1. Joanne and Arvin

2. Plans for Diagnosis and Management 1. Immediate stabilization Day 1 (01-26-10) Patient was hydrated and placed under diet – 1800 kcal/day, 270g CHO, 15g CHON, 25g fats divided into 3 meals and 2 snacks. Course in the Ward

3. Plans for Diagnosis and Management 2. Complete History and Physical Exam 3 of the following 5 criteria (Acute Pyelonephritis): 1)clinical symptoms of APN (chilling, nausea, vomiting, flank pain) 2)CVA tenderness 3)leukocytosis (higher than 10,000/µL) 4)fever (higher than 38.5 ℃ ) 5)WBC count ≥5 cells/hpf on centrifuged urine sediment Course in the Ward Reference: The Philippine Clinical Practice Guideline on the Diagnosis and Management of Urinary Tract Infections: A Quick Reference Guide for Clinicians* Report of the Task Force on Urinary Tract Infections 1998

4. Plans for Diagnosis and Management 3. Patients presenting with signs and symptoms of pyelonephritis should have a urine culture and blood culture. – The results of the urine culture may not be available for 48 hours therefore a urinalysis and CBC can be used to support presumptive diagnosis of pyelonephritis. CBC with platelet count: – WBC of 35.5 predominantly neutrophils. Urinalysis – Yellow, slightly turbid, pH 6.5 sp gr 1.005, albumin (-), sugar (-), RBC 0-2/hpf, pus cell 8-12/hpf and bacteria +++. Urine GS/CS and Blood C/S were not done prior to antibiotic therapy. Course in the Ward Reference: The Philippine Clinical Practice Guideline on the Diagnosis and Management of Urinary Tract Infections: A Quick Reference Guide for Clinicians* Report of the Task Force on Urinary Tract Infections 1998

5. Plans for Diagnosis and Management 4. Broad spectrum IV antibiotics should be started until the results of the urine culture are available and a more selective antibiotic can be identified. 5. Paracetamol 500mg/tab, 1 tab q4h prn for fever Ceftriaxone (2g/IV OD) and Paracetamol (500mg/tab, 1 tab q4h prn) were both started Course in the Ward

6. Empiric Therapy Reference: The Philippine Clinical Practice Guideline on the Diagnosis and Management of Urinary Tract Infections: A Quick Reference Guide for Clinicians* Report of the Task Force on Urinary Tract Infections 1998

7. Plans for Diagnosis and Management Empiric Therapy – Sepsis secondary to acute pyelonephritis Parenteral regimen: ceftriaxone 1-2 g once a day; ciprofloxacin 200-400 mg every 12 hours; ofloxacin 200- 400 mg every 12 hours; gentamicin 3-5 mg/kg once a day or 1 mg/kg every 8 hours. Reference: The Philippine Clinical Practice Guideline on the Diagnosis and Management of Urinary Tract Infections: A Quick Reference Guide for Clinicians* Report of the Task Force on Urinary Tract Infections 1998

8. Plans for Diagnosis and Management 6. Request for chest x-ray and sputum examination for acid-fast bacilli. Chest X-Ray was requested Negative AFB smear on day 1, 2 and 3 of hospital stay Course in the Ward

9. Plans for Diagnosis and Management A. PULMONARY TB DSSM Result: – Smear (+) A patient with at least 2 sputum specimens positive for AFB, with or without radiographic abnormalities consistent with active TB. A patient with 1 sputum specimen positive for AFB and with radiographic abnormalities consistent with active pulmonary TB as determined by a physician A patient with 1 sputum specimen positive for AFB and sputum culture positive for M. tuberculosis

10. Plans for Diagnosis and Management DSSM Result: – Smear (-) A patient with at least 3 sputum specimens negative for AFB with radiographic abnormalities consistent with active TB, and there had been no response to a course of antibiotics and/or TBDC to treat the patient with a full course of anti-TB chemotherapy

11. Plans for Diagnosis and Management Types: A. New – A patient who has never had treatment for TB or who has taken anti-TB drugs for less than one month. B. Relapse – A patient previously treated for TB who has been declared cured or treatment completed, and is diagnosed with bacteriologically positive (smear or culture) TB. C. Failure – A patient who, while on treatment, is sputum smear positive at five months or later during the course of treatment.

