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
PE
97.6 142/85 95 18 96%
Gen: Alert, moderate painful distress
Skin: warm, dry
Chest: CTA and equal.
COR: RRR no g/m
ABD: non-distended, mild R flank tenderness, with
moderate R CVA tenderness, no
guarding/rebound/mass, no palpable pulsatile mass
Extrem: no edema
Neuro: 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
NR 38 y/o female
2 days later
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
PE
1725: 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, confused
Skin: warm, diaphoretic
Chest: CTA with diminished tidal volume
CV: RRR, strong peripheral pulses
ABD: BS present, soft, nontender, no mass, no
peritoneal signs
Extrem: no edema
Neuro: Non focal
EKG: Narrow complex tachycardia at 170 with
questionable P wave. Sinus tach vs. SVT.
Assessment:
1. Sepsis
2. Possible SVT
ED Course:
1. No response to adenosine
2. Tachycardia, BP, mental status responded to fluid
3. Started on Rochephin
4. Previous urine culture showed mixed flora
WBC 7.2, H/H 15.7/47
Chem normal except glucose 239, CRE 1.4, BUN16
LFT minimally elevated
CXR normal except elevated Right hemidiaphragm
U/A dip trace blood, trace leuk
Blood, urine cultures sent
Perinephric stranding
Air in renal pelvis



Percutanous Nephrostomy Placed
Grew Proteus from nephrostomy
Urine cultures negative
Stent 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 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%RA
Abd: 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 negative
WBC 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% RA
Abd: BS normal, non-distended, moderate RLQ
tenderness. No rebound/guarding. No obturator sign, no
psoas sign, can jump without pain.
Rectal: nontender, heme negative
Rest of exam normal
U/A SG 1.030, +ket, moderate blood, otherwise negative
WBC 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 Pain
 Atypical
presentations
 Careful history
 Repeated examinations
 CBC can be misleading in appy.
• 80% with wbc 10k-15k
• 80% with > 75% polys
• 4% 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 distress
Neck: Supple, no thyromegaly
Chest: CTA and equal
CV: irregular, irregular
Extrem: no calf fullness or tenderness, no edema,
distal N/V intact
Neuro: nonfocal, normal
Skin: warm, dry
________________________________
EKG: A fib @107, normal axis, non specific ST changes
Labs: chemistry, cbc normal, cardiac enzymes negative
CXR: normal
Initial Treatment:
ASA, oxygen, albuterol
Digoxin
Heparin
Cardiology consult:
History of venous stripping
Likely recent onset of Afib
Possible cardiac etiology because of age and ST changes
Consider Thyroid disease, pulmonary disease
ABG 7.488/32/66 on 3 liters
TSH normal
Echo
PE
infiltrate
Causes of Atrial Fibrillation
Ischemic heart disease
Hypertensive heart disease
Valvular disease (esp. mitral) Cardiomyopathy
Pericarditis
Cardiac surgery
Hyperthyroidism
Catecholamine excess
Sick sinus syndrome
Pulmonary embolism
Myocardial contusion
Congestive heart failure
Acute ethanol intoxication
(holiday heart syndrome)
Accessory pathway (WPW)
Idiopathic
JC--52 y/o male
2125 time
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.
HTN, DM, CAD
Meds: none, Allergies: none, SH--smokes
No
PE
2031 96.8 63 16 135/34 98%
2101
55 18 151/52 100%
Moderate Distress
Neck: normal
Resp: no distress, nontender chest, CTA
CV: brady, muffled heart tones, no rub
no palpable left femoral, left DP pulses
GI: soft, nontender
Skin: normal, warm and dry
Neuro: Left leg palsy
Extrem: no edema
__________________________
Monitor: NSR at 62
EKG: NSR at 60, inverted T’s with ST
depression v2-v6, I, avL
2125 time
ED Course
CXR normal
Vascular surgery consult
Fellow wants angiogram to evaluate for emboli
Intermittent left leg movement
NTG SL then NTG drip
BP drops
NS bolus
Cardiology recommends thrombolytics
CP and leg pain continue
BP remains low
Bedside ultrasound rules out tamponade
To CT scan--Type I dissection
Transfer
Aortic Dissection
 Treatment--lower
double product
• Nitroprusside
• Labetalol
• Esmolol
 Caveats
• Ensure you are getting accurate BP, the
dissection may compromise the great vessels
• Consider coronary artery involvement
• Consider tamponade
Aortic Dissection
Diagnosis
 CXR
normal in 12%
 Chest CT with IV contrast
 Trans-esophageal echo
 MRI
 Aortograhphy
Aortic Dissection
 Classification
• Type A--ascending aorta
• Type B--no involvment of ascending aorta
• DeBakey I--ascending and descending
• DeBakey II--asceding aorta only
• DeBakey III--descending distal to left
subclavian