CASE REPORT 2 – Nephrology Submitted by: Richedlhyne P.

Orbeta

Initials : HB Religion: Islam

Age/Sex : 32/F

Date of Admission: July 3, 2019

CHIEF COMPLAINT: Vomiting

HISTORY OF PRESENT ILLNESS

1 day PTC, patient had onset of undocumented fever and intermittent dull bilateral flank pain, non-radiating PS 6/10
and unrelated to movement. She also had associated nausea and 5 episodes of non-bilious, non-projectile, non-bloody vomiting
of ¼ cup previously ingested food (30min-1hr postprandial). There was also band-like headache PS 6/10, fronto-orbital. She had
no dysuria, oliguria, hematuria, changes in urinary frequency. Patient self-medicated with 500mg PRN for fever with partial relief.
No consult was done.
3 Hours PTC, there was persistence of vomiting (4 episodes) with the same characteristics as mentioned above which
prompted consult at OMMC-ER. She still had associated undocumented fever, headache, nausea, anorexia, and bilateral flank
pain. Patient had no dysuria, hematuria, nocturia, and changes in urinary frequency.
PAST MEDICAL OBSTETRIC- FAMILY HISTORY PERSONAL AND SOCIAL REVIEW OF SYSTEMS
HISTORY GYNECOLOGIC HISTORY
HISTORY
(+) UTI, hospitalized in OB score: G0P0 (0-0- No HPN Non-smoker General: No weight
May 2019 0-0) No DM Non-alcoholic beverage drinker loss/gain, night sweats,
No HPN, DM LMP: July 5, 2019 No PTB Dietary preference: Eats street jaundice
No history of Regular menstrual No neuropsychiatric food 2x-3x per week, does not
catheterization cycle lasting for 4-5 disorders eat red meat, drinks softdrinks HEENT: No blurring of
No history of days No cancer (4 Coke Sakto bottles) more vision, eye discharge, nape
nephrolithiasis Consumes ~4 pads than water (<8 glasses of pain, earache, tinnitus,
No cancer per day water) per day nasoaural discharge
No previous surgery No dysmenorrhea Denies illicit drug use
No known allergies to Age at first coitus: n/a Currently unemployed Cardiovascular: No
food and medication No of sexual partner: No history of lifting heavy palpitations, chest pain,
No prior PTB treatment 0 objects PND, orthopnea, bilateral
edema

Respiratory: No cough,
hemoptysis, colds, difficulty
of breathing

Abdominal: No abdominal
pain, changes in bowel
movement

Hematologic: No easy
bruising, pallor, epistaxis

Neurologic: No loss of
consciousness, changes in
sensorium, seizures,
numbness, weakness

Endocrine: No heat/cold
intolerance, polydipsia,
polyphagia, polyuria

Genital: No vaginal
discharge, pruritus, foul-
smelling genitalia
PHYSICAL EXAM

General Awake, in pain

Vital Signs BP: 130/80 L arm, sitting HR: 111bpm, regular RR:24cpm, regular
T: 37.5oC at 6pm O2 sat: 97% at room air
HEENT & Neck No visible lesions on the scalp
No tenderness of the face and scalp
Anicteric sclerae, pink palpebral conjunctiva
(+) ROR
Dry oral mucosa, no nasoaural discharge
No cervical lymphadenopathy
Chest and Lungs Transverse > AP diameter, No visible lesions and deformities, Symmetric chest expansion
No retractions and use of accessory muscles, Bronchovesicular breath sounds between the scapula,
Vesicular breath sounds on the bilateral (posterior) peripheral lung fields and the lung apices
No wheezes, crackles, rhonchi
Heart Adynamic precordium
PMI tapping approx. 2 cm lateral to the left midclavicular line at 5th ICS
No lifts, thrills, or heaves
Regular rhythm and tachycardic (105bpm)
No murmurs
Abdomen Flat abdomen, with no visible striae, dilated veins, pulsations and peristalsis
Inverted umbilicus
Normoactive bowel sounds, 12/min
No bruits heard
No visible and palpable masses and deformities
No tenderness on all quadrants
Nonpalpable liver edge
Traube’s space not obliterated
(+) Left CVA tenderness
Extremities Full and equal pulses, no cyanosis, no edema.

