CASE PROTOCOL

PRESENTER: Raihanah M. Panambulan

OBJECTIVES:
1. To present a case of a 62-year-old female who came in due to right flank pain
2. To briefly discuss the clinical presentation, diagnosis, treatment, and prognosis of a
patient with complicated Urinary Tract Infection

CLINICAL CASE:
GENERAL DATA
This is a case of A.D, 62-year-old, female, widowed, Filipino, Muslim, from Piagapo,
Lanao del Sur, who was admitted for the first time in our institution last Nov. 25, 2022.

SOURCE OF INFORMATION AND PERCENT RELIABILITY:

Patient and daughter with 80% reliability

CHIEF COMPLAINT
Right flank pain

HISTORY OF PRESENT ILLNESS

1 day PTA, patient had onset of right flank pain radiating to the back with a pain scale of
8/10 associated with loose bowel movement of 3 episodes, nonbloody, nonmucoid and
vomiting, 4 episodes, approximately 1 cup, of previously ingested food, nausea and dysuria.
Patient had no fever, difficulty of breathing and chest pain. Patient self-medicated with herbal
which provided no relief. Morning PTA, persistence of symptoms thus consult hence admitted.

PAST MEDICAL HISTORY

Patient was diagnosed with diabetes mellitus however uncompliant of unrecalled
medications. No previous hospitalization or surgical operation. No known allergies to food and
medications.

FAMILY HISTORY
No known heredo-familial diseases such as hypertension, Diabetes mellitus, bronchial
asthma, cancer, thyroid disorders, malignancy in the family.

PERSONAL AND SOCIAL HISTORY

Housewife with 4 children. No history of smoking or any vices. Family’s main source of
water is from tap water.

REVIEW OF SYSTEMS:
General: (-) loss of appetite, (+) easy fatigability (-) fever (-) weight loss, (-) chills
Skin: (-) pruritus, (-) rashes, (-) jaundice
HEENT: (-) headache, (-) dizziness, (-) blurring of vision (-) nasal discharges, (-) hearing difficulty,
(-) epistaxis, (-) sore throat, (-) hoarseness of voice
Respiratory: (-) cough, (-) pleuritic chest pain, (-) hemoptysis, (-) shortness of breath, (-)
Orthopnea
Cardiovascular: (-) chest pain, (-) paroxysmal nocturnal dyspnea, (-) orthopnea
Gastrointestinal: (-) dysphagia, (+) nausea, (+) vomiting, (+) abdominal pain, (-) melena, (-)
change in bowel movement
Genitourinary: (-) oliguria, (-) hematuria, (+) dysuria, (-) incontinence
Musculoskeletal: (-) muscle pains, (-) stiffness, (-) joints pains
Hematologic: (-) easy bleeding, (-) easy bruising
Neurologic: (-) altered sensorium, (-) seizures, (-) syncope
Endocrine: (-) heat/cold intolerance, (-) polydipsia, (-) polyphagia, (-) polyuria

PHYSICAL EXAMINATION:
GENERAL SURVEY: ambulatory, conscious, coherent, not in respiratory disease
VITAL SIGNS: BP: 120/70, HR 87, RR 21, TEMP 36.7, O2 SAT 98% at room air, weight 47 kg, height
145cm BMI 22.4kg/m2
SKIN: warm to touch, senile skin turgor, no rashes
HEAD: normocephalic, no masses
EYES: anicteric sclerae, pale palpebral conjunctiva,
EARS: no aural discharge, intact tympanic membrane
NOSE: nasal septum at midline, no nasal flaring
THROAT: no tonsillopharyngeal enlargement, no masses
CHEST and LUNGS: equal chest expansion, no retractions, equal tactile fremitus, clear breath
sounds
CARDIOVASCULAR: adynamic precordium, PMI at 5 th ICS left clavicular line, no heaves, no thrills,
normal rate and regular rhythm, no murmur
ABDOMEN: flat, normoactive bowel sounds, soft tender at left lower quadrant, no
organomegaly
EXTREMITIES: full pulses, no edema, CRT <2 secs
NEUROLOGICAL: GCS 15, oriented to time, place and person, no sensory and motor deficits

ADMITTING DIAGNOSIS:
COMPLICATED URINARY TRACT INFECTION

COURSE IN THE WARD:

Day 0-1: patient was admitted, hooked to PNSS. Initial diagnostics were requested: CBC w/ PLT,
BUN, creatinine, SGPT, SGOT, urinalysis, 12L ECG, urine culture, HBA1c, Lipid profile, RBS, WAB
UTZ and CT stonogram and chest x-ray PA view. Patient was started on ceftriaxone 2 gm IV
q24H, HNBB 10mg IV q8, Paracetamol 300mg IV q4 for fever, Metoclopromide 10mg IV q8, HRI
rescue doses, Vitamin B complex, 1 tab OD and ferrous sulfate 300mg/tab, 1 tab OD.

Day 1-2: patient had right flank pain, no fever and chills. CBG was taken which revealed 281.
Glargine 12 “u” SL OD was started. Still awaiting for the chest x-ray, CT stonogram and WAB UTZ.
Day 2-3: patient had decrease right flank pain with no fever, chills, and no dyspnea. CBC
revealed hemoglobin of 8.9, was secured and transfused with 1 “u” PRBC. Urine culture was
requested.

Day 3-4: patient had decrease abdominal pain, no other subjective complaints. For repeat CBC
after transfused with 1 unit PRBC. Continued present management.

Day 4-5: patient still at the ward. No abdominal pain, dysuria and fever. Repeat chest x-ray was
requested.

DIAGNOSTICS:

CBC W/ PLT 11/25/2022 11/29/2022

WBC 13.67 H 6.7
Hemoglobin 8.9 L 9.3 L
Hematocrit 0.26 L 0.26 L
Neutrophils 74 H 47 L
Lymphocytes 16 L 47 L
Monocytes 11 H 5
Eosinophils 0 1
Basophiles 0 0
MCV 81.40 80.90
MCHC 34.40 35.50
PLATELET 507.00 381
Blood typing A
Rh positive

BLOOD 11/25/2022 11/29/2022

CHEMISTRY
BUN 11.90
CREATININE 0.91
NA 140 138
K 5.3 4.0
CL 109 H
RBS 187 H
SGOT 19
SGPT 20
BLOOD URIC 5.1
ACID
HBA1c 11.15 H

URINALYSIS 11/25/2022
Color Pale yellow
Transparency Cloudy
Reaction pH 6.0
Specific gravity 1.030
Sugar 1+
Protein 3+
Pus cells 25088 H
RBC 643 H
Epithelial cells 16 H
Bacteria 234000 H

IMAGING
Whole abdomen ultrasound Hepatic steatosis
right pelvocaliectasia with nephrolithiasis
underfilled urinary bladder precluding
evaluation and its surrounding structures
sonographicalyy unremarkable gallbladder,
pancreas, spleen, abdominal aorta and left
kidney