NR 38 y/o female

CC: Right Flank Pain

HPI: 4-5 hours severe, right flank pain with radiation to groin and nausea. No urinary symptoms, +N/V, no fever.

ROS: o/w negative

PMH: IDDM, CVA with residual right hemiparesis, renal colic, cholecystectomy

Meds: Insulin

Allergies: PCN

PE97.6 142/85 95 18 96%

Gen: Alert, moderate painful distressSkin: warm, dryChest: CTA and equal.COR: RRR no g/mABD: non-distended, mild R flank tenderness, with moderate R CVA tenderness, no guarding/rebound/mass, no palpable pulsatile massExtrem: no edemaNeuro: Non focal

_____________________________U/A: +nitrites, 2+ blood, trace leuk >100 wbc/hpf, 2-5 rbc/hpf, 4+bact

WBC=14.2, 84% neut, 11% lymph, 4 % mono

Chem: Na=143, K=3.9, CL=103, C02=31, Gluc=300, BUN=17, CRE=0.9

Diagnosis: Early Pyleonephritis

Urine culture sent

Plan: IM rocephin, po keflex monostat vaginal suppos. compazine suppos. 3 day follow up with PMD urine culture sent

2 days laterNR 38 y/o female

CC: Worsening bladder infection

HPI: Continuing right flank pain, fever to 104 and vomiting. Patient has been confused today. Was diagnosed with “bladder infection” 2 days ago.

Meds: Vicodin, glyburide and Keflex

Allergies: PCN

PE1725: 99.1 HR=118 BP=132/90, 98% RA 1825: 100.4 HR=170 BP=117/38, 93% 4 lit.

Gen: critically ill, morbidly obese, confusedSkin: warm, diaphoreticChest: CTA with diminished tidal volumeCV: RRR, strong peripheral pulsesABD: BS present, soft, nontender, no mass, no peritoneal signsExtrem: no edemaNeuro: Non focal

EKG: Narrow complex tachycardia at 170 with questionable P wave. Sinus tach vs. SVT.

Assessment:1. Sepsis2. Possible SVT

ED Course:1. No response to adenosine2. Tachycardia, BP, mental status responded to fluid3. Started on Rochephin4. Previous urine culture showed mixed flora

WBC 7.2, H/H 15.7/47Chem normal except glucose 239, CRE 1.4, BUN16LFT minimally elevatedCXR normal except elevated Right hemidiaphragmU/A dip trace blood, trace leukBlood, urine cultures sent

Perinephric strandingPerinephric stranding

Air in renal pelvisAir in renal pelvis

Percutanous Nephrostomy PlacedGrew Proteus from nephrostomyUrine cultures negativeStent placed

Subsequently at least 4 visits to SDMC for right pyelonephritis with obstruction transferred to CCCRMC 3 times for urology availability.

4 months after initial nephrostomy had a nephrectomy at CCCRMC.

Emphysematous Pyelonephritis

Parenchymal and perinephric infection• Usually gram negative, esp. E. coli• Diabetics• Obstruction--stone, papillary necrosis

Needs aggressive therapy--43% mortality• Antibiotics• Relieve obstruction

Risk Factors for Complicated UTIRisk Factors for Complicated UTI

Male Age <12 y/o or >50 y/o Obstruction

• Pregnancy Instrumentation Immunocompromised Recent antibiotic use Not improving after 72 hours

BD--11 y/o male

CC: Abdominal Pain

HPI: Severe lower abdominal for 5 days. N/V/D present. No fever. Anorexia for 3-4 days. Saw personal doctor 2 days ago. [Nurses notes indicate pain started peri-umbilical and moved to RLQ.]

ROS: otherwise negative

PMH: None, Meds: none, Allergies: none

PE: 97.6 127/79 16 85 99%RAAbd: BS increased, diffusely tender abdomen, more to suprapubic area, non-distended, no rebound.Rest of exam normal

U/A SG 1.015, +ketones, moderate bili, o/w negativeWBC 13.7, Hgb 13.5, Chem-7 normal

CT abdomen shows inflammatory mass midline lower abdomen between rectum and bladder measuring 5.8x6cm. Mass is not near the cecum. Consider ulcerative colitis, granulomatous colitis, amebiasis… Appendicitis unlikely but cannot rule out abscess seeded from appendix or elsewhere.

Surgery consult obtains history that patient had similar symptoms 6 mos. ago and 2 mos. ago and has not felt completely well for 2 mos.

Surgery: Distended bladder and distal urethral stricture, abscess drainage, appendectomy. Appendix was found in retroperitoneum, not connected to cecum.

NT 8 y/o female

CC: Abd Pain

HPI: R upper abdominal pain for a few hours. Has been ill for 4 days with URI symptoms. Had N/V and fever yesterday.

PMH, Meds, Allergies--None

PE: 97.2 135/72 109 18 97% RAAbd: BS normal, non-distended, moderate RLQ tenderness. No rebound/guarding. No obturator sign, no psoas sign, can jump without pain.Rectal: nontender, heme negativeRest of exam normal

U/A SG 1.030, +ket, moderate blood, otherwise negativeWBC 13.7 with left shift

Ultrasound: No appendix identified. No pathalogy identified. Consider repeat ultrasound.Reexam: temp 100.0, abdominal exam unchanged, takes po water well.

