1. Present: R2 林浚仁 Instructor: Dr.吳孟書
Case conference
Present: R2 林浚仁
Instructor: Dr.吳孟書

2. General Data Name: 江XX Age: 9 y/o Sex: Male Time:11/28 09:09
檢傷主述: 左腰痛，噁心嘔吐
Vital signs: BT:36.2, PR: 126, RR:20

3. Chief complaint
Left flank pain noted today

4. Present illness
Fever(-), cough(+),rhinorrhea(+), sorethroat(-), otalgia(-), constipation(-), diarrhea(-), vomiting(+) non-bilious, headache(-), chest pain(-), abdomen pain(+) epigastric area, no referred pain dyspnea(-), limbs weakness(-), no dysuria, no frequency, urgency(+), no skin lesion

5. Present illness
Past history: VUR grade 3~4 with regular prophylatic antibiotic given when he was 1 years old
Vaccination: as schedule
Allergy history: denied
Travel history: denied

6. Physical Examination
PAT: apperance: easy looking , breath smooth, no retraction, circulation stable
Conscious clear
Conjunctiva: not injected, not pale
HEENT:  Throat: injected(-), ulcers(-)        tonsil enlarge(-), exudate(-)         buccal/gingival ulcer(-)         eardrum: not injected
Neck: supple, no LAP     Kernig's sign(-); Brudzinski sign(-)
Chest: breath sound clear       RHB, no murmur
Abdomen : soft and flat , no tender         normoactive bowel sound         McBurney's point tender(-)         rebound pain(-) left CV angle knocking pain(+)
Extremities: Freely movable, focal weakness(-)
skin rash(-)

7. What’s your differential diagnosis?
What’s your plan?

8. Flank pain Urinary tract: Vascular Pneumonia Urolithiasis
Pyelonephritis
Renal abscess
Vascular
Abdominal aortic aneurysm
Renal infarction
Renal vein thrombosis
Pneumonia

9. Left flank pain Musculoskeletal Neurologic Dermatologic
Trauma: motor vehicle collision, falls, child abuse
Neurologic
Dermatologic
Gastrointestinal
Gynecologic

10. Return to our patient S/S: PE Past hx Left flank pain, sudden onset
Epigastric pain
Non-bilious vomiting
Urine frequency
Cough
Rhinorrhea PE
Left CV angle knocking pain
No abdominal tenderness
Past hx
VUR

11. Differential diagnosis
Genitourinary
Obstruction
Urolithiasis
Stricture
External compression
Infection
APN
Abscess
Pneumonia

12. Lab data WBC 11100/ul Seg 75.2% Lym 17.4% Mono 6.7% Hgb 12.6 g/dl PLT
194K/ul
BUN
21 mg/dl Cr
0.5 mg/dl Na
144 meq/L K
3.6 meq/L

13. Lab U/A Color yellow Urobilirubin 0.1 Turbidity L.turbid Bilirubin
negative pH
8.0
Blood 1+
Leukocyte
Amphorus Phos
positive
Nitrite
RBC 42
Protein
WBC 2
Glucose
Epith-cell
Ketone

14. CXR

15. ER course
echo

16. Left severe hydronephrosis
ER course
Left severe hydronephrosis

17. Abdomen CT

18. Abdomen CT

19. Abdomen CT

20. CT report
Impression:  1. Left UVJ stricture with severe left hydronephrosis, R/O benign stricture.  2. R/O urine retention.  3. Prominent circular folds of segmental jejunum in the left upper abdomen, increased peristalsis?

21. ER course
Admission
Arrange MRU

22. Admission course
MRI/MRU
1. huge dilated left renal pelvis without visualization of left   ureter; normal appearance of right kidney and ureter, suggesting left   UPJ stenosis. 2. dynamic study of bilateral kidneys with the result of split renal  function of R:L = 54%:46%
3. earlier excretion of of contrast noted in right kidney noted and    whirl-like appearance in left huge renal pelvis noted on dynamic   study. 4. maximum ureteral size, right  4.8 mm left 4.7 mm        
IMP: Left hydronephrosis, due to UPJ obstruction.   Split renal function: R: L= 54% :46%

23. Admission course 12/12 op Pyeloplasty and ureterolysis
Pathology: UPJ congestion, edema and fibrosis
12/16 MBD

24. Ureteropelvic junction (UPJ) obstruction
Congenital
The most common pathologic cause of antenatally detected hydronephrosis
Incidence: 1/500
Boy>girl
Left>right
Acquired
Previous surgery
Inflammation of upper urinary tract
Partial obstruction with progressive deterioration of renal function

25. Ureteropelvic junction (UPJ) obstruction
Clinical presentation
Palpable abdominal mass caused by an enlarged obstructed kidney.
Urinary tract infection
Renal failure
Hematuria
Failure to thrive
Flank pain
Nausea and vomiting.

26. Evaluation and management
Ultrasound
CT scan
VCUG
Diuretic renography
Intravenous urogram
MRU

27. Management Surgery Observation Pyeloplasty Excellent outcome
Asymptomatic
Renal scan>40%
Closely follow up

28. Key points Differential diagnosis in flank pain
Performing bedside echo is crucial skill for evaluating patients with flank pain