Current Case Review Robert R Zaid March 9

Current Case Review Robert R. Zaid March 9 th, 2004 MS-III (GRMC)

Chief Complaint • Pt presents with pain between her abdomen and back and suprapubic area

• What questions do we want to ask this patient?

• • • • CC HPI PMHx MEDS Allergies Soc. Hx FMHx ROS Physical Exam Differential LABS Radiological Differential Diagnosis Treatment History of Present Illness Pt is a 34 y/o c female who presents with mild back pain in her R flank area that started a week ago. Pt states that the pain is intermittent and has become worse in the last couple of days but does not radiate to other parts of her body. She states that she has had this pain on several occasions, the last one occurring 6 months ago. She has taken tylenol without relief and notes nothing that improves her symptoms. She denies trauma, hematuria, f/c, n/v, sob, diarrhea or constipation. She has noticed an increase in urinary frequency, some dribbling and mild dysuria. Pt denies dyspareunia, vaginal discharge and hx of std’s. She later adds that she has been on furosemide for the last year and has recently in the last month been taking double her prescribed dose.

• • • • CC HPI PMHx MEDS Allergies Soc. Hx FMHx ROS Physical Exam Differential LABS Radiological Differential Diagnosis Treatment Past Medical History Hypertension (controlled) Obesity Type II diabetes

• • • • CC HPI PMHx MEDS Allergies Soc. Hx FMHx ROS Physical Exam Differential LABS Radiological Differential Diagnosis Treatment Medications Furosemide Atenolol Glucophage Multi-vitamin

• • • • CC HPI PMHx MEDS Allergies Soc. Hx FMHx ROS Physical Exam Differential LABS Radiological Differential Diagnosis Treatment Allergies NKDA 3 rd year medical students that ask too many questions

• • • • CC HPI PMHx MEDS Allergies Soc. Hx FMHx ROS Physical Exam Differential LABS Radiological Differential Diagnosis Treatment Social History Pt lives at home with her two kids and husband. She is a nurse at Genesys and works approximately 40 hours a Week. Pt does not smoke and admits to an occasional glass of wine. Pt denies illicit drug use. Pt has a good support system and has family members that can help her if needed.

• • • • CC HPI PMHx MEDS Allergies Soc. Hx FMHx ROS Physical Exam Differential LABS Radiological Differential Diagnosis Treatment Family Medical History Mother- Alive (DM, HTN) Father- Alive (Hypercholesterolemia)

• • • • CC HPI PMHx MEDS Allergies Soc. Hx FMHx ROS Physical Exam Differential LABS Radiological Differential Diagnosis Treatment Review of systems General: Head: Respiratory: Cardiac: GI: GU: MSK: Neuro: Psychiatric- weight change, fever, chills, weak headache, nasuea, vomitting SOB, wheeze, cough HTN, murmurs, angina, palpitations appetite, n/v, incont. , const/diarrhea frequency, hesitancy, urgency, dysuria hematuria, incont. , stones, no dyspareunia, no discharge muscle weakness, flank pain parasthesias, loss of sensation Pt is not depressed

• • • • CC HPI PMHx MEDS Allergies Soc. Hx FMHx ROS Physical Exam Differential LABS Radiological Differential Diagnosis Treatment Physical Exam VSBP- 140/87 T-98. 2 R-16 P-82 General- Pt is well nourished and Ax. Ox 3 Heent- EOMI, PERRLA, no vision changes CVRRR w/o murmurs or rubs, clicks or gallops RESP- Clear to auscultation bilaterally, no wheezes Abdomen- Soft, NT, ND, no masses, BS, no bruits GUNo discharge, bleeding, nodules or masses Positive lloyd’s test MSK- No weakness, mild tenderness in R flank TTA T 11 -L-1 EXT- No edema, negative moses, pulses b/l

• • • • CC HPI PMHx MEDS Allergies Soc. Hx FMHx ROS Physical Exam Differential LABS Radiological Differential Diagnosis Treatment Differential Infections: Cystitis Pyelonephritis Appendicitis/Diverticulitis Urethritis Nephritis (i. e. glomerular, interstitial) Obstructive: Kidney Stones Kidney Cyst Musckuloskeletal Muscle spasms/pain Herniated disk Drugs Lasix- Back pain/ urinary frequency, cramps Pathological Acute renal failure GU Endometriosis/Ovarian torsion/PID

• • • • CC HPI PMHx MEDS Allergies Soc. Hx FMHx ROS Physical Exam Differential LABS Radiological Differential Diagnosis Treatment What do we want to order?

