Chronic pyelonephritis, bilateral, active stage

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FAR EASTERN FEDERAL UNIVERSITY

PRIMORSKY KRAI, VLADIVOSTOK

RUSSIA

FAR EASTERN FEDERAL UNIVERSITY

SCHOOL OF BIOMEDICINE

Academic medical history

Chronic pyelonephritis, bilateral, active stage

Completed by - S. Sharlina Annie Florence, c7116A

1. Passport details

· Name - Elena

· Age - 15 years

· Profession - student

· Place of work - school

· Date and time of admission -

· Mother name - Tatyana

· Father name - Anthon

· Address - Svetlanskayast, Vladivostok

2. Complaints

· The patient complaints at admission of temperature of up to 38.5 C,chills, pain in the lumbar region on both sides, lethargy, reduced urination, single vomiting.

3. Anamnesis morbid

· For the first time in 2017, she suffered from acute pyelonephritis.

· On this occasion, an examination and treatment were conducted in the hospital at the place of residence. Against the background of the ongoing treatment, there was a positive trend, she was discharged with recommendations.

· During the following years, there were no complaints from the kidneys, I did not go to the doctor.

· 3 months ago, since December 2020, the patient began to notice the appearance of periodic pain in the lower back, a rise in temperature to sub-febrile numbers, a violation of well-being in the form of general weakness, drowsiness, irritability, headache, increased sweating.

· Independently took analgesics and antipyretic drugs, without much effect.

· According to the patient, 2 weeks ago she suffered from ARVI. I began to notice an increase in temperature to 38, increased pain in the lumbar region on both sides, decreased urination, chills.I went to the hospital at my place of residence, and was given a referral for hospitalization in the hospitalization.

· In the hospital at the place of residence, no examinations were carried out.

4. Anamnesis vitae

Ш Obstetric history - According to the mother she wasborn from the second pregnancy, the second birth against the background of the threat of miscarriage of the first and second sexual pregnancies for which the mother was treated with a positive effect.

The mother's nutrition during pregnancy was satisfactory, and there were no occupational hazards.

She was born at 39-40 weeks, weighing 3400 grams. She screamed at once.

I screamed at once. It was applied to the chest on the first day.

On day 4, she was transferred to the OPI GDB, with a diagnosis of conjugated jaundice.

He denies birth injuries of the neonatal period.

Ш Physical and neuropsychiatric development-

The increase in body weight and length occurred according to gender and age.

She attended kindergarten from the age of 3, and school from the age of 7.

School performance is good.

Ш Past disease -

SARS often, Chicken pox.

Ш Hereditary and Family history -

The mother has Chronic gastroduodentis.

Ш Material and Living Condition -

Material and living condition is satisfactory.

5. Epidemiological history

Contact with infectious patients, including influenza, in the last 3 weeks denies.

Allergic history -

§ Drug-induced allergic reaction denies.

§ Food-for citrus fruits, sweets.

Drug history -

§ Parents deny the presence of bad habits and the use of narcotics.

Vaccination history -

§ Vaccination was up to date and it was without any complications.

Transfusion history -

§ No transfusion of blood was done during her life time.

FAMILY TREE:-

6. Status prasens

External examination -

General condition of the patient - Unsatisfactory.

Well being - Good.

Position - Active.

Consciousness - Clear.

Physique - Normosthenic. Height is 152cm, Weight is 39kg. Physique is harmonious.

Skin -Skin is pale, elastic and moderately moist.

Rash, scars, varicose veins, edema are absent.

Mucous membranes : mucous membranes of the eyes, nasal and oral cavities, lips are pale pink.

Subcutaneous tissue - developed moderately to 1.0 cm, evenly, according to gender and age. Pasty is not defined.

Lymph nodes - submandibular, cervical, occipital, axillary, 3-4 mm in size, soft-elastic, uniform consistency, not soldered to the surrounding tissue and among themselves, painless on palpation.

Muscles - painless with palpation, passive and active movements; moderate development; muscle tone corresponds to age.

Bones - painless on palpation and pounding; no deformity.

Joints - normal configuration without deformities; painless on palpation; skin hyperemia and local temperature increase in the area of the joints are not noted; movements in the joints are active and passive-free, painless.

