Crimean State Medical University named

after S.I. Georgievsky

DEPARTMENT OF HOSPITAL PEDIATRICS

HEAD OF DEPARTMENT: PROF. LAGUNOVA N.V.

TEACHER: OLGA DIMITROVNA LYBIDOVA

CASE HISTORY

RADCHENKO DARYA VLADIMIROVNA

Clinical Diagnosis:

Main diseases: Acute Pyelonephritis, Renal Failure 0,

Exacerbation Stage
Complications: -
Accompanied diseases: -

Student: VinodKumar Gunushakran

Course: 4TH , Group: 440
PASSPORT DATA

Name : Radchenko Darya Vladimirovna

Age : 3
Sex : Female
Nationality : Ukrainian
Home : Simferopol,Crimea
Date of birth : 12th August 2004
Place of birth : Simferopol, Crimea
Date of admission : 12th October 2007

INQUIRY

COMPLAINTS

The patient’s parents complained that the child had increased temperature,loss
of appetite pain in lumbar region and increased diuresis more than 20 times per
day.

ANAMNESIS MORBI

The patient did not have any previous diseases or complaints.

ANAMNESIS VITAE

She was the 3rd child in the family,she has a sister 14 years old and a brother 6
years old.She was born in normal pregnancy. She was born with weight of
3800grams and height of 57cm,she cried on the spot. She was sent to postnatal
ward after 6 hours of birth. Her height and weight corresponds to his age. She
was breast fed until 10 months. Prophylactic vaccination was done according to
vaccination calendar. She had no infectious disease and absent of infectious
disease in the family.

DATA OF THE PHYSICAL EXAMINATION

GENERAL EXAMINATION (status praesens)

The general condition of the patient is satisfactory.The patient’s

appearance is normal and corresponds to his age.

The skin colour of the patient is pinkish. The patient’s skin humidity is
usual. The patient’s skin has normal turgor and elasticity. There are no
visible rashes on the patient’s body.
The colour of the mucous membrane is pinkish in color. The mucous
membrane was examined at the conjunctiva, nasal and oral mucosa.

The shape of the patient’s head is proportional, and symmetrical. The

patient’s facial expression is symmetrical. The shape of his eyes and nose
is normal. The shape of his neck is usual; carotid pulsations, jugular
pulsations and dilated jugular veins are not visible. There is no sign of
encephalopathy.

The muscles are developed moderately, tone and muscle force are
identical on both sides. Palpation and tapping of the bones are painless.
Joints are regular in shape, painless during palpation and movements. The
muscles, bone and joints are in a generally good condition.

The patient’s temperature is normal, 36.1ºC

The patient’s pulse is 83/min.

Weight is 13kg.

Respiratory System

The patient breathes through his nose. Breathing is rhythmic. His breathing
rate is 36 times per minute. The chest is symmetric. Ribs are moderately
inclined when viewed from the side, scapular are closely fit to the chest
and are at the same level. The chest is the same height as the abdominal
part of the trunk.

The chest is painless during palpation. Pleura friction sounds are absent
during palpation.

Comparative percussion and lower borders of the lung are normal. Clear
lung sounds are heard in the whole part of the chest. Tympanic sound of
Traube’s space can be heard during percussion.

Lower border of the lung:

Lines Right Left

Parasternal V rib -
Midclavicular VI rib -
Anterior axillary VII rib VII rib
Middle axillary VIII rib VIII rib
Posterior axillary IX rib IX rib
Scapular X rib X rib
Paraspinal XI spinous process XI spinous process

During auscultation of the chest, vesicular breathing is heard over

symmetrical points of the lung. Adventitious sounds like dry rales are
present. Crepitations are absent.

Cardiovascular System

Apex beat is palpated at the 5th intercostal space, 1cm medially from the
left mid-clavicular line. The apex beat is low, restricted and medium in
strength. “Cat’s purr” symptom is negative. The heart rate is 136 beat per
minutes.

Percussion: Border of the Heart dullness (relative)

Border In Child Normal
Right Linea sternalis Linea sternalis
Upper 2nd intercostals space 2nd rib or 2nd intercostals
space
Left Linea midclavicularis Linea midclavicularis

On auscultation of the heart two sounds are heard at all 5 points. The
sounds are rhythmic. The 1st sound is louder than the 2nd at the heart apex
and tricuspid valve. The 2nd sound is louder than the 1st at the heart base.
No murmurs were observed.

Digestive System

The patient does not have any difficulty in swallowing or passing food
through the esophagus. There are no incidences of hypersalivation as well.

The mouth is in a generally clean condition, without any unpleasant smells.

The size of the patient’s tongue is usual. The tongue is also moist and
clean.

