pyeloneph

1. You thought it’s going down.
It’s going up!
Case Presentation 2023

2. PEDIATRIC:
WARD CASE
Bandiola, Aldwin Ivan D.
Clinical Clerk – Group 6

3. Age: 17
Sex: Female
Address: Malvar, Batangas City
Religion: Roman Catholic
Informant: Mother
Admission: 02/20/2023
A case of S.G

4. Chief Complaint:
Abdominal Pain

5. History of Present Illness
4 days PTA
+ Fever (Tmax:40.6 C) given paracetamol with partial relief
+ chills
+abdominal pain RLQ- radiating to the back
No consult was done

6. History of Present Illness
3 days PTA:
+ Persistent fever (tmax 40C)
+postprandial vomiting, non projectile, bilious - ¼ cup 10x
no medication was given
→ brought to tagaytay hospital admitted for 1 day as case
of UTI

7. History of Present Illness
3 days PTA:
Labs at Tagaytay Hospital:
UA: dark yellow, turbid, pus: TMTC, RBC: 10-50,
Epithelial cells: mod leukocytes +3.
• Hydrated, prescribed with Cefuroxime, allegedly the ff
day still symptomatic but sent home

8. History of Present Illness
FHPTA:
+ recurrence of abdominal pain at right lower quadrant
Consulted at Malvar health center:
Given pain meds and domperidone
Persistence of symptoms —> admission and was referred for
consult at our institution.

9. Review of Systems
General: (-) headache, (-) body malaise (-) chills (-) weight
changes
Skin: (-) rashes, (-) cyanosis, (-) pallor (-) jaundice
HEENT: (-) icteric sclera, (-) eye redness (-) eye discharge, (-)
ear discharge, (-) epistaxis, (-) throat pain, (-) cough, (-) colds
Thorax: (-) dyspnea, (-) shortness of breath, (-) PND
Heart: (-) palpitations (-) Chest Pain
Abdomen: (-) Diarrhea, (-) melena, (-) hematochezia
GU: (-) dysuria, (-) frequency, (-) urgency, (-) hematuria
Extremities: (-) edema
Neuro: (-) changes in mental status, (-) Loss of consciousness
(-) seizures

10. Past Medical History
+ Febrile convulsion 1yr old (2007) secondary to
UTI - given unrecalled meds
● No past surgeries
● No Allergies
● No Asthma
● No Trauma/injuries
•

11. Immunization History
● BCG & Hepa B vaccine given at birth
● OPV, Tdap
● Rotavirus
● Influenza
● Measles
● MMR
● Varicella
Immunization done at the Local Health Center

12. Family History
● No HPN, DM, PTB, Heart Disease
● No asthma
● No other heredofamilial diseases

13. Personal and Social History
● Total of 5 in the household
● First of three children
● Both parents works as security agents
● Lives in a bungalow house along the road with adequate
ventilation

14. Personal and Social History
● Water source: Mineral Water
● Garbage collected weekly
● Grade 12
● Work Part-time as service crew at Mcdonald’s

15. Birth History
● Born full term (37 weeks) via NSD to a then 24 y/o G1P1 (1001)
mother via NSVD
● No fetomaternal complications
● BS and APGAR Score unrecalled
● Other anthropometrics unrecalled
● Newborn Screening and Newborn Hearing Test were normal

16. Menstrual History
LMP: 02-13-23
● Menarche – 12 yrs old
● Interval – Irregular
● Duration – 7 days
● Amount – 7 ppd/ fully soaked
● Symptoms – (+) dysmenorrhea

17. Growth and Development History
Gross Motor:
● Rolled over: 5 months
● Sit with support: 6 months
● Walk alone: 1 y/o
● Toilet training: 3 y/o

18. Growth and Development History
Fine Motor:
● Hands not fisted: 3 months
● Reached & pulled objects: 8 months
Language:
● Words/sentences: ~2 y/o
Personal-Social:
● Social smile: 2 months

19. Nutritional History
● Mixed Breastfeed + Formula milk until 6 months
● Current food preferences: rice, vegetables, fried chicken,
pork, egg
● Snacks/drinks: Street foods, fries