Ш Respiratory system -

Breathing through the nose is not difficult, mixed type, rhythmic, shallow, BH 24 / min. The voice is not changed. Shortness of breath, cough are not detected. The chest is of the correct shape. The supra-and subclavian are moderately pronounced, the epigastric angle is less than 90 .The right and left sides of the chest are symmetrically involved in the act of breathing.

On palpation, the thorax is elastic, painless, and the pleural friction noise is not detected. The voice tremor is carried out symmetrically.

With comparative percussion over both lungs, a clear pulmonary sound.

Topographic percussion data: the height of the standing top in front:

a. on the right - - - above the clavicle by 2 cm.

b. on the left - - - above the clavicle by 2 cm.

Lower borders of the lungs:

Right:

midclavicular line - 6 edge

middle axillary - 8 rib

posterior axillary - 9 rib

spatula - 10 rib

Paravertebral / spinous process 11 of the thoracic vertebra:

The left one:

middle axillary -9rib

posterior axillary- 10 rib

spatula - 11 rib

Paravertebral spinous process of the 11th vertebra.

The mobility of the lower borders of the lungs along the posterior axillary line with forced breathing is 2.5 cm.

During auscultation, breathing is vesicular. Wheezing, crepitation, pleural friction noise is not audible.

The bronchophonia is symmetrical.

Ш Circulatory organs -

On examination: no heart hump. There is no visible pulsation of the carotid arteries, cervical veins, in the epigastric region.

On palpation: left ventricular impulse in V m / r along the midclavicular line, localized, of medium strength, positive.

Right ventricular impulse: not palpable. Pathological pulsation, cardiac tremors, pericardial friction are not detected.

Borders of relative cardiac dullness: right-right edge of the sternum in IV m/r, upper-III rib, left - along the left mid-clavicular line in V m/r.

During auscultation: heart tones of medium volume, rhythmic. Heart rate 102 beats per minute.

The pulse is the same on both hands, rhythmic, pulse rate 102 beats per minute, satisfactory filling, not strained, normal in shape. There is no pulse deficit.

Blood pressure on the left arm - 120/80 mm Hg, on the right-120/80 mm Hg.

The walls of the peripheral arteries are soft-elastic consistency, smooth, painless.

Ш Digestive organs -

The tongue and mucous membranes of the oral cavity are moist. The tongue is covered with a white coating. The pharynx is not hyperemic. Swallowing is not disturbed. The teeth are sanitized.

The abdomen of the usual configuration, participates in the act of breathing, visible peristalsis and expansion of the veins of the anterior abdominal wall is not noted. Divergence of the rectus abdominis muscles is not observed. Navel on the median line.

The percussive sound is tympanic, the free fluid is not detected. Liver size according to Kurlov percussion data: I -8 cm, II - 7 cm, III - 6 cm. Dimensions of the spleen: length of 10 edges-6 cm, diameter - 4 cm.

On superficial palpation, the abdomen is soft, painless.

With deep palpation: the sigmoid; caecum; ascending and descending sections of the large intestine are palpated in the form of soft, elastic, moderately mobile, painless cords with a width of 1.5-2.0 cm. The body and the pyloric part of the stomach, the transverse colon are not palpable. The spleen and gallbladder are not palpable. The liver does not protrude from under the edge of the costal arch.

During auscultation: moderate peristalsis, quiet. Stool 1 time a day without blood, mucus and pathological impurities.

Ш Urinary system -

The lumbar region is not changed. There is no tension in the muscles of the lumbar region. The region of the kidneys is without deformations and changes. The kidneys in the position of the patient lying and standing are not palpable. The ureteral points are moderately painful. The tapping symptom is moderately positive on the right, slightly positive on the left. The bladder is not palpable, percussion is not determined.

Ш Nervous system -

Consciousness is clear. Speech, coordination of movements are not impaired. Meningeal signs are absent. Sleep is normal.

Ш Endocrine system -

On examination and palpation, the thyroid gland is not detected. Pathological eye symptoms are not detected. Secondary sexual characteristics are developed according to gender and age.

7. Preliminary diagnosis

· Chronic pyelonephritis, a stage of active inflammation.

Justification of preliminary diagnosis -

The diagnosis was made on the basis of:

· complaints of fever up to 38.5 C, pain in the lower back, frequent urge to urinate, reduced urination up to 2-3 times a day.