12. Plans for Diagnosis and Management D. Return after default (RAD) – A patient who returns to treatment with positive bacteriology (smear or culture), following interruption of treatment for 2 months or more. E. Transfer-in – A patient who has been transferred from another facility with proper referral slip to continue treatment.

13. Plans for Diagnosis and Management F. Others – All cases that do not fit into any of the above definitions. This group includes: a patient who is starting treatment again after interrupting treatment for more than 2 months and has remained or became smear-negative a sputum smear negative patient initially before starting treatment and became sputum smear-positive during the Rx.

14. Plans for Diagnosis and Management Category I (2 HRZE/ 4HR) – New pulmonary smear (+) cases – New seriously ill pulmonary smear (-) cases with extensive lung lesions on CXR as assessed by TB Diagnostic Committee – New extra-pulmonary TB – Concomitant HIX infxn – Intensive phase – HRZE for 2 months – Maintenance phase – HR for 4 months Category II (2 HRZES/ 1HRZE/ 5HRE) – failure cases – relapse cases – return after default RAD (smear +) – other ( smear+ or -) – Intensive phase – HRZES for 2 months then HRZE for 1 month – Maintenance phase – HRE for 5 months

15. Plans for Diagnosis and Management Category III ( 2 HRZ(E) / 4HR) – new smear (-) but with minimal PTB on CXR as assessed by TB diagnostic committee – ethambutol may be omitted for non-cavitary, smear (-), fully susceptible cases Category IV – chronic ( still smear (+) after supervised re- treatment) – refer to specialized facility or DOTS plus/ PMTM Center

16. Plans for Diagnosis and Management Treatment regimen for category II: – 2HRZES/HRZE/4HRE – 30-37kg Intensive phase – first 2 mon. 2 HRZE, 0.75g streptomycin 3rd mon. 2 HRZE. Continuation phase – 2 HR, 1 E 400 mg – 38-54 kg Intensive phase – first 2 mon. 3 HRZE, 0.75g streptomycin 3rd mon. 3 HRZE Continuation phase – 3 HR, 2 E 400 mg

17. Plans for Diagnosis and Management Treatment regimen for category II: – 55-70kg » Intensive phase – first 2 mon. » 4 HRZE, 0.75g streptomycin » 3rd mon. 4 HRZE » Continuation phase – 4 HR, 3 E 400 mg – >70kg » Intensive phase – first 2 mon. » 5 HRZE, 0.75g streptomycin » 3rd mon. 5 HRZE » Continuation phase – 5HR, 3 E 400 mg Follow-up: Category II - end of 3rd month and 5th month, start of 8th month

18. Insert CHEST X-RAY FINDINGS and picture

19. Plans for Diagnosis and Management Usual Dx and Mx plans for pneumonia were complicated by the CC. of Pyelonephritis. Pneumonia Dx based on clinical presentation and confirmed by chest x-ray. Hydrate the patient CBC Gram stain and culture of the sputum Sputum AFB smear to rule out active TB Patient was hydrated and placed under diet CBC Urinalysis Chest X-Ray was requested Negative AFB smear on day 1, 2 and 3 of hospital stay Course in the Ward

21. CAP Any of the ff: RR ≥30/min PR ≥125/min Temp ≥40 or ≤35°C Suspected aspiration Extrapulmonary evidence of sepsis Unstable comorbid conditions CXR: multilobar, pleural effusion, abscess, progression of lesion to 75% in 24 hours Low risk CAP Out-patient NO YES Any of the ff: 1.Shock or signs of hypoperfusion, hypotension, altered mental state, urine output <30ml/hr 2.PaO 2 50mmHg) at room air YES NO Moderate risk CAP In-patient High risk CAP ICU Philippine Community-Acquired Pneumonia (CAP) Guidelines 2004

22. Plans for Diagnosis and Management The course in the ward for treating Pyelonephritis and Pneumonia are similar. Empirical regimen is administered: – Azithromycin 500 mg IV q 24 h plus β-lactam IV (cefotaxime 1 to 2 g q 8 to 12 h; ceftriaxone 1 g q 24 h) – Macrolides Ceftriaxone (2g/IV OD) and Paracetamol (500mg/tab, 1 tab q4h prn) were both started (In treating the pyelonephritis, the pneumonia also could have been treated) Course in the Ward