20. HEADSSS
H- lives with both parents and 2 siblings,
with good family relationship.
E- online grade 12 student/online with
good grades. Favorite subject is math No
conflict with classmates and teachers.
A- stays at home most of the time, 4-5 hrs
screen time. Not interested with
sports/outdoor activities
D- no exposure to cigarette smoking,
alcohol or drugs amongst friends and family

21. HEADSSS
S- not in a relationship. Not
sexually active
S- no suicidal ideations, no recent
depressive episodes. Talks to
mother when feeling sad..
S- feels generally safe at home, at
workplace and in school
S – roman catholic with regular
church attendance

22. PHYSICAL EXAMINATION
Awake, coherent, Oriented to time, place and person
not in cardiorespiratory distress.
VS – BP: 100/60, HR: 102, RR: 20, Temp: 39 c, O2sat: 98% at room air
Height: 165 cm Weight: 61 kg BMI: 22.4 kg/m2

23. PHYSICAL EXAMINATION
Skin: (-) rashes (-) skin lesions (-) hematoma (-) jaundice (-) cyanosis
HEENT:
Head:symmetrical facial features, no mass, no lesions, hair with normal
texture & equally distributed
Eyes:anicteric sclera, pink palpebral conjunctivae, pupils equally round and
reactive to light, no sunken eyeballs

24. PHYSICAL EXAMINATION
Ears:no discharge, no redness, no tenderness noted
Nose: symmetrical, septum midline, no nasal flaring noted, no
discharge noted
Oral cavity: moist lips and oral mucosa, no lesions, no masses noted
Neck: trachea midline, no CLADs, no palpable mass, no thyroid
enlargement noted, no distended neck veins noted

25. PHYSICAL EXAMINATION
Chest & Lungs
no mass, no lesions, no retractions Symmetrical chest expansion, with equal
tactile fremitus, resonant on percussion, clear breath sounds on all lung fields
Cardiovascular
Adynamic precordium with normal rate and rhythm, PMI at 5th ICS in mcl, no
murmurs noted

26. PHYSICAL EXAMINATION
Abdomen
● Flat, no scars, no lesions, no discolorations noted
● Normoactive bowel sound
● Tympanitic on all quadrants,
● (+) right lower quadrant direct tenderdess, (-) rebound tenderness
● Liver edge non-palpable, intact Traube space
(-) murphy’s sign, (-) Rovsing’s, (-) Obturator’s (-) Psoas sign
(+) CVA Tenderness Right

27. PHYSICAL EXAMINATION
Extremities
(-) cyanosis, (-) edema, full equal pulses, (-) clubbing
Capillary refill time: <2 sec

28. SALIENT FEATURES

29. SUBJECTIVE OBJECTIVE
Age: 17
Sex: female
(+) Abdominal pain
(+) recurrent abdominal pain
(+) flank pain
(+) fever tmax 40.6 c
(+) postprandial vomiting
(+) Hx of UTI
(+) Febrile 39 c
(+) RLQ tenderness
(+) CVA, right tenderness
(-) Murphy’s sign
(-) Rovsing’s sign
(-) Psoas sign
(-) Obturator sign

30. Differentials
Acute
Appendicitis
Ectopic
Pregnancy
Acute
Cholecystitis
Cystitis

31. 01 Acute Appendicitis
RULE IN RULE OUT
(+) Abdominal Pain
(+) Fever 39 c
(+) Vomiting
(+) RLQ tenderness
(-) Rovsing’s sign
(-) Psoas Sign
(-) Obturator Sign

32. 02 Ectopic Pregnancy
RULE IN RULE OUT
(+) Abdominal Pain
(+) Vomiting
(+) RLQ tenderness
(+) Low back pain
(+) fever
(-) vaginal bleeding
(-) breast tenderness
(-) LMP too recent

33. 03 Acute Cholecystitis
RULE IN RULE OUT
(+) Female
(+) Abdominal Pain
(+) Fever 39 c
(+) Vomiting
(+) Lower Back Pain
(-) pain after fatty meal
(-) Murphy’s sign
(-) RUQ pain

