32/M presenting with right flank pain
description
Transcript of 32/M presenting with right flank pain
![Page 1: 32/M presenting with right flank pain](https://reader035.fdocuments.us/reader035/viewer/2022081505/5681649d550346895dd681c5/html5/thumbnails/1.jpg)
32/M presenting with right flank pain
Angelie P. DugasanNovember 25, 2009
![Page 2: 32/M presenting with right flank pain](https://reader035.fdocuments.us/reader035/viewer/2022081505/5681649d550346895dd681c5/html5/thumbnails/2.jpg)
Patient Profile
• 32 year-old, male• Married• Roman Catholic• Jeepney driver• From Tondo, Manila• Nonhypertensive, nondiabetic, non-asthmatic
![Page 3: 32/M presenting with right flank pain](https://reader035.fdocuments.us/reader035/viewer/2022081505/5681649d550346895dd681c5/html5/thumbnails/3.jpg)
History of Present Illness
•(+) R flank pain described as on and off, colicky, non-radiating, 6-7/10 on VAS, resolved spontaneously •(+) fever Tmax of 38.9 OC, temporary lysis with Paracetamol 500mg/tab•(+) 2 episodes of vomiting of previously ingested food, non-bilious, non-bloody, amounting to ¼ cup/episode•(+) dysuria•(+) good appetite•(-) tea-colored urine•(-) chills•(-) diarrhea•(-) history of trauma•(-) consult was done
5 days PTC
![Page 4: 32/M presenting with right flank pain](https://reader035.fdocuments.us/reader035/viewer/2022081505/5681649d550346895dd681c5/html5/thumbnails/4.jpg)
History of Present Illness
• (+) recurrence of R flank pain with the same characteristic but with increase in severity, 8/10 on VAS
• (+)recurrence of fever Tmax 38.7 OC
• (+) nausea• (+) decreased appetite• sought consult at private clinic
in Tondo, urinalysis was done which showed:
1 day PTC
![Page 5: 32/M presenting with right flank pain](https://reader035.fdocuments.us/reader035/viewer/2022081505/5681649d550346895dd681c5/html5/thumbnails/5.jpg)
Urinalysis
ValueCharacter Yellow, turbid
pH 6.0
CHO Negative
CHON Negative
WBC 8-10/hpf
RBC 4-5/hpf
Epith cells Negative
Bacteria Moderate
Casts/crystals Negative
![Page 6: 32/M presenting with right flank pain](https://reader035.fdocuments.us/reader035/viewer/2022081505/5681649d550346895dd681c5/html5/thumbnails/6.jpg)
History of Present Illness
• Management at Tondo Clinic• A> Urinary Tract Infection• P> Cotrimoxazole
160/800mg/tab , 1 tab BID x 7 days• HNBB 10mg/tab for pain
• However, the patient took only the HNBB which afforded minimal relief of pain.
• Cotrimoxazole was not taken.
1 day PTC
![Page 7: 32/M presenting with right flank pain](https://reader035.fdocuments.us/reader035/viewer/2022081505/5681649d550346895dd681c5/html5/thumbnails/7.jpg)
History of Present Illness
• persistence of symptoms hence patient decided to seek another consult at PGH-Ambulatory Clinic
Few hours PTC
![Page 8: 32/M presenting with right flank pain](https://reader035.fdocuments.us/reader035/viewer/2022081505/5681649d550346895dd681c5/html5/thumbnails/8.jpg)
Review of Systems
(-) weight loss(-) anorexia(-) headache(-) chest pain(-) changes in bowel movement(-) melena(-) hematochezia(-) jaundice(-) bloatedness(-) muscle weakness
![Page 9: 32/M presenting with right flank pain](https://reader035.fdocuments.us/reader035/viewer/2022081505/5681649d550346895dd681c5/html5/thumbnails/9.jpg)
Past Medical History
(-) Hypertension(-) Diabetes Mellitus(-) Bronchial Asthma(-) previous hospitalizations/surgeries(-) known allergies
![Page 10: 32/M presenting with right flank pain](https://reader035.fdocuments.us/reader035/viewer/2022081505/5681649d550346895dd681c5/html5/thumbnails/10.jpg)
Tapang-Olivo Genogram
Legend: - Hypertension
Data taken on Nov. 18, 2009 by Int. Dugasan
Informant: the patient
60 59
36
2940 323436
![Page 11: 32/M presenting with right flank pain](https://reader035.fdocuments.us/reader035/viewer/2022081505/5681649d550346895dd681c5/html5/thumbnails/11.jpg)
