Medical Academy Named After

S.I Georgievsky of V.I Vernadsky

Crimean Federal University (CFU).

Department: - Clinical Pathophysiology.

Teacher:

Case report:-
Clinical diagnosis:

Main disease : Acute pyelonephritis

Student: EJDIKE CHIBUONU VICTORY

Group: LA1-c-o-141A
Passport data

Name : Anastasiya Ivanov Cherniak

Age : 28 years old

Date of birth : 06th july 1990

Sex : female

Nationality : Russian

Marital Status : Married

Occupation : Accountant

Address : Lemontova 3, Simferopol, Crimea

Date of admission : 19th April 2019

Inquiry ( Interrogatio )
Complaints: Patient complaints of fever, pain at the back and abdomen, burning with urination,
red frequent urination, vomiting, weakness and chills.

Anamnesis Morbi

The patient is an accountant for a bank. On the 17th of April the patient started to develop fever
and pain at the abdomen then to the back. Which progressed with vomiting twice, at work with
red colored urine. She started to feel weak and having more severe pain at the back.
Anamnesis Vitae:

Patient’s history:

She was born in the Simferopol Crimea, Russia. She is married with 2 children and lives a normal life
style. She occasionally takes walks in the park in the weekends but does not do any heavy
exercises. She does not smoke or drink alcohol and has no allergic reactions towards any food
or medicines.

The patient suffered from Urinary tract infection, Cystitis some months ago. She had pain and
burning sensation in urination from 1week ago.

Physical examination:

Temperature: 39.5 degree Celsius

Blood pressure: 110/70mmHg

Pulse rate: 120 beats/min

General examination (Status Presence):

Her height is 159cm and weight is 65kg. The patient was in a satisfactory condition. The patient’s
temperature is 39.5 degree Celsius. Patient’s pulse rate per minute is 120 beats per minute. Her
abdomen and suprapubic area is tender. She also stated pain is normally located in the right
side. No rashes can be seen. There is no skin elements on her skin. Nail shape is also normal without any
brittleness or breakages. Longitudinal and transverse lines appear normal. She has no delirium or
hallucination. Her appearance corresponds to her age.

Physical examination:

The skin is pale and dry and very hot characterizing of fever. She looks weak and malaise.
Abdomen looks tendering and symmetrical and seems to be breathing normal. Person feeling
warm even in the presence on air condition.
Systems:

Respiratory system:

Normal.

Inspection:

Chest shape is normal .No pathological signs and chest found but Respiratory rate is 18 breaths
per minute and it is regular.

Palpation:

Vocal fremitus at all the points is symmetrical and normal. Pleural friction is absent.

Percussion:

At comparative percussion, symmetrical normal, tympanic sound is heard over both sides of the
lungs.

Auscultation:

vesicular breathing sounds are heard over all symmetrical parts of the chest.

Cardiovascular system

Blood pressure: 110/70 mmHg

Pulse is equal on both the arms. Rhythm type. Pulse rate: 120 beats per minute.

Inspection:

The pulse pressure in both the wrists is symmetrical. It is strong. Visible pulsation is noted at
the carotid, jugular or the temporal vessels. No pulsation is visible. No cyanosis is seen.

Palpation:

Apex beat moderately high than normal. “Cat’s purr” symptom is negative.

Percussion:

Borders of the relative cardiac dullness are normal .

Auscultation:

Heart tone is normal but little high. No murmurs are heard.

Digestive system

Inspection: Oral cavity looks normal. Patient has no odor in oral cavity, normal size of tongue with
pink colour, moist condition and normal condition of papillae. Teeth is of healthy condition. Gums are
pink in colour without ulceration, edematous or hemorrhages. Soft and hard palate is normal.
Abdominal protrusion is absent.

Palpation/Percussion:

Superficial palpation:

Muscle resistance is not normal. Signs of abdominal tenderness are seen.

Schetkin-Blumberg’s symptom - negative.

Mendel’s symptom- negative.

Caecum is palpated. It is moderately elastic, soft, and painless.