34. 04 Cystitis
RULE IN RULE OUT
(+) Abdominal Pain
(+) Vomiting
(+) History of UTI
(+) Fever 39 c
(-) dysuria
(-) polyuria
(-) urinary symptoms
(+) CVA tenderness

35. Diagnostics

36. Laboratories
ERYTHROCYTES 3.59
Hemoglobin 105
Hematocrit 0.308
LEUKOCYTE 7.22
Neutro 0.684
Lympho 0.150
Mono 0.157
Eosino 0.003
Baso 0.006
Thrombo 159
MCH 29.2
MCV 85.8
MCHC 0.34
RDW 12.0
MPV 11.3
ABO TYPE O
RH TYPE Positive

37. Laboratories
Urinalysis
Color Yellow
Transparency Slightly Turbid
Blood negative
Bilirubin negative
Urobilinogen normal
Ketone plus 2
Albumin plus 2
Nitrite negative
Glucose negative
pH <5.5
Specific Gravity 1.020
Leukocyte trace
Pus Cells (WBC) 2-5/hpf
Red Blood Cells (RBC) 0-2
Epithelial Cells plenty
Bacteria few
Crystal none seen
Casts none seen
PREGNANCY TEST negative

38. Laboratories
Chemistry
Creatinine 170
Na 133.1
K 3.42
iCa 1.11

39. Whole Abdomen Ultrasound
• Consider Diffuse Renal Parenchymal Disease,
Bilateral.
• Serum Correlation is Suggested.
• Unremarkable Ultrasound Study of the Liver,
Gallbladder, visualized Pancreas (Head and Body),
Spleen, Abdominal Aorta and Urinary Bladder.
• Normal-sized Anteverted Uterus with an Intact
Endometrial Stripe
Imaging

40. Final Diagnosis
Acute Pyelonephritis

41. You can enter a subtitle here if you need it
01
DISCUSSION

42. Epidemiology
• 1st year of life: male predominance
• Beyond 1-2 years old: female predominance
Etiopathogenesis

43. Etiology
• 75-90% caused by E.coli in girls, followed by Klebsiella
and Proteus
• For both sexes, Staphylococcus saprophyticus and
Enterococcus
Etiopathogenesis

44. Pathogenesis
• Most UTIs are ascending infections: bacteria arise from
fecal flora and colonize the perineum, and then enters
the bladder via the urethra
• Voiding dysfunction is a risk factor for UTI
Etiopathogenesis

46. Pathophysiology

49. Clinical Pyelonephritis
• Abdominal, flank, or back pain.
• malaise, nausea/vomiting.
• Fever may be the only manifestation.
• Newborns – nonspecific symptoms
• Most common serious bacterial infection in younger than 24
months
Clinical Forms of UTI

50. Cystitis
• bladder involvement
• Gross hematuria and dysuria
• Urgency, frequency, malodorous urine, incontinence, suprapubic pain
• does not cause fever
• does not result in renal injury
• Usually resolves within 1 week
Clinical Forms of UTI

51. Asymptomatic Bacteriuria
• (+) urine culture without any manifestations of infection
• Most common in girls
• Incidence declines with increasing age
• Benign and does not cause renal injury except in pregnant
women (can result in symptomatic UTI
Clinical Forms of UTI

53. Risk Factors for UTI
• Female gender
• Uncircumcised male
• Vesicoureteral reflux
• Toilet training
• Voiding Dysfunction
• Obstructive uropathy
• Urethral Instrumentation
• Wiping from back to front in girls

54. Risk Factors for UTI
• Tight clothing (underwear)
• Pinworm infestation
• Constipation
• Bacteria with P fimbriae
• Anatomic abnormality (labial adhesion)
• Neuropathic bladder
• Sexual activity
• Pregnancy

56. Definition of Terms
Recurrent UTI
• 2 or more acute pyelonephritis/
presumptive UTI OR
• 3 or more cystitis OR
• 1 pyelonephritis + 1-2 cystitis
Presumptive UTI • Clinical symptoms + urinalysis
findings suggestive of UTI, NOT
supported by urine culture

