Case Analysis Assignment # 1

1. A 27-year-old woman is admitted to the emergency department complaining of pain across her
back. She became unwell 2 days previously when she started to develop a fever and an ache in
her back. The pain has become progressively more severe. She has vomited twice in the past 6
h. She has had no previous significant medical history, apart from an uncomplicated episode of
cystitis 3 months ago. Examination She looks unwell and is flushed. Her temperature is 39.5°C.
Her pulse is 120 beats/min and blood pressure 104/68 mmHg. Examination of the cardiovascular
and respiratory systems is unremarkable. Her abdomen is generally tender, but most markedly
in both loins. Bowel sounds are normal.

a) This woman has the symptoms and signs that are suggestive of? acute pyelonephritis.
b) What are the risk factors that can be associated with this disease? Pregnancy, diabetes mellitus,
immunosuppression and structurally abnormal urinary tracts increase the likelihood of
ascending infection.
c) What can be the possible cause of this type of infection? Acute pyelonephritis is much more
common in women than men, and occurs due to ascent of bacteria up the urinary tract.
d) The raised white cell count and CRP are consistent with? an acute bacterial infection.
e) Microscopic hematuria, proteinuria and leucocytes in the urine occur because of? inflammation
in the urinary tract.
f) How do you confirm the presence of bacteria in the urine? The presence of bacteria in the urine
is confirmed by the reduction of nitrates to nitrites.
2. An 85-year-old woman is investigated by her general practitioner (GP) for increasing tiredness
which has developed over the past 6 months. She has lost her appetite and feels constantly
nauseated. She has lost about 8 kg in weight over the past 6 months. For the last 4 weeks she
has also complained of generalized itching and cramps. She has been hypertensive for 20 years
and has been on antihypertensive medication for that time. She has had two cerebrovascular
accidents which have limited her mobility. She is an African-Caribbean, having emigrated to the
UK in the 1960s. She lives alone but uses a ‘meals on wheels’ service and goes to a day hospital
twice a week. She has two daughters.

a) This patient presents with the typical symptoms of? end-stage renal failure, namely anorexia,
nausea, weight loss, fatigue, pruritus and cramps.
b) Does the elevated urea and creatinine levels confirm renal failure? yes. but do not distinguish
between acute and chronic renal failure. Usually, in the former, there is either evidence of a
systemic illness or some other obvious precipitating cause, e.g. use of nephrotoxic
drugs/prolonged episode of hypotension, whereas in the latter there is a prolonged history of
general malaise.
c) If the patients blood tests measuring serum creatinine, informs us that? there is a progression
of deterioration of renal function.
d) In this patient, the anemia and hyperparathyroidism (raised alkaline phosphatase) are features
indicating what? chronicity of the renal failure.