Personal and Social History
• (+) 3 pack year smoking history• Occasional alcoholic beverage drinker• Denies use of illicit drugs• High school graduate• Jeepney driver
![Page 12: 32/M presenting with right flank pain](https://reader035.fdocuments.us/reader035/viewer/2022081505/5681649d550346895dd681c5/html5/thumbnails/12.jpg)
Physical Examination
ORGAN SYSTEM PHYSICAL FINDINGSGENERAL awake, conscious, coherent, NICRD
VITAL SIGNS BP 120/80, HR 92, RR 22, T37.9 OC
HEENT pink conj, anicteric sclerae,(-) tonsillopharyngeal congestion, (-) cervical lymphadenopathies
CHEST & LUNGS equal chest expansion, clear breath sounds, (-) crackles/wheezes
CVS normal rate, regular rhythm, distinct heart sounds, (-) murmurs, (-) heaves/thrills
ABDOMEN soft, flabby, normoactive bowel sounds, nontender, (-) organomegaly, (+) CVA tenderness, R
EXTREMITIES pink nail beds, full equal pulses, (-) edema, (-) cyanosis
DRE good sphincter tone, intact rectal vault, (-) masses, (-) blood, (+) stool PER
![Page 13: 32/M presenting with right flank pain](https://reader035.fdocuments.us/reader035/viewer/2022081505/5681649d550346895dd681c5/html5/thumbnails/13.jpg)
Assessment
Acute Pyelonephritis T/C Urolithiasis
![Page 14: 32/M presenting with right flank pain](https://reader035.fdocuments.us/reader035/viewer/2022081505/5681649d550346895dd681c5/html5/thumbnails/14.jpg)
Plan
Diagnotics: Urine GS/CS KUB Ultrasound
Therapeutics: Ofloxacin 400mg/tab, 1 tab every 12 hours for 14
days Diclofenac 25mg/ml apm – given IM, afforded relief of
pain, 2-3 on VAS Diclofenac 50mg/tab, 1 tab every 8 hours for pain, on full
stomach Paracetamol 500mg/tab, 1 tab every 4 hours for T >38.5
OC
Increase oral fluid intake. Aggressive TSB for fever. Follow-up at OPD-FCM with lab results.
![Page 15: 32/M presenting with right flank pain](https://reader035.fdocuments.us/reader035/viewer/2022081505/5681649d550346895dd681c5/html5/thumbnails/15.jpg)
Diagnostic Dilemma
![Page 16: 32/M presenting with right flank pain](https://reader035.fdocuments.us/reader035/viewer/2022081505/5681649d550346895dd681c5/html5/thumbnails/16.jpg)
Diagnostic Dilemma
Population Adults with urolithiasisIntervention KUB ultrasoundControl Non-contrast helical CT ScanOutcome Sensitivity and Specificity in
detecting urolithiasisMethodology Cross-sectional Study
![Page 17: 32/M presenting with right flank pain](https://reader035.fdocuments.us/reader035/viewer/2022081505/5681649d550346895dd681c5/html5/thumbnails/17.jpg)
Diagnostic Dilemma
Among adults with urolithiasis, is the sensitivity and specificity of KUB ultrasound comparable to that of non-contrast CT Scan in detecting stones, in a cross-sectional study?
![Page 18: 32/M presenting with right flank pain](https://reader035.fdocuments.us/reader035/viewer/2022081505/5681649d550346895dd681c5/html5/thumbnails/18.jpg)
Pre-Test Probability
0 0.3 0.5 0.8 1.0
![Page 19: 32/M presenting with right flank pain](https://reader035.fdocuments.us/reader035/viewer/2022081505/5681649d550346895dd681c5/html5/thumbnails/19.jpg)
Therapeutic Dilemma
![Page 20: 32/M presenting with right flank pain](https://reader035.fdocuments.us/reader035/viewer/2022081505/5681649d550346895dd681c5/html5/thumbnails/20.jpg)
Therapeutic Dilemma
Population Adults with urolithiasisIntervention Anti-spasmodic (eg. Hyoscine
N-butyl Bromide)Control Non-Steroidal Anti-inflammatory
DrugsOutcome Reduction of pain as measured
using VASMethodology RCT
![Page 21: 32/M presenting with right flank pain](https://reader035.fdocuments.us/reader035/viewer/2022081505/5681649d550346895dd681c5/html5/thumbnails/21.jpg)
Therapeutic Dilemma
In a RCT investigating adults with urolithiasis, what is more effective in reducing pain as measured by VAS, Anti-spasmodic or NSAIDs?