· Anamnesis: in 2017, she was hospitalized for acute pyelonephritis in the hospital.

· Based on objective data: positive symptom of pounding on the right, weakly positive on the left, moderate pain of ureteral points.

8. Survey plan

1. Blood analysis ( complete blood count )

2. Urine analysis

3. Bacteriological examination of urine

4. Stool test

5. Blood chemistry

6. Coprogram

7. Ultrasound of the abdominal organs and kidney

8. ECG

9. Urine test according to Nechiporenko

10. Urine according to Zimnitsky

11. Urine analysis for daily oxalates

12. Excretory urography

13. Blood pressure control

9. Data from laboratory and instrumental examination methods

I. General urine analysis from 26.02.2021:

	Elena		Normal
Colour	Straw yellow	Colour	Straw yellow
Transparency	Transparent	Transparency	Transparent
Density	1010	Density	1012
Protein	0.033 g/L	Protein	0
Glucose	0	Glucose	0
Bacteria	+	Bacteria	+
Epithelium	1-2	Epithelium	0-2
Leucocytes	10-12	Leucocytes	1-2
Mucus	-	Mucus	-
Salts	Oxalates , Ca++	Salts	Oxalates, Ca+

Conclusion :- Bacteriuria, microproteinuria, leukocyturia.

II. General urine analysis from 01.03.2021

	Elena	Normal
Colour	Straw yellow	Straw yellow
Transparency	Transparent	Transparent
Density	1012	1010
Protein	0	0
Sugar	0	0
Bacteria	+	-
Epithelium	0-2	0-2
Leucocytes	1-2	1-2
Salts	Oxalates, Ca+	Oxalates, Ca+

Conclusion - bacteriuria

· Bacteriological examination of urine. From 26.02.2021.

Staphylococcus saprophyticus, Corynebacteriumpseudodiphtheriticum were isolated.

III. General blood test-

	Normal	26.02.2021	01.03.2021
RBC (erythrocytes)	4.0-5.0 * 10*12/l	4.8 * 10 12 / l	4.9 * 10 12 / l
Colour index	0.8-1	0.94	0.96
Haemoglobin	120-140 g / l	141g / l	145g / l
Platelets	180-240g / l	200g / l	215g / l
WBC	4.0-8.0 * 10 9 / l	9.6 * 10 9 / l	6.3 * 10 9 / l
Stick core neutrophils	1-6%	2	1
Segmented neutrophils	47-72%	49%	50%
Eosinophils	0.5-5%	4%	1%
Lymphocytes	19-30%	46%	30%
Monocytes	3-9%	1%	1%
ESR	1-10 mm / h	12mm / h	5 mm / h

Conclusion:-leukocytosis, lymphocytosis, minor eosinophilia, increased ESR.

IV. Urine analysis according to Zimnitsky. From 27.02.2021.

Time	Specific gravity	Quantity
6-9	1012	100.0
9-12	1010	130.0
12-15	1012	300.0
15-18	1010	150.0
18-21	1010	220.0
21-24	1008	170.0 + 300.0
24-3	1012	140.0
3-6	1008	50.0

Daily diuresis 680.0

Night diuresis 880.0

Total diuresis 1560.0

Conclusion: Isohypostenuria, nocturia

V. Ultrasound of the abdominal organs from 02/27/2021.

Liver, gallbladder, pancreas without visible pathology .. Mesenteric l / s are not enlarged.

Spleen 116*43 mm, coarse-grained.

Left kidney 108*30 mm, parenchyma-10, the structure of the parenchyma is preserved,CHLS is not expanded. With D. graph, the vascular pattern is preserved.

URsegm.art 0.729, wed. speed 19.0 cm / sec.

The right kidney 96 * 44, parenchyma-13. The structure of the parenchyma is preserved, the PCS is not enlarged. URsegm.art 0.632, wed. speed 37cm / sec.

After physical. upright loads are typically located.

Conclusion - The right one in a prone position, standing, sitting is located lower than usual, the left one is in a typical place. The right kidney is smaller than the left.

VI. ECG -

The rhythm is sinus. The electric axis is normal.

VII. Urinalysis for daily oxalates 3.02.2021.

Daily oxalates are 31.5 mg / day.

( the norm is 25-40 measures/day)

Conclusion: no pathology.

