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Case of the week August 27th
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Case of the week August 27th - August 27, 2007 9:16:19 AM
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Dr.Wagner
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One of my cases from a month ago.
26 year old female with persistent left back pain. She states that she recalls no recent injury, she was in a car accident 5 years ago, but was relatively minor accident. Pain is described as an "ache". She is pleasant and cooperative.
Vitals: HR 80, Ox 100%, R 15, BP 130/85, Temp 98
Good Luck, ask any questions you like, I will try to answer them. Answer on Friday!
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Dr. Wagner DO
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RE: Case of the week August 27th - August 27, 2007 11:09:20 AM
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Tom Reeves DPT ATC
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Is the ache constant?
Does it change with position or activity?
Has she had any changes in color of urine?
Is it painful to urinate?
Is it possible that she is pregnant?
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RE: Case of the week August 27th - August 27, 2007 12:19:54 PM
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USAPT
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where specifically is the pain?
night pain, ie, does it awake her from sleep and can she get back to sleep?
and the above ?s
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RE: Case of the week August 27th - August 27, 2007 1:20:08 PM
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jma
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Did this back pain begin recently or after the MVA accident? Was it gradual or did it appear suddenly? What positions aggravates the pain and what relieves it, if any? Any significant past medical history?
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RE: Case of the week August 27th - August 27, 2007 1:42:43 PM
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Dr.Wagner
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The ache is fairly constant, seems to have come on suddenly, and involves the left side. She seems to note the pain diffusely over the L1-L4 region.
She could always be pregnant, but she notes she just had her period.
She reports her urine as "normal"
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Dr. Wagner DO
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RE: Case of the week August 27th - August 27, 2007 1:55:16 PM
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Tom Reeves DPT ATC
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so the pain does not change with position or motion. I am sure that the physician would do a urine sample/culture to look for blood or bugs to rule out kidney stones or pyelonephritis or UTI. Pregnancy test to r/o ectopic pregnancy.
If I cannot affect the symptoms either make them worse or make them better with motion or position I would need some medical diagnoses ruled out.
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RE: Case of the week August 27th - August 27, 2007 5:04:40 PM
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Tom Reeves DPT ATC
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bp is mildly high for someone her age. What are the symptoms/signs with a dissecting aortic aneurysm? You are sneaky, you mentioned the car accident for a reason.
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RE: Case of the week August 27th - August 28, 2007 1:30:51 PM
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USAPT
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What are the results of her labs?
Diagnostic testing? (radiographs/CT/MRI)
Palpable tenderness or defect noted during physical exam?
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RE: Case of the week August 27th - August 28, 2007 1:33:07 PM
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USAPT
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nevermind you answered the tenderness part (L1-L4)
But were there any lumps, rash, etc
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RE: Case of the week August 27th - August 28, 2007 3:30:06 PM
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Dr.Wagner
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Q:so the pain does not change with position or motion. I am sure that the physician would do a urine sample/culture to look for blood or bugs to rule out kidney stones or pyelonephritis or UTI. Pregnancy test to r/o ectopic pregnancy.
A: When you palpate the left lumbar region she states "I guess it hurts a little" She notes only minimal increase in pain with movement to the right, but she notes that she feels she is most comfortable laying on her left side.
Q: Urinalysis:
A: Preg neg, WBC 5, RBC 15 , blood min, leukocyte esterase 0, nitrite neg, epithelial cells 10,
Q: What are the results of her labs
A: What labs?
Q: Diagnostic testing? (radiographs/CT/MRI)
A: well...which do you want, and of what, and how...
Q:were there any lumps, rash, etc
A: She has no noted abnormal lumps or rashes
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RE: Case of the week August 27th - August 28, 2007 9:59:34 PM
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SJBird55
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Why is she in the ER? Is it an emergency? Is her back pain severe? People live with persistent back pain day in and day out so... why is she in the ER? What's her story? Persistent back pain that came on suddenly... suddenly when? I am completely confused. Does she look like she is in pain? Is she squirming around? Does she grimace? What is her gait pattern like? What intensity of pain does she report for average, best and worst?
If she doesn't have hemorrhoids, then why an increase in RBC with urinalysis? Not sure the exact tests to be done diagnostically - but r/o kidney. (Maybe kidney function tests?)
What does she report with percussing?
Does she report a recent previous urinary tract infection?
Is she taking any prescribed medications, over the counter stuff, herbs/natural stuff, or street drugs?
Any constitutional symptoms?
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RE: Case of the week August 27th - August 28, 2007 10:50:13 PM
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steve
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From: victoria, bc Canada
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I agree with SJ, rule out kidney based on high RBC and pain area. Could we get the BUN?
