ue La Salle PealLh Sclences lnsLlLuLe

ue La Salle unlverslLy Medlcal CenLer

ueparLmenL of lnLernal Medlclne

lls c/inico/ Monoqement conference Protoco/


aLlenL's name 8eabad Lrmellno 8obl[es
8oom 14298
uaLe of Admlsslon CcLober 26 2011
ALLendlng hyslclan Lugene CasLlllo Mu


Ceneral Cb[ecLlve
1 1o presenL a case of nephrollLhlasls admlLLed aL uLSuMC on CcLober november 2011

Speclflc Cb[ecLlves
1 1o presenL a cllnlcal hlsLory of a paLlenL wlLh nephrollLhlasls admlLLed aL uLSuMC on CcLober
november 2011
2 1o presenL Lhe dlfferenLlal dlagnoses of nephrollLlasls
3 1o presenL Lhe paLhophyslology and cllnlcal manlfesLaLlons of nephrollLlasls
4 1o presenL Lhe managemenL of nephrollLhlasls

C||n|ca| n|story

Genera| Data
L8 32 year old male marrled llllplno 8oman CaLhollc hlgh school graduaLe currenLly
employed as a Lruck drlver aL keansburg MarkeLlng CorporaLlon born ln 8aao Camarlnes Sur and
currenLly resldlng ln anapaan 7 8acoor CavlLe was admlLLed for Lhe flrsL Llme on CcLober 26 2011 aL
around 1130 am

Ch|ef Comp|a|nt
8lghL flank paln

n|story of resent I||ness
3 days prlor Lo admlsslon paLlenL developed clear rhlnorrhea and lnLermlLLenL nonproducLlve
cough assoclaLed wlLh undocumenLed fever 1here was no headache vomlLlng malalse abdomlnal
paln dlarrhea or dysurla SympLoms perslsLed for 3 days Pe selfmedlcaLed wlLh henyleprlne PCl +
Chlorphenamlne maleaLe + araceLamol (8loflu) 10/2/300mg LableL aL bedLlme whlch relleved Lhe fever
aLlenL was sLlll able Lo work and was noLed Lo be exposed Lo exLreme heaL wlLh sweaLlng and
decreased fluld lnLake whlle drlvlng hls company's Lruck no consulL was done

1 day prlor Lo admlsslon Lhere ls perslsLence of rhlnorrhea cough Whlle aL work paLlenL
suddenly developed acuLe onseL of rlghL flank paln 10/10 paln scale lnLenslLy sLeady and conLlnuous
radlaLlng Lo Lhe lpsllaLeral buLLocks and LesLlcle unaffecLed by poslLlon aLlenL lmmedlaLely soughL
consulL aL lmus lamlly PosplLal buL opLed Lo Lransfer Lo a publlc hosplLal ln Las lnas ClLy Pe was glven
unrecalled paln rellever admlnlsLered lnLramuscularly whlch moderaLely relleved Lhe flank paln A
urlnalysls was requesLed whlch revealed Leacolored urlne on gross examlnaLlon wlLh mlcroscoplc
hemaLurla uue Lo Lhe resoluLlon of paln Lhe paLlenL opLed Lo go home agalnsL medlcal advlse 1here ls
sLlll no dysurla nausea vomlLlng abdomlnal paln fever frequency urgency ollgurla or anurla anorexla
as well as dlarrhea

lew hours prlor Lo admlsslon Lhere ls recurrence of rlghL flank paln 10/10 ln paln scale severlLy
radlaLlng Lo Lhe lpsllaLeral buLLocks and LesLlcle wlLh no oLher assoclaLed sympLoms noLed aLlenL Lhen
consulLed aL Lhe uLSuMC L8 and was subsequenLly admlLLed