VIII. Urine analysis according to Nechiporenko from 27.02.2021.

White blood cells-6750/ml norm: up to 2 thousand/ml

Red blood cells-1000 / ml norm: 1 thousand/ml.

Conclusion :leukocyturia.

IX. Excretory urography from 2.03.2021.

The shadows of the lumbar muscles are clear. A transitional thoracolumbal vertebra with rudimentary ribs is determined. The kidneys are typically arranged, with clear, even contours, of normal size. The contrast of the CHLS is timely, symmetrical. On the right, there is a cleavage of the upper group of calyxes, on the left, an incomplete doubling of the CHLS. Mobility of the right kidney is 1.5 vertebrae, the left is 1.5 vertebrae. The ureters are not dilated. The bladder is not full.

Conclusion: increased mobility of both kidneys, incomplete doubling of the left heart rate, bilateral nephroptosis of the 1st degree.

X. Biochemical blood test:-

	Normal	Elena
Urea	1.7-8.3мmol / l	1.7 мmol / L
Creatinine	50-77 мmol / l	66.6 mmol / L
Total protein	65-85 g / l	70 g / l
Total bilirubin	3.4-17.0 мmol / l	6 мmol / L
Bilirubin	0-4.3 мmol / L	2мmol / l
AST	0-47 i / l	36.6 i / l
ALT	0-39 i / l	7.9 i / l

Conclusion: no pathology.

10. Clinical diagnosis, Justify

Clinical diagnosis - Chronic pyelonephritis, bilateral, phase of active inflammation.

Justification of the clinical diagnosis:-

The diagnosis is made on the basis of:

The following symptoms:

General intoxication: fever (from subfebrile to hyperthermia, which has no specific features in terms of duration and frequency); impaired well-being in the form of general weakness, drowsiness, irritability, headache; increased sweating

Gastrointestinal :nausea, single vomiting

Urological pain : pain in the lower back on both sides during the last two weeks, pain during palpation along the ureters, as well as a positive symptom of pounding on the right.

Dysuric: frequent urge to urinate, nocturia

complaints of fever up to 38.5 C, pain in the lower back, frequent urge to urinate, reduced urination up to 2-3 times a day

medical history: in 2017, she was treated for acute pyelonephritis.As well as conducted laboratory and instrumental studies.

laboratory data: blood test: leucocyte formula shift to the left, increased ESR, urine :leucocyturia, microproteinuria, bacteriuria, salts (oxalates, Ca). AM according to Zimnitsky: isohypostenuria, nicturia. A bacteriologist. urinalysis-isolated Staphylococcus saprophyticus, Corynebacteriumpseudodiphteriticum

Ultrasound of the kidneys: the right kidney in the lying, standing, sitting position is located lower than usual, the left in a typical place. The right kidney is smaller than the left.as well as changes in the parenchyma of both kidneys.

Excretory urography: increased mobility of both kidneys, incomplete doubling of the left heart rate.

differential diagnosis with glomerulonephritis and cystitis.

11. Differential diagnosis

Signs	Pyelonephritis	Cystitis	Elena
Fever over 38	+	-	+
Chills	+	-	+
Dysuria	+	+	+
Mucus in urine	-	+	-
Pounding symptom	Positive	Negative	Positive on both sides
Back pain	+	-	Positive on both sides
Pain in the lower abdomen (above the bosom)	-	+	-
Leukocytosis	+	-	+
Hematuria	-/+	-/+	-
Cylindruria	+	-	+
Bacteriuria	+	+	++
Signs	Pyelonephritis	Glomerulonephritis	Elena
Time of appearance	B/w 10-12 days after ARVI	B/w 2-3 weeks	b / w 12 days after ARVI
Age	Any age	5-12 years	15 years
Swelling	Nil	Have 60-80%	Nil
Arterial hypertension	Nil	Have 60-80%	Nil
Fever	Present	Seldom	Present
Dysuria	Present	Nil	Present
Low back pain	Present	May be present	Present
Proteinuria	Micro	Macro	Yes (0.033g/
Hematuria	Nil	Macro	Nil
Leukocyturia	Present	Nil	Present
Bacteriuria	Present	Nil	Yes (++)
Cylindruria	Nil	Present	Nil
Increased urea content	Nil	Present	Nil
Ultrasound of the kidneys, excretory urography	ChLS deformation, m. decrease in the parenchyma of the kidneys with an outcome in sclerosis. According to the data of excretory uro-ii-decrease in contrast-excretory function of the kidneys	Increasing the size of the kidneys, emphasizing the pyramids	Decreased renal parenchyma