SALIENT FEATURES
PERTINENT POSITIVES PERTINENT NEGATIVES
• 32/F • No history of trauma
• Non-bilious, non-projectile, non-bloody vomiting • No history of lifting heavy objects
• Undocumented fever • No gross hematuria
• Headache
• Flank pain, non-radiating, not aggravated by
movement
• High intake of softdrinks
• Left CVA Tenderness
APPROACH TO DIAGNOSIS

DIFFERENTIALS

Musculoskeletal

Localized pain may be musculoskeletal in origin. However, the lack of history of trauma, lifting heavy objects, and pain
not being aggravated by movement make this diagnosis less likely. Also, this musculoskeletal pain will not explain the other
pertinent symptoms such as nausea, headache, vomiting.

Nephrolithiasis

Nephrolithiasis, or kidney stone disease, can subsequently move into the ureter and cause renal colic. Compared to
the patient's bilateral dull flank pain, nephrolithiasis often has radiating pain. When a stone moves into the ureter, the discomfort
often begins with a sudden onset of unilateral flank pain. The intensity of the pain can increase rapidly, and there are no
alleviating factors. This pain, which is accompanied often by nausea and occasionally by vomiting, may radiate, depending on
the location of the stone. If the stone lodges in the upper part of the ureter, pain may radiate anteriorly; if the stone is in the lower
part of the ureter, pain can radiate to the ipsilateral testicle in men or the ipsilateral labium in women. Occasionally, a patient has
gross hematuria without pain.
An obstructing stone with proximal infection may present as acute pyelonephritis. Furthermore, the patient has dietary
predisposition due to high intake of softdrinks. Thus, this diagnosis cannot be ruled out.

Recurrent UTI

According to the Philippine Guideline on UTI part 2, recurrent UTI is diagnosed when a healthy non-pregnant woman
with no known urinary tract abnormalities has 3 or more episodes of acute uncomplicated cystitis documented by urine culture
during a 12-month period or 2 or more episodes in a 6- month period. The patient had a history of UTI on May 2019. For this
hospital admission, her sign and symptoms of flank pain, fever, nausea, vomiting, and CVA tenderness are present in acute
pyelonephritis.

DIAGNOSTIC/MANAGEMENT PLANS

Patient was admitted to IM ward 402/404 under the service of Drs. Esmero/Gler/Laroa/De Mesa, Miguel. Patient was placed on
DAT, fluid was PNSS 1L x 180cc/hr. Diagnostics requested: CBC, BUN, Crea, AST, ALT, Serum Na, K, Cl, Ca, Mg, 12L-ECG,
FBS, LP, BUA, UA, CXR PA. Diagnostic that should also be done is KUB UTZ for the possibility of nephrolithiasis. Therapeutics:
Ceftriaxone 2g TIV q24hr, Paracetamol 500mg/tab 1 tab PRN. VSq4. I/O q shift.

COURSE IN THE WARDS

On the first day of admission (7/03), patient was seen awake, comfortable, not in distress with BP of 140/80, HR of 96,
RR of 28, Temperature of 36.9oC, and O2 sat of 96%. There was no fever, change in sensorium, cough, palpitations, chest pain.
Pertinent PE finding is the CVA tenderness. Patient was placed on DAT. Patient was given PNSS 1L X 80 cc/hr. Diagnostics
were repeat CBC, chest xray PA, BUN, Creatinine, and 12-lead ECG. Therapeutics given were Ceftriaxone 2g OD, Paracetamol
500mg/tab q4 PRN for Temp > 39.0oC, Metoclopramide 10 mg IV q8h PRN for vomiting. VSQ4.

