Current Case Review

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

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

3. What questions do we want to ask this patient?

4. 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 • SocHx • FMHx • ROS • Physical Exam • Differential • LABS • Radiological • Differential • Diagnosis • Treatment

5. 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

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

7. 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

8. 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.

9. 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)

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

11. 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 lloyd’s test MSK- No weakness, mild tenderness in R flank TTA T11-L-1 EXT- No edema, negative moses, pulses b/l

12. 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

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

14. CC • HPI • PMHx • MEDS • Allergies • SocHx • FMHx • ROS • Physical Exam • Differential • LABS • Radiological • Differential • Diagnosis • Treatment Urinalysis Specific gravity- 1.002 RBC- None WBC- >10 WBC’s per HPF Bacteria Moderate Leukocyte Esterase Positive Protein Trace Microscopy No casts found Culture- pending

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

16. 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

17. 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 • SocHx • FMHx • ROS • Physical Exam • Differential • LABS • Radiological • Differential • Diagnosis • Treatment

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

19. 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

20. 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

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

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

23. Thank you! • Questions, comments, concerns?