Sigmoid colon is palpated. It is smooth elastic, painless,, mobile .

The transverse colon is palpated. Nothing abnormal is detected in the large intestine.

Large curvature of the stomach is palpated on 2cm above the navel. Palpation was painless.

Deep palpation:

Examination of the intestines: During deep palpation, intestine is movable, no tenderness..

Examination of the liver:

Liver is normal. No enlargement during palpation. The respected borders are at its normal
anatomical position.

Conclusion: Nothing abnormal is detected upon palpation and percussion of the liver.
Examination of the gall bladder

Kera symptom : negative

Murphy symptom : negative

Lepene symptom : negative

Vasilenko’s symptom : negative

Orther’s symptom : negative

No pain is felt at the choledocho-pancreatic, diaphragmatic, acromial, subscapular and

paravertebral points at the right.

Examination of the pancreas

No pain is felt at the choledocho-pancratic, diaphragmatic, acromial, subscapular and

paravertebral points at the left.

Urinary system:
Inspection: Pain in the lumbar region is present. The patient has disturbance in urination on
rhythm of urination. No edema in face and loins are noted. Color of the urine is reddish . The urine
is seen to be cloudy signifying the presence of the bacteria in the urine .

Palpation: On the palpation of the kidneys, the right side kidney seems to give a sign of pain on
palpation (superficial).

Percussion

Pasternatsky symptom is positive.

Endocrine System
Inspection
Upon inspection, patient has no sign of endocrine diseases. Height and weight of patient is normal. Face
expression is normal, no hirsutism or exopthalmia is noted. Condition of the skin is normal.Ocular
symptoms of Graefe’s, Kocher’s, Moebius’s and Shtelvag’s is negative. No attacks of convulsions on the
parathyroid glands, no parathesia, pain in leg muscles or bones, no fragility of nails or falling of hairs, no
fracture of bones.

Skin and bones:

Inspection: Pale in color .

Palpation: No pain on flat tubular bones on tapping. The skin is extreme hot giving the signs of
high fever.

Initial diagnosis
Main Diagnosis: Acute Pyelonephritis

Accompaning Disease: -

Complication: -

Additional investigations:
1. General blood analysis
2. Urine analysis.
3. Abdominal X-ray
4. Urine Culture
Results of additional investigations:

General blood analysis:

Normal
Hemoglobin 15g/dl 11.7-15.7g/dl
Erythrocyte 4 4-5
Thrombocyte 250 180-320
WBC 15 4.0-9.0
Stab 2 1-6%
Segmented 60 47-72%
Eosinophil 3 0.5-5%
Basophils 0 0-1 %
Lymphocyte 36 19-37 %
Monocyte 3 3-11%
ESR 20mm/h 2-10mm/h
C-reactive Protein 30 >10mg/l

Conclusion: Increased amount of CRP, ESR and WBC are noticed but other blood fractions are
normal. These increase show signs of infection.

Urine Analysis
Colour : RED

Consistency: cloudiness.

Urea: 10mmol/l

Creatinine: Normal

Protein present: 5.0 mg/dl.

Nitrite is present

Presence of leukocyte (leukocyte esterase) and red blood cells seen: more than 50 cells.

Presence of White blood cell cast: present.

Presence of pus in urine: more than 10 leucocyte/ microL

Sodium is decreased

Potassium: normal
Conclusion:
The combination of the leukocyte esterase and nitrite tests (with a positive result on either) for UTI is
more specific for a bacterial infection in your urinary tract. There is increase in urea, presence of pus,
hematuria, WBC cast.

Abdominal X-ray is normal

Urine Culture.

Positive culture test

On the lab presence of bacteria is seen.

Final diagnosis
Main Diagnosis: Acute Pyelonephritis

Accompaning Disease: -

Complication: -

*Bed regimen.

Conservative treatment: Antibiotics

*Fluoroquinolones IV for 2days then oral antibiotics

*Ciprofloxacin, 500 mg

po every 12 hours protocol for 7 days.