle driver for some years now.
They have a small store that her wife manages.

Diet History
He sometimes does not eat rice during his meals. He sometimes eats salty street foods
and carbonated beverages. He also loves drinking alcohol with his friends. Their source of food
at home is from the public market. Their water is from a refilling water station.
Case Analysis Proper
Hydronephrosis and hydroureter are common clinical conditions encountered bu
urologists and primary care physicians. Hydronephrosis is defined as distention of the renal
calyces and pelvis with urine as a result of obstruction of the outflow of urine distal to the renal
pelvis. Analogously, hydroureter is defined as a dilation of the ureter.
The presence of hydronephrosis or hydroureter can be physiologic or pathologic. It may
be acute or chronic, unilateral or bilateral. It can be secondary to obstruction of the urinary
tract, but it can also be present even without obstruction.

Signs and symptoms

This disease has a number of symptoms. Mr. RM only manifested the following prior to
his admission in the hospital:
 Pain on RLQ that radiates to his back
 Nocturia
 Hematuria
 Cloudy urine
 Dysuria
 Fever

Urine forms in the kidneys and then it passes through the ureters to the urinary bladder.
Urine gets stored in the urinary bladder and when it reaches a certain amount, an individual
feels the urge to pass urine. The urethra is a small tube which connects the bladder to the
outside of the body and is responsible for draining the urine out of the body. Any sudden
interruption in the above drainage system of the urine results in obstructive uropathy. It can
occur due to a variety of factors. As to Mr. RM, he had:
 Large stone in the ureteropelvic junction
 Obstructive uropathy
 Renal inflammatory disease on the right
 Tissue trauma due to stab wound on his RLQ

Risk Factors
The patient’s only risk factors that are related to obstructive uropathy is the presence of
large stone in the ureteropelvic junction that will cause an obstructive uropathy. Obstructive
uropathy refers to the functional or anatomic obstruction of urinary flow at any level of the
urinary tract. Obstructive nephropathy is present when the obstruction causes functional or
anatomic renal damage.

When the patient was admitted last February 20, several tests were ordered.
Laboratory tests revealed high WBC (10.54x109/L), high Neutrophils (80.0%), low
Lymphocytes (12%) and high Monocytes (5%) that indicates infection. His urinalysis showed a
dark colored and cloudy urine with 1+ protein, 1+ bilirubin, 4+ urobilirubin, 1+ blood (due to
stones), traces of ketones, 75 leu/uL leukocytes (indicates infection), moderate epithelial cells
and moderate mucus thread.
Serum potassium (136 mg/dL), sodium (4.68 mg/dL), creatinine (1.18 mg/dL), BUN (17.2
mg/dL) and RBS (105 mg/dL) are normal. There are also no abnormalities in his plain abdominal
His whole abdominal ultrasound showed a hydronephroureter on his right and ascites and
due to his altered renal function, the doctor also ordered whole abdomen CT scan with IV
contrast. A CT scan provides information regarding the urinary tract, as well as any possible
retroperitoneal or pelvic pathologic condition that can affect the urinary tract via direct
extension or external compression. A contrasted CT scan is needed to provide information on
renal pathology. It revealed obstructive uropathy (right kidney) secondary to a large stone in the
ureteropelvic junction and renal inflammatory disease on the right.
His creatinine, BUN and urinalysis were ordered to be repeated after a few days of
interventions. The results were all improved. His creatinine (1.11 mg/dL) decreased as well as his
BUN (7.2 mg/dL). The patient’s urine has become clear and straw-colored urine. There were also
negative results of protein, bilirubin, blood, and ketones; normal urobilirubin; moderate
epithelial cells, rare mucus thread and a few A. phosphate.

Treatment begins upon the patient’s admission. A 1L PLR IVF was hooked to run for
eight hours. Laboratories were ordered to have baseline data and differential diagnostics. The
only medications that were ordered throughout his admission are Omeprazole (40 mg TIV once
a day), Paracetamol (500 mg prn) and Cefuroxime (750 mg TIV every 8 hours). Antibiotics are
often given for prophylaxis and should cover common urinary tract pathogens.
The patient’s signs and symptoms were considered as a small bowel obstruction that is
probably secondary to adhesions related to uropathy and appendicitis. To help rule out these
conditions, CT scan and x-rays were ordered.
A consultation with a urologist was ordered by the attending physician. A patient with
urinary tract obstruction should see a urologist promptly because of the serious complications
that the obstruction can impose.