CASE Presentation

PGI DELA TORRE, RALPH DALE S.

General Data
 K.M
 29/F
 Born on October 8, 1993 at Cebu City
 Filipino
 Roman Catholic
 Currently Residing at M-131 Purok Mazari, Inayagan, Naga
 Was admitted on November 20, 2022 for the first time at
South General Hospital
Chief Complaint

Hypogastric Pain
History of Present Illness

1 day prior to admission, patient noted sudden

onset of intermittent hypogastric pain, burning in
character, with a pain score of 8/10 which
radiates to the lower back. Patient did not take
any medications. No fever, no nausea or vomiting
No consultation was done.
History of Present Illness

 Morning prior to admission, condition

persisted now with urinary frequency and
dysuria hence the consult. Patient was
subsequently advised for admission
Past Medical History

 Childhood illnesses include measles

 Complete childhood immunizations from local barangay

health center

 Medical Illnesses: Recurrent UTI

 Past Surgeries: Primary Cesarean Section 2017

 No injuries, accidents or prior hospitalizations

Past Medical History
 OB/Gyne: G1P1 (1001)

 Menarche: 12 years old

 Subsequent menses: regular, consumes 2-3 pads per day, lasting for
3-5 days

 Sexual History

 Coitarche: 24 years old

 Sexual partner: 1

 No contraceptive use

 No dyspareunia
Personal and Social History
 Patient is a housewife
 non-alcoholic and non-smoker
 No history of illicit drug use
 No known allergies to food or medications
 Living in own house with adequate water and
electric supply with regular garbage disposal
Family History
 Non-hypertensive
 Non-Diabetic
 Non-asthmatic
Review of Systems
 General. (-) weight change, weakness, fatigue
 Skin. Rashes, lumps, sores, itching, color change, changes in hair or nails
 Head, Eves, Ears, Nose, Throat (HEENT)
 Head. Headache, head injury, dizziness, light-headedness
 Eyes. Vision, glasses or contact lenses, last examination, pain, redness, excessive tearing,
double vision, blurred vision, spots, specks, flashing lights, glaucoma, cataracts
 Ears. Hearing, tinnitus, vertigo, earaches, infection, discharge, use or nonuse of hearing aids
 Nose and sinuses. Frequent colds, nasal stuffiness, discharge, or itching hay fever, nosebleeds,
sinus trouble
 Throat. Condition of teeth, gums, bleeding gums, dentures, if any and how they fit, last dental
examination, sore tongue, dry tongue, frequent sore throats, hoarseness
 Neck. Lumps, "swollen glands", goiter, pain or stiffness in the neck
Review of Systems
 Respiratory. Cough, sputum, hemoptysis, dyspnea, wheezing, pleurisy, last
chest x-ray, asthma, pneumonia, TB
 Cardiovascular. Heart trouble, high BP, rheumatic fever, heart murmurs,
chest pain or discomfort, palpitations, dyspnea, orthopnea, paroxysmal
nocturnal dyspnea, edema
 Gastrointestinal. Trouble swallowing, heartburn, loss of appetite,
hematemesis, bowel movements, change in bowel habits, rectal bleeding or
black/tarry stools, hemorrhoids, constipation, diarrhea, abdominal pain,
excessive belching or passing of gas, jaundice, liver or gallbladder trouble,
hepatitis
 Urinary. Frequency of urination, polyuria, nocturia, urgency, burning or pain
on urination, hematuria, urinary infections, kidney stones, incontinence, in
males, reduced caliber or force of the urinary stream, hesitancy, dribbling
 Genital. Masses, lesions, vaginal discharges, dyspareunia
Review of Systems
 Peripheral Vascular. Intermittent claudication, leg cramps, varicose veins,
past clots in the veins
 Musculoskeletal. Muscle or joint pains, stiffness, arthritis, gout, backache. If
present, describe location of affected joints, muscles, presence of any
swelling, redness, pain, tenderness, stiffness, weakness or limitation in
motion or activity, duration & any history of trauma
 Neurologic. Fainting, blackouts, seizures, weakness, paralysis, numbness or
loss of sensation, tingling or "pins and needles", tremors or other involuntary
movements
 Hematologic. Anemia, easy bruising or bleeding, past transfusions and or
transfusion reactions
 Endocrine. Thyroid trouble, heat or cold intolerance, excessive sweating,
excessive thirst or hunger, polyuria, change in glove or shoe size
 Psychiatric. Nervousness, tension, mood, including depression, memory
change, suicide attempts, if relevant
Physical Examination
 General Survey: Awake, conscious and not in respiratory distress
 Vital Signs:
 BP: 110/70
 Temperature: 36.6C
 HR: 91
 RR: 21
 Height: 160cm
 Weight: 60kg
 BMI: 23.4 – Normal
Physical Examination
 Skin: no rashes, no bruises, no lesions, warm, good turgor and mobility

