Patient summary (from the handwritten note)

• She reports a "kidney infection" with left-sided pain.
• The pain has lasted 10 days. She has been admitted for 2 days.
• She has no fever.
• She has no dysuria (no burning or pain on urination).
• She has no hematuria (no blood in the urine).

Clinical impression

1. Urolithiasis or renal colic (left ureteric or renal stone). This fits a prolonged, one-sided flank pain. Infection can coexist, and an obstructed infected system is an emergency.
2. Pyelonephritis or a complicated UTI, including early, partially treated or subacute disease.
3. Hydronephrosis or pelviureteric junction obstruction. This can cause intermittent flank pain at a young age.
4. Less likely causes: musculoskeletal pain, renal TB (she has no TB history, but this is common where TB is endemic), and gynecologic causes such as an ovarian cyst or pelvic infection. Pregnancy should also be excluded in any woman of childbearing age with abdominal pain.

Suggested workup

• Vitals and examination: temperature, BP, pulse, costovertebral angle tenderness and abdominal examination.
• Urine tests: urinalysis (leukocytes, nitrites, RBCs) and urine culture.
• Blood tests: CBC, CRP, creatinine and electrolytes.
• Urine pregnancy test.
• Imaging: Bailey & Love notes that plain film can miss stones and cannot show obstruction. Ultrasound shows hydronephrosis and can show stones in the kidney and the proximal and distal ureter. Non-contrast low-dose CT KUB is the optimal investigation. It shows stones, obstruction signs (hydronephrosis, perinephric stranding) and alternative diagnoses (Bailey and Love's Short Practice of Surgery 28th Edition, Renal colic section).
  • In a young woman, I would start with ultrasound to avoid radiation, and use CT if the diagnosis is still unclear or stone disease is suspected.
• Treatment: this depends on the results. For example, antibiotics if the culture is positive, analgesia, and urology referral if there is obstruction or a stone.

Recent evidence check

Caveats

• The image analysis tool failed, so I read the note directly. Some words are hard to make out, including the name and "Dia-X", which I read as "no diabetes".
• This is a decision-support summary from a brief note, not a substitute for clinical assessment. If you tell me the vitals, urinalysis or imaging results, I can narrow the differential.

• Obstetric history: Three NVD deliveries by 22 still means early childbearing, so the earlier point holds.
• Clinical impression and workup: These don't change. A 22-year-old woman with 10 days of afebrile left flank pain, and no dysuria or hematuria, still raises stone disease, a subacute or partially treated UTI, and obstruction (such as hydronephrosis) as the main possibilities. Ultrasound first, with a urine pregnancy test, remains the sensible start.

Updated picture (second page of the note)

• Left lower back pain.
• Fever.
• Painful urination.
• Polyuria.
• Change in urine color and smell.

• BP 180/100. This is severely elevated.
• Pulse 88/min, rhythmic.
• RR 17.
• Lungs normal on auscultation. Heart sounds are noted.
• Pasternatsky's sign (the Russian name for the fist-percussion test for costovertebral angle tenderness) is positive on both sides.

How this fits together

• Page 1 says no fever and no dysuria. Page 2 lists fever and painful urination.
• Either her condition changed after admission, or the history was recorded differently.
• Please confirm which is correct.

• Fever, dysuria, change in urine color and smell, flank pain, positive percussion tenderness and ultrasound all fit pyelonephritis.
• This was one of my earlier differentials, and the new findings favor it over a stone.
• The ultrasound did not mention hydronephrosis or a stone. If it showed neither, that is reassuring. Please check the full report.
• Bilateral tenderness suggests both kidneys may be involved. Her pain is left-sided.

