DATE OF INTERVIEW: July 10, 2019

TIME OF INTERVIEW: 3:30 PM

SOURCE OF INFORMATION: Patient
RELIABILITY: 95%
REFERRAL: N/A

IDENTIFYING DATA
M.A., 44 years old, female, Filipino, Roman Catholic, teacher, currently residing at Imelda
Village, Tacloban City was admitted for the second time in Remedios Trinidad Romualdez
Hospital July 8, 2019 around 2pm.

CHIEF COMPLAINT
Hematuria

HISTORY OF PRESENT ILLNESS

2 weeks PTA, Patient experienced dull flank pain (with a pain rating scale of 3/10), terminal
hematuria manifesting as a drop of blood at the end of each void, dysuria, and urinary urgency.
The patient claims to frequently have the urge to urinate but minimal urine comes out. No fever
was noted. This prompted the patient to seek consult at Leyte Provincial Hospital OPD. The
patient was prescribed with an antibiotic with unrecalled name and dosage, taken OD for 3 days.
The patient had temporary relief of hematuria and the other aforementioned symptoms after the
course of the antibiotic therapy. Hematuria recurred after 4 days and continued for a week.
4 days PTA, the patient decided to seek consult at RTRH OPD and was advised to submit
herself for urinalysis. She was unable to receive the results of the test.
1 day PTA, the patient sought consult at LPH ER and was prescribed with antibiotics with
unrecalled name and dosage, taken for seven days. She was then given referral for Laboratory
diagnostics (FBS, Serum Creatinine).
On the day of admission, the patient experienced undocumented high-grade fever with chills.
The patient had no chest pain, no abdominal pain, no body malaise, no syncope. The patient self-
medicated with Ibuprofen+Paracetamol and Naproxen which gave her temporary relief of her
symptoms. The patient’s hematuria persisted now with flank pain (PRS: 4/10) which affected
her sleep. This prompted her to seek consult at City Hospital, but was unable to secure a room.
This prompted her to seek admission at RTRH instead.

PAST MEDICAL HISTORY

Childhood Illness: (+) chickenpox, (+) mumps, (+) measles
Psychiatric: None
Transfusions: None.
Immunizations: Patient claims to have completed immunizations
Allergies: Shrimp (diagnosed at RTRH last 2012)
Surgical: Caesarian delivery (at Risk due to Age of 39) at EVRMC last 2013
OB/Gyne: G2P1(0110) Menarche at 13 years old, able to consume 3 pads a day and lasts for 4
days. Each cycle consists of 28 days. Menopause at the age of 40.
Adult Illness: UTI – consult and diagnosis at Leyte provincial Hospital June 2019
Hospitalizations:
Shrimp Allergy – RTRH – 2012

FAMILY HISTORY
Mother – apparently well at the age of 68. Diagnosed with DM.
Father – died at 50 due to stroke.
Patient has 5 siblings, 4 males and 1 female. The second sister has hypertension, 3 of her sibling
were asthmatic only as children, and all are apparently well. The patient is the eldest.
Has family history of hypertension, asthma, and cancer on her paternal side. No other family
history of TB and other heredofamilial diseases.

PERSONAL AND SOCIAL HISTORY

Patient resides in a 3 bedroom well ventilated concrete bungalow in Imelda Village, Tacloban
near the highway. She works as a teacher in VSU Alangalang. The patient lives with her
husband, 7 year old healthy daughter and extended family. Their source of drinking water and
their water for daily consumption comes from LMWD. Patient wakes up at 5:30 AM to prepare
for work. She eats breakfast at 7 AM, usually consisting of eggs, processed meat and rice. Patient
consumes about 3-4 cups of coffee a day and claims to frequently consume salty, sour and sweet
food. She frequently craves with junk food and pairs it with softdrinks. Patient conducts lecture
in the classroom for the whole day and goes home at 5PM. Lunch and dinner usually consist of
processed meat, rice and softdrinks. She watches television before retiring to sleep and gets
about 7 hours of sleep each night. Patient is allergic to shrimp, nonsmoker and an occasional
alcoholic drinker. Patient has no history of using illicit drugs. Patient has a good relationship
with her husband, family, friends and colleagues and has no history of suicidal thoughts.

