Transcript Current Case Review - Novi Family Doctor | Novi MI Family

Current Case Review
Robert R. Zaid
March 9th, 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?
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HPI
PMHx
MEDS
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SocHx
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Physical Exam
Differential
LABS
Radiological
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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.
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Past Medical History
Hypertension (controlled)
Obesity
Type II diabetes
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Radiological
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Treatment
Medications
Furosemide
Atenolol
Glucophage
Multi-vitamin
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Radiological
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Diagnosis
Treatment
Allergies
NKDA
3rd year medical students that ask
too many questions
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Physical Exam
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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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Family Medical History
Mother- Alive (DM, HTN)
Father- Alive (Hypercholesterolemia)
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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
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Physical Exam
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LABS
Radiological
Differential
Diagnosis
Treatment
Physical Exam
VSBP- 140/87 T-98.2 R-16 P-82
General- Pt is well nourished and AxOx3
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 T11-L-1
EXT- No edema, negative moses, pulses b/l
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Physical Exam
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Radiological
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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
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Radiological
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Diagnosis
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What do we want to order?
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Radiological
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Urinalysis
Specific gravityRBCWBCBacteria
Leukocyte Esterase
Protein
Microscopy
Culture- pending
1.002
None
>10 WBC’s per HPF
Moderate
Positive
Trace
No casts found
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CBC
14 g/dl
10
300
40
Chemistry
140
100
8.0
100
4.2
24
1.1
Pregnancy Test
Negative
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Radiological
Differential
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Treatment
Could possibly order a renal ultrasound or KUB
contrast study to rule out cysts/stones
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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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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
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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
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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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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
Thank you!
• Questions, comments, concerns?