ast Med|ca| n|story
aLlenL has no hlsLory of allergles Lo any medlcaLlon rlor Lo admlsslon he ls only Laklng
henyleprlne PCl + Chlorphenamlne maleaLe + araceLamol (8loflu) 10/2/300mg LableL aL bedLlme and
only noLed sedaLlon as slde effecL Pe has no hlsLory of lnLake of herbal drugs sLerolds dlureLlcs
colchlclnes or chemoLherapeuLlc agenLs Pls lmmunlzaLlon sLaLus ls unknown Pe has no prevlous hlsLory
of gouL or hyperurlcemla hypercalcemla hyperparaLhyroldlsm or oLher endocrlnopaLhles renal Lubular
acldosls recurrenL u1l renal or ureLeral sLones dlabeLes asLhma hyperLenslon 18 lnfecLlous
cardlac pulmonary Cl1 musculoskeleLal neurologlc or psychlaLrlc dlsorders 1he paLlenL has no
prevlous urologlc abdomlnal or oLher Lypes of operaLlons Pe denles havlng any hlsLory of prevlous
ln[urles or accldenLs

Iam||y Med|ca| n|story
1he paLlenL's faLher has a hlsLory of hyperLenslon and dled of endsLage renal dlsease
CLherwlse Lhere ls no famlly hlsLory of kldney sLones gouL hyperurlcemla hypercalcemla
hyperparaLhyroldlsm or oLher endocrlnopaLhles renal Lubular acldosls recurrenL u1l renal or ureLeral
sLones dlabeLes asLhma 18 lnfecLlous cardlac pulmonary Cl1 musculoskeleLal neurologlc or
psychlaLrlc dlsorders

ersona| Soc|a| n|story
1he paLlenL ls a hlgh school graduaLe currenLly works as a Lruck drlver aL keansburg MarkeLlng
CorporaLlon Pls shlfL sLarLs around 3 am ln Lhe mornlng and ends around 67 pm ln Lhe afLernoon
hence he ls usually exposed Lo Lhe lnLense heaL of Lhe day resulLlng Lo lncreased sweaLlng Pe also
clalms lnadequaLe fluld lnLake 1he paLlenL ls marrled Lo Shalra for 4 years wlLh 3 chlldren Pe was a
prevlous smoker wlLh 123 pack years sLopped ln 2008 due Lo healLh concerns Pe ls an occaslonal
alcohollc beverage drlnker drlnklng Z boLLle of hard alcohollc beverages Pe ls noL a coffee drlnker Pe
prefers Lo eaL salLy foods

kev|ew of Systems

REVEW OF SYSTEMS

GENERAL: (-) weight loss, (-) easy fatigability, (-) loss of appetite, (-) fever and chills,
(-) weakness

NTEGUMENT: (-) pruritus, (-) rashes, (-) clubbing of nails, (-) pallor, (-) jaundice, (-) lesions, (-) lumps, (-
) hematoma, (-) discoloration of nail beds on fingers & toes

HEAD AND NECK: (-) headaches, (-) nausea, (-) stiffness, (-) neck pain, (-) lumps, (-) goiter,
(-) swollen glands, (-) pain, (-) antero-lateral mass, (-) dysphagia

EYES: (-) discharges, (-) spots, (-) correctional lenses, (-) redness, (-) excessive tearing

EARS: (-) discharges, (-) hearing difficulty, (-) tinnitus, (-) vertigo, (-) infection
(-) hearing aids, (-) earaches

NOSE & SNUSES: (-) discharges, (-) epistaxis, (-) obstruction, (-) frequent colds, (-) itchiness

MOUTH: (-) bleeding, (-) gum swelling

RESPRATORY: (-) coughoccassional, (-) phlegm, (-) hemoptysis, (-) pleuritic chest pain,
(-) dyspnea (-) tachypnea

CARDOVASCULAR: (-) palpitations, (-) orthopnea, (-) angina, (-) arrhythmia, (-) chest discomfort

GT: (-) abdominal pain, (-) anorexia, (-) vomiting, (-) diarrhea, (-) constipation,
(-) hematochezia, (-) nausea, (-) retching, (-) heartburn

URNARY: (+) dysuria, (-) polyuria, (-) nocturia, (-) hematuria, (-) pain on urination,
(-) burning on urination, (+) frequency

VASCULAR: (-) varicose veins, (-) claudication, (-) ulcers, (-) leg cramps

HEMATOLOGC: (-) easy bruising, (-) easy bleeding, (-) pallor

ENDOCRNE: (-) Polyphagia, (-) Polydypsia, (-) Diaphoresis, (-) Heat intolerance,
(-) Cold intolerance, (-) Excessive sweating, (-) Excessive thirst,
(-) Excessive hunger