REVIEW OF SYSTEM
General: No body weakness, no fever, no fatigue, no body malaise, no weight loss
Skin: No dryness of the skin, no itching, no redness, no rashes, no discoloration of hair and nails
Head: Has lightheadedness, no dizziness, no headache, no head trauma
Eyes: No excessive tearing, has blurring of vision(with reading glasses), no pain, no itchiness,
no diplopia
Ears: No hearing loss, no tinnitus, no vertigo, no earaches.
Nose and sinuses: No colds, no nasal stuffiness, no itchiness, no epistaxis
Throat and Mouth: No sore throat, no dry mouth, no toothache, no sore tongue, no bleeding
gums, no dentures
Neck: No torticollis, no pain or stiffness in the neck
Breast: No lumps, no pain, no discharge
Respiratory: No dyspnea, no orthopnea, has dry cough, no hemoptysis
Cardiovascular: No palpitations, no paroxysmal nocturnal dyspnea
Gastrointestinal: Good appetite. No bloating. No constipation, no dysphagia, no tenesmus.
Peripheral Vascular: No cramps, no edema, no intermittent claudication. Patient defecates 1-2
times a day to a well-formed brown stool.
Urinary: Patient usually urinates 4 times a day to a yellow colored urine of approximately 350-
500mL per void. No nocturia, no polyuria, had dysuria, had hematuria, no urinary
incontinence, no dribbling.
Genital: No itching, no sores,
Musculoskeletal: No myalgia, no arthralgia
Psychiatric: No mood swings, no tension, no anxiety, no depression, no suicidal tendencies.
Neurologic: No numbness, no seizures, no paresthesia, no tremors, no paralysis
Hematologic: No easy bruising, No bleeding, No history of past transfusion.
Endocrine: No polydipsia, no polyphagia, no heat or cold intolerance, no hyperhidrosis.

PHYSICAL EXAMINATION ( 2nd Hospital Day)

General Survey
Patient was examined sitting and lying down, conscious, coherent, cooperative, and oriented
to time, place and person. She has good eye contact and has no unremarkable facies. She is
well-groomed with a endomorph physique, and with no signs of cardiorespiratory distress.

Vital Signs
 BP: 120/80 mmHg (right arm) : Normotensive
 HR: 86bpm : Normal, regular
 PR:86bpm : Normal, regular
 RR: 16 cycles/min (regular) : Eupneic
 Temperature: 37.2° C (axillary) : Afebrile
 O2 saturation: 98 %

Integument
 Skin: Brown complexion, warm, moist, with good turgor and mobility. No petechiae. No
ecchymoses, cyanosis, jaundice
 Hair: Black, short, straight, evenly distributed, fine hair.
 Nails: Good capillary refill <2 sec. No clubbing. Smooth with no ridges nor breaks.
HEAD:
Skull is normocephalic, atraumatic with symmetric contour.
Scalp has no dandruff, no lumps or lesions.
Face is symmetric with no involuntary movements, no masses or edema.

EYES:
Eyebrows are fine, black, symmetric with evenly distributed hair.
Eyelashes are black, evenly distributed, and oriented outwards
Eyelids are symmetrical, lid margins intact with adequate lid closure. No ptosis, no
edema and no periorbital tenderness.
Sclera is anicteric, no spots or hemorrhages.
Palpebral conjunctivae pale in color. No hemorrhage, nodules, lesions or swelling.
Cornea is clear and transparent. No ulcerations, scars or opacities.
Pupils are round, symmetrical, 2mm in diameter and brisk reaction to direct and
consensual light stimulation.
Full extraocular movement, with normal conjugate gazes and with good convergence.
No nystagmus.
EARS:
Ears are symmetrical with no discoloration. Mobile, firm and non-tender auricles. with
No active lesions with visible cerumen on both ears.
NOSE:
Nose is symmetrical. No alar flaring, no discharge, deviation of septum and sinus
tenderness noted.
MOUTH and THROAT:
Lips are dry. No angular deviations or cold sores.
Mucous membrane is moist. No bleeding or sores are noted.
Gums are pink. No bleeding.
Tongue is pinkish and has no ulceration and papillary atrophy.
Uvula at midline. No inflammation.