12. Etiology, Pathogenesis

Pyelonephritis develops as a result of direct bacterial invasion of the kidneys by hematogenic, urinogenic (ascending along the wall of the urinary tract), or lymphogenic pathways from various foci (Gnatyuk A. I. and co-authors, 1980). This is disputed by B. I. Shulutko, who believes that it is not bacteria that enter the kidney tissue, but immune complexes (IC), which leads to immune, not bacterial, inflammation. The proof of this is, in his opinion, the absence of bacteria in the nephrobioptate in pyelonephritis.

Pyelonephritis often develops against the background of acute respiratory viral infection, pneumonia, angina, sepsis, scarlet fever, dysbacteriosis, metabolic disorders and other diseases. The most common path is the ascending path of infection from the bladder, urethra or prostate along the wall of the ureter or its lumen. This pathway is realized due to a violation of urodynamics in the ureters, vesicoureteral, pyelo-papillary and pyelo-venous reflux. After reaching the pelvis of the kidneys, the microbes enter the interstitial tissue through ruptures of the mucous membrane of the pelvis and calyces, resulting from increased pressure. Predisposing factors for this pathway in girls are stenosis, and in boys-the urethral valve.

Violation of urodynamics may be a consequence of neurogenic disorders of urination in the defeat of the nervous pathways and centers of innervation of the bladder may be due to endoplasmic antigens of microorganisms that determine the strength of the endotoxic action of pathogens, including on the innervation of the ureters with a violation of their cystoid function and the development of" physiological " obstruction of the ureters, with an increase in intraocular pressure. And this leads to vesicoureteral and pelvic-renal reflux.

After the entry of microorganisms of immune complexes into the renal tissue, their fixation can be facilitated by areas of renal dysembriogenesis, microstructures due to dysmetabolic nephropathy with oxalate-calcium crystalluria, as well as renal enzymopathies and impaired blood circulation in the kidney, inducing the influence of bacterial antigens, changes in immunological tolerance, violations of the eliminating function of the macrophage-phagocytic system and local immunity.

The lymphogenic pathway of pyelonephritis is considered insignificant, and the hematogenic pathway is mainly inherent in children of the first months of life, although there is another point of view. In particular, T. B. Sentsova and co-authors (1994) consider dysbacteriosis to be one of the most important causes of pyelonephritis: colonization by the anaerobic flora of the intestine causes polyclonal stimulation of the synthesis of Ig of various classes, including IgE. The reaction of immune inflammation in the intestinal mucosa promotes the translocation of opportunistic microorganisms from the intestine to the urinary system.

A certain significance in the development of pyelonephritis is a viral infection, which predisposes to bacterial lesions of the kidneys, weakening the tissue defense mechanisms, as a result of which the bacteria more easily penetrate and develop in the epithelium of the urinary tract and kidney tissues.

Although the presence of non-enveloped forms of bacteria indicates the subsiding of the inflammatory process, however, their presence, the presence of chlamydia, viruses, mycoplasmas leads to the prolongation of tubulointerstitial inflammation, which is caused by the formation of focal interstitial nephritis, peritubular and periglomerularnephrosclerosis, sometimes carpal metaplasia of the tubules and renal bodies. The causes leading to the chronization of the process include general exhaustion of the body, hyperfiltration leading to sclerosis, and previously transferred abacal nephritis.

13. Treatment

1. Diet, protein restriction, exclude: extractives, fried foods, onions, garlic, coffee.

* Protein restriction to 1.5-2 g / kg

* NaCl< 3g/day

2. Antibacterial therapy

The central place in the treatment of pyelonephritis is occupied by etiotropic, that is, antibacterial therapy. When prescribing treatment, the nature of the bacterial flora is taken into account(bac urine culture from 26.02.21)

* Amoxicillin 500 mg*. 3p / d

Semi-synthetic penicillin, has a bactericidal effect, has a wide spectrum of action. It disrupts the synthesis of peptidoglycan (the cell wall support polymer) during division and growth, and causes bacterial lysis. It is active against aerobic Gram-positive microorganisms-Staphylococcus spp.