• Membranous nephropathy is an autoimmune disease, usually directed at PLA2R on podocytes. It causes granular subepithelial immune deposits and thickening of the glomerular basement membrane (Robbins, Cotran & Kumar Pathologic Basis of Disease, Nephrotic Syndrome section).
• It usually presents as nephrotic syndrome, with heavy proteinuria and edema, without a preceding illness (Robbins & Kumar Basic Pathology, Morphology section).
• It is confirmed by biopsy and/or anti-PLA2R serology.
• Nothing in the note records proteinuria, edema, albumin, lipids, serology or a biopsy.
• Fever, dysuria and flank pain are not features of membranous disease. Polyuria is not a typical feature either.
• Infection and an infection-related urine abnormality can also confuse the picture. So the diagnosis needs urine and blood data, and ideally a biopsy.

• 180/100 in a 22-year-old suggests secondary hypertension, most likely renal parenchymal disease, until proven otherwise.
• Check for pregnancy and pre-eclampsia, because she is of childbearing age.
• Check renal function and look for proteinuria.

• It could explain some of the fever and pain, but it does not explain left lower back pain or the urinary symptoms.
• Ask about right upper quadrant pain, Murphy's sign and the ultrasound findings (stones, wall thickness).
• It may be an incidental finding or a coexisting diagnosis.

Suggested next steps

• Urine:
  • Urinalysis with microscopy and culture.
  • Spot protein/creatinine ratio, or 24-hour protein.
• Blood:
  • Creatinine and eGFR.
  • Albumin and lipids.
  • CBC and CRP.
• Pregnancy test.
• If proteinuria is confirmed:
  • Anti-PLA2R antibodies.
  • Secondary causes of membranous disease: hepatitis B and C, HIV, ANA/anti-dsDNA and complement (lupus), syphilis, drugs and malignancy.
  • Hepatitis B matters in endemic regions. HBV-associated membranous disease is described in Comprehensive Clinical Nephrology, 7th Edition.
• Biopsy only if proteinuria is confirmed and the infection has been treated.
• Treat the infection first. Take cultures before starting antibiotics, and give antibiotics suited to complicated pyelonephritis.
• Blood pressure: control it carefully. Which agent to use depends on her renal function and pregnancy status.

Caveats

• Handwriting is hard to read in places, so some words are my best reading.
• I did not repeat the PubMed search. The earlier one found no recent evidence that contradicts these textbook points.
• This is decision support from a brief note and not a substitute for examining her.

Topics covered

1. Admission record and identity
2. Blood and urine results
3. Heart and pleural findings
4. Abdominal and kidney ultrasound
5. Treatment she is receiving
6. Whether "diffuse membranous glomerulonephritis" fits
7. Discrepancies and suggested next steps

High-level overview

• Ceftriaxone 1.0 g.
• Co-Amlessa 8/10/2.5 mg (perindopril, amlodipine, indapamide).
• Furosemide IV.
• Dexamethasone IV, tapering.
• Furamag 50 mg.
• Canephron.
• Curantyl (dipyridamole).
• Levocarnitine, ascorbic acid, a B-vitamin complex and infusions.

• Membranous nephropathy is not proven. The file has no biopsy, no PLA2R antibodies, no albumin, no lipids and no 24-hour protein. The record is also thin on infection, since there is no urine culture.
• Lupus nephritis needs to be excluded. She is a young woman with proteinuria, hematuria, anemia, lymphopenia, raised ESR, pleural effusions and hypertension. Lupus (including class V, which looks like membranous disease) is the main alternative. Postinfectious glomerulonephritis and hepatitis B are others.
• Heart failure with effusions is a separate serious problem. The pleural fluid is much larger than the "lungs normal" exam suggests. Possible causes are hypertensive heart disease, volume overload and low albumin. The anemia adds to the load on the heart.
• Safety checks: Is there a documented pregnancy test, given she is on perindopril? Her potassium needs monitoring on perindopril, indapamide and furosemide together. Steroid use during an active urinary infection and without a confirmed diagnosis also needs review.
• Discrepancies in the record:
  • Her DOB is 14/02/1999, which makes her 27 in 2026, not 22 (or 20, as on page 1).
  • Page 1 said no fever, dysuria or hematuria. The admission extract and urinalysis show all three.
  • The "lungs normal" exam conflicts with the echo effusions.