NECK:
Neck is supple, no tenderness.
Lymph nodes not palpable.
Trachea is at midline.
Thyroid gland not palpable and moves upon deglutition.
Breast
 Symmetrical. Everted nipples. No lumps, discolorations, or discharges.

Chest and Lungs:

 Inspection: Symmetrical chest expansion. No lagging. No bulging, no retractions.
 Palpation: Confirmed symmetrical chest expansion. Unimpaired tactile fremitus, no
masses or tenderness.
 Percussion: Resonant on all lung field.
 Auscultation: No adventitious breath sounds, no crackles, no wheezing, no pleural
friction rub.

Heart
 Inspection: No neck veins engorgement. No visible precordial pulsation.
 Palpation: No heaves, no thrills. PMI is located at 5TH ICS with a distance of 6 cm from
the midclavicular line and a diameter of 2.5 cm. Carotid pulse with single peak and no
delay or bounding upstroke.
 Auscultation: Heart rate is regular in rhythm and synchronous with the radial pulse.
Absent bruit, murmurs and pericardial friction rub.

Abdomen
 Inspection:
Abdomen is symmetrical. No striae & prominent dilated veins. Umbilicus is non-
protruberant. Abdomen is flabby. Peristaltic waves not noted. No visible pulsations
noted. No visible organs or masses noted.

 Palpation:
No guarding and muscle rigidity upon palpation. No abdominal masses palpated.
Spleen was not palpable.
Percussion:
 Tympanitic. Liver span was 9 cm in the right midclavicular line. Has bilateral
costovertebral angle tenderness. Splenic span of 6cm.
 Auscultation:
 With normoactive bowel sounds (26 per minute). No bruits and friction rubs.
Genito-urinary
 The external genitalia without erythema, exudates, trauma, lacerations, nor discharge.
Vaginal vault is without discharge. No masses are palpated. The adnexa are without
masses or tenderness.
Peripheral Vascular
 Extremities are warm. No varicosities or stasis changes. Calves are supple and
nontender. Brachial, radial, popliteal, dorsalis pedis, and posterior tibial pulses are
2+.
Musculoskeletal
 No evidence of swelling or joint deformities. With full range of motion of upper
and lower extremities. Symmetric configuration of the back without masses,
lesions and deformities. No stiffness and pain upon exertion. No tenderness across
the length of the spine.
Rectum (Digital Rectal Exam)
 No rashes, no skin tag, no haemorrhoids, no anal fissure, no external bleeding.
 Anal sphincter intact, constricted during inspection and dilates upon insertion of
finger.
 Rectum has no masses or any irregularities. Stool was soft.
 Upon withdrawal of the finger, no blood or melena seen, brown, soft stool with no
mucus.

NEUROLOGIC EXAMINATION
A. Mental status exam: Patient was examined awake, conscious, coherent, cooperative, and
oriented to time, person and place.
B. Cranial Nerves:
CN I – No anosmia
CN II – Pupils constricting to 2mm, round with brisk reaction to direct and consensual
light stimulation. Good peripheral vision.
CN III, IV, and VI – Full extraocular movements.
CN V – Face is symmetrically sensitive to pain and touch. With positive corneal reflex
CN VII – Face is symmetrical, with normal eye closure. Patient is able to smile.
CN VIII – With normal auditory acuity through whispered voice test.
CN IX and X – Normal phonation, with positive gag reflex, and is able to swallow.
CN XI – Able to turn head to both sides against resistance, able to shrug shoulders
CN XII – Able to protrude tongue, tongue is at midline.
C. Motor: Can flex and extend both upper and lower extremities without limitation. Muscle
grade 5
D. Sensory: Withdraws hand where pain stimulus is applied, no astereognosis, no graphestesia,
positive position sense, positive 2-point discrimination
E. Reflexes:
 Deep Tendon Reflexes:
  Pathologic Reflexes: (-) Babinski; (-) Clonus
F. Cerebellum: Able to do pronation-supination, finger to nose, and heel to knee along shin.
G. Autonomics: No hyperhidrosis of hands & feet.

