DEANNE KATHLEEN T.

VILLANUEVA September 26, 2022

FGL 4

ACTUAL PATIENT ENCOUNTER

NEPHROLOGY

I. Patient’s Profile

Name: Myrna Marcos Tarroza

Age: 58 y.o.
Sex: Female
Address: Vitali, Zamboanga City
Marital Status: Married
Occupation: Housewife
Religion: Roman Catholic
Nationality: Filipino
Educational Attainment: Highschool Graduate

II. Chief Complaint

Hematuria

III. History of Present Illness

2 weeks prior to admission, the patient had been experiencing frequent, burning
pain upon urination. Moreover, she noticed her urination to only be of small amounts
of about 10-20 mL per episode for 10-15 times a day associated with hypogastric pain
with pain scale of 5 out of 10, localized, non-radiating on and off, not associated with
food intake. No medications were taken but drank unrecalled herbal tea of unrecalled
amount to alleviate the pain.

A week prior to admission, absence of urine accompanied with suprapubic pain

was noted. Still, the patient didn’t attempt to seek consult since she claimed that the
pain was still bearable at that point. Furthermore, she also stated the urgency to void
late at night, and had difficulty returning to sleep.

On the day of admission, she experienced suprapubic pain with a pain scale of
10/10. She had sudden urge of urination and noted tea-colored urine which finally
prompted her to seek for medical attention at Zamboanga City Medical Center (ZCMC).
She was then admitted for further evaluation and treatment.
 IV. Past Medical History

Childhood Illnesses: Unrecalled

Medical: Last 2021, patient developed an infected wound on right foot for 5 days;
admitted at Zamboanga Doctor’s Hospital (ZDH)

Diabetes Mellitus Type II; treated with metformin; compliant to medication

Surgical: Underwent above knee amputation of right leg  last March 2021 due to
necrotic wound at ZDH

Ob/Gyn: G4P4 (4-0-0-4), with normal vaginal deliveries

 taken contraceptive pills in between pregnancies

 menopause
 not sexually active

V. Family History

 Both parents died from DM Type II

 Four other siblings were diagnosed with DM Type II
 (-) hypertension, (-) tuberculosis, or any other chronic disease

VI. Personal and Social History

 Food: Mostly carbohydrates, fats, spices, coffee, and vegetables

 Drinks: about 2 liters of coke per day for about 5 years
 No vices and allergy

VII. Review of Systems

General: No loss of consciousness, no body malaise

Skin: No rashes
Head, Eyes, Ears, Nose, Throat (HEENT): No difficulty of swallowing, no nasal and
ear discharges
Respiratory:  No cough, colds, and shortness of breath; unremarkable
Cardiovascular: No difficulty of breathing associated with activity, chest pain, and
palpitations
Gastrointestinal: No nausea, vomiting and indigestion
Urinary: tea-colored urine and pubic pain
Genital: Genital inspection not done
Peripheral Vascular: No varicosities and swelling
Musculoskeletal: Aching pain on left knee
Psychiatric: No hearing of voices, no hallucinations
Neurologic: Oriented to place, time, and event
Hematologic: No easy bruisability, no bleeding
Endocrine: Known case of DM Type II
 VIII. Physical Examination

Vital Signs: BP – 140/80 mmHg ;  T – 36.8°C ; PR – 90 bpm ; RR – 20 cpm

General Appearance: Alert, conscious weak-looking in supine position. Not in respiratory

distress. 

Skin: Good skin turgor. No rashes. Noted hyperpigmentation on the dorsum of the left foot.

Head, Eyes, Ears, Nose, Throat (HEENT): 

Head— Upon inspection, hair with average texture.  No scars, mass upon palpation.
Eyes—anicteric sclera, pale palpebral conjunctiva and small, raised, white colored growth in
the conjunctiva on both eyes. Pupils are 2mm in size, equally round and reactive to light.
Ears—no nodular swellings, no discharges, no signs of inflammation.
Nose — No tenderness over maxillary sinuses, no swollen mucosa and clear drainage.
Septum midline.
Throat (or Mouth)—Pale lips, dental caries, lower teeth, pharynx without exudates. 