Patient summary (from the handwritten note)

• She reports a "kidney infection" with left-sided pain.
• The pain has lasted 10 days. She has been admitted for 2 days.
• She has no fever.
• She has no dysuria (no burning or pain on urination).
• She has no hematuria (no blood in the urine).

Clinical impression

1. Urolithiasis or renal colic (left ureteric or renal stone). This fits a prolonged, one-sided flank pain. Infection can coexist, and an obstructed infected system is an emergency.
2. Pyelonephritis or a complicated UTI, including early, partially treated or subacute disease.
3. Hydronephrosis or pelviureteric junction obstruction. This can cause intermittent flank pain at a young age.
4. Less likely causes: musculoskeletal pain, renal TB (she has no TB history, but this is common where TB is endemic), and gynecologic causes such as an ovarian cyst or pelvic infection. Pregnancy should also be excluded in any woman of childbearing age with abdominal pain.

Suggested workup

• Vitals and examination: temperature, BP, pulse, costovertebral angle tenderness and abdominal examination.
• Urine tests: urinalysis (leukocytes, nitrites, RBCs) and urine culture.
• Blood tests: CBC, CRP, creatinine and electrolytes.
• Urine pregnancy test.
• Imaging: Bailey & Love notes that plain film can miss stones and cannot show obstruction. Ultrasound shows hydronephrosis and can show stones in the kidney and the proximal and distal ureter. Non-contrast low-dose CT KUB is the optimal investigation. It shows stones, obstruction signs (hydronephrosis, perinephric stranding) and alternative diagnoses (Bailey and Love's Short Practice of Surgery 28th Edition, Renal colic section).
  • In a young woman, I would start with ultrasound to avoid radiation, and use CT if the diagnosis is still unclear or stone disease is suspected.
• Treatment: this depends on the results. For example, antibiotics if the culture is positive, analgesia, and urology referral if there is obstruction or a stone.

Recent evidence check

Caveats

• The image analysis tool failed, so I read the note directly. Some words are hard to make out, including the name and "Dia-X", which I read as "no diabetes".
• This is a decision-support summary from a brief note, not a substitute for clinical assessment. If you tell me the vitals, urinalysis or imaging results, I can narrow the differential.Noted: she is 22, not 20.

• Obstetric history: Three NVD deliveries by 22 still means early childbearing, so the earlier point holds.
• Clinical impression and workup: These don't change. A 22-year-old woman with 10 days of afebrile left flank pain, and no dysuria or hematuria, still raises stone disease, a subacute or partially treated UTI, and obstruction (such as hydronephrosis) as the main possibilities. Ultrasound first, with a urine pregnancy test, remains the sensible start.

• Left lower back pain.
• Fever.
• Painful urination.
• Polyuria.
• Change in urine color and smell.

• BP 180/100. This is severely elevated.
• Pulse 88/min, rhythmic.
• RR 17.
• Lungs normal on auscultation. Heart sounds are noted.
• Pasternatsky's sign (the Russian name for the fist-percussion test for costovertebral angle tenderness) is positive on both sides.

How this fits together

• Page 1 says no fever and no dysuria. Page 2 lists fever and painful urination.
• Either her condition changed after admission, or the history was recorded differently.
• Please confirm which is correct.

• Fever, dysuria, change in urine color and smell, flank pain, positive percussion tenderness and ultrasound all fit pyelonephritis.
• This was one of my earlier differentials, and the new findings favor it over a stone.
• The ultrasound did not mention hydronephrosis or a stone. If it showed neither, that is reassuring. Please check the full report.
• Bilateral tenderness suggests both kidneys may be involved. Her pain is left-sided.

