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    Case Protocol Panambulan, Raihanah

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    Raihanah Panambulan
    This case presents a 62-year-old female who presented with right flank pain. Her history revealed diabetes that was non-compliantly managed. Physical exam and diagnostic testing confirmed a complicated urinary tract infection, with urine culture showing 234,000 bacteria and imaging revealing nephrolithiasis. She was admitted and treated with IV antibiotics, pain medications, and blood transfusion. Her symptoms improved over her hospital stay.

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    Case Protocol Panambulan, Raihanah

    Uploaded by

    Raihanah Panambulan
    39 views4 pages
    This case presents a 62-year-old female who presented with right flank pain. Her history revealed diabetes that was non-compliantly managed. Physical exam and diagnostic testing confirmed a complicated urinary tract infection, with urine culture showing 234,000 bacteria and imaging revealing nephrolithiasis. She was admitted and treated with IV antibiotics, pain medications, and blood transfusion. Her symptoms improved over her hospital stay.

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    This case presents a 62-year-old female who presented with right flank pain. Her history revealed diabetes that was non-compliantly managed. Physical exam and diagnostic testing confirmed a complicated urinary tract infection, with urine culture showing 234,000 bacteria and imaging revealing nephrolithiasis. She was admitted and treated with IV antibiotics, pain medications, and blood transfusion. Her symptoms improved over her hospital stay.

    Copyright:

    © All Rights Reserved
    Download as DOCX, PDF, TXT or read online from Scribd
    Download as docx, pdf, or txt
    39 views4 pages

    Case Protocol Panambulan, Raihanah

    Uploaded by

    Raihanah Panambulan
    This case presents a 62-year-old female who presented with right flank pain. Her history revealed diabetes that was non-compliantly managed. Physical exam and diagnostic testing confirmed a complicated urinary tract infection, with urine culture showing 234,000 bacteria and imaging revealing nephrolithiasis. She was admitted and treated with IV antibiotics, pain medications, and blood transfusion. Her symptoms improved over her hospital stay.

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    © All Rights Reserved
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    of 4

    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

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