57. Laboratory Test in UTI
Collection of
Urine
• <2 years old = clean catch urine collection
• >2 years old = mid-stream sample
• Suprapubic aspiration or urethral
catheterization if and only if above methods
cannot be done properly

58. Laboratory Test in UTI
Urine Dipstick
Nitrite • Nitrate reductase present in most gram-negative
uropathogenic rods
• Requires sufficient bladder incubation time (around 4
hours)
Leukocytes • May be associated with UTI and non-infectious renal
diseases
• False negative: glycosuria, high specific gravity,
contamination with debris
Interpretation Leukocyte + Leukocyte -
Nitrite + • Urine CS
• Treat as UTI
• Send Urine CS
• Treat as UTI
Nitrite - • Urine CS
• Treat IF WITH
SYMPTOMS
• Not UTI

59. Laboratory Test in UTI
Urine Microscopy
Pyuria • WBC >5/hpf in centrifuged urine
• WBC >10/uL in centrifuged
Bacteria • May be positive from contamination
• Not significant unless accompanied by presence of
WBCs
Interpretation Pyuria + Pyuria -
Bacteriuri
a +
• Urine CS
• Treat as UTI
• Send Urine CS
• Treat as UTI
Bacteriuri
a -
• Urine CS
• Treat IF WITH
SYMPTOMS
• Not UTI

60. Urinalysis
● Pyuria (leukocytes in the urine) suggests infection,
but may be present without UTI
● Nitrites and leukocyte esterase are usually positive in
infected urine
Diagnostics

61. Urine culture
• Positive culture:
o Suprapubic or catheterized sample: >50,000 colonies of a single
pathogen OR 10,000 colonies and the child is symptomatic.
o In a bag/midstream urine sample: single organism cultured with a
colony count >100,000 and (+) urinalysis and symptomatic.
Diagnostics

62. Sonogram of kidneys and bladder
● To assess kidney size, detect hydronephrosis and ureteral dilation
● To evaluate bladder anatomy
● Indicated for:
>First UTI <6 months
>No response to antibiotic therapy within 24-48 hours
If ultrasound is abnormal, DMSA or VCUG may be done
Diagnostics

63. Dimercaptosuccinic acid (DMSA) scan
● To assess renal scarring and identify areas of acute
pyelonephritic involvement
Voiding cystourethrogram (VCUG)
● To assess for reflux
Diagnostics

64. Acute uncomplicated UTI:
Acute cystitis and pyelonephritis
• <2 months: Cefotaxime + Amikacin for 10-14 days
• >2 months to 18 years old: Coamoxiclav, Cefuroxime,
Ampicillin-Sulbactam for 7-14 days
Nitrofurantoin can be given for adolescents (but ONLY for
acute cystitis)
Management

65. ● Oral therapy is equally effective to IV therapy
● IV therapy preferred if seriously ill, cannot tolerate oral
therapy
Switch to oral therapy once afebrile for 24 hours and able
to tolerate oral therapy
Management

66. Recurrent UTI, Catheter-related, comorbidities
(Complicated UTI)
• Refer to IDS, nephrologist and urologist
• Ceftriaxone +/- Amikacin
Antibiotic Switch
•If culture shows different sensitivity pattern and/or
poor response after 48-72 hours
Management

67. Bacteremia (2% to 5% of episodes of pyelonephritis)
● more likely in infants than in older children.
Focal renal abscesses uncommon complication
Complications and Prognosis

68. ● Relapse rate of UTI: 25% to 40%.
● Most relapses occur within 2 to 3 weeks of treatment.
● follow up for evaluation for subsequent fevers to evaluate for the
possibility of recurrence of UTI.
● If a recurrence is diagnosed, further imaging studies (VCUG) are
indicated to evaluate the possibility of vesicoureteral reflux
Complications and Prognosis

69. Primary prevention is achieved by promoting good perineal
hygiene and managing underlying risk factors for UTI
● such as chronic constipation, encopresis, and daytime and
night time urinary incontinence.
Prevention

