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Present: R2 林浚仁 Instructor: Dr.吳孟書
Case conference Present: R2 林浚仁 Instructor: Dr.吳孟書
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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
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Chief complaint Left flank pain noted today
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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
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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
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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(-)
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What’s your differential diagnosis?
What’s your plan?
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Flank pain Urinary tract: Vascular Pneumonia Urolithiasis
Pyelonephritis Renal abscess Vascular Abdominal aortic aneurysm Renal infarction Renal vein thrombosis Pneumonia
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Left flank pain Musculoskeletal Neurologic Dermatologic
Trauma: motor vehicle collision, falls, child abuse Neurologic Dermatologic Gastrointestinal Gynecologic
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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
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Differential diagnosis
Genitourinary Obstruction Urolithiasis Stricture External compression Infection APN Abscess Pneumonia
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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
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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
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CXR
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ER course echo
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Left severe hydronephrosis
ER course Left severe hydronephrosis
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Abdomen CT
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Abdomen CT
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Abdomen CT
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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?
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ER course Admission Arrange MRU
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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%
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Admission course 12/12 op Pyeloplasty and ureterolysis
Pathology: UPJ congestion, edema and fibrosis 12/16 MBD
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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
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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.
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Evaluation and management
Ultrasound CT scan VCUG Diuretic renography Intravenous urogram MRU
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Management Surgery Observation Pyeloplasty Excellent outcome
Asymptomatic Renal scan>40% Closely follow up
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Key points Differential diagnosis in flank pain
Performing bedside echo is crucial skill for evaluating patients with flank pain
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