SALIENT FEATURES

Patient Profile HPI Health History Physical Examination

 44 year old  Hematuria  Nonsmoker  Pale palpebral
 Female  Dull Flank pain 4/10  Occasional alcoholic conjunctiva
 Filipino  Dysuria beverage drinker  Dry lips
 Teacher  Increased frequency  Allergic to shrimp  Has bilateral
 Resident of  Urinary urgency  Consumes 3-4 cups costovertebral angle
tenderness
Tacloban City  High grade fever of coffee
 Chills  Frequently consumes
 Self-medicates with salty, sour, sweet
Ibuprofen+Paracetam food, junk food and
ol and Naproxen. soft drinks
 History of DM,
maternal side
 History of cancer,
paternal side

Pivot: Gross Hematuria

DIFFERENTIAL DIAGNOSIS
Differential Rule In Rule Out Differentiating Tests
Diagnosis
Uncomplicated Gross hematuria No suprapubic pain Urinalysis
cystitis Dysuria Has high grade fever Shows pyuria and
Urinary frequency No nausea and bacteuria and varying
Urinary urgency vomiting degrees of hematuria.
Women No cloudy urine Positive leukocyte
predominance esterase and nitrite test
in urine dipstick.
Urine Culture
Colony counts ≥103/ml
 of a uropathogen is
diagnostic of acute
uncomplicated cyatitis.
Abdominal Ultrasonography
Cytoscopy
CT Scan
Warranted if
pyelonephritis, recurrent
infections, or anatomic
abnormalities are
suspected

Nephrolithiasis  Gross  No nausea and  Urinalysis – reveals either

hematuria vomiting microscopic or gross
 Dietary  No obesity hematuria, reveals
Factor:  Male associated UTI if pyuria or
Frequently prevalence bacteriuria are present,
consumes  No family examine the urinary
salty, sour, history of sediment for crystals
sweet, junk nephrolithiasis (calcium, cystine, uric acid,
food and or struvite crystals),
soft drinks determine the urinary pH –
 Flank pain alkaline urine might indicate
presence of urease-
producing bacteria that
cause an infection stone.
Acidic urine is suggestive of
uric acid stone.
 Urine culture – obtained if
infection is suspected
 Serum chemistry – obtain
BUN and Creatinine levels
for evaluation of renal
function
 KUB radiograph – initial
imaging tests to detect
stones, cystine and uric acid
stones are not usually
visible on plain films
 CT Scan (spiral CT) without
contrast – Gold standard for
diagnosis. Most sensitive
test for detecting stones. All
stones, even radiolucent
ones such as uric acid stones
and cystine stones, are
visible on the CT Scan
 Intravenous Pyelogram –
most useful test for defining
degree and extent of urinary
 tract obstruction, may be
appropriate for deciding
whether a patient needs
procedural therapy
 Renal ultrasonography –
helps in detecting
hydropnephrosis or
hydroureter, procedure of
choice in patients who
cannot receive radiation
Vaginitis  Gross  No vaginal
hematuria discharge Microscopic examination (with 10%
 Dysuria  No genital KOH/ NSS)
 Menopause itching, pain Vulvovaginal Candidiasis –
 History of  No presence of hyphae and spores;
antibiotic dyspareunia white curd-like discharge that is not
use  No erythema malodorous
 No T. vaginalis vaginitis – “strawberry
promiscuous cervic”, motile organisms with
actions flagella under wet mount with NSS
Bacteriual vaginosis – grayish,
frothy, malodorous discharge; pH
5.0-5.5, Whiff test/10% KOH –
amine-like/fishy odor is present if a
drop if discharge is alkalinized with
KOH. On wet mount – clue cells.

**Vaginal cultures are generally not

useful in diagnosis.

Bladder  Gross  No anorexia Urine Cytology and Cytoscopy

Carcinoma Hematuria  No weight loss Cytoscopy is a key
 Dysuria  Male diagnostic procedure for
 Urinary predominance bladder cancer.
frequency  Median age of Biopsy/ Transurethral resection of
 History of 73 years bladder tumor (TURBT)
cancer  Nonsmoker Endoscopic evaluation
paternal side  Denies (Includes mapping the
 Flank pain exposure to location, size, number
carcinogenic of lesions, as wells as
elements description of the
 No obesity growth pattern. –
Harrisons)
CT or CAT scan
MRI
PET-CT
Ultrasonography
(Ultrasound, CT, and/or
MRI may help
determine whether
tumor extends to
 perivesical fat and to
document nodal spread/
- Harrisons)