Neck: Trachea midline. Neck supple. No lymphadenopathy.

Thorax and Lungs: Upon inspection, equal chest expansion. Upon palpation, equal tactile
fremitus. No dullness to percussion, vesicular breath sounds upon auscultation.
 
Cardiovascular: Adynamic precordium. Normal rate and rhythm with palpable PMI at 5th
intercostal space, midclavicular line. No murmur. No extra heart sound. No obvious jugular
vein distention. 

Abdomen: Flat, no scars, lesions, stretch marks or discoloration. Normoactive bowel

sounds (about 15 bowel sounds/min). Noted tenderness at hypogastric area and right
lumbar region. Hypogastric area rigid upon palpation. No palpable masses or
hepatosplenomegaly.  The liver span is 7cm in the right midclavicular line. Spleen and
kidney not felt. No costovertebral angle tenderness. Negative kidney punch.

Genitalia: Was not able to be performed.

Extremities: 
Upper Extremities: No tenderness and inflammation on both shoulders, elbows, wrists and
finger joints. Both extremities were able to demonstrate active full range of motion and were
able to present fair strength, including squeezing the assessor's hands. Good muscle tone
was observed. 
Lower Extremities: Status post right above knee amputation with phantom limb sensation.
On the left extremity, no varicosities and inflammation was seen but upon active extension
of the knee, dull aching pain was felt. Normothermic on both extremities and no edema
noted upon palpation.

Peripheral vascular: Patient can feel sensation. All peripheral pulses are palpable. 

Neurologic: Phantom pain on right amputated leg.

 IX. Differential Diagnoses

DDx Anuria Scanty Gross Dysuria Nocturia Supra DM Ruled Out

urine/ hematuria pubic related
Oliguria pain

Acute Kidney ❌ ✔️ ❌ ✔️ ❌ ❌ ✔️ Anuria is

Injury uncommon;
Need further
supporting
data eg. SCr

Urolithiasis ✔️ ✔️ ✔️ ✔️ ✔️ ❌ ✔️ (-) ureteric

pain radiating
to upper
abdomen and
labia

Interstitial ❌ ❌ ✔️ ✔️ ✔️ ✔️ ✔️ (-) fever

Cystitis/ (-) frequency
Painful in urination
Bladder (-) pain with
Syndrome full bladder
that improves
once bladder
is emptied

Acute ❌ ❌ ❌ ✔️ ❌ ✔️ ✔️ (-) flank pain,

pyelonephritis (-) fever,
(-) chills

Urethritis ❌ ❌ ❌ ✔️ ❌ ✔️ ❌ (+)
menopause
(+) pyuria
(-) high risk for
STI (young
age, multiple
sexual
partners)
(-) urethral
mucopurulent
discharge

Pelvic ❌ ❌ ❌ ✔️ ❌ ✔️ ❌ (-)
Inflammatory mucopurulent
Disease endocervical
discharge
(-) fever
(-) common in
women < 45yo
 Acute kidney injury (AKI), previously called acute renal failure (ARF), denotes a
sudden and often reversible reduction in kidney function, as measured by
glomerular filtration rate (GFR). Although, immediately after a renal insult, blood
urea nitrogen (BUN) or creatinine levels may be within the normal range. The
only sign of acute kidney injury may be a decline in urine output. AKI can lead to
the accumulation of water, sodium, and other metabolic products. It can also
result in several electrolyte disturbances.

Source: Goyal A, Daneshpajouhnejad P, Hashmi MF, et al. Acute Kidney Injury. [Updated 2022
Jun 21]. Treasure Island (FL): StatPearls Publishing; 2022 Jan-. Available from:
https://www.ncbi.nlm.nih.gov/books/NBK441896/

 Urolithiasis is a condition that occurs when renal stones formed within the
kidneys (nephrolithiasis) exit the renal pelvis and move into the remainder of the
urinary collecting system, which includes the ureters, bladder, and urethra. 

