Current Case Review

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Current Case Review

• Robert R. Zaid
• March 9th, 2004
• MS-III (GRMC)

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Chief Complaint

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

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• What questions do we want to ask this patient?

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• CC
• HPI
• PMHx
• MEDS
• Allergies
• SocHx
• 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 stds. 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.
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• CC
• HPI
• PMHx
• MEDS
• Allergies
• SocHx
• FMHx
• ROS
• Physical Exam
• Differential
• LABS
• Radiological
• Differential
• Diagnosis
• Treatment

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

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

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

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

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

Physical Exam VS- BP- 140/87 T-98.2 R-16
P-82 General- Pt is well nourished and
AxOx3 Heent- EOMI, PERRLA, no vision
changes CV- RRR w/o murmurs or rubs, clicks or
gallops RESP- Clear to auscultation bilaterally,
no wheezes Abdomen- Soft, NT, ND, no masses, BS,
no bruits GU- No discharge, bleeding, nodules or
masses Positive lloyds test MSK- No weakness,
mild tenderness in R flank TTA T11-L-1 EXT-
No edema, negative moses, pulses b/l
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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
• SocHx
• FMHx
• ROS
• Physical Exam
• Differential
• LABS
• Radiological
• Differential
• Diagnosis
• Treatment

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• CC
• HPI
• PMHx
• MEDS
• Allergies
• SocHx
• FMHx
• ROS
• Physical Exam
• Differential
• LABS
• Radiological
• Differential
• Diagnosis
• Treatment

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

Urinalysis Specific gravity- 1.002 RBC-
None WBC- gt10 WBCs per
HPF Bacteria Moderate Leukocyte
Esterase Positive Protein Trace Microscopy No
casts found
Culture- pending
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• CC
• HPI
• PMHx
• MEDS
• Allergies
• SocHx
• FMHx
• ROS
• Physical Exam
• Differential
• LABS
• Radiological
• Differential
• Diagnosis
• Treatment

CBC
14 g/dl
10
300
40
Chemistry
8.0
140
100
100
4.2
24
1.1
Pregnancy Test Negative
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• CC
• HPI
• PMHx
• MEDS
• Allergies
• SocHx
• 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
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• CC
• HPI
• PMHx
• MEDS
• Allergies
• SocHx
• 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
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• CC
• HPI
• PMHx
• MEDS
• Allergies
• SocHx
• FMHx
• ROS
• Physical Exam
• Differential
• LABS
• Radiological
• Differential
• Diagnosis
• Treatment

• Diagnosis
• Urinary Tract Infection
• Most likely cystitis

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• 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

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• 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

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• CC
• HPI
• PMHx
• MEDS
• Allergies
• SocHx
• 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 250mg PO BID x 3 d
-Norfloxacin 400mg PO BID x 3 d Phenazopyridine
- Urinary tract analgesic that may help
with pain (orange urine) Treating
pyelonephritis -can give ciprofloxacin x 14d
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• CC
• HPI
• PMHx
• MEDS
• Allergies
• SocHx
• 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
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Thank you!

• Questions, comments, concerns?