 Head: normocephalic, no facial asymmetry

 Eyes: pink palpebral conjunctivae, anicteric sclerae

 Ears: no deformities, no discharge

 Nose: symmetrical nares,

 Mouth/throat: moist oral mucosa, non-enlarged tonsils, (-) bleeding gums

 Neck: no lymphadenopathy
Physical Examination
 Chest & Lungs:
 Inspection: (-) retraction, no gross deformities
 Palpation: equal chest expansion, equal tactile fremitus on
both lungs
 Percussion: resonant
 Auscultation: Clear breath sounds, (-) wheezing
 Cardiovascular System:
 Inspection: no gross deformities
 Auscultation: (-) murmur, distinct heart sounds
Physical Examination
 Abdomen:
 Inspection: flat, non-distended, no lesions or scars
 Auscultation: normoactive bowel sounds
 Percussion: tympanitic, no hepatomegaly
 Palpation: soft, no masses, (+) direct tenderness on hypogastric area
 Murphy’s sign: Negative
 Rovsing’s sign: Negative
 Obturator sign: Negative
 Psoas sign: Negative
 Extremities: warm, strong peripheral pulses, CRT <2s
Physical Examination
 Neurologic examination:
 Mental status: awake, conscious, oriented to time, place and person
 Cranial Nerves:
 CN I: Able to smell on both nostrils
 CN II: PERRLA, isocoric
 CN III, IV, VI: Full EOM
 CN V: Able to chew without difficulty
 CN VII: symmetrical facial expression
 CN VIII: able to hear questions and respond
 CN IX, X: able to swallow without difficulty
 CN XI: Symmetrical shoulder shrug
 CN XII: tongue in the midline
Summary of Findings

 29-year old Female

 patient noted sudden onset of intermittent hypogastric

pain, burning in character, with a pain score of 8/10 which
radiates to the lower back

 urinary frequency and dysuria

Summary of Findings

 (+) direct Tenderness on hypogastric area

 Rovsing’s sign: Negative
 Obturator sign: Negative
 Psoas sign: Negative
Impression

 Acute uncomplicated Cystitis

 Urinary tract infection, recurrent
Basis
 History

 Acute Uncomplicated Cystitis is suspected in premenopausal non-

pregnant women presenting with acute onset of dysuria,
frequency; and without vaginal discharge

 Recurrent UTI is diagnosed when a healthy non-pregnant woman

with no known urinary tract abnormalities has 2 or more episodes
of acute uncomplicated cystitis in a 6-month period
Basis

 Between 1 year and 50 years of age, UTI and recurrent UTI

are predominantly diseases of females

 As many as 50-80% of women in the general population

acquire atleast one UTI during their lifetime –
uncomplicated cystitis in most cases
Differential Diagnosis
Rule in Rule out
Nephrolithiasis (+) Flank pain (-) hematuria
(+) dysuria Ruled out through labs
(+) urinary frequency
Pelvic Inflammatory (+) hypogastric pain (-) fever
Disease (+) pain radiating to the (-) multiple sexual
back partners
(+) direct hypogastric Ruled out through
tenderness transvaginal ultrasound
(+) dysuria
Acute Appendicitis (+) abdominal pain (-) Rovsing’s sign
(+) direct hypogastric (-) Obturator sign
tenderness (-) Psoas sign
 Course in the Wards
Hospital Day 0 (11/20/22)
S/O A P

Warm skin, good turgor Acute Uncomplicated - Patient admitted

and mobility, pink Cystitis - Vital signs monitoring
palpebral conjunctiva Recurrent UTI Q4h
Hypogastric pain(PS 8/10) - Patient placed on DAT
and tenderness - Patient for diagnostic
tests
Awake, NIRD - IVF: PNSS 1L at
T: 36.6C 80cc/hr
P: 91 - Start
R: 21 Cefepime/Tazobactam
BP: 110/70 2g IV infusion as
loading dose then 1
gram/125mg IV q 12
hours
 Course in the Wards
Hospital Day 0 (11/20/22)
S/O A P

Warm skin, good turgor Acute Uncomplicated - Pantoprazole

and mobility, pink Cystitis 40mg/tab 1 tablet OD
palpebral conjunctiva Recurrent UTI PO
Hypogastric pain (PS - Tramadol +
8/10) and tenderness Paracetamol
37.5/325mg/tab 1 tab
Awake, NIRD 3x daily PO prn for PS
T: 36.6C >4/10
P: 91
R: 21
BP: 110/70
Labs
CBC (11/20/22)
Hemoglobin 14.2 13.5
Hematocrit 40.8 17.5
WBC 15.2 5.0-10.0
Neutrophils 82 47-80
Lymphocytes 13 13-40
Eosinophils 1 0-5
Basophils 0 0-2
RBC Count 4.8 4.5-5.9
MCV 85 80-100
MCH 30 27-33
MCHC 35 31-36
RDW 12.3 11.6-14.8
Platelet Count 302 140-440
Labs
 Urinalysis 11/20/2022

