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32/M presenting with right flank pain. Angelie P. Dugasan November 25, 2009. Patient Profile. 32 year-old, male Married Roman Catholic Jeepney driver From Tondo , Manila Nonhypertensive , nondiabetic , non-asthmatic. History of Present Illness. History of Present Illness. - PowerPoint PPT Presentation
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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?