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Re: Case: 19 year old with back pain

 
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Re: Case: 19 year old with back pain - August 22, 2006 7:04:00 PM   
KAK

 

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I would check for abdominal tenderness(McBurney point). I?m thinking appendicitis due to her age, low grade fever, the fact that lying on her side relieves the symptoms and the complaints of nausea. I realize that right lower abdominal pain is the typical presentation?

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Re: Case: 19 year old with back pain - August 23, 2006 2:09:00 PM   
Dr.Wagner


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She states "yeah I drank...I'm in college! But not that much."

You push on her abdomen and she has no rebound, no mcburney's point and normal bowel sounds.
The abdominal wall is free of bruises, abrasions, hernias or rash.

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Re: Case: 19 year old with back pain - August 24, 2006 11:19:00 AM   
USAPT

 

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how sexually active is she? Any pain with/without urination?

suspect a UTI with possible kidney infection since she has a fever??

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Re: Case: 19 year old with back pain - August 24, 2006 9:28:00 PM   
Jon Newman

 

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Cholecystitis

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Re: Case: 19 year old with back pain - August 24, 2006 10:08:00 PM   
jma

 

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Was there a positive Murphy's sign? Was there discomfort after eating?

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Re: Case: 19 year old with back pain - August 25, 2006 12:38:00 PM   
Dr.Wagner


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I will organize thoughts prior to the answer...

Young lady with right sided thoraco-lumbar pain, just noticed after moving into dorms.
Temp 100
No real significant medical history.
Benign abdomen.
No real history with etoh
sexually active
Pain with lateral flexion and laying on side.
metabolic profile is posted.


any additional thoughts, tests, etc?

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Re: Case: 19 year old with back pain - August 25, 2006 12:55:00 PM   
Jeffre

 

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How about a good "whack" by the DO/PT over the kidney? Pain better/worse after eating? Pain with urination? I agree with USAPT about infection due to fever.

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Re: Case: 19 year old with back pain - August 25, 2006 1:20:00 PM   
KAK

 

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WBC?

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Re: Case: 19 year old with back pain - August 25, 2006 2:01:00 PM   
Dr.Wagner


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WHACK..."OUCH!"

"I've never had a urinary tract infection before...that I know of"

UA: >100 wbc's, pos Nitrites, pos leukocyte esterase

CBC: hgb 13, hct 35, platelets 230, wbc 14

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Re: Case: 19 year old with back pain - August 25, 2006 2:29:00 PM   
steve

 

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She's a little anemic and the other readings indicate UTI. What is she using for birth control?

Steve

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Re: Case: 19 year old with back pain - August 25, 2006 3:43:00 PM   
Jeffre

 

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"pos Nitrites"- Does that mean too much processed meat products?

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Re: Case: 19 year old with back pain - August 25, 2006 3:55:00 PM   
steve

 

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Positive nitrites - indicative of infection

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Re: Case: 19 year old with back pain - August 25, 2006 9:37:00 PM   
eam

 

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Sounds like a UTI, especially with the + nitrates and the WBC of 14. Pain with lateral flexion and lying on side don't jive if UTI.
Erica

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Re: Case: 19 year old with back pain - August 26, 2006 1:57:00 AM   
Synergy

 

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If she has a kidney infection, she would have other s/s such as pain with urination, blood or pus in her urine, and urgency to urinate.Isn't her platelet count awfully low, or were you referring to 230,000? She is mildly anemic as Steve suggested. Have we ruled out possible malignancy?

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Re: Case: 19 year old with back pain - August 26, 2006 10:20:00 AM   
steve

 

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I think there could be a possible kidney infection, I dont think we have asked her about pus in urine and her UA indicates there is some blood in the urine.

Steve

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Re: Case: 19 year old with back pain - August 26, 2006 2:30:00 PM   
touchiba

 

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Let's see, a sexually active female with flank pain and signs of infection in both the urine and blood...

The metabolic profile is ok, so the kidneys seem to be working fine at this moment. No need to admit her or go crazy at this point.

How about we pump her full of some antibiotics and monitor the sx closely?

Oh, and when she is done with that and everything is fine, start her on a course of probiotics in order to prevent the yeast infections that may follow after taking those high dose antibiotics.

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Re: Case: 19 year old with back pain - August 26, 2006 2:51:00 PM   
Dr.Wagner


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This is a classic case of Pyelonephritis (kidney infection).
Many classic signs are there, CVA tenderness, fever, pain with movement, nausea...and of course a positive urinalysis and CBC.
Dysuria is not necessary to make the diagnosis as many women (especially young women) do not recognize the signs of a UTI. Abdominal pain in the right upper quadrant sometimes happens, but is not the rule.

In this case a pelvic exam may also be initiated to rule out pelvic inflammatory disease...but is not necessary if there is no lower abdominal pain on palpation.
A pregnancy test is absolutely needed in this case.

As for admission, depending on her ability to take fluids and NOT vomit, she should be able to go home. This is also made more concrete as she is not dehydrated and shows no renal insufficiency.

Treatment is antibiotics (numerous can be used), fluids and anti-emetics. Tylenol for fever and pain.
It makes no difference to me if she takes "probiotics" as yeast infection following antibiotic administration is rarely symptomatic and easily treatable with OTC vaginal suppositories. That is up to her.

Could this patient still have Cholecystitis...perhaps, not likely, but perhaps. Depends on the subtle aspects of the exam and her family history as well as personal history of emesis with certain foods.
If she had a negative urinalysis, I would certainly look at her gallbladder.

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Re: Case: 19 year old with back pain - August 26, 2006 5:17:00 PM   
jma

 

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Nice one! Keep them coming!

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Re: Case: 19 year old with back pain - August 27, 2006 12:11:00 AM   
Synergy

 

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Agree with JMA...thanks Dr. Wags!

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Re: Case: 19 year old with back pain - August 27, 2006 12:14:00 AM   
jbird007

 

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Doc Wagner, would you want to rule out the possibility of a kidney stone/s?..with a plain film or pylogram?

just wonderin'

Jbird

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