• Membranous nephropathy is an autoimmune disease, usually directed at PLA2R on podocytes. It causes granular subepithelial immune deposits and thickening of the glomerular basement membrane (Robbins, Cotran & Kumar Pathologic Basis of Disease, Nephrotic Syndrome section).
• It usually presents as nephrotic syndrome, with heavy proteinuria and edema, without a preceding illness (Robbins & Kumar Basic Pathology, Morphology section).
• It is confirmed by biopsy and/or anti-PLA2R serology.
• Nothing in the note records proteinuria, edema, albumin, lipids, serology or a biopsy.
• Fever, dysuria and flank pain are not features of membranous disease. Polyuria is not a typical feature either.
• Infection and an infection-related urine abnormality can also confuse the picture. So the diagnosis needs urine and blood data, and ideally a biopsy.

• 180/100 in a 22-year-old suggests secondary hypertension, most likely renal parenchymal disease, until proven otherwise.
• Check for pregnancy and pre-eclampsia, because she is of childbearing age.
• Check renal function and look for proteinuria.

• It could explain some of the fever and pain, but it does not explain left lower back pain or the urinary symptoms.
• Ask about right upper quadrant pain, Murphy's sign and the ultrasound findings (stones, wall thickness).
• It may be an incidental finding or a coexisting diagnosis.

Suggested next steps

• Urine:
  • Urinalysis with microscopy and culture.
  • Spot protein/creatinine ratio, or 24-hour protein.
• Blood:
  • Creatinine and eGFR.
  • Albumin and lipids.
  • CBC and CRP.
• Pregnancy test.
• If proteinuria is confirmed:
  • Anti-PLA2R antibodies.
  • Secondary causes of membranous disease: hepatitis B and C, HIV, ANA/anti-dsDNA and complement (lupus), syphilis, drugs and malignancy.
  • Hepatitis B matters in endemic regions. HBV-associated membranous disease is described in Comprehensive Clinical Nephrology, 7th Edition.
• Biopsy only if proteinuria is confirmed and the infection has been treated.
• Treat the infection first. Take cultures before starting antibiotics, and give antibiotics suited to complicated pyelonephritis.
• Blood pressure: control it carefully. Which agent to use depends on her renal function and pregnancy status.

Caveats

• Handwriting is hard to read in places, so some words are my best reading.
• I did not repeat the PubMed search. The earlier one found no recent evidence that contradicts these textbook points.
• This is decision support from a brief note and not a substitute for examining her.

Topics covered

1. Admission record and identity
2. Blood and urine results
3. Heart and pleural findings
4. Abdominal and kidney ultrasound
5. Treatment she is receiving
6. Whether "diffuse membranous glomerulonephritis" fits
7. Discrepancies and suggested next steps

High-level overview

• Ceftriaxone 1.0 g.
• Co-Amlessa 8/10/2.5 mg (perindopril, amlodipine, indapamide).
• Furosemide IV.
• Dexamethasone IV, tapering.
• Furamag 50 mg.
• Canephron.
• Curantyl (dipyridamole).
• Levocarnitine, ascorbic acid, a B-vitamin complex and infusions.

• Membranous nephropathy is not proven. The file has no biopsy, no PLA2R antibodies, no albumin, no lipids and no 24-hour protein. The record is also thin on infection, since there is no urine culture.
• Lupus nephritis needs to be excluded. She is a young woman with proteinuria, hematuria, anemia, lymphopenia, raised ESR, pleural effusions and hypertension. Lupus (including class V, which looks like membranous disease) is the main alternative. Postinfectious glomerulonephritis and hepatitis B are others.
• Heart failure with effusions is a separate serious problem. The pleural fluid is much larger than the "lungs normal" exam suggests. Possible causes are hypertensive heart disease, volume overload and low albumin. The anemia adds to the load on the heart.
• Safety checks: Is there a documented pregnancy test, given she is on perindopril? Her potassium needs monitoring on perindopril, indapamide and furosemide together. Steroid use during an active urinary infection and without a confirmed diagnosis also needs review.
• Discrepancies in the record:
  • Her DOB is 14/02/1999, which makes her 27 in 2026, not 22 (or 20, as on page 1).
  • Page 1 said no fever, dysuria or hematuria. The admission extract and urinalysis show all three.
  • The "lungs normal" exam conflicts with the echo effusions.