Steve
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RE: Case of the week August 27th - August 29, 2007 12:53:21 PM
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USAPT
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CT of her abdomen
how? supine??
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RE: Case of the week August 27th - August 29, 2007 10:21:26 PM
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Sebastian Asselbergs
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Looking for painkillers?
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RE: Case of the week August 27th - August 30, 2007 1:58:54 AM
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bonez
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The lack of specific provocation with exam, the urinalysis findings and most comfort in left side down position has to make you think of internal issues in or around renal structures. In the lateral recumbent position pressure from a renal mass or blockage of flow high in the urinary tract might likely be eased. Is there nocturnal pain, pain in the supine position?
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RE: Case of the week August 27th - August 30, 2007 2:10:53 PM
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Dr.Wagner
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The patient does note pain in the supine position as well, there is pain in all positions, just some worse than others.
Basic Metabolic Profile: Na 138, Cl 101, CO2 27, K 3.9, BUN 30, Cr. 1.3
USAPT: "CT of what"..."HOW"... with or without contrast (ie do you want PO contrast, IV, both, or none)
SJ stated:People live with persistent back pain day in and day out so... why is she in the ER? What's her story? Persistent back pain that came on suddenly... suddenly when? I am completely confused. Does she look like she is in pain? Is she squirming around? Does she grimace? What is her gait pattern like? What intensity of pain does she report for average, best and worst? "
A: This is pretty complex question, but boiled down...she is in the ER because when her pain "suddenly came on"...unprovoked and without trauma, it has persisted without relief (time frame is 3 days at time of visit).
She is NOT squirming around.
Her gait is upright and gentle...if asked, she would prefer not to run.
(and my favorite...the pain scale) She reports her pain as an 8/10
SJ asks:
If she doesn't have hemorrhoids, then why an increase in RBC with urinalysis? Not sure the exact tests to be done diagnostically - but r/o kidney. (Maybe kidney function tests?)
What does she report with percussing?
Does she report a recent previous urinary tract infection?
Is she taking any prescribed medications, over the counter stuff, herbs/natural stuff, or street drugs?
Any constitutional symptoms? "
A: To be honest, the ratio rbc:wbc:epithelial cells is not disturbing and not a home run, but perhaps a piece of the puzzle. It is not necessarily abnormal at all...it may be from traumatic catheterization, spotting from menstruation, spotting from vigorous intercourse, or a random event. It may also be a piece of the puzzle.
She reports pain, but not profound pain with percussion over the kidneys.
No recent UTI.
THank you, YES she is taking a prescription medication!!! Always ask this as part of the history if not given.
Oral Birth Control Pills
She smokes marijuana (as do 50% of the patients I see in this age range)...and she is not diaphoretic, no vomiting, she has nausea and mild anorexia, no fevers, no diarrhea, no constipation
Note: This is not an easy case, and there are subtle questions and answers. Remember, I will NOT hand over too many answers, you must ask for them (usually), and as most of you are familiar with, tests need to be specifically addressed, as there are many ways to do them.
I enjoy all of the questions and this, of course, is not graded, purely for fun, so ask away...the more you ask, the more you may find out.
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Dr. Wagner DO
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RE: Case of the week August 27th - August 30, 2007 3:10:19 PM
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Tom Reeves DPT ATC
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I would like to see an MRI of her kidneys Maybe an US first for cost reasons perhaps. I suspect kidney function scores are elevated because of kidney dysfunction. maybe a stone, maybe pyelonephritis, probably something I've never heard of. :-)
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RE: Case of the week August 27th - August 30, 2007 4:07:31 PM
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Dr.Wagner
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What tests may be helpful to rule out pyelonephritis completely despite her sterile urine?
Can you see a kidney stone with IV contrast?
That is part of my point regarding use of contrast...
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Dr. Wagner DO
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RE: Case of the week August 27th - August 30, 2007 4:59:51 PM
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Tom Reeves DPT ATC
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zactly. I don't know. No med school remember. lol BUN and creatinine are elevated. suggests kidney problems. diffuse upper lumbar pain on one side, also consistent with kidney problems. tests, cystogram? MRI with out contrast (contrast is contraindicated with kidney disease and we have not ruled that out yet)
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RE: Case of the week August 27th - August 30, 2007 9:45:41 PM
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Dr.Wagner
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From: Indianapolis
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Ok, this is not pyelonephritis, afebrile, no emesis, sterile urine
This could be a kidney stone, but there is no blood in the urine and really doesn't present as such (usually much more pain and they present acutely).
The biggest hint...she is on birth control pills...what does that increase the risk of?
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Dr. Wagner DO
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