Source: Thakore P, Liang TH. Urolithiasis. [Updated 2022 Jun 11]. Treasure Island (FL):
StatPearls Publishing; 2022 Jan-. Available from:
https://www.ncbi.nlm.nih.gov/books/NBK559101/

 Cystitis refers to the infection of the lower the urinary bladder. It may be broadly
categorized as either uncomplicated or complicated. Uncomplicated cystitis
refers to lower urinary tract infection (UTI) in either men or non-pregnant women
who are otherwise healthy. Complicated cystitis, on the other hand, is associated
with risk factors that increase the virulence of the infection or the potential of
failing antibiotic therapy.
Source: Li R, Leslie SW. Cystitis. [Updated 2022 Jun 15]. Treasure Island (FL): StatPearls
Publishing; 2022 Jan-. Available from: https://www.ncbi.nlm.nih.gov/books/NBK482435/

 Interstitial cystitis/Painful Bladder Syndrome is a condition that affects the

urinary bladder, characterized by chronic inflammation. It is not secondary to an
infection. In many cases, because it remains a diagnosis of exclusion, the
condition is often diagnosed late in the patient's journey.
Source: Lim Y, O'Rourke S. Interstitial Cystitis. [Updated 2022 Apr 14]. Treasure Island (FL):
StatPearls Publishing; 2022 Jan-. Available from:
https://www.ncbi.nlm.nih.gov/books/NBK570588/

 Acute pyelonephritis is a bacterial infection causing inflammation of the kidneys

which occurs as a complication of an ascending urinary tract infection (UTI)
which spreads from the bladder to the kidneys and their collecting systems.
 Source: Belyayeva M, Jeong JM. Acute Pyelonephritis. [Updated 2022 Jul 5]. Treasure Island
(FL): StatPearls Publishing; 2022 Jan-. Available from:
https://www.ncbi.nlm.nih.gov/books/NBK519537/

 Urethritis is a lower urinary tract infection causing inflammation of the urethra, a

fibromuscular tube through which urine exits the body in both males and females.
It is strongly associated with sexually transmitted infections, and is characterized
as gonococcal or nongonococcal. 

Source: Young A, Toncar A, Wray AA. Urethritis. [Updated 2022 May 8]. Treasure Island (FL):
StatPearls Publishing; 2022 Jan-. Available from:
https://www.ncbi.nlm.nih.gov/books/NBK537282/

 Pelvic inflammatory disease (PID) is defined as an inflammation of the upper

genital tract due to an infection in women. The disease affects the uterus,
Fallopian tubes, and/or ovaries. It is typically an ascending infection, spreading
from the lower genital tract.
Source: Jennings LK, Krywko DM. Pelvic Inflammatory Disease. [Updated 2022 Jun 5]. Treasure
Island (FL): StatPearls Publishing; 2022 Jan-. Available from:
https://www.ncbi.nlm.nih.gov/books/NBK499959/

CLINICAL IMPRESSION

CLINICAL
IMPRESSION Anuria Scanty Gross Dysuria Nocturia Suprapubic DM-
urine/Oliguria hematuria pain related

URINARY
TRACT ✔️  ✔️ ✔️  ✔️  ✔️  ✔️  ✔️
OBSTRUCTION
SECONDARY
TO CYSTITIS

X. Laboratory Tests

Cost effective, priority tests:

 URINALYSIS: to check for the present of blood, nitrite, leukocyte esterase or

elevated WBC
 COMPLETE BLOOD COUNT: to check for the present of anemia(our patient is
pale) and elevated WBC count.
 BUN AND CREATININE: to assess kidney function.
 KUB ULTRASOUND: to assess the location of obstruction and involvement of
kidney.

Others: 
 Urine culture: if nitrite is negative in urinalysis. Identify the causative pathogen.
 CT SCAN: to give us a clear picture of the Urinary tract system.

Concept Map