What membranous nephropathy (MN) looks like

• MN is an autoimmune disease, most often against PLA2R on podocytes. It causes granular subepithelial deposits, thickened basement membrane and little inflammation (Robbins, Cotran & Kumar Pathologic Basis of Disease, Nephrotic Syndrome section).
• Most cases present as nephrotic syndrome without a preceding illness. The proteinuria is nonselective and usually does not respond to corticosteroids alone (Robbins & Kumar Basic Pathology, Morphology section).
• It is a pathology diagnosis. Under KDIGO 2021, a biopsy is not required only when the patient has nephrotic syndrome and a positive anti-PLA2R test. Every MN patient should also be screened for associated conditions: malignancy, infections, lupus and drugs.

Her findings against MN

What I would think about first

• She is a young woman with proteinuria, hematuria, hypertension, anemia, lymphopenia, raised ESR and bilateral effusions, which could be serositis.
• Diffuse lupus nephritis commonly gives hematuria, proteinuria, hypertension and nephrotic syndrome (Comprehensive Clinical Nephrology, 7th Edition, Pathology section).
• Class V (membranous) lupus nephritis can look like MN, with nephrotic-range disease (National Kidney Foundation Primer on Kidney Diseases, 8e).
• Anti-PLA2R is often absent in lupus with MN (Brenner and Rector's The Kidney, PLA2R section). A negative PLA2R test therefore would not rule lupus out.

• Textbook causes include SLE, hepatitis B, hepatitis C, syphilis, malaria, schistosomiasis, thyroiditis, malignancy and drugs such as gold, penicillamine and captopril (Tietz Textbook of Laboratory Medicine, 7th Edition; Robbins).
• Hepatitis B matters in endemic regions (Comprehensive Clinical Nephrology, 7th Edition).

• MN carries the highest venous thrombosis risk among the nephrotic diseases.
• New flank pain with gross hematuria in a possible MN patient should prompt a renal Doppler.
• The current drug list includes dipyridamole, which is not anticoagulation.
• Whether she needs prophylaxis depends on her albumin, which is unknown.

Tests that would settle it

• Urine: 24-hour protein or protein/creatinine ratio, culture, and repeat urinalysis after the infection is treated.
• Blood: albumin, lipids, C3/C4, ANA, anti-dsDNA, anti-PLA2R, HBsAg, anti-HCV, HIV and syphilis serology. Add ferritin, iron studies, reticulocytes and B12 for the anemia.
• Pregnancy test: none is recorded, and she is on perindopril.
• Imaging: renal Doppler (for renal vein thrombosis), and a chest film or ultrasound review of the effusions.
• Biopsy: a kidney biopsy once the infection is treated and BP is controlled. Without nephrotic syndrome and a positive anti-PLA2R, KDIGO's biopsy exemption does not apply.

Comment on the current treatment

• Dexamethasone is being given before the diagnosis is confirmed and during an active urinary infection. It is a reasonable choice if lupus is the cause, but it is worth sending the serology first. Steroids alone are unlikely to help true MN.
• Perindopril with indapamide and furosemide needs creatinine and potassium monitoring, and a negative pregnancy test beforehand.

Bottom line

• She has a glomerular disease with a probable urinary infection on top.
• MN is a label, not a confirmed diagnosis. I would treat lupus nephritis as the leading alternative until ANA, anti-dsDNA and complement are back.
• The ICD code on the record (N03.2) is a diagnostic coding label. It does not tell you whether a biopsy was done.

