Professional Documents
Culture Documents
Name
: Latif b. Muhammad
Age
: 68
Gender
Race
: Male
: Malay
Address
Marital Status
: Married
DOA
DOC
Chief Complaint
Right side abdominal pain 1 day prior to admission
Review of System
Family History
7
5
5
7
5
5
7
3
6
8
3
4
6
3
2
8
2
4
He is the 3rd child out from 3 siblings. Both of his parents passed away. His father
died due to chronic kidney disease while his mother died due to MVA. His elder
brothers died due to complication of diabetes mellitus. Both his parent and both
his sibling had diabetes mellitus and hypertension for more than 10 years. Other
than that, there was no ischemic heart disease, chronic obstructive airway
disease or malignancy run in the family.
Social History
He is working as travelling agency since 2 years ago. Previously, he works as
firefighter for the past 30 years and retired at age of 50. He lives in a double
storey house in Taman Sentosa with his wife. The house equip with basic
amenities. He had sedentary lifestyle. Previouly, he was a smoker but stop
smoking for the past 30 years. He starts smoking at the age of 20 and used to
smoke 20 packs year. He is non alcoholic and not taking any illicit drugs.
Physical Examination
On general examination, patient is lying in propped up 45 position. Patient was
alert, conscious, oriented to time, place and person. He is an obese person with
BMI of 31. He was in pain but not in respiratory distress as no sign of usage of
accessory muscle. On the peripheries, the palm was warm and there was no
clubbing, leukonychia or koilonychia. There was no peripheral cyanosis. Capillary
refill time was less than 2 seconds.
There was no icterus on the sclera or pallor on the palpable conjunctiva. There is
present of corneal arcus.. The tongue was coated however there was no angular
stomatitis, no gum bleeding or no glossitis. There was no thyroid swelling or no
cervical lymphadenopathy. Apart of that, there was no pedal oedema.
Vital signs
Systemic Examination
Abdomen Examination:
On inspection, abdomen was full. There was no scar, no dilated vein or visible
peristalsis. The umbilicus was centrally located and inverted. Abdomen move
correspond to each respiration. Hernia orifices were all intact.
On palpation, there was generalized abdominal tenderness over right lumbar and
right illiac fossa. There was no guarding and no rebound tenderness. There is no
hepatosplenomegaly as liver span was 10cm while the spleen is not palpable.
Both kidney is non ballotable. There is present of right sided costovertebral angle
(CVA) tenderness.
On percussion, abdomen is tymphanic. There is no shifting dullness or fluid thrill.
Traube spaces are resonant. On auscultation, bowel sound is present which are 5
per minutes.
Cardiovascular Examination:
On Inspection, there were no visible scars or surgical scars noted. There were no
any dilated veins or visible pulsation present. Jugular venous pressure was not
increase. The chest was symmetry and there was no any deformities seen. On
palpation, the apex beat was felt at the left fifth intercostals space, mid clavicular line. There were no thrills or heaves present. On auscultation, it shows
dual rhythm which S1 and S2 were heard with no added heart sound or murmurs.
Respiratory Examination:
On inspection, the chest is symmetrical, no visible dilated veins or scars. The
chest moves with respiration. There is no usage of accessory muscle. On
palpation, there is no trachea deviation or upper mediastinal shift and it was
bilateral chest expansion. On percussion, the anterior and posterior chest, it was
resonant bilaterally on percussion with normal tactile fremitus. On auscultation, it
was vesicular breath sounds, equally on both lungs. Normal vocal resonance with
no rhonchi or crepitations heard.
Summary
Mr Mohammad, a 68 year old Malay gentleman presented with right sided
abdominal pain associated with intermittent high grade fever and hematuria.
Upon examination, there was tenderness over right lumbar and right illiac fossa
with right sided costovertebral angle (CVA) tenderness.
Provisional Diagnosis
Acute Pylonephritis.