* Masgorepi 1 tab. 3 r/d (1200 mg/day)

Macropen is an antibiotic from the group of macrolides. Inhibits protein synthesis in bacterial cells. In low doses, the drug has a bacteriostatic effect, and in high doses, it also has a bactericidal effect. It is active against intracellular pathogens, Gram-positive and some Gram-negative bacteria. Among the Gram-positive bacteria, the drug is susceptible to Pseudobacteriumpseudodiphtheriae(bac urine culture from 26.02.21) and Gram-positive anaerobic bacteria.

3. Immune system stimulation

* Timalini daily for 7 days

Dilute one bottle in 2 ml of phys. Solution.

Enter 0.5 ml, in/m (0.003)

Immuno-stimulator. Restores impaired immunological reactivity (regulates the number and ratio of T-and B-lymphocytes, stimulates cellular immunity reactions, increases phagocytosis), stimulates regeneration processes, and also improves the course of cellular metabolism

The main effect of pyelonephritis is to increase the duration of remission and accelerate its onset

Immune stimulation enhances the effect of basic therapy.

4. Normalization of digestion, fight against dysbiosis.

* Hilak-forte 30 drops before or during meals, washed down with a small amount of liquid.

Promotes the sanitation of the intestinal flora in a biological way: with the help of biosynthetic lactic acid on the enriched buffer system, a shift in pH to physiological values for this segment of the intestine is achieved, which creates unfavorable conditions for alien bacteria, such as pathogenic and conditionally pathogenic. A significant addition of biosynthetic bacterial products contributes to the maintenance of the physiological function of the intestinal mucosa. Due to the antagonistic action against pathogenic bacteria and the acceleration of the growth of normal intestinal microflora, the composition of the intestinal flora is normalized (achieved due to the contained metabolic products of Gram-positive and gram-negative obligate intestinal microbes). Lactic acid and the products of the exchange of antagonist microbes contribute to maintaining the sterility of the stomach and upper small intestine. Promotes the rapid restoration of the optimal intestinal flora, disturbed during the use of sulfonamides, antibiotics, and other antimicrobial drugs.

5. Antispasmodic agent

* No-spa: Ѕ tablet 2 times a day (0.02) myotropic

antispasmodic. Reduces the tone of smooth muscles, moderately dilates blood vessels. It helps to reduce kidney edema, as a result, the overgrowth of the kidney capsule decreases and the pain syndrome decreases.

6. Urological collection of Ѕ cup 3 r / d

7. Kanefron 1 dr. 3 times a day, 1 month

Immediately after antibacterial therapy, anti-relapse herbal medicine is prescribed. The effect of herbal medicine is multifaceted: first of all - diuretic: as diuretic drugs, herbs help to improve the passage of urine. In addition, it has anti-inflammatory, regenerating, immunomodulatory properties.

14. List of temperature - From 25.02-2021 - 03.03.2021

Temp

25.2.21

26.2.21

27.2.21

28.2.21

1.3.21

2.3.21

3.3.21

M

E

M

E

M

E

M

E

M

E

M

E

M

E

41 C

40 C

39 C

38 C

38.5 C

38.5 C

38.4 C

38.3 C

37 C

37.9 C

37.9 C

37.5 C

37.3 C

37.3 C

37.0 C

37.0 C

36 C

36.9 C

36.9 C

36.9 C

Heart rate

84

84

83

82

82

82

82

80

80

82

82

80

81

82

From 04.03.2021 - 09.03.2021

Temp	4.3.21	5.3.21	6.3.21	7.3.21	8.3.21	9.3.21
	M	E	M	E	M	E	M	E	M	E	M	E
36 C
	36.7 C	36.7 C
			36.6 C	36.6 C	36.6 C	36.6 C	36.6 C	36.6 C	36.6 C	36.6 C	36.6 C	36.6 C
Heart rate	82	80	78	80	80	81	82	78	79	80	80	82