EXTREMTES: (-) edema, (-) joint painankles, (-) weakness, (-) fractures, (-) tenderness
(-) numbnessafter surgery

NERVOUS SYSTEM: (-) seizures, (-) syncope, (-) tremors, (+) numbness, (-) tingling of "pins & needles

AUTONOMC: (-) fecal or urinary incontinence

PHYSICAL EXAMINATION

GENERAL SURVEY:
Patient is mesomorph, conscious, coherent, ambulatory, sitting upright, oriented to time place and person,
cooperative, not in cardiorespiratory distress & appears to be his stated age of 32, he was hooked to an V line,
containing plain lactated ringers 1 liter to run for 8 hours

VITAL SIGNS:
Blood pressure: 120/80 mmHg
Heart rate: 72 bpm
Respiratory rate: 20 cpm
Temperature: 36.5
o
C

REGIONAL EXAMINATION

A. Integument
Patient's skin is fair in color. There is no pallor, jaundice, cyanosis, erythema, or edema. His skin was dry,
smooth, and neither warm nor cool to touch. He has good skin turgor. There is no clubbing and cyanosis of nails. He
has pink palpebral conjunctivae. His nail beds and nail folds do not have lesions and are devoid of tenderness. There
is good capillary refill. There are no visible lesions or color changes on the oral mucosa, nasal mucosa, and
conjunctiva. The tongue is midline, pinkish red in color, and has no lesions. There is no microglossia or macroglossia.

. Head and Neck
The patient's head was normocephalic and symmetrical. There are no noted lumps, tenderness, swelling, or
defects. The trachea is midline, with no tenderness. The thyroid gland is not palpable, and has no tenderness. There
are no distended neck veins. The parotid, submandibular, and sublingual glands are not enlarged. There are also no
cervical lymphadenopathies, masses, scars or tenderness noted.

C. Eyes
Position and alignment of both eyes were symmetrical, there is no periorbital bulging. The eyes are not
deviated or unusually prominent, and the eyebrows are equally distributed devoid of any scaliness of the underlying
skin. There are no lesions, color change or edema on the lids. The lids can open equally and adequately close. Both
pupils are reactive to light with the size of 3mm. Lacrimal gland and sac has no swelling or any other abnormalities.
There is no excessive tearing. His anicteric sclerae. Pupil size, shape and equality are evident.

D. Ear
The external ear has no masses, swelling, ulcerations, or tenderness. The pinna is mobile. There are no
tags or deformities noted. The canal is patent, there is no discharge, or excessive epithelial debris. The tympanic
membranes are intact, pearly-gray, and shiny.

E. Nose
The external nose is symmetrical, aligned vertically with the midline and free of any masses, lesion,
deformities or tenderness. The external nares are equal in size and shape. The vestibule and the rest of the visible
nasal cavity are pink, smooth, moist and devoid of ulcerations, discharge or masses. The nasal septum is in the
midline. Both nasal cavities are patent.

F. OraI Cavity & Pharynx
The lips are symmetrical, pinkish and devoid of masses or ulcerations. Further examination not conducted.

G. Chest & Lungs

Inspection: Chest is symmetrical, no deformities, masses, or abnormal bulging. Thoracic expansion is
symmetrical and expands with respiration. No precordial bulging observed.

Palpation/Percussion: There is symmetrical chest expansion with no lagging on respiratory excursion. There is
equal tactile fremitus on both lung fields. Both lung fields are resonant on percussion.

Auscultation: Normal breath sounds heard on all lung fields. No crackles or wheezing or other adventitious were
heard.


H. CardiovascuIar

Inspection: Chest is symmetrical, no deformities, masses, dilated superficial veins or abnormal bulging.

Palpation: Apex beat at the 5
th
CS left mid clavicular line

Auscultation: Normal heart rate, normal rhythm, S1>S2 at apex, S2>S1 at base, no murmurs appreciated.





I. Abdomen

The abdomen of the patient was symmetrical, flat, no striae with an inverted umbilicus. No significant scars,
masses or visible veins, striae, pulsations and peristalsis noted. No Cullen sign and no grey turner's sign. The bowel
sounds were 9 per minute. The abdomen is tympanic all over. No Direct or rebound tenderness, Liver span at 9cm.
Traube space is intact. He has CVA tenderness.

