ALERTA, Kathrinna Feliz F.

13-0146
Write-up

Identifying Information
F.G. 24 G1PO 24 weeks AOG
Single, Filipino, Catholic, resides in East Rembo, Makati

Informant
Patient herself with good reliability

Chief Complaint
Fever

History of Present Illness

The patient is a 24 year old G1P0, LMP May 9, AOG 22 4/7 weeks AOG coming in for fever.

Night prior to consult, patient noted fever with highest temperature at 39 degrees Celsius. There was associated body
malaise, and generalized body weakness. Right flank pain was noted, non-radiating, heavy in character, 2/10, aggravated
by movement and by coughing. There was also hypogastric pain and dysuria. There was also non-productive cough and
colds.

There was no noted watery, bloody or foul-smelling vaginal discharge, nor uterine contractions. The patient claims good
fetal movement.

Symptoms prompted consult.

Trimestral History
First trimester
A pregnancy test was done after 1 month of missed menses. No prenatal checkup was done. The patient denies any
exposure to radiation, any history of viral exanthema or maternal illnesses at that time. There was also no multivitamins
or folic acid taken.
Second trimester
Quickening was noted between 4 and 5 months of pregnancy. There was still no prenatal checkups done. She self-
medicated with multivitamins and ferrous sulfate.
Third trimester
The symptoms mentioned in the history of present illness heralded her third trimester.

Temporal Profile

Review of Systems
General (+) fever, (-) weight loss, (-) weight gain, (-) loss of appetite, (+) weakness, (+)
fatigue
HEENT (+) headache, (-) dizziness, (-) blurring of vision, (-) tinnitus, (-) deafness, (-)
epistaxis, (-) frequent colds, (-) hoarseness, (-) dry mouth, (-) gum bleeding
Respiratory (-) dyspnea, (-) hemoptysis, (+) cough, (+) colds, (-) wheezing
Cardiovascular (-) palpitations, (-) chest pains, (-) syncope, (-) orthopnea
Gastrointestinal (-) nausea, (-) vomiting, (+) hypogastric pain, (-) dysphagia, (-) heartburn, (-)
constipation, (-) diarrhea, (-) rectal bleeding, (-) jaundice
 Endocrine (-) excessive sweating, (-) heat intolerance, (-) cold intolerance, (-) polyuria, (-)
excessive thirst
Genitourinary (+) dysuria, (-) changes in urine color, (-) sexual dysfunction
Neurological (-) seizures, (-) tremors

Past Medical History

The patient has no known comorbids; no asthma, no hypertension, no diabetes mellitus. The patient also has no
previous hospitalizations or surgeries.

Family History

The family history was similarly unremarkable, with no known heredo-familial illnesses.

Personal/Social History

The patient is a non-smoker, and an occasional alcoholic beverage drinker whose last consumption was prior to the
pregnancy. She denies illicit drug use.

The patient is college graduate, currently unemployed and lives with her family.

Gynecologic History

The patient had her menarche at 10 years old. She is regularly menstruating at an interval of 28-30 days, lasting about 3
days per menstruation, using 4 pads per day. She experiences dysmenorrhea on the last day of her menses.

She has no history of use of contraceptives, IUD, OCPs, injectables, or otherwise.

Sexual History

The patient had her coitarche at 20 years of age, and has had one partner to date. She claims that they are
monogamous. She denies any dyspareunia and postcoital bleeding.

Obstetric History

The patient is a primigravid.

Stakeholder’s Analysis
Stakeholder Stake Stand Intensity of Degree of Remarks
Stand Influence
Patient Concerned for her own health Ally High High Will be dependent on her
and her baby caregivers for the rest of her
pregnancy
Unborn child Life Ally N/A N/A
Partner One of the breadwinners/ Ally High High Will have to divide his time
caregivers of the patient between working and
watching over his partner at
the hospital
Mother One of the breadwinners/ Ally Moderate High Does not believe that the
caregivers of the patient patient should have gotten
pregnant in the first place,
 but is willing to care for the
patient
Father One of the breadwinners of Ally High Moderate
the patient