Point for:
Present of hematuria
Differential Diagnosis
Renal Colic
Present of Hematuria
Point against:
No vomiting
Acute cholecystitis
Point for:
Point for:
Loss of appetite
Point against:
Acute Appendicitis
Point for:
Loss of appetite
Point against:
No rebound tenderness
Acute pancreatitis
Point for:
Point against:
Investigation
Full blood Count:
Result Normal Range
4.51
Haemoglobin
13.4
11 18 g/dl
Haematocrit
41
40 52 %
88
80 96 fl
31
28 32 pg
32 36 g/dl
13.2
< 14.5%
Platelet
426
% Neurtophil
99.8
% Monocyte
48.3
% Eosinophil
0.1
% Basophil
0.1
Absolute Neutrophil
Absolute Lymphocyte
4.4
Absolute Monocyte
0.67
Absolute Eosinophil
0.03
Absolute Basophil
0.3
1.5 4
Impression: the blood result shows systemic infection where the total white cell
count where raises and neutrophils count where high which suggest bacterial
infection.
Renal Profile:
Result
Normal
3.7
Range
Urea
Sodium
Potassium
3.6
Chloride
105
95 107 mmol/L
Creatinine
104
60 110 umol/L
138
Normal Range
61 77 g/L
Total protein
60
Globulin
33
1.3
Total Bilirubin
18
1 - 22 umol/L
Alanine Transaminase
34
5 35 U/L
Albumin
Alkaline Phosphatase
34
37 49 g/L
48
45 105 U/L
Urine Anaalysis:
RBC
BIL
KET
PRO
NIT
LEU
GLU
SG
pH
1+
Neg
Neg
2+
Neg
2+
Neg
1.030
5.5
Urine Culture:
**urine culture where taken but the results was not released at that moment
Chest X-ray
Chest X-ray review was normal.
Suggestive Investigation:
I would like to perform few additional investigations to this patient as below:
CT scan for KUB:
Patient are indicated because patient having high grade fever, positive sign of
CVA and also positive urinalysis as there is present of RBC, leucocyte and
protein. The modality of CT scan gives better images compare to normal X-ray. It
is useful to rule out other causes such as renal colic or hydronephrosis.
Final Diagnosis
Acute pyelonephiritis
Management
Patient was triage to the yellow zone based on the pulse rate, temperature
and age.
Vital signs monitoring 2 hourly(temperature, Blood pressure, pulse rate)
Nil by mouth
Given IV Normal Saline 4 pints /12 hours
Given IV tramadol 50mg TDS
Refer to surgical team:
o KUB CT scan and ultrasound
o start IV Ciprofloxacin, 400 milligrams IV every 12 h after taking
urine C&S
Patient Progression :
As the patient was triaged into the yellow zone, he has been stabilized by
reducing his main complaint by giving IV trammadol 50mg. His vital signs were
monitored carefully by the medical team every 2 hour to determine his
progression. As his vital sign where stable, he was transferred to blue zone for
further monitoring and they asking surgical team to review the patient.
As the surgical team review the patient, the taking patient urine for urine C&S
and started IV ciprofloxacin 400mg every 12 hourly. He was transferred to
surgical ward at 6pm for further management. The patient was told to do CTscan on the following days.
Discussion
The patient presented with classical symptoms of pyelonephritis such as right
sided abdominal pain associated with intermittent high grade fever and
hematuria and upon examination, there was tenderness over right lumbar and
right illiac fossa with right sided costovertebral angle (CVA) tenderness which
supports the diagnosis further.Other than that,I also learned that pyelonephritis
could be a complicated or uncomplicated case whereby the complicated case is
always secondary to underlying medical condition.A few cases can be discharged
with home adherence to medication.Wherelse,if they meet the criteria for
admission,the have to monitored.The main cause of pyelonephritis is mainly due
to infection.
I also learned that the fast diagnostic investigation to prove my diagnosis would
be urinalysis,urine culture and susceptibility test.Other than that,renal profile and
CT scan of KUB that will help rule out underlying disorders.Other than that,I also
learned that the management of this patient is not affected by his diabetic
history.He was given treatment that would have been given to all pyelonephritis
patients.He was given opioids to relieve his pain and antibiotic for the infections
which is given after the urine cultures identifies the bacteria which is causing the
infection.
There are few ways of preventing which is by keeping your genital area clean
and by drinking a lot of water.The complication that can arise from this is that it
could lead to acute kidney failure and recurrence.
REFERENCES
Tintinalli's Emergency Medicine Manual, 7edition
Advance Trauma Life Support,7th edition
Guide To The Essentials In Emergency Medicine
Sheehys Manual of Emergency Care,7th edition