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NR 38 y/o female CC: Right Flank Pain

NR 38 y/o female CC: Right Flank Pain HPI: 4-5 hours severe, right flank pain with radiation to groin and nausea. No urinary symptoms, +N/V, no fever. ROS: o/w negative PMH: IDDM, CVA with residual right hemiparesis, renal colic, cholecystectomy Meds: Insulin Allergies: PCN. PE

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NR 38 y/o female CC: Right Flank Pain

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  1. NR 38 y/o female CC: Right Flank Pain HPI: 4-5 hours severe, right flank pain with radiation to groin and nausea. No urinary symptoms, +N/V, no fever. ROS: o/w negative PMH: IDDM, CVA with residual right hemiparesis, renal colic, cholecystectomy Meds: Insulin Allergies: PCN

  2. PE 97.6 142/85 95 18 96% Gen: Alert, moderate painful distress Skin: warm, dry Chest: CTA and equal. COR: RRR no g/m ABD: non-distended, mild R flank tenderness, with moderate R CVA tenderness, no guarding/rebound/mass, no palpable pulsatile mass Extrem: no edema Neuro: Non focal _____________________________ U/A: +nitrites, 2+ blood, trace leuk >100 wbc/hpf, 2-5 rbc/hpf, 4+bact

  3. WBC=14.2, 84% neut, 11% lymph, 4 % mono Chem: Na=143, K=3.9, CL=103, C02=31, Gluc=300, BUN=17, CRE=0.9 Diagnosis: Early Pyleonephritis Urine culture sent Plan: IM rocephin, po keflex monostat vaginal suppos. compazine suppos. 3 day follow up with PMD urine culture sent

  4. 2 days later NR 38 y/o female CC: Worsening bladder infection HPI: Continuing right flank pain, fever to 104 and vomiting. Patient has been confused today. Was diagnosed with “bladder infection” 2 days ago. Meds: Vicodin, glyburide and Keflex Allergies: PCN

  5. PE 1725: 99.1 HR=118 BP=132/90, 98% RA 1825: 100.4 HR=170 BP=117/38, 93% 4 lit. Gen: critically ill, morbidly obese, confused Skin: warm, diaphoretic Chest: CTA with diminished tidal volume CV: RRR, strong peripheral pulses ABD: BS present, soft, nontender, no mass, no peritoneal signs Extrem: no edema Neuro: Non focal EKG: Narrow complex tachycardia at 170 with questionable P wave. Sinus tach vs. SVT.

  6. Assessment: 1. Sepsis 2. Possible SVT ED Course: 1. No response to adenosine 2. Tachycardia, BP, mental status responded to fluid 3. Started on Rochephin 4. Previous urine culture showed mixed flora WBC 7.2, H/H 15.7/47 Chem normal except glucose 239, CRE 1.4, BUN16 LFT minimally elevated CXR normal except elevated Right hemidiaphragm U/A dip trace blood, trace leuk Blood, urine cultures sent

  7. Perinephric stranding   Air in renal pelvis 

  8. Percutanous Nephrostomy Placed Grew Proteus from nephrostomy Urine cultures negative Stent placed Subsequently at least 4 visits to SDMC for right pyelonephritis with obstruction transferred to CCCRMC 3 times for urology availability. 4 months after initial nephrostomy had a nephrectomy at CCCRMC.

  9. Emphysematous Pyelonephritis • Parenchymal and perinephric infection • Usually gram negative, esp. E. coli • Diabetics • Obstruction--stone, papillary necrosis • Needs aggressive therapy--43% mortality • Antibiotics • Relieve obstruction

  10. Risk Factors for Complicated UTI • Male • Age <12 y/o or >50 y/o • Obstruction • Pregnancy • Instrumentation • Immunocompromised • Recent antibiotic use • Not improving after 72 hours

  11. BD--11 y/o male CC: Abdominal Pain HPI: Severe lower abdominal for 5 days. N/V/D present. No fever. Anorexia for 3-4 days. Saw personal doctor 2 days ago. [Nurses notes indicate pain started peri-umbilical and moved to RLQ.] ROS: otherwise negative PMH: None, Meds: none, Allergies: none PE: 97.6 127/79 16 85 99%RA Abd: BS increased, diffusely tender abdomen, more to suprapubic area, non-distended, no rebound. Rest of exam normal U/A SG 1.015, +ketones, moderate bili, o/w negative WBC 13.7, Hgb 13.5, Chem-7 normal

  12. CT abdomen shows inflammatory mass midline lower abdomen between rectum and bladder measuring 5.8x6cm. Mass is not near the cecum. Consider ulcerative colitis, granulomatous colitis, amebiasis… Appendicitis unlikely but cannot rule out abscess seeded from appendix or elsewhere. Surgery consult obtains history that patient had similar symptoms 6 mos. ago and 2 mos. ago and has not felt completely well for 2 mos. Surgery: Distended bladder and distal urethral stricture, abscess drainage, appendectomy. Appendix was found in retroperitoneum, not connected to cecum.

