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Dr.Wagner -> RE: Case of the week August 27th (August 30, 2007 2:10:53 PM)
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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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