Record discrepancies

• Her DOB (14/02/1999) makes her 27 on the 2026 documents. You said 22, and page 1 said 20.
• Page 1 said no fever, dysuria or hematuria. The labs show red urine, bacteria and pyuria.
• "Lungs normal" conflicts with the effusions on the echo.

Limits

• Some handwriting and several photos were hard to read.
• A PubMed search for recent reviews found nothing that contradicts these points. The KDIGO 2021 guideline and the textbooks above carry most of the weight here.
• This is decision support from documents, not a clinical assessment.

1. Title
2. Presentation and history
3. Examination on admission (BP 180/100, bilateral Pasternatsky's sign)
4. Blood and urine results, with abnormal values in red
5. Echo and abdominal ultrasound
6. Summary and problem list
7. Does membranous glomerulonephritis fit? Lupus nephritis and the other alternatives
8. Treatment so far and proposed next steps
9. Take-home points

• Patient identifiers: I removed her name and ID numbers from the deck.
• Age: The slide gives the date of birth, age 27 by the 2026 record, and notes that 22 was stated verbally. Please confirm which is correct.
• Medicines: Some handwritten orders were hard to read. I listed only the ones I'm fairly sure of, and the slide says one evening tablet could not be identified.
• Missing results: Her albumin, lipids, 24-hour protein, ANA, anti-dsDNA, complement and anti-PLA2R results are not in the file. The slides list them as "not yet done." If any exist, tell me and I'll update the deck.

Medicines, doses and uses

Concerns I would raise with the team

1. Pregnancy test. Perindopril and indapamide are unsafe in pregnancy. No pregnancy test is documented.
2. Hypotension and kidney risk. She is on three antihypertensives plus furosemide, and later possibly a beta-blocker, which is a lot to start at once in a 27-year-old. An ACE inhibitor with two diuretics needs creatinine and potassium checked within days. A lower starting strength is usual.
3. Steroid with active infection. Dexamethasone can raise BP and retain fluid, and she has an untreated urinary infection and no confirmed diagnosis. Steroid alone is unlikely to help true membranous disease.
4. Fluid load. Rheopolyglucin 200 mL, bicarbonate 200 mL and sodium-containing infusions add volume and sodium. She has about 700 mL of pleural fluid, an EF of 48% and a BP of 180/100. Dextran 40 can also injure the kidney in some patients. I would question these two.
5. Furamag for pyelonephritis. Nitrofurans don't reach good tissue levels in the kidney, so ceftriaxone is doing the real work. A low dose adds little.
6. What is missing. There is no iron or B12 for the Hb of 77 until the cause is found. There is no anticoagulant, and none is needed unless albumin is low and nephrotic syndrome is confirmed.

Limits

• I read the doses from handwriting. Several durations, one drug name and the 25 mg evening tablet are uncertain.
• Where I wrote mL-to-mg conversions, I assumed standard ampoule strengths.
• Please check the original orders with the treating doctor or pharmacist before acting on any of this.

1. Title
2. Presentation and history
3. Examination on admission
4. Blood and urine results
5. Echo and ultrasound
6. Summary and problem list
7. Does membranous glomerulonephritis fit? The differential, with lupus nephritis first
8. Current medicines, with doses and purpose (new)
9. Treatment concerns and proposed plan (new). Concerns are no documented pregnancy test, the fluid and sodium load, and steroid use during infection.
10. Take-home points

• I haven't opened the deck to check the layout, so please look for text that runs over.
• Patient identifiers are removed.
• The medicine doses are read from handwriting and standard ampoule strengths. Two orders are unclear, one reading like Tiocetam or Mexidol and one 25 mg evening tablet. Slide 8 marks them "to be verified." Please check them against the chart.
• Her age is shown as 27 from the date of birth, with your stated 22 noted. Please confirm which is right.

• Written next to each order is a number of days. I can't read it reliably, so I haven't given treatment durations.
• Where I wrote "probably once daily," that is my assumption, not what the order says.
• Please confirm these frequencies against the original orders or with the nurse or pharmacist.