Patient DetailName: Latif b. MuhammadAge: 68Gender: MaleRace: MalayAddress: Taman Sentosa, KlangMarital Status: MarriedDOA: 1st April 2014DOC: 1st April 2014

Chief ComplaintRight side abdominal pain 1 day prior to admission

History of Presenting IllnessHe is a known case of diabetes mellitus for the past 10 years and currently under follow-up and adherence to medication. Patient is apparently well when suddenly developed sudden onset of right abdominal pain at 4am in the morning. It was sudden in onset and continuous since 4 am in the morning. He described the pain as pricking in nature which radiates toward the right flank, to the back and also to the central abdomen. The pain is aggravated when he moves and coughs and relieves when he lies down or take pain killer. The pain also is not associated with food intake. He scored the pain as 8/10 and reduces to 6/10 when he takes his pain killer. The pain was associated with high grade fever for two days prior to admission. It is intermittent and high grade with temperature recorded in the clinic was 38.2C. It was associated with chills and rigor but there were no night sweats. The fever subsides when taking paracetamol given by the clinic which he visited yesterday and was prescribed with paracetamol 500mg TDS and also vitamin C. Other than that, patient also complaint of lost of appetite since two days ago. He also complaint loss of weight since 1 month ago where his previous weight was 97kg and currently 89kg. Besides that, he complaint reduce urine output since 2 days ago. His normal urine output is 3-4 times daily and currently only once a day. He also claimed that his urine colour became tea coloured. On admission, patient claims his urine colour turns into red. Other than that, he does not complaint of dysuria, hesitancy, urgency or frequency. He had normal bowel opening.

Apart from that, there was no chest pain, no dyspnoea, no orthopneoa, no decrease effort tolerence, no syncopal attacks, no dizziness, no headache, no tingling sensation or loss of consciousness, no lethargy, no nausea or vomiting, no sick contacts, no travelling history to any endemic area, and no water activities.

Review of System Neurology System: No trauma, no loss of consciousness, no seizure, no altered mental status, no blurry of vision. HEENT: no runny nose Cardiovascular System: No sweating, no dyspnoea, no orthopnoea, Musculoskeletal System: No muscle weakness, no myalgia, no athralgia Respiratory System: no cough, no sputum Gastrointestinal System: No vomiting, no diarrhea, no constipation, no vomiting blood, no changes in stool colour, no altered bowel habit Genitourinary System: No dysuria, no urgency, no frequency or no hesitancy.

Past Medical HistoryHe is a known case of diabetes mellitus for the past 10 years and currently under follow-up and adherence to medication. He currently on insulinwhere he took 10u in the morning and 18u in the night.

Past Surgical HistoryNo known past surgical history.

Drug and Food Allergy No known drug or food allergy.

Family History

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 HistoryHe 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 ExaminationOn 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 Pulse rate : 110 bpm (regular rhythm, normal volume, no abnormal character) Tachycardic Blood pressure : 124 / 92 (normotensive) Respiratory rate : 17 breath per minute Temperature : 38.1C (febrile) Spo2 : 99% under room air

Systemic ExaminationAbdomen 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.

SummaryMr 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: Presented right sided abdominal pain, radiate to flank and back High grade fever Present of hematuria On examination, tenderness over right lumbar and right illiac fossa with right sided costovertebral angle (CVA) tenderness

Differential Diagnosis Renal Colic Point for: Right sided abdominal pain that radiate to flank Present of Hematuria Common on male > 50 years old Point against: No urinary symptoms, eg: dysuria, oliguria, anuria Present of high grade fever No vomiting Acute cholecystitis Point for: Right lumbar pain High grade fever Loss of appetite Point against: No rebound tenderness, gallbladder not palpable,no nausea or vommiting Not associated with hematuria and not aggravated by food intake Acute Appendicitis Point for: Right illiac fossa pain High grade fever Loss of appetite Point against: Uncommon for this age group No rebound tenderness Not associated with hematuria Acute pancreatitis Point for: Right sided abdominal pain radiate to central High grade fever Point against: Not nausea or vomiting Not associated with food intake Not associated with hematuria

InvestigationFull blood Count:ResultNormal Range White Blood Cell13.194-11 x 10*9/L Red Blood Cell 4.514.5 5.5 x 10*12/L Haemoglobin13.411 18 g/dl Haematocrit4140 52 % Mean Cell Volume8880 96 fl Mean Cell Haemoglobin3128 32 pg Mean Cell Haemoglobin Concentration36.132 36 g/dl Red Cell Distribution Witdth13.2< 14.5% Platelet426150 400 x 10*9/L % Neurtophil99.8 % Monocyte48.3 % Eosinophil0.1 % Basophil0.1 Absolute Neutrophil14.271.5 8 x 10*9/L Absolute Lymphocyte 4.41.5 4 Absolute Monocyte0.670.1 0.8 x 10*9/L Absolute Eosinophil0.030.01 0.4 x 10*9/L Absolute Basophil0.30.01 0.1 x 10*9/L 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:ResultNormal Range Urea3.72.5 7.5 mmol/L Sodium138137 144 mmol/L Potassium3.63.5 4.9 mmol/L Chloride10595 107 mmol/L Creatinine10460 110 umol/L Impression: Normal renal function

Liver Function Test:ResultNormal Range Total protein6061 77 g/L Globulin 33 Albumin/ Globulin Ratio1.3 Total Bilirubin181 - 22 umol/L Alanine Transaminase345 35 U/L Albumin 3437 49 g/L Alkaline Phosphatase48 45 105 U/L Impression: Normal liver function

Urine Anaalysis: RBC1+ BILNeg KETNeg PRO2+ NITNeg LEU2+ GLUNeg SG1.030 pH5.5Impression: suggestive UTI or kidney infection or injury

Urine Culture:**urine culture where taken but the results was not released at that moment

Chest X-rayChest 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.CT findings findings are usually positive when the involvement is moderate or severe. It is the standard study for demonstrating gas-forming infections, hemorrhage, inflammatory masses, and obstruction.

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: KUB CT scan and ultrasound 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 CT-scan on the following days.

DiscussionThe 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.

REFERENCESTintinalli's Emergency Medicine Manual, 7editionAdvance Trauma Life Support,7th editionGuide To The Essentials In Emergency MedicineSheehys Manual of Emergency Care,7th edition