• • • • CC HPI PMHx MEDS Allergies Soc. Hx FMHx ROS Physical Exam Differential LABS Radiological Differential Diagnosis Treatment Urinalysis Specific gravity. RBCWBCBacteria Leukocyte Esterase Protein Microscopy Culture- pending 1. 002 None >10 WBC’s per HPF Moderate Positive Trace No casts found

• • • • CC HPI PMHx MEDS Allergies Soc. Hx FMHx ROS Physical Exam Differential LABS Radiological Differential Diagnosis Treatment CBC 14 g/dl 10 300 40 Chemistry 140 100 4. 2 24 Pregnancy Test Negative 8. 0 100 1. 1

• • • • CC HPI PMHx MEDS Allergies Soc. Hx FMHx ROS Physical Exam Differential LABS Radiological Differential Diagnosis Treatment Could possibly order a renal ultrasound or KUB contrast study to rule out cysts/stones

• • • • CC HPI PMHx MEDS Allergies Soc. Hx FMHx ROS Physical Exam Differential LABS Radiological Differential Diagnosis Treatment Differential Infections: Cystitis Pyelonephritis Appendicitis Urethritis Nephritis (i. e. glomerular, interstitial) Obstructive: Kidney Stones Kidney Cyst Musckuloskeletal Muscle spasms/pain Drugs Lasix- Back pain/ urinary frequency, cramps

• • • • CC HPI PMHx MEDS Allergies Soc. Hx FMHx ROS Physical Exam Differential LABS Radiological Differential Diagnosis Treatment Diagnosis 1. Urinary Tract Infection Most likely cystitis

• Urinary Tract Infections – Frequency in US • Approx. 25 -40% of females age 20 -40 have had a UTI – Location • Bladder (cystitis) vs. kidney (pyelonephritis) – General clinical features • • • Dysuria Increased frequency Urgency Nocturia Hematuria Malodorous urine

• Cystitis – E-coli is most common organism 70 -95% – S. saprophyticus is also found – Others include Proteus species, Klebsiella species, Enterococcus faecalis, other Enterobacteriaceae, and yeast – F/C, N/V and anorexia are uncommon – Pain in suprapubic area (sometimes low back pain) • Pyelonephritis – – – E. Coli is a causative agent in 70 -95% F/C, N/V, flank pain and abdominal pain are often found May find leukocyte casts Unilateral or bilateral costovertebral tenderness is common Patients can become septic and often require a hospital admission

• • • • CC HPI PMHx MEDS Allergies Soc. Hx FMHx ROS Physical Exam Differential LABS Radiological Differential Diagnosis Treatment Treating cystitis Administer IV fluids to dilute urine Antibiotics -Empiric therapy may be used before identifying bacteria -TMP/SMZ for 3 days is standard treatment (160/800 mg PO BID) -Ciprofloxacin 250 mg PO BID x 3 d -Norfloxacin 400 mg PO BID x 3 d Phenazopyridine - Urinary tract analgesic that may help with pain (orange urine) Treating pyelonephritis -can give ciprofloxacin x 14 d

• • • • CC HPI PMHx MEDS Allergies Soc. Hx FMHx ROS Physical Exam Differential LABS Radiological Differential Diagnosis Treatment Prevention: Risk factors 1. Frequency of sexual intercourse 2. Use of spermicide 3. Loss of estrogen effects 4. Structural abnormalities Recommendations: 1. Post-coital voiding 2. Alternative contraception 3. Self-initiated antibiotics 4. Understanding warning signs

Thank you! • Questions, comments, concerns?