70. There is evidence that antibiotic prophylaxis may prevent
more severe symptomatic recurrent infections, although the
effect is small.
The impact of secondary prophylaxis to prevent renal scarring
is unknown.
Prevention

71. E N D

72. “This is a quote, words full of
wisdom that someone
important said and can make
the reader get inspired.”
—SOMEONE FAMOUS

73. KEY NUMBERS
This is the number
of patients we had
last month
20,000
This is the number
of total visitors we
had last month
50,000
This is the number
of transplants we
had last month
14,000
This is the
approximate profit
we had last month
$800,000

74. OUR GRAPH
It’s the smallest planet in the
Solar System
MERCURY
Venus is the second planet
from the Sun
VENUS
Saturn is composed mostly of
hydrogen and helium
SATURN
Follow the link in the graph to modify its data and then
paste the new one here. For more info, click here

75. MILESTONES REACHED
Venus is the second
planet from the Sun
and is terribly hot
2007-2012 2012-2017 2017-2022
2002-2007
Despite being red,
Mars is actually a
very cold place
The Sun is the star
at the center of the
Solar System
Jupiter is a gas giant
and the biggest
planet of them all

76. Venus is the second
planet from the Sun
and is terribly hot
Despite being red,
Mars is actually a
very cold place
The Sun is the star
at the center of the
Solar System
Saturn is composed
mostly of hydrogen
and helium
AREAS WE COVER
MARS VENUS
SATURN
SUN

77. Mercury is the closest planet
to the Sun
VENUS
SERVICES
SATURN
Venus is the second planet
from the Sun
Saturn is composed mostly
of hydrogen and helium
MARS MERCURY
Despite being red, Mars is
actually a cold place

78. MERCURY Mercury is the closest planet to the Sun
VENUS Venus is the second planet from the Sun
KEY ACCOMPLISHMENTS
SATURN Saturn is a gas giant and has rings

79. 95%
Mercury is the closest planet to the Sun
and the smallest one in the Solar System
PATIENT SATISFACTION

80. INNOVATIONS
VENUS
MERCURY
It has a beautiful name and is the second
planet from the Sun. It’s terribly hot, even
hotter than Mercury, and its atmosphere is
extremely poisonous
It’s the closest planet to the Sun and the
smallest one in the Solar System. This
planet's name has nothing to do with the
liquid metal

81. MARS
Mars is actually a very
cold place
VENUS
Venus is the second
planet from the Sun
JUPITER
Jupiter is the biggest
planet of them all
MERCURY
It’s the closest planet to
the Sun
SATURN
It’s composed of hydrogen
and helium
NEPTUNE
It’s the farthest planet
from the Sun
QUALITY IMPROVEMENT
MEASURES

82. TESTIMONIALS
FRED
BLOGGS, 65
LAURA
SMITH, 58
“Despite being red,
Mars is a cold place”
“Saturn is a gas giant
and has rings”
JENNA
JONES, 79
TIMMY
JIMMY, 36
“Neptune is the fourth-
largest planet”
“Mercury is the closest
planet to the Sun”

83. OUR LOCATIONS
It’s the smallest planet in
the Solar System
MERCURY
Venus is the second
planet from the Sun
VENUS
Saturn is composed of
hydrogen and helium
SATURN

84. 9h 55m 23s
Jupiter's rotation period
The Sun’s mass compared to Earth’s
333,000
386,000 km
Distance between Earth and the Moon

85. A PICTURE IS
WORTH A
THOUSAND
WORDS

86. AWARDS
2016 2018 2020
AWARD Mercury Venus Mars
DOCTORS Dr. Adam Johnson Dr. Kelly Williams Dr. Carol Smith
REASON
It’s the closest
planet to the Sun
Venus has a
beautiful name
Mars is actually a
very cold place

87. AWESOME
WORDS

88. DR. JOHN
SMITH
You can talk a bit about
this person here
DRA. JENNA
DOE
You can talk a bit about
this person here
DR. TIMMY
JIMMY
You can talk a bit about
this person here
OUR TEAM

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click on it and select “Replace image”
OUR WEBSITE

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