Macroscopic Examination Sugar NEGATIVE

Color STRAW Nitrite NEGATIVE
Transparency CLEAR Protein NEGATIVE
Chemical Examination Urobilinogen 0.2
pH 6.5 Ketone NEGATIVE
Sp. Gravity 1.005 Bilirubin NEGATIVE
Leukocytes NEGATIVE
MICROSCOPIC EXAMINATION
Blood NEGATIVE
Pus Cells 32.5 0-5/HPF
Red Cells 0.6 0-3/HPF
Epithelial 0.2 0-3/HPF
Cells
Bacteria 0.6 0-50/HPF
Cast 2.6 0-3/HPF
 Course in the Wards
Hospital Day 1 (11/21/22)
S/O A P

Warm skin, good turgor Acute Uncomplicated -Patient for diagnostic

and mobility, pink Cystitis tests: Urine Culture and
palpebral conjunctiva Recurrent UTI Sensitivity and Repeat
Hypogastric pain(PS = Urinalysis
3/10) Medications:
1.) Cefepime +
Awake, NIRD Tazobactam 1gm/125mg
T: 36.4C q12h IV infusion
P: 89 2.) Pantoprazole 40mg OD
R: 21 PO
BP: 110/70

UO: 2.1cc/kg/hr
Labs

 Urine Culture and Sensitivity (11/21/22)

 MORE THAN 100,000 COLONIES OF GRAM NEGATIVE BACILLI PER ML
OF URINE WAS ISOLATED
Labs
 KUB (11/21/22)
 Unremarkable kidneys, ureters and bladder
 Course in the Wards
Hospital Day 2 (11/22/22)
S/O A P

Warm skin, good turgor Acute Pyelonephritis -Patient for diagnostic

and mobility, pink (E.coli isolate) tests: Repeat Urinalysis
palpebral conjunctiva and follow up on urine
sensitivity results
Awake, NIRD Medications:
T: 36.4C 1.) Cefepime +
P: 89 Tazobactam 1gm/125mg
R: 21 q12h IV infusion
BP: 110/70

UO: 2.4cc/kg/hr
Labs
 Urinalysis 11/22/2022

Macroscopic Examination Sugar NEGATIVE

Color YELLOW Nitrite NEGATIVE
Transparency CLEAR Protein NEGATIVE
Chemical Examination Urobilinogen 0.2
pH 6.5 Ketone NEGATIVE
Sp. Gravity 1.005 Bilirubin NEGATIVE
Leukocytes NEGATIVE
MICROSCOPIC EXAMINATION
Blood TRACE
Pus Cells 0.9 0-5/HPF
Red Cells 4.2 0-3/HPF
Epithelial 0.4 0-3/HPF
Cells
Bacteria 3.4 0-50/HPF
Cast 0.3 0-3/HPF
Labs
 Urine Culture and Sensitivity (11/22/22)
 Course in the Wards
Hospital Day 3 (11/23/22)
S/O A P

Warm skin, good turgor Acute Pyelonephritis -Patient for diagnostic

and mobility, pink (E.coli isolate) - improved tests: Repeat Urinalysis
palpebral conjunctiva -Terminate IVF
-may go home
Awake, NIRD Medications:
T: 36.4C 1.) Cefepime +
P: 89 Tazobactam 1gm/125mg
R: 21 q12h IV infusion
BP: 110/70
Medications to continue:
UO: 2.2cc/kg/hr 1.) Coamoxiclav
620mg/tab take 1 tab 3x
daily for 5 days
Labs
 Urinalysis 11/23/2022

Macroscopic Examination Sugar NEGATIVE

Color LIGHT YELLOW Nitrite NEGATIVE
Transparency CLEAR Protein NEGATIVE
Chemical Examination Urobilinogen 0.2
pH 7.5 Ketone NEGATIVE
Sp. Gravity 1.010 Bilirubin NEGATIVE
Leukocytes NEGATIVE
MICROSCOPIC EXAMINATION
Blood NEGATIVE
Pus Cells 0.4 0-5/HPF
Red Cells 1.4 0-3/HPF
Epithelial 0.1 0-3/HPF
Cells
Bacteria 0.7 0-50/HPF
Cast 0.0 0-3/HPF
Diagnosis

 Acute Pyelonephritis (Escherichia coli isolate)

Management

 Maintenance Fluids:
 PNSS 1L at 80cc/hr

 Medications:
 Cefepime/Tazobactam 2g IV infusion as loading dose then 1gram/125mg IV q
12hours
 Pantoprazole 40mg/tab 1 tablet orally once daily
 Tramadol + Paracetamol 37.5/325mg tab 1 tab orally 3x daily as needed for pain PS
> 4/10
 Coamoxiclav 625mg/tab 3x daily for 5 days
DISCUSSION
Urinary Tract Infection
 Epidemiology

 Except among infants and elderly, UTI occurs far more

commonly in females than males

 Between 1 year and 50 years of age, UTI and recurrent

UTI are predominantly diseases of females

 As many as 50-80% of women in the general population

acquire at least one UTI during their lifetime
Urinary Tract Infection

 Etiology

 E.coli accounts for 75-90% of isolates;

Staphylococcus saprophyticus for 5-15%; and
Klebsiella, Proteus, Enterococcus, and
Citrobacter species for 5-10%
Pathogenesis
Diagnostic Approach
THANK YOU!