_________________________________________Scheduled return in 6 hours:Exam unchanged. WBC 11.4

Repeat ultrasound: appendolith with inflamed appendix

Pediatric Abdominal PainPediatric Abdominal Pain

Atypical presentationsAtypical presentations Careful historyCareful history Repeated examinationsRepeated examinations CBC can be misleading in appy.CBC can be misleading in appy.

• 80% with wbc 10k-15k80% with wbc 10k-15k• 80% with > 75% polys80% with > 75% polys• 4% normal4% normal

KJ 76 y/o female

CC: Dyspnea and irregular heartbeat

HPI: 7-10 days of progressive dyspnea. No palpatations. Went to physician’s office and was referred to ED for possible atrial fibrillation. Recent dry cough. There is no edema, PND, nor orthopnea.

ROS: otherwise negative.

PMH: Polymylagia Rheumatica, Hypothyroidism

Meds: Prednisone, Synthroid. All: NKDA

SH: No tobacco, active lifestyle with bike riding, now limited over the last 10 days by dyspnea.

PE

140/70 124i 24 97.2 91% RA

GEN: Pleasant, no obvious distressNeck: Supple, no thyromegalyChest: CTA and equalCV: irregular, irregularExtrem: no calf fullness or tenderness, no edema,distal N/V intactNeuro: nonfocal, normalSkin: warm, dry

________________________________EKG: A fib @107, normal axis, non specific ST changesLabs: chemistry, cbc normal, cardiac enzymes negativeCXR: normal

Initial Treatment:ASA, oxygen, albuterolDigoxinHeparin

ABG 7.488/32/66 on 3 litersTSH normalEcho

Cardiology consult:History of venous strippingLikely recent onset of AfibPossible cardiac etiology because of age and ST changes Consider Thyroid disease, pulmonary disease

PE

infiltrate

Causes of Atrial FibrillationIschemic heart disease

Valvular disease (esp. mitral)

Pericarditis

Hyperthyroidism

Sick sinus syndrome

Myocardial contusion

Acute ethanol intoxication (holiday heart syndrome)

Hypertensive heart disease

Cardiomyopathy

Cardiac surgery

Catecholamine excess

Pulmonary embolism

Congestive heart failure

Accessory pathway (WPW)

Idiopathic

JC--52 y/o male

JC is brought in by EMS with leg pain, numbness and chest pain. EMS found patient alert, on the floor, diaphoretic, in severe pain. 90/p, 66, 24, NSR. Received ASA, and NS bolus.

HPI: severe pressure like CP began 1930 and 3-4 minutes later left leg tingling began followed by pain and weakness to left leg. Pain is pleuritic, but there is no shortness of breath. CP has eased now and is 3/10. Initially radiated to neck. Leg pain is 10/10.

ROS occ. LBP, mild cough, mild HA, otherwise negative

PMH: C3 laminectomy, peptic ulcer disease in the past. No HTN, DM, CAD

Meds: none, Allergies: none, SH--smokes

2125 time

PE2031 96.8 63 16 135/34 98%2101 55 18 151/52 100%

Moderate DistressNeck: normalResp: no distress, nontender chest, CTACV: brady, muffled heart tones, no rub no palpable left femoral, left DP pulsesGI: soft, nontenderSkin: normal, warm and dryNeuro: Left leg palsyExtrem: no edema

2125 time

__________________________Monitor: NSR at 62EKG: NSR at 60, inverted T’s with ST depression v2-v6, I, avL

CXR normalVascular surgery consultFellow wants angiogram to evaluate for emboli

Intermittent left leg movementNTG SL then NTG dripBP dropsNS bolusCardiology recommends thrombolyticsCP and leg pain continueBP remains low

ED Course

Bedside ultrasound rules out tamponadeTo CT scan--Type I dissection Transfer

Aortic DissectionAortic Dissection

Treatment--lower double productTreatment--lower double product• NitroprussideNitroprusside• LabetalolLabetalol• EsmololEsmolol

CaveatsCaveats• Ensure you are getting accurate BP, the dissection may Ensure you are getting accurate BP, the dissection may

compromise the great vesselscompromise the great vessels• Consider coronary artery involvementConsider coronary artery involvement• Consider tamponadeConsider tamponade

Aortic DissectionAortic DissectionDiagnosisDiagnosis

CXR normal in 12%CXR normal in 12% Chest CT with IV contrastChest CT with IV contrast Trans-esophageal echoTrans-esophageal echo MRIMRI AortograhphyAortograhphy

Aortic DissectionAortic Dissection

ClassificationClassification• Type A--ascending aortaType A--ascending aorta• Type B--no involvment of ascending aortaType B--no involvment of ascending aorta

• DeBakey I--ascending and descendingDeBakey I--ascending and descending• DeBakey II--asceding aorta onlyDeBakey II--asceding aorta only• DeBakey III--descending distal to left DeBakey III--descending distal to left

subclaviansubclavian