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53 year old woman

low immune system

Post menopause- risk for uti

Flank pain

pain at side btw rib and hip

Indicate kidney problem

Fever

infection

Painful micturition

any obstruction

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TRIGGER 2:

- revealed that continuous fever - infection(UTI),

moderate dull left flank pain - left sided infection, not cause due to obstrutcion

the passing of cloudy urine associated

with dysuria started a week ago. - due to infection, dehydration, UTI, or kidney stones

The dysuria was described as burning

pain during micturition - classic desc dysuria,

Past medical history

The patient had a history of diabetes mellitus for the last 13 years - long term increase risk of infection due to impair immune system, high glucose promote growth bact, sorbitol accumulation

first controlled with oral medications, but now requiring daily insulin injections -

The patient admitted that her diabetes control was poor. Also,

the patient had a previous history of hypertension controlled by propranolol - long period can contribute to renal changes,

She was treated before for bladder infections.

Medications and allergies. There were no known allergies revealed - symptom not cause by allergies,

Social history. There was no history of smoking, alcohol consumption or

drug abuse - no neph toxic symptom

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Differential diagnosis

acute pyelonephritis

Cystitis (bladder)

Renal stone

UTI

Hydronephrosis (due to obstruction)

Cancer (renal tumour)

Appendicitis

Pelvic inflammatory disease

Ovarian cyst

Further questioning

1.Hopi

Site:bilateral or unilateral

Onset: when notice this sx

Characteristics: dull/sharp pain, color of urine, any burning pain

Radiate: it radiate to where

Associated sx: fever, weight loss, haematuria, any suprapubic pain

Times: duration of pain

Exacerbates: any movement

Severity: rate the scale

Past medical history

history of dm/hypertension

Any inherited disease

Any frequence history of admition

Any medication (side effect)

Past social history

alcohol- dehydration (reduce blood flow/trigger ckd)

Smoking- immune dysfunction

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Differential diagnosis

acute pyelonephritis

Cystitis (bladder)

Renal stone

UTI

Hydronephrosis (due to obstruction)

Cancer (renal tumour)

Appendicitis

Pelvic inflammatory disease

Ovarian cyst

further exam :

vital sign

BMI

phy exam

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renal angle tenderness - area costovertebral angle

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Vital signs The patient's values: Reference range

Temperature 39.0 ºC 36.6 – 37.2ºC

Heart rate 100 beats per minute 60 – 100 beats per minute

Respiratory rate 16 breaths per minute 12 – 16 breaths per minute

Blood pressure 130/84 mmHg 120/80 mmHg

BMI 24 kg/m2 (normal range: 18.5 – 24.9 kg/m2)

On physical examination, no peripheral oedema was found - not chronic(kidney still dpt diselamatkan)

Examination of the abdomen

The abdomen was soft, liver and spleen were not palpable.

Mild suprapubic pain without rebound tenderness was present.

there was a moderate left renal angle tenderness,

Left kidney ballottement was revealed on palpation - kidney enlarge (due to accumulation of fluid and inflammatory cell accumulate sebabkan oleh edema)

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Differential diagnosis

acute pyelonephritis

Cystitis (bladder)

Renal stone

UTI

Hydronephrosis (due to obstruction)

Cancer (renal tumour)

Appendicitis

Pelvic inflammatory disease

Ovarian cyst

further exam :

FBc

RFT

urinalysis

urine C & S

radionuclide scanning

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Haemoglobin 141 g/L 120 – 152g/L

Total WBC count 13.0 x 109/L 4 – 11 x 109/L

Differential WBC count :

▪ Neutrophils 11.05 2.5 – 7.2 x 109/L

▪ Lymphocytes 1.5 1.5 – 3.5 x 109/L

▪ Monocytes 0.52 0.2 – 0.8 x 109/L

▪ Eosinophils 0.26 0.1 – 0.5 x 109/L

▪ Basophils 0.13 0 – 0.1 x 109/L

Platelets 250 x 109/L 150 – 450 x 109/L

Glucose 237 mg/dL 100 – 125 mg/dL

Serum creatinine 120.8 μmol/L 71 – 117 μmol/L

Blood urea 8.7 mmol/L 1.8 – 7.1 mmol/L - kidney problem jdi takleh buang

Urinalysis

▪ Blood ++ Negative

▪ Nitrite ++++ Negative

▪ Leukocyte esterase +++ Negative

▪ RBCs 5 – 10cells/hpf Negative

▪ WBCs >41 cells/hpf <2 cells/hpf

▪ Protein ++ Negative

▪ Glucose ++ Negative

▪ Bacteria +++ Negative

▪ WBC casts Present Negative

Imaging studies: A KUB (kidneys, ureters, bladder) x-ray revealed a

radiopaque calculus involving the entire pelvicalyceal system of the left kidney.

Urine culture and antibiotic sensitivity: results will be discussed later.

Management.

The patient was placed on bed rest. After specimens for urine cultures were taken, empiric antibiotics were administered.

However, the next day, she noted an acute worsening of her left flank pain, and she remained

febrile.

Performed renal ultrasound of both kidneys showed left renal hydronephrosis and radionuclide scanning (DMSA) revealed a non-functional left kidney

The patient was diagnosed with nephrolithiasis, complicated with

hydronephrosis and acute pyelonephritis.

The patient underwent an elective

left nephrectomy, compromised function and the extent of stones.given the

During the procedure, dense adhesions of kidney and psoas muscle along with

marked perinephritis were noted.

On longitudinal bisection of the left kidney, a large staghorn calculus was observed obstructing the proximal ureter with

considerable dilation of the left pelvicalyceal system, and scattered papillae

have a grey-white discolouration. Histological investigation of the papillae and

cortex showed necrotising papillitis. The patient recovered well after surgery.

Urine cultures taken before surgery grow Proteus, and her antibiotic regimen

was adjusted. She was discharged after two weeks