CASE PRESENTATION (Evidence-based medicine) By: Intern Sheena B. Fernando Block O

General Data: This is a case of A.E, 43 year-old male, married, Catholic, right-handed, from Taguig City who came in due to dysuria.

History of Present Illness One week PTC - (+) dysuria, (+) dribbling, (+) flank pain on the left side, VAS 8/10 Described as ‘parang namamanhid’ radiating to the left lower abdominal quadrant, (-) frequency, (-) penile discharge, (-)fever, (-) vomiting (-) passage of urine sediments, (-) nocturia, (-) straining, (-) urgency, (-) retention No consult done. No medications taken.

3 Days PTC - persistence of symptoms, sought consult at private MD, prescribed with Ciprofloxacin 500mg/tab, 1 tab BID x 7 days, on Day 2 of treatment, Rowatinex tablet, 1 tablet TID x 7 days, HNBB (Buscopan) 10mg/tab, 1 tab TID x 5 days. Temporary relief of symptoms. KUB Ultrasound was done and showed Mild hydronephrosis with nephrolithiases left.

Few hrs PTC, persistence of symptoms Consult at AMBU

Review of Systems No weight loss, no headache, no easy fatigability, no loss of appetite, no jaundice No cough, no colds, no difficulty of breathing, no chest pain No orthopnea, no paroxysmal nocturnal dyspnea, no palpitation No abdominal pain, no diarrhea, no change in bowel movement, no melena, no hematochezia, no hematemesis No polyuria, polydipsia, polyphagia No loss of consciousness, no seizures

Past Medical History (-) previous operation (+) previous hospitalization due to AGE 1989, San Juan De Dios Hospital (+) Hypertension since May 2008 HBP 160/110 UBP 120/90 with poor compliance to unrecalled medications (-) DM, (-) PTB, (-) BA (-) allergy to food and drugs

Family History

Personal and Social History finished 3rd year HS works as a family driver - his family’s source of income drinks alcohol, once a week (beer, gin and hard drinks) non-smoker prefers to eat fatty and salty food drinks water from NAWASA, unboiled, consuming 1 liter of water per day.

Sexual History Coitarche at 15 years old With 3 nonpromiscuous sexual partners (-) MSM

Physical Examination conscious, coherent, in pain Vital Signs: BP= 140/90mmhg HR=84 bpm RR=20cpm T= 36.5C BMI= 22.49 kg/m2 SHEENT: dirty sclerae, pink palpebral conjunctivae, no nasoaural discharge, no cervicolympadenopathy, no TPC, PERTL 2-3 mm

CHEST: symmetric chest expansion, no retraction, clear breath sounds CVS: adynamic precordium, distinct heart sounds, normal rate regular rhythm, no murmur ABDOMEN: flabby, normoactive bowel sounds, nontender, (+) costovertebral angle ternderness left EXTREMITIES: full and equal pulses, no cyanosis, no edema GENITALIA: grossly normal genitalia, no discharge DRE: good sphincteric tone, no skin tags, no masses, no tenderness, no blood on examining finger, empty rectal vault

Differential Diagnoses DYSURIA Infection STI Acute Pyelonephritis Prostatitis Complicated UTI Structural Testicular torsion Obstruction 2o to mass Obstruction 2o to prostate enlargement Obstruction 2o to renal stones

Assessment Complicated UTI Mild Hydronephrosis with Nephrolithiases, Left Hypertension Stage II, uncontrolled

Plan Diclofenac 25mg/ml, 1 amp TIM was given Low salt, low fat diet Dx: FBS, Crea, Na, K, TG, TC, LDL, HDL 12L ECG, Long Lead II Urinalysis Tx: Continue: 1. Ciprofloxacin 500mg/tab, 1 tablet BID for 5 more days Start: 2. Diclofenac Na 50mg, 1 tab TID and PRN for pain on full stomach 3. Losartan + HCTZ 50mg/12.5mg 1 tab OD TCB once with results at OPD DFCM after 1 week Refer to Urology-Surgery OPD Basis Advised

Diagnostic Dilemma In adult patients with clinical symptoms of renal stones, what is the sensitivity and specificity of KUB- UTZ compared to CT scan in confirming the diagnosis, using a cross sectional study?

Adult patients with clinical symptoms of renal stones Intervention Population Adult patients with clinical symptoms of renal stones Intervention KUB UTZ Comparison CT scan Outcome Sensitivity and specificity in confirming the diagnosis Method Cross sectional study KUB UTZ: Diagnostic Threshold - 30 Therapeutic Threshold – 80 Pre-Test Probability – 70%

Clinical Dilemma In adult patients diagnosed with renal stones, is Rowatinex effective in facilitating passage of renal stones, using a randomized control trial?

Population Adult patients with renal stones Intervention Rowatinex Comparison Placebo Outcome Effect in facilitating passage of renal stones Method Randomized control trial

Thank you!