15. Diaries

04.03.2021	Ap-120 / 80mm Hg Ps - 82 bpm T-36.7 C	The general condition is satisfactory. The skin and visible mucous membranes are clean, moist. Skin color is pale pink. Tongue coated with white bloom. Heart sounds are clear, rhythmic. Breathing in the lungs is vesicular, no wheezing. The abdomen on palpation is soft, painless, participates in the act of breathing. The lumbar region is not changed, palpation in the projection of the kidneys is painless, the kidneys are not palpable. Beating symptom positive on both sides, more on right. The stool is normal. Strained urination (4 times a day).
05.03.2021	Ap- 120 / 70mmHg Ps-78 T- 36.6 C	The general condition is satisfactory. The skin and visible mucous membranes are clean, moist. Skin color is pale pink. Heart sounds are clear, rhythmic. Breathing in the lungs is vesicular, no wheezing. The abdomen on palpation is soft, painless, participates in the act of breathing. The lumbar region is not changed, palpation in the projection of the kidneys is painless, the kidneys are not palpable. The tapping symptom is weakly positive on the right. Stool and urine output are normal.
06.03.2021	Ap-120 / 80mm Hg Ps-80 bpm T- 36.6 C	The general condition is satisfactory. The skin and visible mucous membranes are clean, moist. Skin color is pale pink. Heart sounds are clear, rhythmic. Breathing in the lungs is vesicular, no wheezing. The abdomen is soft, painless on palpation. The lumbar region is not changed, palpation in the projection of the kidneys is painless, the kidneys are not palpable. The tapping symptom is negative. Stool and urine output are normal.

16. Forecast

Ш Follow-up with a pediatrician and urologist at the place of residence.

Ш The first 3 months after discharge from the hospital general urine analysis 2-3 times a month, urine analysis for Nechiporenko 1 time per quarter, test for Zimnitsky 1 time in 6 months, UAC monthly in 1 quarter, consultation of the ENT doctor 2 times a year, dentist 1 time per quarter. In the first 3-6 months after discharge, 10 days of each month-antimicrobial drugs: nitrofuran, quinolines( 5-NOK, gramurin), biseptol, urosulfan, then 2 times a year.

Ш Collection of herbs( bearberry, lingonberry, horsetail) within 3 months after discharge.

17. Epicrisis

Patient Elena was inpatient treatment in the pediatric department from 25.02.21 to 9.03.21.

On admission, she complained of fever up to 38.5 C, pain in the lumbar region, frequent urge to urinate, reduced urination up to 2-3 times a day. Hospitalized in the department with a diagnosis of chronic pyelonephritis, active stage.

Laboratory and instrumental examination was carried out:

UAC from1.03.21

+Erythr-4.3 * 1012 / l, CP-0.96, Hb-145g / l, Tr-215, leuke-5.3 * 109 / l, stick-1, seg-50, eos-1, lymph- 30, monoc-1, ESR-5 mm / h

General urine analysis from 02/26/21.

Quantity 100.0, acid reaction, specific weight-1009, protein-0 g / l, sugar-0, leuke-1-2, erythr-0, squamous epithelium 0-1

Urine analysis according to Zimnitsky. From 27.02.21

Time	Specific gravity	number
6-9	1012	100.0
9-12	1010	130.0
12-15	1012	300.0
15-18	1010	150.0
18-21	1010	220.0
21-24	1008	170.0 + 300.0
24-3	1012	140.0
3-6	1008	50.0

Daytime diuresis 680.0

Night diuresis 880.0

Total diuresis 1560.0

+Coprogram from 26.02.2021.

The consistency is formed, the color is brown, the reaction is weakly alkaline, mouse fiber +, neutr fats-no, fat -no, iodophilic flora-no, detritus +++, mucus-no, I / g, protozoa-no.

Ultrasound of the abdominal organs from 27.02.2021

Liver, gallbladder, pancreas without visible pathology .. Mesenteric l / s are not enlarged.

The spleen is 116 * 43 mm, coarse.

Left kidney 108 * 30 mm, parenchyma - 10, the structure of the parenchyma is preserved,

ChLS is not expanded. In the case of D. grafting, the vascular pattern is preserved.

URsegm.art 0.729, wed. speed 19.0 cm / sec

The right kidney 96 * 44, parenchyma-13. The structure of the parenchyma is preserved, the PCS is not enlarged. URsegm.art 0.632, wed. speed 37cm / sec

+After physical. upright loads are typically located.

Urine analysis for daily oxalates from 01.03.21

Daily oxalates 31.5 measures / day.

(norm 25-40 measures / day)

Conclusion : no pathology.

