November case 1 (Full Version)

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Dr.Wagner -> November case 1 (November 13, 2007 1:56:10 PM)

37 year old female presents with left flank and mid back pain for 3 days of duration. Reports no fevers, vomiting, or radiculopathy.  Mild nausea only.  She reports no injury that she can remember.  She was seen the day previously in the ER and diagnosed with a UTI.  She has reported no success with antibiotic treatment thus far and still reports discomfort at a 6/10.
She is accompanied by her husband.







bonez -> RE: November case 1 (November 13, 2007 2:35:41 PM)

Did her labs support antibiotic therapy? What were the responses to examination, rebound tenderness ab rigidity positions of relief or aggravation ? Is she suferring from any other health issues or on any other meds?



FLAOrthoPT -> RE: November case 1 (November 13, 2007 2:53:57 PM)

Vitals: BP, Temp.
Inspection/Palpation? Tenderness?
AROM/PROM of back

Maybe an US on kidney.....kidney stones?




Shill -> RE: November case 1 (November 13, 2007 4:35:26 PM)

Does she have any menstrual abnormalities? Is there any possibility of being pregnant? Prior troubles with pregnancy(ies)?



jma -> RE: November case 1 (November 13, 2007 11:38:33 PM)

Has the pain been constant for 3 days and nights with no relief? Is their painful urination? Was this patient given broad or narrow spectrum antibiotics initially?



Dr.Wagner -> RE: November case 1 (November 14, 2007 3:10:59 PM)

Previous day UA.
Neg preg
5 wbc
5 rbc
0-1 epi
no nitrites
no esterase
1+ bacteria


Palpation reveals no spasm and no trauma.  She notes discomfort with left flank deep palpation but no CVA tenderness.  She notes mild pain with flexion but that does not reproduce her symptoms.  She has no radiculopathy.  Strength testing is normal. 
She states most of the pain is thoracolumbar, but it is difficult to reproduce.
Abdominal exam: soft, neg mcburney, no rebound, non specific discomfort to deep palpation in epigastrium.


Antibiotics prescribed: Keflex

Vitals 125/70, ox 98, temp 97.9, resp 18

PMHx: 1 uncomplicated live birth otherwise healthy non smoker of 70kg
She takes OTC MVI and has taken tylenol for the pain.  She has used heat with limited success.





bonez -> RE: November case 1 (November 14, 2007 8:31:37 PM)

Nothing specifically jumps out at me. Is there any soft tissue imaging US or CT?



FLAOrthoPT -> RE: November case 1 (November 14, 2007 9:37:58 PM)

what does :
0-1 epi
no nitrites
no esterase
1+ bacteria
mean?
not sure where to find the norms on that and what the abnormals mean to be honest.?

wbc and rbc are pretty normal...so thinking there is something there if flexion and palpation are causing some pain...so somethign is enlarged or inflamed? I'd go for an US or CT at this point of abdomen and maybe a kidney.



SJBird55 -> RE: November case 1 (November 14, 2007 10:02:17 PM)

FLA... urine analysis  http://www.thedoctorsdoctor.com/labtests/urinalysis.htm  Info on some normal and abnormal results:  http://www.nlm.nih.gov/medlineplus/ency/article/003579.htm#Normal%20Values

An excellent book by Boissonnault has lab values with norms and what an increase in a value or a decrease in a value indicates.  He did a great job putting this text together.  Primary Care for the Physical Therapist  Examination and Triage.  I have the 2005 copyright - not sure if Bill has upgraded it or not.  It's a really good reference book - can find info quickly when I'm trying to differential diagnose whether a patient is a candidate for PT or whether I should refer to PCP or specialist.



FLAOrthoPT -> RE: November case 1 (November 15, 2007 6:10:18 PM)

i have it too, but it was a lot easier to just ask...i was being lazy...thanks for ruining it :(



SJBird55 -> RE: November case 1 (November 15, 2007 9:26:28 PM)

You lazy sucker!  10 lashes with.... I'll let you choose.  ;)



Dr.Wagner -> RE: November case 1 (November 16, 2007 2:44:33 PM)

The previous UA is essentially non pathological showing no evidence (objectively) of a UTI.

A new UA is ordered with the following results.

RBC 50
WBC 5
nitrites negative
esterase 25
bacteria negative

Microscopic blood noted.


Non Contrasted CT of the abdomen and pelvis : no renal stones, small nonspecific inflammation of the transverse colon, no abscesses, mildly enlarged mesenteric lymph nodes, no free air, no masses, no obstructions, no fractures, ovaries intact, appendix noted and not enlarged.



chiroortho -> RE: November case 1 (November 16, 2007 9:20:36 PM)

What's her CBC and creatinine?  Wondering about glomerulonephritis. 

Clearly her kidney(s) is/are an issue, if it was in the lower UT she'd look different clinically.  Good case - referred pain easily attributed to primary LBP when it's not. 



Dr.Wagner -> RE: November case 1 (November 18, 2007 1:44:17 AM)

Basic Metabolic Profile:
Cr. 1.2
BUN 22
K 3.6
Na 135
CL  109
CO2 28
Glu 109

Complet Blood Count (CBC)
WBC 45
Hgb 11
Hct 30
Platelets 70



bonez -> RE: November case 1 (November 19, 2007 12:14:30 AM)

Was there a differential for the white count? With the low platelets elevated white cells and low hematocrit would seem to point to bone marrow disorder. Possibly a leukemia. Since there was no reference to ease of bruising the spinal pain would warrant imaging like bone scan.
The enlarged lymph nodes fits with the possibility but the presentation is fast if this is the condition.



Dr.Wagner -> RE: November case 1 (November 19, 2007 1:32:07 AM)

Diagnosis:
Acute Myelogenous Leukemia (AML) 

The patient died 2 weeks later when here platelets dropped below 5 and she died of a brain hemorrhage.


Acute myelogenous leukemia (AML) is a fast-growing cancer of the blood and bone marrow. In AML, the bone marrow makes many unformed cells called blasts. Blasts normally develop into white blood cells that fight infection. However, the blasts are abnormal in AML. They do not develop and cannot fight infections. The bone marrow may also make abnormal red blood cells and platelets. The number of abnormal cells (or leukemia cells) grows quickly. They crowd out the normal red blood cells, white blood cells and platelets the body needs.



chiroortho -> RE: November case 1 (November 19, 2007 9:05:42 AM)

makes me wonder about the RBCs/WBCs in the urine.  Is this a classic presentation?



Dr.Wagner -> RE: November case 1 (November 19, 2007 6:58:45 PM)

rbc's and microscopic blood were a result of the low platelet count...small but the first thing that made me think "hmm...maybe I should look further, she didn't really have this much blood yesterday"



chiroortho -> RE: November case 1 (November 19, 2007 10:10:06 PM)

thanks for the case.

And that is one funky picture you've attached to your sig.  Looks like me dancing.



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