32/M presenting with right flank pain

Angelie P. DugasanNovember 25, 2009

Patient Profile

• 32 year-old, male• Married• Roman Catholic• Jeepney driver• From Tondo, Manila• Nonhypertensive, nondiabetic, non-asthmatic

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

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

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

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

History of Present Illness

• persistence of symptoms hence patient decided to seek another consult at PGH-Ambulatory Clinic

Few hours PTC

Review of Systems

(-) weight loss(-) anorexia(-) headache(-) chest pain(-) changes in bowel movement(-) melena(-) hematochezia(-) jaundice(-) bloatedness(-) muscle weakness

Past Medical History

(-) Hypertension(-) Diabetes Mellitus(-) Bronchial Asthma(-) previous hospitalizations/surgeries(-) known allergies

Tapang-Olivo Genogram

Legend: - Hypertension

Data taken on Nov. 18, 2009 by Int. Dugasan

Informant: the patient

60 59

36

2940 323436

Personal and Social History

• (+) 3 pack year smoking history• Occasional alcoholic beverage drinker• Denies use of illicit drugs• High school graduate• Jeepney driver

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

Assessment

Acute Pyelonephritis T/C Urolithiasis

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.

Diagnostic Dilemma

Diagnostic Dilemma

Population Adults with urolithiasisIntervention KUB ultrasoundControl Non-contrast helical CT ScanOutcome Sensitivity and Specificity in

detecting urolithiasisMethodology Cross-sectional Study

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?

Pre-Test Probability

0 0.3 0.5 0.8 1.0

Therapeutic Dilemma

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

Therapeutic Dilemma

In a RCT investigating adults with urolithiasis, what is more effective in reducing pain as measured by VAS, Anti-spasmodic or NSAIDs?