Urine analysis according to Nechiporenko dated 27.02.2021.

Leukocytes - 6750 / ml norm: up to 2 thousand / ml

Erythrocytes-1000 / ml norm: 1000 / ml

Conclusion :leukocyturia

Excretory urography from 02.03.2021.

+The shadows of the lumbar muscles are clear. The transitional thoracolumbar vertebra with rudimentary ribs is determined. The kidneys are located typically, with clear, even contours, of normal size. ChLS contrast is timely, symmetrical. On the right, splitting off of the upper group of cups is noted, on the left, incomplete doubling of the PCS. Mobility of the right kidney is 1.5 vertebra, left 1.5 vertebra. The ureters are not dilated. The bladder is not full.

Bacteriological examination of urine. From 26.02.21.

Staphylococcus saprophyticus, Corynebacteriumpseudodiphteriticum isolated.

B / x blood test from 27.02.09

Urea 1.7 мmol / L, Totalprotein 70 g / L, Creatinine 66.6 mmol / L, Bilirubin 2 мmol / L, bilirubin 6 мmol / L, AST 36.6, ALT 7.9.

Differential diagnostics with glomerulonephritis, cystitis was carried out.

18.Clinical diagnosis: chronic pyelonephritis, bilateral, phase of active inflammation

diagnosis chronic pyelonephritis

The diagnosis is based on:

The following symptoms:

v General intoxication: temperature rise to 38.5; violation of well-being in the form of general weakness, drowsiness, irritability, headache, poor appetite; excessive sweating

v Gastrointestinal: nausea, single vomiting (02.25.21)

v Urological pain: pain in the lower back on both sides during the last two weeks, tenderness on palpation along the ureters, as well as a positive symptom of tapping on the right.

v Dysuric: frequent urge to urinate, nocturia

v complaints of fever up to 38.5 C, pain in the lumbar region, frequent urge to urinate, reduced urination up to 2-3 times a day

v anamnesis: in 2017, she was treated for acute pyelonephritis.

As well as laboratory and instrumental studies:-

v laboratory data: KLA: shift of the leukocyte formula to the left, increased ESR, OAM: leukocyturia, microproteinuria, bacteriuria. AM according to Zimnitsky: isohypostenuria, nocturia.

v Ultrasound of the kidneys: the right kidney in a prone position, standing, sitting is located lower than usual, the left is in a typical place. The right kidney is smaller than the left.

v Excretory urography: increased mobility of both kidneys, incomplete doubling of the PCS on the left, bilateral nephroptosis of the 1st degree.

v the differential diagnosis with glomerulonephritis and cystitis.

During her stay in the hospital she received treatment:

1. Diet, restriction of protein, exclude: extractives, fried, onions, garlic, coffee.

· Protein limitation to 1.5 - 2 g / kg

· NaCl<3g / day

2. Antibacterial therapy

· Amoxicillin 400 mg *. 3r / d, 10 days

· Macropeni 500 mg * 3 r / d, 10 days

3. Stimulating immunity

· Timini daily for 7 days

Dilute one bottle in 2 ml nat. Solution.

Inject 0.5 ml, i / m (0.003).

4. Normalization of digestion, the fight against dysbiosis.

· Hilak-fortе 30 drops before or during meals with a little liquid. Within 10 days

5. Antispasmodic:

· No-spa Ѕ tablet 2 times a day (0.02), 5 days

6. Urological collection for Ѕ glass 3 r / d, 7 days

7. Exercise therapy.

Against the background of the treatment, the patient's condition improved: the pain in the lumbar region disappeared. Urination is normal and painless.

The patient is in a state of clinical and laboratory remission.

Discharged home with recommendations:

Observation by a pediatrician and urologist at the place of residence.

The first 3 months after discharge from the hospital OAM 2-3 times a month, AM according to Nechiporenko 1 time per quarter, test according to Zimnitsky 1 time in 6 months, OAK monthly in 1 quarter, consultation of an ENT doctor 2 times a year, a dentist 1 time per quarter. In the first 3-6 months. after discharge 10 days of each month, antimicrobial drugs: nitrofuran, quinolines (5-NOK, gramurin), biseptol, urosulfan, then 2 times a year.

Collection of herbs (bearberry, lingonberry, field horsetail) within 3 months after discharge.

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