Patient Detail

Name

: Latif b. Muhammad

Age

: 68

Gender
Race

: Male
: Malay

Address

: Taman Sentosa, Klang

Marital Status

: Married

DOA

: 1st April 2014

DOC

: 1st April 2014

Chief Complaint
Right side abdominal pain 1 day prior to admission

History of Presenting Illness

He 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 History

He 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 History

No known past surgical history.

Drug and Food Allergy

No known drug or food allergy.

Family History

7
5
5
7

5
5
7
3

6
8
3
4

6
3
2
8

2
4

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 History
He 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 Examination
On 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 Examination
Abdomen 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.

Summary
Mr 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

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:

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

Investigation
Full blood Count:
Result Normal Range

White Blood Cell

13.19 4-11 x 10*9/L

Red Blood Cell

4.51

4.5 5.5 x 10*12/L

Haemoglobin

13.4

11 18 g/dl

Haematocrit

41

40 52 %

Mean Cell Volume

88

80 96 fl

Mean Cell Haemoglobin

Mean Cell Haemoglobin Concentration 36.1

31

28 32 pg
32 36 g/dl

Red Cell Distribution Witdth

13.2

< 14.5%

Platelet

426

150 400 x 10*9/L

% Neurtophil

99.8

% Monocyte

48.3

% Eosinophil

0.1

% Basophil

0.1

Absolute Neutrophil

14.27 1.5 8 x 10*9/L

Absolute Lymphocyte

4.4

Absolute Monocyte

0.67

0.1 0.8 x 10*9/L

Absolute Eosinophil

0.03

0.01 0.4 x 10*9/L

Absolute Basophil

0.3

0.01 0.1 x 10*9/L

1.5 4

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:
Result

Normal
3.7

Range

Urea

2.5 7.5 mmol/L

Sodium

Potassium

3.6

3.5 4.9 mmol/L

Chloride

105

95 107 mmol/L

Creatinine

104

60 110 umol/L

138

137 144 mmol/L

Impression: Normal renal function

Liver Function Test:

Result

Normal Range
61 77 g/L

Total protein

60

Globulin

33

Albumin/ Globulin Ratio

1.3

Total Bilirubin

18

1 - 22 umol/L

Alanine Transaminase

34

5 35 U/L

Albumin

Alkaline Phosphatase

34

37 49 g/L
48

45 105 U/L

Impression: Normal liver function

Urine Anaalysis:

RBC
BIL
KET
PRO
NIT
LEU
GLU
SG
pH

1+
Neg
Neg
2+
Neg
2+
Neg
1.030
5.5

Impression: suggestive UTI or kidney infection or injury

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

Chest X-ray
Chest 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:
o KUB CT scan and ultrasound
o 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 CTscan on the following days.

Discussion
The 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.

REFERENCES
Tintinalli's Emergency Medicine Manual, 7edition
Advance Trauma Life Support,7th edition
Guide To The Essentials In Emergency Medicine
Sheehys Manual of Emergency Care,7th edition