J. Extremities
No edema, no cyanosis, deformities, no limitation of range of motion. Full and equal peripheral pulses.

K. NeuroIogicaI Examination

The patient's general behavior, stream of talk and presentation were normal. She has no illusions,
hallucinations, or delusions in her content of thought. Her intellectual capacity was average for his age. She was alert,
with a normal attention span, well oriented and with good immediate, recent, and distant memory. The patient has
good understanding of abstract thought.

CraniaI Nerves:
CN I: not assessed
CN II: normal direct and consensual light reflexes
CN III, IV, VI: Symmetric palpebral fissure, eyes aligned; normal eye movements; able to gaze towards the six
cardinal positions without difficulty
CN V: Corneal reflex intact. The patient was able to open and clench his jaw; 5/5 contraction of temporal and
masseter muscles demonstrated.
CN VII: the patient was able to smile and express other facial moods symmetrically
CN VIII: Weber's test lateralized, Rinne's test AC > BC, Schwabach test normal.
CN IX and X: Patient articulates well with normal speech, able to swallow, with hoarseness
CN XI: Patient able to shrug shoulders against resistance
CN XII: Patient able to protrude tongue; no fasiculations and no deviations from the midline.

Motor System:
O nspection: symmetric muscles, normal posture, does not present with gait nor involuntary movements
O !alpation: no tenderness noted
O :scle strength testing: 5/5 on all motor strength, normal deep tendon reflexes.

CerebeIIar Exam:
O Nystagmus negative
O Dysmetria finger to nose (negative), heel to shin (negative)
O Dysdiadokinesis negative

MeningeaIs:
O Kernig's test done without any pain
O Brudzinski's done without any pain

Higher CerebraI Functions
Not assessed


Course |n the Wards
uay 0 (CcLober 26 2011)
S aLlenL sLlll has 8 flank paln buL wlLh no assoclaLed dysurla frequency vomlLlng hemaLurla and
fever no oLher sub[ecLlve complalnLs
C Ceneral Consclous coherenL ambulanL noL ln apparenL dlsLress
v/S 8 110/80 mmPg P8 84 8M 88 20 CM 1emp 371
o
C
SPLLn1 no pallor no [aundlce anlcLerlc sclerae plnk palpebral con[uncLlvae no neck veln
dlsLenLlon no cervlcal lymphadenopaLhles
C/L symmeLrlcal chesL expanslon no reLracLlons clear and equal bronchoveslcular breaLh
sounds no crackles wheezes rales
CvS no precordlal bulge adynamlc precordlum no heaves/Lhrllls normal raLe regular
rhyLhm no murmurs S3 or S4
Abdomen flaL sofL LympanlLlc nonLender normoacLlve bowel sounds %+% CVA tenderness
LxLremlLles no edema no cyanosls no llmlLaLlon of range of moLlon full equal perlpheral
pulses
D|agnost|cs
CompleLe 8lood CounL wlLh laLeleL CounL
Analyte Patient's values
Bemoglobin
Bematociit .
WBC count 8.
Segmenteis .8
Lymphocytes .
Eosinophils .
Nonocytes .
Platelets
RBC Noiphology Noimocytic, noimochiomic



urlnalysls
Patient's values
Coloi Yellow
Chaiactei Cleai
Specific uiavity .
pB .
Albumin Tiace
Sugai (-)
WBC -BPF
RBC -BPF
Epithelial cells few
Nucus cells +

Cllnlcal ChemlsLry
Analyte Patient's values
Na B
K .
Seium Cieatinine
B0N .8
0iic Aciu .
CBu mgul

ChesL A vlew
C1 raLlo of 034 resL of Lhe oLher Lhoraclc sLrucLures are unremarkable
lmpresslon SllghL Cardlomegaly

Lumbosacral Splne A/L vlew
ke|at|ve stra|ghten|ng of |umbar |ordos|s most ||ke|y due to musc|e spasm
No fractures ||sthes|s ||th|ases noted


12L LCC
ALrlal and venLrlcular 8aLe of 72 Slnus 8hyLhm no axls devlaLlon no lschemla or lnfarcL on any leads

