Name: Alan Jones

Section/group number: IMD 18 batch 5

Date: December 22, 2021
Email number: alan34jones@gmail.com

PART 1

Salient features:

History
1. 32 Year old female
2. Came in due to right flank pain
3. 3 days pta – the patient has right flank pain which was associated with fever
of unknown temperature. The patient self medicated with paracetamol (of
unknown dose and frequency) which gave her temporary relief
4. Patient also had hematuria and increase frequency of urination.

Past medical history

1. Patient experienced painful urination once in her childhood and treated it with
unrecalled medicines.

Family history
1. mother has DM
2. Father has hypertension

Personal and social history

1. Patient is a non smoker
2. Patient does not consume alcoholic drinks
3. Patient have one sexual partner.

Physical examination
The patient is awake, conversant and seems to be in pain.
1. vitals - BP 110/60 mmHg
R.R 20 cpm
H.R 101 bpm
Temperature 38.1 degrees Celsius
2. Upon palpation, tenderness on her right costovertebral angle was noted.
3. Her extremities were warm to touch
Initial impression
Pyelonephritis

I feel this is so, because the progression of the symptoms, which is 3 days, fever,
hematuria and increased frequency of urination, along with pain/tenderness in the
right costovertebral angle is consistent with the presentation of pyelonephritis. The
patient has 2 out of 3 in the triad for diagnosis.

Diagnostic test

1. Urinalysis – Clean catch only

 Wbc - greater than 20 WBCs/hpf, although the numbers may be
smaller, particularly in those with subacute pyelonephritis.
 The dipstick leukocyte esterase test (LET) should show signs of
pyuria.
 NPT may or may not be positive depending on the bacteria.
 Urine culture will reveal the causative organism.
2. CT with contrast can be normal for the current case as it appears to be a mild
pyelonephritis.

Differential diagnosis

1. Nephrolithiasis

Rule in – the patient has flank pain and hematuria, along with pain in the
costovertebral angle, which is consistent with nephrolithiasis.

Rule out – the patient has fever, which is not a manifestation of the disease. And
most often, it leads to reduced urine output, but our patient has increased frequency
of urination.

Diagnostic test
1. CT should reveal the presence of a calculi.
2. Urinalysis should have a low WBC count. 10 or <10 or less than the number
of RBC.

2 – hemorrhagic cystitis
Rule in - the patient has flank pain and hematuria, along with pain in the
costovertebral angle, which is consistent with the condition.

Rule out – patient has fever, which is not a common presentation. Most cases of
hemorrhagic cystitis are noted after exposure to toxins or chemicals, which is not
seen in the current case.

Diagnosis
1. CBC with platelets
2. Urine cultures for bacteria and virus – may be positive of negative.
3. Renal Cystogram
4. Cystoscopy

3. UTI and cystitis

Rule in - the patient has flank pain and hematuria, along with pain in the
costovertebral angle, which is consistent with the condition. The patient also has
fever and increased urination.

Rule out – symptoms of fever and chills are more commonly associated with
pyelonephritis, than UTI or cystitis.

Diagnostic test

Urinalysis – midstream catch or clean catch

Wbc – greater than 10 per mL
Dipstick test – positive