Case Protocol

URINARY TRACT INFECTION

CASE PROTOCOL

KRISTINA KARYLLE S. ARAOJO

MEDICAL CLERK

CASE PROTOCOLGENERAL OBJECTIVE:

• To present a case on Acute Pyelonephritis

SPECIFIC OBJECTIVES:

• To present the clinical manifestations of Acute Pyelonephritis

• To present an algorithm of the pathophysiology of Acute Pyelonephritis

• To present an approach and management of Acute Pyelonephritis

This is a case of R. F, a 23 year- old married housewife, a resident of this city and a Roman Catholic who came in with the chief complaint of abdominal pain.

History of Present Illness:

6 days prior to admission, patient experienced abdominal pain with a scale of 5 / 10, characterized as___which radiates to the flank area. This was associated with on and off moderate grade fever, 3 episodes of loose bowel movement which was watery, yellowish, and none bloody and four episodes of vomiting of previously ingested food amounting to 1/ 2 cup. Patient took Paracetamol 500 mg tablet which provided relief from fever. No consult done.

2 days prior to admission, patient sought consult at Mindanao Central Sanitarium and was admitted and managed as a case of urinary tract infection. Patient was referred to Zamboanga City Medical Center for further work –up and management and was subsequently admitted.

Past Medical History:

Patient has no previous hospitalizations. No known allergies to food and medications/

Family History:

No heredo- familial diseases such as diabetes mellitus, hypertension, asthma, cancer and kidney problems.

Personal and Social History:

Patient is a housewife, a non- smoker, non – alcoholic beverage drinker.

ON ADMISSION:

Review of Systems:

General: (-) weight loss, (+) body malaise, (+) weak looking

HEENT: (-) dizziness, (- )headache, (-) blurring of vision, (-) hearing problems, (-)nasal congestion, (-) gum bleeding, (-) dysphagia ,

RESPIRATORY: (-) difficulty of breathing, (-) coughing out of blood, (-) noisy breathing

CARDIOVASCULAR: (-) palpitations, (-) chest pain,

GASTROINTESTINAL: (+)anorexia, (-) nausea, (+) vomiting, (+) abdominal pain

URINARY: (-) polyuria, (+) dysuria (+) urinary frequency, (+) tea colored urine

Physical Exam:

General Survey: conscious, coherent, weak looking and not in respiratory distress.

Vital Signs:

Temperature: 37.7 ˚C

Pulse Rate: 85 beats/min

Respiratory Rate: 21breaths/min

Blood Pressure: 130/70 mmHg

HEENT

Eyes: Anicteric sclerae, pink palpebral conjunctivae, pupils reactive to light

Mouth: dry oral mucosa

CHEST AND LUNGS

Equal chest expansion, no chest lagging, clear breath sounds, equal tactile fremitus

HEART

Adynamic precordium, regular rate, normal rhythm, PMI at the 5th ICS MCL, (-) murmurs, (-) heaves, (-) thrills

ABDOMEN

Flabby ,normoactive bowel sounds, tympanitic, (+) tenderness on all quadrants, (+) kidney punch

EXTREMITIES

Strong peripheral pulses, good capillary refill time

ADMITTING ORDERS:

Patient was admitted last December 8, 2010 at Ward 5A.

IVF: Plain NSS 1 Litre at 30 drops per minute was started.

Vital signs every four hours

Input and Output monitoring every shift

On regular diet

COURSE IN THE WARD:

On the first hospital day,

On the second hospital day,

DIAGNOSTIC WORK UP:

Urinalysis

KUB – Ultrasound

CBC, Platelet Count

Serum Potassium, Sodium, Creatinine

Urine Culture and Sensitivity

Random Blood Sugar

SIGNIFICANCE OF THE STUDY: