Wunderlich syndrome in a patient with pyelonephritis.

An elderly female patient with left pyelonephritis developed worsening left flank pain, hypotension and a drop in haemoglobin (Hb) from 97 g/L to 67g/L on the third day of her admission. There was no recent trauma, history of coagulopathy or risk factors for renal malignancy or vascular disease.A contrasted CT scan of the kidneys revealed a 3.8 cm left renal subcapsular haematoma with no active contrast extravasation. Her atraumatic subcapsular haematoma fulfils two out of three clinical features of Lenk's triad (acute flank pain, hypovolaemic shock), suggestive of Wunderlich syndrome. Urine and blood cultures grew Klebsiella pneumoniae and she was managed conservatively with culture-directed antibiotics, fluids and blood products.Wunderlich syndrome is a rare complication of pyelonephritis and should be considered in patients with pyelonephritis who develop acute severe flank pain, Hb drop and haemodynamic instability. Appropriate medical and surgical therapies need to be instituted early to ensure good outcomes.

Chronic disease self-management competency and care satisfaction between users of public and private primary care in Singapore.

INTRODUCTION: Primary healthcare providers play a crucial role in educating their patients on chronic disease self-management (CDSM). This study aims to evaluate CDSM competency and satisfaction in patients receiving their healthcare from public or private healthcare providers. METHODS: A cross-sectional household study was conducted in a public housing estate using a standardised questionnaire to interview Singaporeans and permanent residents aged 40 years and above, who were diagnosed with at least 1 of these chronic diseases: hyperlipidaemia, hypertension or diabetes mellitus. CDSM competency was evaluated with the Partners In Health (PIH) scale and a knowledge based questionnaire. Satisfaction was evaluated using a satisfaction scale. RESULTS: In general, the 420 respondents demonstrated good CDSM competency, with 314 followed up at polyclinics and 106 by general practitioners (GPs). There was no significant difference between patients of polyclinics and GPs in CDSM competency scores (mean PIH score 72.9 vs 75.1, P=0.563), hypertension knowledge scores (90.9 vs 85.4, P=0.16) and diabetes knowledge scores (84.3 vs 79.5, P=0.417), except for hyperlipidaemia knowledge scores (78.6 vs 84.7, P=0.043). However, respondents followed up by GPs had higher satisfaction rates than did those followed up at polyclinics (odds ratio 3.6, confidence interval 2.28-5.78). Favourable personality of the doctors and ideal consultation duration led to higher satisfaction in the GP setting. A longer waiting time led to lower satisfaction in the polyclinic group. CONCLUSION: Polyclinics and GPs provide quality primary care as evidenced by high and comparable levels of CDSM competency. Redistribution of patients from public to private clinics may result in improvements in healthcare service quality.