A 1/C ureLerollLhlasls 8
MusculoskeleLal SLraln Lumbar area

D|agnost|cs
ku8rosLaLe ulLrasound

Support|ve
uleL uleL as LoleraLed
lvl laln L8 1L x 8
o


1herapeut|cs
1 Cfloxacln (lnoflox) 200mg lv q 12
o

2 1ramadol 30 mg lv q8
o
8n for paln
uay 1 (CcLober 27 2011)

S aLlenL sLlll has 8 flank paln Lolerable Pe also developed dysurla and frequency Pe sLlll has no
vomlLlng hemaLurla and fever no oLher sub[ecLlve complalnLs
C Ceneral Consclous coherenL ambulanL noL ln apparenL dlsLress
v/S 8 120/80 mmPg P8 80 8M 88 19 CM 1emp 368
o
C
SPLLn1 no pallor no [aundlce anlcLerlc sclerae plnk palpebral con[uncLlvae no neck veln
dlsLenLlon no cervlcal lymphadenopaLhles
C/L symmeLrlcal chesL expanslon no reLracLlons clear and equal bronchoveslcular breaLh
sounds no crackles wheezes rales
CvS no precordlal bulge adynamlc precordlum no heaves/Lhrllls normal raLe regular
rhyLhm no murmurs S3 or S4
Abdomen flaL sofL LympanlLlc nonLender normoacLlve bowel sounds %+% CVA tenderness
LxLremlLles no edema no cyanosls no llmlLaLlon of range of moLlon full equal perlpheral
pulses
klunL?S u8lnA8? 8LAuuL8 Anu 8CS1A1L CLAnu uL18ASCunu
8oLh kldneys have homogenous parenchymal echogenlclLy 1he rlghL kldney measures 103 x 49 cm
wlLh a corLlcal Lhlckness of 10 cm whlle lefL kldney measures 103 x 36 cm wlLh a corLlcal Lhlckness of
12 cm 1here |s separat|on of the r|ght centra| echo comp|ex 1he lefL cenLral echo complex ls lnLacL
No rena| ||th|as|s seen b||atera||y

1he urlnary bladder ls adequaLely fllled wlLh smooLh walls and no lnLernal echoes seen 1he LoLal
amounL of urlne ln Lhe bladder ls 188 cc whlch was reduced Lo 20cc on posL voldlng scan

1he prosLaLe gland ls homogenous and noL enlarged lL measures 28 x 23 x 33 cm wlLh an approxlmaLe
volume of 11 grams

lmpresslon
elveocallecLasla 8lghL C1 sLenographlc correlaLlon ls suggesLed for furLher evaluaLlon
unremarkable ulLrasound sLudy of Lhe LefL kldney urlnary 8ladder and rosLaLe Cland


A ureLerollLhlasls 8
elveocallecLasla 8


D|agnost|cs
lor C1sLonogram
Support|ve
uleL uleL as LoleraLed
lvl laln L8 1L x 8
o


1herapeut|cs
1 Cfloxacln (lnoflox) 200mg lv q 12
o

2 1ramadol 30 mg lv q8
o
8n for paln


uay 2 (CcLober 28 2011)

S aLlenL sLlll has 8 flank paln Lolerable Pe also developed dysurla and frequency Pe sLlll has no
vomlLlng hemaLurla and fever no oLher sub[ecLlve complalnLs
C Ceneral Consclous coherenL ambulanL noL ln apparenL dlsLress
v/S 8 120/80 mmPg P8 82 8M 88 20 CM 1emp 362
o
C
SPLLn1 no pallor no [aundlce anlcLerlc sclerae plnk palpebral con[uncLlvae no neck veln
dlsLenLlon no cervlcal lymphadenopaLhles
C/L symmeLrlcal chesL expanslon no reLracLlons clear and equal bronchoveslcular breaLh
sounds no crackles wheezes rales
CvS no precordlal bulge adynamlc precordlum no heaves/Lhrllls normal raLe regular
rhyLhm no murmurs S3 or S4
Abdomen flaL sofL LympanlLlc nonLender normoacLlve bowel sounds %+% CVA tenderness
LxLremlLles no edema no cyanosls no llmlLaLlon of range of moLlon full equal perlpheral
pulses
C1SLonogram
8oLh kldneys normal ln slze no evldenL solld or cysLlc parenchymal masses
Sma|| uretera| ves|ca| stone measur|ng 47mm seen |n the r|ght s|de
rox|ma| ureter and r|ght pe|veoca|ycea| system are noted to be d||ated
8oLh ureLers are noL dllaLed