  13. NT 8 y/o female CC: Abd Pain HPI: R upper abdominal pain for a few hours. Has been ill for 4 days with URI symptoms. Had N/V and fever yesterday. PMH, Meds, Allergies--None PE: 97.2 135/72 109 18 97% RA Abd: BS normal, non-distended, moderate RLQ tenderness. No rebound/guarding. No obturator sign, no psoas sign, can jump without pain. Rectal: nontender, heme negative Rest of exam normal

  14. U/A SG 1.030, +ket, moderate blood, otherwise negative WBC 13.7 with left shift Ultrasound: No appendix identified. No pathalogy identified. Consider repeat ultrasound. Reexam: temp 100.0, abdominal exam unchanged, takes po water well. _________________________________________ Scheduled return in 6 hours: Exam unchanged. WBC 11.4 Repeat ultrasound: appendolith with inflamed appendix

  15. Pediatric Abdominal Pain • Atypical presentations • Careful history • Repeated examinations • CBC can be misleading in appy. • 80% with wbc 10k-15k • 80% with > 75% polys • 4% normal

  16. KJ 76 y/o female CC: Dyspnea and irregular heartbeat HPI: 7-10 days of progressive dyspnea. No palpatations. Went to physician’s office and was referred to ED for possible atrial fibrillation. Recent dry cough. There is no edema, PND, nor orthopnea. ROS: otherwise negative. PMH: Polymylagia Rheumatica, Hypothyroidism Meds: Prednisone, Synthroid. All: NKDA SH: No tobacco, active lifestyle with bike riding, now limited over the last 10 days by dyspnea.

  17. PE 140/70 124i 24 97.2 91% RA GEN: Pleasant, no obvious distress Neck: Supple, no thyromegaly Chest: CTA and equal CV: irregular, irregular Extrem: no calf fullness or tenderness, no edema, distal N/V intact Neuro: nonfocal, normal Skin: warm, dry ________________________________ EKG: A fib @107, normal axis, non specific ST changes Labs: chemistry, cbc normal, cardiac enzymes negative CXR: normal

  18. Initial Treatment: ASA, oxygen, albuterol Digoxin Heparin Cardiology consult: History of venous stripping Likely recent onset of Afib Possible cardiac etiology because of age and ST changes Consider Thyroid disease, pulmonary disease ABG 7.488/32/66 on 3 liters TSH normal Echo

  19. PE infiltrate

  20. Causes of Atrial Fibrillation Hypertensive heart disease Cardiomyopathy Cardiac surgery Catecholamine excess Pulmonary embolism Congestive heart failure Accessory pathway (WPW) Idiopathic Ischemic heart disease Valvular disease (esp. mitral) Pericarditis Hyperthyroidism Sick sinus syndrome Myocardial contusion Acute ethanol intoxication (holiday heart syndrome)

  21. JC--52 y/o male JC is brought in by EMS with leg pain, numbness and chest pain. EMS found patient alert, on the floor, diaphoretic, in severe pain. 90/p, 66, 24, NSR. Received ASA, and NS bolus. HPI: severe pressure like CP began 1930 and 3-4 minutes later left leg tingling began followed by pain and weakness to left leg. Pain is pleuritic, but there is no shortness of breath. CP has eased now and is 3/10. Initially radiated to neck. Leg pain is 10/10. ROS occ. LBP, mild cough, mild HA, otherwise negative PMH: C3 laminectomy, peptic ulcer disease in the past. No HTN, DM, CAD Meds: none, Allergies: none, SH--smokes 2125 time

  22. PE 2031 96.8 63 16 135/34 98% 2101 55 18 151/52 100% Moderate Distress Neck: normal Resp: no distress, nontender chest, CTA CV: brady, muffled heart tones, no rub no palpable left femoral, left DP pulses GI: soft, nontender Skin: normal, warm and dry Neuro: Left leg palsy Extrem: no edema 2125 time __________________________ Monitor: NSR at 62 EKG: NSR at 60, inverted T’s with ST depression v2-v6, I, avL

  23. ED Course CXR normal Vascular surgery consult Fellow wants angiogram to evaluate for emboli Intermittent left leg movement NTG SL then NTG drip BP drops NS bolus Cardiology recommends thrombolytics CP and leg pain continue BP remains low Bedside ultrasound rules out tamponade To CT scan--Type I dissection Transfer

  24. Aortic Dissection • Treatment--lower double product • Nitroprusside • Labetalol • Esmolol • Caveats • Ensure you are getting accurate BP, the dissection may compromise the great vessels • Consider coronary artery involvement • Consider tamponade

  25. Aortic DissectionDiagnosis • CXR normal in 12% • Chest CT with IV contrast • Trans-esophageal echo • MRI • Aortograhphy

  26. Aortic Dissection • Classification • Type A--ascending aorta • Type B--no involvment of ascending aorta • DeBakey I--ascending and descending • DeBakey II--asceding aorta only • DeBakey III--descending distal to left subclavian

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