FINAL IMPRESSION
Urinary Tract Infection to consider Acute Pyelonephritis
Reasons for ruling in Urinary Tract Infection to consider Acute Pyelonephritis
 Gross hematuria
 High grade fever
 Dull flank pain
 Urinary frequency, urgency
 Female gender
 Family History of DM, maternal side

A. Pathophysiology
B. Diagnostics

RCNI Journals. Diagnostic Dilemmas associated with Urinary Tract Infection

Diagnostics Expected Findings
1. Urinalysis Pyuria, bacteuria, and varying degrees of
hematuria. WBC casts may be seen.
Leukocyte esterase and nitrite positive in
urine dipstick. WBC casts indicates renal-
origin pyuria, supporting diagnosis of acute
pyelonephritis.

2. Complete Blood Count Leukocytosis and Shift to the left

3. Urine culture and Antimicrobial susceptibility ≥105 CFU of a single gram-negative

testing organism per ml of urine. If gram-positive,
suspect Enterococcus or S. saprophyticus

4. Abdominal or Pelvic CT scan with contrast Imaging study of choice

*Imaging studies will usually not be
requires for the dx of acute pyelonephritis
but are indicated for patients with renal
transplant, patients in septic shock, those
with poorly controlled DM, complivated
UTIs, immunocompromised, or those with
toxicity persisting for longer that 72 hours.

5. Blood culture Obtained from patient who acute

pyelonephritis who are ill enough to
warrant hospital admission, although they
may not routinely be necessary in patient
with uncomplicated acute pyelonephrititis.
Approx. 15 to 30% of patients with acute
pyelonephritis are bacteremic.

C. Treatment
TREATMENT OF ACUTE PYELONEPHRITIS
A. OUTPATIENT REGIMEN

DRUG CLASS ANTIBIOTIC DOSAGE

Floroquinolones Ciprofloxacin 500 mg orally, twice per day for
seven days

Ciprofloxacin, extended-release 1,000 mg orally, once per day

for seven days
Levofloxacin (Levaquin)
750 mg orally, once per day for
five days
Folate Inhibitors Trimethoprim/sulfamethoxazole† 160 mg/800 mg orally, twice per
(Bactrim, Septra) day for 14 days

 Fluoroquinolones are the preferred empiric antimicrobial class in communities where the local
prevalence of resistance of community-acquired E. coli is 10 percent or less.
 If the prevalence of fluoroquinolone resistance among relevant organisms does not exceed 10
percent, patients not requiring hospitalization can be treated with oral ciprofloxacin (Cipro; 500
mg twice per day for seven days), or a once-daily oral fluoroquinolone, such as ciprofloxacin
(1,000 mg, extended-release, for seven days) or levofloxacin (Levaquin; 750 mg for five days)
 Folate Inhibitors is used if pathogen is known to be susceptible to trimethoprim/sulfamethoxazole
 Because of the generally high prevalence of resistance to oral betalactam antibiotics and
trimethoprim/sulfamethoxazole (Bactrim, Septra), these agents usually are reserved for cases
where susceptibility results for the urine isolate are known and indicate likely activity
B. INPATIENT REGIMEN

PHASE OF THERAPY ANTIBIOTIC DOSAGE

INITIAL Ciprofloxacin 400 mg IV, twice per day

Levofloxacin 250 to 500 mg IV, once per

day

Ceftriaxone 1,000 mg IV, once per day

Aminoglycoside 5 mg per kg IV, once per day

Imipenem/cilastatin (Primaxin) 500 mg IV every six hours

STEP DOWN Ciprofloxacin 500 mg orally, twice per day

for seven days

Ciprofloxacin, extended-release 1,000 mg orally, once per

day for seven days

Levofloxacin 750 mg orally, once per day

for five days
Trimethoprim/sulfamethoxazole 160 mg/800 mg orally, twice
(Bactrim, Septra) per day for 14 days
TREATMENT OF URINARY TRACT INFECTION
A Case of a 44 Year-Old Female Patient
with Hematuria

Clinical Preceptor

Maria Pilipinas Jaya MD

Submitted by:

Bitgue, Mabel L.
Cawile, Menchu Mel
Caparroso, Patricia
Cordial, Michael Dindo U.

July 16, 2019