Physical Examination
System Findings
General Survey Awake, weak-looking, conscious, coherent, not in cardiorespiratory distress
Anthropometrics Wt 57 kg Ht 157.5 cm
Vital Signs BP 120/80 HR 82 RR 20 T 39 degC Pain scale 0/10
HEENT Pink palpebral conjunctivae, anicteric sclerae, no tonsillopharyngeal congestion, no
cervicolymphadenopathies
Cardiovascular Adynamic precordium, PMI at 5th ICS left MCL, no murmurs
Chest and Lungs Symmetric chest expansion, clear breath sounds
Breasts Not examined
Abdomen Globular, no scars, normoactive bowel sounds, soft, non-tender, (-) guarding
FH: level of the umbilicus FHT: 150s
Back (+) CVA tenderness, right
Pelvis Speculum exam: Cervix violaceous, no mass, no erosions, no bleeding per os
Internal exam: normal looking external genitalia, parous introitus, vagina admits 2 fingers with
ease, cervix posterior, firm, closed
Rectal Not examined
Extremities <2 s CRT, no cyanosis, (+) bipedal edema, non-pitting, grade I

Salient Features
Subjective Objective
24 G1P0 22 4/7 weeks AOG Conscious, coherent, not in cardiorespiratory distress
~10 hour history of high grade fever, highest Normotensive, normal heart rate and respiratory rate
temperature at 39 degC Febrile at 39 degC
(+) body malaise, generalized body weakness Symmetric chest expansion, clear breath sounds
(+) dysuria, hypogastric pain (+) CVA tenderness
(+) nonproductive cough, and colds Speculum exam: Cervix violaceous, no mass, no erosions,
(+) flank pain, right, non-radiating 2/10 no bleeding per os
(-) watery, bloody or foul-smelling vaginal discharge Internal exam: normal looking external genitalia, parous
(-) uterine contractions introitus, vagina admits 2 fingers with ease, cervix
(+) good fetal movement. posterior, firm, closed

Primary Impression
Acute pyelonephritis

Differential Diagnoses
Diagnosis Rule in Rule out
Lower urinary tract (+) dysuria Does not usually present with high grade fever
infection (39 degC)
(+) flank pain
(+) CVA tenderness
 Upper respiratory (+) fever 39 degC (-) nasal discharge
tract infection (+) cough and colds (+) symmetric chest expansion
(+) clear breath sounds
Sepsis (+) weak-looking Normotensive
Febrile at 39 degC Normal heart rate, normal respiratory rate
(+) focus of infection
*Important differential to rule out because
of its morbidity and mortality

Discussion
Pathophysiology. Hormonal changes during pregnancy, like progesterone-induced relaxation of smooth muscles, also
affect the urinary tract. The pelvic calyces dilate significantly, for example, especially during mid-pregnancy. Because of
the decrease in tone, it’s more likely for vesicoureteral reflux to occur, increasing the rate for ascending urinary tract
infection.
Etiology. Perineal flora are the most common etiologic agents that cause urinary tract infection even in pregnancy. This
primarily includes Escherichia coli strains. They usually cause nonobstructive pyelonephritis via adhesins which enhance
bacterial adherence and virulence. Viral adherence and virulence is also made easier by the increase in vesicoureteral
reflux and the consequent pooling of urine in the upper urinary tract already mentioned.

Course and Management

Diagnostics. At the ER, preliminary diagnostics done were CBC+PC to check for the WBC count and platelet; urinalysis to
check for urinary tract infection; blood urea nitrogen and creatinine to check for kidney function given that the patient
was already presenting with flank pain and CVA tenderness. HbSAg, RPR and ABO were also requested as routine tests for
baseline values, as the patient wasn’t compliant with her prenatal checkups. The results of the diagnostics at the ER level
are as follows.
Diagnostic Results Interpretation
CBC+PC Hgb 8.5 Hct 0.28 WBC 26.2 Neu 0.89 Lymph Anemia, probably secondary to the
0.04 Mono 0.07 Plt 204 ongoing infection
Leukocytosis, probably secondary to the
ongoing infection; high WBC count could
mean high level of virulence; neutrophilic
predominance points to an ongoing
bacterial infection
Urinalysis Light yellow, turbid; albumin negative, sugar Bad catch because of the high epithelial
negative cell count
pH 6.5 sp grav 1.02 Might still point to an ongoing urinary
WBC 13.1 tract infection
EC 9.9 Does not rule in or rule out any upper
Bacteria 226.5 urinary tract infection
Kidney
function tests

Routine tests HBsAg negative No hepatitis B infection

RPR negative No syphilis infection
B+
Dengue blot IgG negative IgM negative NS1 negative No ongoing dengue infection
Therapeutic
Preventive