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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 - PowerPoint PPT Presentation
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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
PE97.6 142/85 95 18 96%
Gen: Alert, moderate painful distressSkin: warm, dryChest: CTA and equal.COR: RRR no g/mABD: non-distended, mild R flank tenderness, with moderate R CVA tenderness, no guarding/rebound/mass, no palpable pulsatile massExtrem: no edemaNeuro: Non focal
_____________________________U/A: +nitrites, 2+ blood, trace leuk >100 wbc/hpf, 2-5 rbc/hpf, 4+bact
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
2 days laterNR 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
PE1725: 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, confusedSkin: warm, diaphoreticChest: CTA with diminished tidal volumeCV: RRR, strong peripheral pulsesABD: BS present, soft, nontender, no mass, no peritoneal signsExtrem: no edemaNeuro: Non focal
EKG: Narrow complex tachycardia at 170 with questionable P wave. Sinus tach vs. SVT.
Assessment:1. Sepsis2. Possible SVT
ED Course:1. No response to adenosine2. Tachycardia, BP, mental status responded to fluid3. Started on Rochephin4. Previous urine culture showed mixed flora
WBC 7.2, H/H 15.7/47Chem normal except glucose 239, CRE 1.4, BUN16LFT minimally elevatedCXR normal except elevated Right hemidiaphragmU/A dip trace blood, trace leukBlood, urine cultures sent
Percutanous Nephrostomy PlacedGrew Proteus from nephrostomyUrine cultures negativeStent 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.
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
Risk Factors for Complicated UTIRisk 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
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%RAAbd: 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 negativeWBC 13.7, Hgb 13.5, Chem-7 normal
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.
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% RAAbd: BS normal, non-distended, moderate RLQ tenderness. No rebound/guarding. No obturator sign, no psoas sign, can jump without pain.Rectal: nontender, heme negativeRest of exam normal
U/A SG 1.030, +ket, moderate blood, otherwise negativeWBC 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
Pediatric Abdominal PainPediatric Abdominal Pain
Atypical presentationsAtypical presentations Careful historyCareful history Repeated examinationsRepeated examinations CBC can be misleading in appy.CBC can be misleading in appy.
• 80% with wbc 10k-15k80% with wbc 10k-15k• 80% with > 75% polys80% with > 75% polys• 4% normal4% normal
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.
PE
140/70 124i 24 97.2 91% RA
GEN: Pleasant, no obvious distressNeck: Supple, no thyromegalyChest: CTA and equalCV: irregular, irregularExtrem: no calf fullness or tenderness, no edema,distal N/V intactNeuro: nonfocal, normalSkin: warm, dry
________________________________EKG: A fib @107, normal axis, non specific ST changesLabs: chemistry, cbc normal, cardiac enzymes negativeCXR: normal
Initial Treatment:ASA, oxygen, albuterolDigoxinHeparin
ABG 7.488/32/66 on 3 litersTSH normalEcho
Cardiology consult:History of venous strippingLikely recent onset of AfibPossible cardiac etiology because of age and ST changes Consider Thyroid disease, pulmonary disease
Causes of Atrial FibrillationIschemic heart disease
Valvular disease (esp. mitral)
Pericarditis
Hyperthyroidism
Sick sinus syndrome
Myocardial contusion
Acute ethanol intoxication (holiday heart syndrome)
Hypertensive heart disease
Cardiomyopathy
Cardiac surgery
Catecholamine excess
Pulmonary embolism
Congestive heart failure
Accessory pathway (WPW)
Idiopathic
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
PE2031 96.8 63 16 135/34 98%2101 55 18 151/52 100%
Moderate DistressNeck: normalResp: no distress, nontender chest, CTACV: brady, muffled heart tones, no rub no palpable left femoral, left DP pulsesGI: soft, nontenderSkin: normal, warm and dryNeuro: Left leg palsyExtrem: no edema
2125 time
__________________________Monitor: NSR at 62EKG: NSR at 60, inverted T’s with ST depression v2-v6, I, avL
CXR normalVascular surgery consultFellow wants angiogram to evaluate for emboli
Intermittent left leg movementNTG SL then NTG dripBP dropsNS bolusCardiology recommends thrombolyticsCP and leg pain continueBP remains low
ED Course
Bedside ultrasound rules out tamponadeTo CT scan--Type I dissection Transfer
Aortic DissectionAortic Dissection
Treatment--lower double productTreatment--lower double product• NitroprussideNitroprusside• LabetalolLabetalol• EsmololEsmolol
CaveatsCaveats• Ensure you are getting accurate BP, the dissection may Ensure you are getting accurate BP, the dissection may
compromise the great vesselscompromise the great vessels• Consider coronary artery involvementConsider coronary artery involvement• Consider tamponadeConsider tamponade
Aortic DissectionAortic DissectionDiagnosisDiagnosis
CXR normal in 12%CXR normal in 12% Chest CT with IV contrastChest CT with IV contrast Trans-esophageal echoTrans-esophageal echo MRIMRI AortograhphyAortograhphy
Aortic DissectionAortic Dissection
ClassificationClassification• Type A--ascending aortaType A--ascending aorta• Type B--no involvment of ascending aortaType B--no involvment of ascending aorta
• DeBakey I--ascending and descendingDeBakey I--ascending and descending• DeBakey II--asceding aorta onlyDeBakey II--asceding aorta only• DeBakey III--descending distal to left DeBakey III--descending distal to left
subclaviansubclavian