The shape of the abdomen is soft, normal and symmetrical. Tympanic

sound is heard over all parts of bowel in the abdomen. Dull sound can be
heard over the part where located liver and spleen.
Liver and spleen can not be palpated.

During auscultation of the abdomen, rumbling sound is heard over in all

parts of large intestines.

ENDOCRINE SYSTEM

During inspection, changes of the eyes (exophthalmus or enophthalmus) are not

visible. Ocular symptoms like Graefe’s, Kocher’s, Moebius’, and Stellwag’s are
negative.

During palpation, the thyroid gland is not enlarged. Its isthmus is palpated as
soft, and painless.

Organs of Internal Secretion (Endocrine Organs)

Hypophysis: Hypothalamus
Patient is normal weight. Changes in body proportion equal.

Thyroid Gland
No presence of tumors in the neck region. Pain in neck region present. No
complaints of compressing of internal organs of the neck. No difficulty in
breathing, stridor breathing, husky voice, aphonia, dysphagia, edema on face
and swelling of veins. No eye pain, bitting & compression feeling or diplopia.

Parathyroid Glands
No attacks of convulsions, no paresthesia, pain in leg muscles or bones, no
fragility of nails or falling of hairs, no fracture of bones.

Islet of Langerhans of Pancreas

Normal function of pancreatic gland.

Adrenal Gland
Progressing weakness was absent. There is no change of shape, moon face or
scarlet Colour of skin. Redistribution of fat tissue is absent. He has not lost hair.

Genital Glands
He has not experienced any physical changes characteristic to genital
development. He has regular development of secondary sexual manifestations.
He doesn’t experience loss of hair.
INITIAL DIAGNOSIS
Patient has an increased temperature which shows signs of infection and
inflammation. Pain in lower abdominal and back area shows pathology of
urogenital origin. With a history of pyelonephritis, the initial diagnosis is
pyelonephritis in active stage.

PLAN OF ADDITIONAL INVESTIGATIONS

1. General blood analysis

2. General urine analysis
3. Nechiparenko test
4. Zimnitsky test
5. Blood chemical analysis
6. Ultrasound of kidney
7. Urography

RESULTS OF ADDITIONAL INVESTIGATIONS

1. General Analysis of Blood

12/10/2007
Hemoglobin 122 g/l
Erythrocytes 3.9 x 1012 /l
Leukocytes 18.2 x 109/l
Eosinophils 1%
Basophils 1%
Stab 1%
Band 6%
Segmented 62%
Lymphocytes 29%
Monocytes 1%
ESR 7mm/hr

Conclusion: The result of the blood analysis shows marked leucytosis

with a shift to the left indicating infection.

Biochemical Analysis

Glucose 3.3 mmol/L

Protein 69 g/L
Urea _
Creatinine O.059
Conclusion: The result of the blood analysis is normal.

General Analysis of Urine

Amount 80 ml
Colour yellow
Protein negative
Specific gravity 1.015

Microscopy of urine sediment

Leukocytes 2-3-4 in field of vision

Epithelial cells 1-1 in field of vision
Salt -
Mucous ++
Bacteria +
Conclusion: The result of the urinalysis indicates bacteruria and
leucocyturia.

NECHIPORENKO TEST

Leukocytes 6000
Erythrocytes 1000

Conclusion: Nechiporenko test confirms pyelonephritis with increased

leucocytes.

ZIMNITSKY TEST

NO
I 1013 40
II 1007 200
III 1017 100
IV 1013 100
V 1013 60
VI 1015 60
VII 1013 40
VIII 1013 80

CONCLUSION: URINE IS NORMAL.

Ultrasound
Right kidney: 69x24 mm
Left kidney: 68x25 mm
Norm: 70x25 mm
Conclusion: Both kidneys are normal.

Urography
Urography shows the kidneys are normal.

FINAL DIAGNOSIS

Based on patient’s complaints and laboratory analysis, patient has

pyelonephritis active stage without disorders of renal function.
The increase of leucocytes in both the blood and urine accompanied by
bacteuria indicates this disease. Nechiparenko test, ultrasound and
urography results comfirms the diagnosis.

Main Disease: Secondary pyelonephritis active stage without renal

disorders.

Accompanying Disease: -

Complications: -

TREATMENT
Free regime.
Diet no.7.

Drug: Antibiotics for infection

Rp : Amoxycillini 250 mg in capsules

D.S 20- 40 mg/kg/day divided 8 hours per day per orally.

Drug: Non steroidal anti inflammatory for fever

Rp: Sir. Paracetamoli 5 ml/ 120mg

D.S. 1-2 teaspoon PO before meals 3-4 times a day. 120-240 mg per dose with
maximum 4 doses per day.

Uroseptic therapy

Rp; Furamag 15 ml
Ds. 1-2 teaspoon PO 3-4 times a day.