24. Plans for Diagnosis and Management Routine urologic evaluation (ultrasound or CT scan of the kidney) and routine use of imaging procedures are not recommended. Radiologic evaluation should be considered if the patient remains febrile within 72 hours of treatment to rule out the presence of nephrolithiasis, renal or perirenal abscesses, or other complications of pyelonephritis. Course in the Ward Reference: The Philippine Clinical Practice Guideline on the Diagnosis and Management of Urinary Tract Infections: A Quick Reference Guide for Clinicians* Report of the Task Force on Urinary Tract Infections 1998

25. Plans for Diagnosis and Management Day 2 (01-27-10) Spot sputum AFB stain still showed no acid fast bacilli. Urine and blood specimen were collected for urine GS and CS, and blood culture There were still episodes of fever and cough, with no dysuria Crackles were heard bilaterally on both lung fields Ceftriaxone was continued and Erdosteine (300mg/cap, 1 cap BID) was started. Course in the Ward

26. Day 2 (01-27-10) Serum sodium and potassium levels were requested – Hyponatremia and hypokalemia Kalium durule, 2 durules TID x 6 doses was given and hydration with PNSS was continued. A repeat CBC showed WBC of 11.80. (35.5 in Day 1) FBS was also requested showing normal value.

27. Day 3 (01-28-10) Spot sputum AFB stain still showed no acid fast bacilli. Patient was referred to DOTS for further evaluation and management. Patient was afebrile, with stable vital signs, no dysuria but still has cough and (+) bilateral crackles Ceftriaxone was shifted to Cefixime 200mg/cap, 1 cap BID for 5 days (until Feb 1, 2010) Patient had stable vital signs. The rest of the hospital stay was unremarkable. Patient was then discharged improved and stable.

28. Discharge Medications: – Cefixime 200mg/cap, 1 cap BID for 5 days (until Feb 1, 2010) Special Instructions – Refer back to DOTS with X-ray and sputum AFB results as outpatient, increase oral fluid intake Follow-up or Transfer Instruction – To come back at Med OPD on Feb 11, 2010 (Thurs, 8am) with DOTS referral.

29. LABORATORY RESULTS

30. CBC DateJan 26 2010Jan 28 2010 Hgb (NV: 120-170 g/dl)127113 RBC (NV: 3.8-5.5x10 6 /µL )4.413.98 Hct (NV: 0.37-0.54)0.370.33 MCV (NV: 78-101 fL)84.383.7 MCH (NV: 27-31 pg)28.928.3 MCHC (NV: 32-36 g/dl)34.333.8 RDW (NV: 11.6-14.6)12.612.9 MPV (NV: 7.4-10.4 fL)5.55.3 Plt (NV: 150-450x10 9 /L320298 WBC (NV: 4.5-10x10 9 /L35.511.8 Neutro (NV: 0.5-0.9)0.920.63 Bands (NV: 0-0.05)0.09- Segmenters (NV: 0.5-0.7)0.830.63 Lym (NV: 0.20-0.40)0.080.34 Mono (NV: 0-0.07)-0.02 Eos (NV: 0-0.01)-0.01 Baso (NV: 0-0.01)--

31. Abnormal Findings Jan 26 2010 Jan 28 2010 Hgb (NV: 120-170 g/dl) 127113 Hct (NV: 0.37-0.54)0.370.33 WBC (NV: 4.5-10x10 9 /L) 35.511.8 Neutro (NV: 0.5-0.9)0.920.63 Segmenters (NV: 0.5-0.7) 0.830.63

32. Blood Chemistry DateJan 27, 2010 (Day 2) Sodium (NV: 137-147 mmol/L)133 Potassium (NV: 3.8-5 mmol/L)3.3 FBS (NV: <100mg/dl)87

33. Urinalysis DateJan 26 2010 ColorYellow TransparencyTurbid pH6.5 Specific Gravity1.005 AlbuminNegative SugarNegative Hyaline casts0-2/coverslip RBC0-2/hpf Pus cell8-12/hpf Squamous cell++ Bacteria+++

34. Urine GS/CS Urine culture showed no growth after 2 days of incubation Urine gram stain showed no findings on centrifuged and on uncentrifuged urine.

35. Blood Culture Blood culture showed no growth after 5 days of incubation.