1. 32/M presenting with right flank pain
Angelie P. Dugasan
November 25, 2009

2. Patient Profile 32 year-old, male Married Roman Catholic
Jeepney driver
From Tondo, Manila
Nonhypertensive, nondiabetic, non-asthmatic

3. History of Present Illness
5 days PTC
(+) R flank pain described as on and off, colicky, non-radiating, 6-7/10 on VAS, resolved spontaneously
(+) fever Tmax of 38.9 OC, temporary lysis with Paracetamol 500mg/tab
(+) 2 episodes of vomiting of previously ingested food, non-bilious, non-bloody, amounting to ¼ cup/episode
(+) dysuria
(+) good appetite
(-) tea-colored urine
(-) chills
(-) diarrhea
(-) history of trauma
(-) consult was done

4. History of Present Illness
1 day PTC
(+) recurrence of R flank pain with the same characteristic but with increase in severity, 8/10 on VAS
(+)recurrence of fever Tmax 38.7 OC
(+) nausea
(+) decreased appetite
sought consult at private clinic in Tondo, urinalysis was done which showed:

5. Urinalysis Value Character Yellow, turbid pH 6.0 CHO Negative CHON WBC
8-10/hpf
RBC
4-5/hpf
Epith cells
Bacteria
Moderate
Casts/crystals

6. History of Present Illness
1 day PTC
Management at Tondo Clinic
A> Urinary Tract Infection
P> Cotrimoxazole 160/800mg/tab , 1 tab BID x 7 days
HNBB 10mg/tab for pain
However, the patient took only the HNBB which afforded minimal relief of pain.
Cotrimoxazole was not taken.

7. History of Present Illness
Few hours PTC
persistence of symptoms hence patient decided to seek another consult at PGH-Ambulatory Clinic

8. Review of Systems
(-) weight loss (-) anorexia (-) headache (-) chest pain (-) changes in bowel movement (-) melena (-) hematochezia (-) jaundice (-) bloatedness (-) muscle weakness

9. Past Medical History
(-) Hypertension (-) Diabetes Mellitus (-) Bronchial Asthma (-) previous hospitalizations/surgeries (-) known allergies

10. Tapang-Olivo Genogram
Legend:
- Hypertension
Data taken on Nov. 18, 2009 by Int. Dugasan
Informant: the patient 60 59 3 6 29 40 32 34 36

11. Personal and Social History
(+) 3 pack year smoking history
Occasional alcoholic beverage drinker
Denies use of illicit drugs
High school graduate
Jeepney driver

12. Physical Examination ORGAN SYSTEM PHYSICAL FINDINGS GENERAL
awake, conscious, coherent, NICRD
VITAL SIGNS
BP 120/80, HR 92, RR 22, T37.9 OC
HEENT
pink conj, anicteric sclerae,(-) tonsillopharyngeal congestion, (-) cervical lymphadenopathies
CHEST & LUNGS
equal chest expansion, clear breath sounds, (-) crackles/wheezes
CVS
normal rate, regular rhythm, distinct heart sounds, (-) murmurs, (-) heaves/thrills
ABDOMEN
soft, flabby, normoactive bowel sounds, nontender, (-) organomegaly, (+) CVA tenderness, R
EXTREMITIES
pink nail beds, full equal pulses, (-) edema, (-) cyanosis
DRE
good sphincter tone, intact rectal vault, (-) masses, (-) blood, (+) stool PER

13. Assessment
Acute Pyelonephritis T/C Urolithiasis

14. Plan Diagnotics: Therapeutics: Urine GS/CS KUB Ultrasound
Ofloxacin 400mg/tab, 1 tab every 12 hours for 14 days
Diclofenac 25mg/ml apm – given IM, afforded relief of pain, 2-3 on VAS
Diclofenac 50mg/tab, 1 tab every 8 hours for pain, on full stomach
Paracetamol 500mg/tab, 1 tab every 4 hours for T >38.5 OC
Increase oral fluid intake. Aggressive TSB for fever.
Follow-up at OPD-FCM with lab results.

15. Diagnostic Dilemma

16. Diagnostic Dilemma Population Adults with urolithiasis Intervention
KUB ultrasound
Control
Non-contrast helical CT Scan
Outcome
Sensitivity and Specificity in detecting urolithiasis
Methodology
Cross-sectional Study

17. Diagnostic Dilemma
Among adults with urolithiasis, is the sensitivity and specificity of KUB ultrasound comparable to that of non-contrast CT Scan in detecting stones, in a cross-sectional study?

18. Pre-Test Probability

19. Therapeutic Dilemma

20. Therapeutic Dilemma Anti-spasmodic (eg. Hyoscine N-butyl Bromide)
Population
Adults with urolithiasis
Intervention
Anti-spasmodic (eg. Hyoscine N-butyl Bromide)
Control
Non-Steroidal Anti-inflammatory Drugs
Outcome
Reduction of pain as measured using VAS
Methodology
RCT

21. Therapeutic Dilemma
In a RCT investigating adults with urolithiasis, what is more effective in reducing pain as measured by VAS, Anti-spasmodic or NSAIDs?