On the second day of admission (7/04), patient was seen awake, comfortable, not in distress with BP of 120/70, HR of
82, RR of 20, Temperature 36.2 oC, and O2 sat of 96%. Patient still has flank pain and (+) Left CVA tenderness. There was no
fever, vomiting, change in sensorium, cough, palpitations, chest pain. Pertinent PE finding is the absence of CVA tenderness.
Patient was placed on DAT. Patient was given PNSS 1L X 80 cc/hr. Diagnostic procedure was KUB-UTZ. Therapeutics given
were Ceftriaxone 2g OD, Paracetamol 500mg/tab q4 PRN for Temp > 39.0 oC, Metoclopramide 10 mg IV q8h PRN for vomiting.
VSQ4.

On the third day of admission (7/05), patient was seen awake, comfortable, not in distress with BP of 110/70, HR of 80,
RR of 14, Temperature 36.3 oC, and O2 sat of 97%. There was no fever, vomiting, change in sensorium, cough, palpitations,
chest pain, flank pain. Pertinent PE finding is the absence of CVA tenderness. Patient was placed on DAT. Patient was given
PNSS 1L X 80 cc/hr. Diagnostic procedure was repeat CBC. Therapeutics given were Ceftriaxone 2g OD, Paracetamol
500mg/tab q4 PRN for Temp > 39.0oC, Metoclopramide 10 mg IV q8h PRN for vomiting. VSQ4.

7/2 7/2
UA 7/2 CBC 10AM 2PM Chem
7/2 7/3 7/4
Color Yellow WBC 18.3 18.9 BUN 3.04 1.89
Trans Turbid Lymph 7.0 10.9 Crea 52.7 47.0
Blood 1+ Mono 4.8 5.3 ALT 16.1 10.1
Bilirubin Negative Neut 88.2 83.8 AST 14.5 5.6
Urobilinogen 1+ RBC 4.80 4.63 Na 132.9 140.2
Ketone 2+ Hgb 9.2 8.9 K 3.5 3.55
Protein Trace Hct 30.7 29.6 Cl 97.6 107.8
Nitrite Positive MCV 64.0 63.9 FBS 5.6
Glucose Negative MCH 19.3 19.2 TC 5.17
pH 6.5 MCHC 30.1 30.0 TG 1.17
SG 1.025 Platelet 429 460 HDL-C 0.73
Leukocytes 2+
EC Few
MT Few
AU Few
WBC Abundant
RBC 0-3
Bacteria Moderate

SHORT NARRATIVE DISCUSSION

Patient is a 32-year old female, not known hypertensive and not known diabetic. No previous history of MI or stroke.
Patient has good baseline functional capacity. No orthopnea, no PND, no chest pain, no intermittent bipedal edema.
1 day PTC, patient had onset of undocumented fever and intermittent dull bilateral flank pain, non-radiating PS 6/10
and unrelated to movement. She also had associated nausea and 5 episodes of non-bilious, non-projectile, non-bloody vomiting
of ¼ cup previously ingested food (30min-1hr postprandial). There was also band-like headache PS 6/10, fronto-orbital. She had
no dysuria, oliguria, hematuria, changes in urinary frequency. Patient self-medicated with 500mg PRN for fever with partial relief.
No consult was done.
3 Hours PTC, there was persistence of vomiting (4 episodes) with the same characteristics as mentioned above which
prompted consult at OMMC-ER. She still had associated undocumented fever, headache, nausea, anorexia, and bilateral flank
pain. Patient had no dysuria, hematuria, nocturia, and changes in urinary frequency.
During the physical examination, the patient was awake, alert, and in pain. Her vital signs were BP: 130/80 L arm,
sitting, HR: 111bpm, regular, RR:24cpm, regular, T: 37.5oC at 6pm, O2 sat: 97% at room air. Her pertinent PE findings were (+)
Left CVA tenderness and essentially normal chest, lungs, heart.
Ceftriaxone 2g TIV OD was the drug of choice for the patient. Metoclopramide is not recommended since this symptom
is caused by the underlying infection. Treating the infection will eventually cause the resolution of the symptom. On the patient’s
3rd HD, there was resolution of the flank pain and CVA tenderness. The patient also did not vomit and felt well. The patient was
cleared for discharge during the 3rd HD.