1he urlnary bladder ls dlsLenslble wlLh no evldence of lnLralumlnal mass or sLones 1he wall ls noL
Lhlckened 1he vlsuallzed llver ls normal ln slze wlLh homogenous paLLern no deflnlLe


lmpresslon
elveocallecLasla 8lghL C1 sLenographlc correlaLlon ls suggesLed for furLher evaluaLlon
unremarkable ulLrasound sLudy of Lhe LefL kldney urlnary 8ladder and rosLaLe Cland


8 ureLerollLhlasls 8
elveocallecLasla 8



Support|ve
uleL uleL as LoleraLed
lvl laln L8 1L x 8
o


1herapeut|cs
1 Cfloxacln (lnoflox) 200mg lv q 12
o

2 1ramadol 30 mg lv q8
o
8n for paln
3 1amsulosln (rozelax) 200mcg 1 Lab Cu
4 Acalka 1 Lab 1lu

uay 3 (CcLober 29 2011)

S aLlenL ls comforLable no vomlLlng dysurla frequency hemaLurla and fever no oLher
sub[ecLlve complalnLs
C Ceneral Consclous coherenL ambulanL noL ln apparenL dlsLress
v/S 8 120/80 mmPg P8 72 8M 88 19 CM 1emp 363
o
C
SPLLn1 no pallor no [aundlce anlcLerlc sclerae plnk palpebral con[uncLlvae no neck veln
dlsLenLlon no cervlcal lymphadenopaLhles
C/L symmeLrlcal chesL expanslon no reLracLlons clear and equal bronchoveslcular breaLh
sounds no crackles wheezes rales
CvS no precordlal bulge adynamlc precordlum no heaves/Lhrllls normal raLe regular
rhyLhm no murmurs S3 or S4
Abdomen flaL sofL LympanlLlc nonLender normoacLlve bowel sounds %% CVA tenderness
LxLremlLles no edema no cyanosls no llmlLaLlon of range of moLlon full equal perlpheral
pulses
A ureLerollLhlasls 8

Support|ve
uleL uleL as LoleraLed
lvl laln L8 1L x 8
o


1herapeut|cs
1 Cfloxacln (lnoflox) 200mg lv q 12
o

2 1ramadol 30 mg lv q8
o
8n for paln
3 1amsulosln (rozelax) 200mcg 1 Lab Cu
4 Acalka 1 Lab 1lu
uay 4 (CcLober 30 2011)

S aLlenL ls comforLable no vomlLlng dysurla frequency hemaLurla and fever no oLher
sub[ecLlve complalnLs
C Ceneral Consclous coherenL ambulanL noL ln apparenL dlsLress
v/S 8 110/60 mmPg P8 68 8M 88 20 CM 1emp 368
o
C
SPLLn1 no pallor no [aundlce anlcLerlc sclerae plnk palpebral con[uncLlvae no neck veln
dlsLenLlon no cervlcal lymphadenopaLhles
C/L symmeLrlcal chesL expanslon no reLracLlons clear and equal bronchoveslcular breaLh
sounds no crackles wheezes rales
CvS no precordlal bulge adynamlc precordlum no heaves/Lhrllls normal raLe regular
rhyLhm no murmurs S3 or S4
Abdomen flaL sofL LympanlLlc nonLender normoacLlve bowel sounds %% CVA tenderness
LxLremlLles no edema no cyanosls no llmlLaLlon of range of moLlon full equal perlpheral
pulses
A ureLerollLhlasls 8

Support|ve
MCP
uleL uleL as LoleraLed
lvl laln L8 1L x 8
o


1herapeut|cs
nome Meds
1 Cfloxacln (lnoflox) 200mg Lab Cu
2 1amsulosln (rozelax) 200mcg 1 Lab Cu
3 Acalka 1 Lab 1lu