1. Case Conference 2007.7.24 By intern 李凱靈

2. Patient ’ s Profile Name: 孫 x 欣Name: 孫 x 欣 Age: 21 year-oldAge: 21 year-old Sex: femaleSex: female Date of admission: 11-July-2007Date of admission: 11-July-2007 Time: 8.23pmTime: 8.23pm Triage: P3Triage: P3

3. Status on Arrival E4V5M6E4V5M6 RR:20/minRR:20/min BP:149/128BP:149/128 Temp: 37.7 ’ CTemp: 37.7 ’ C Pulse:57/minPulse:57/min

4. Chief Complain Low abdominal pain shifted to RUQ and right flank for 2-3 days.Low abdominal pain shifted to RUQ and right flank for 2-3 days.

5. Present illness Low abdominal pain shifted to RUQ and right flankLow abdominal pain shifted to RUQ and right flank Associated symptoms:Associated symptoms: –Urination: Dysuria (+), Burning sensation (+) –Fever(+) –Constipation(+) –Nausea(-)

6. Past history Drug allergy :deniedDrug allergy :denied Diabetes mellitus :deniedDiabetes mellitus :denied Hypertension:deniedHypertension:denied Asthma:deniedAsthma:denied LMP: 2007.7.9LMP: 2007.7.9

7. Physical examination Right flank knocking pain (+)Right flank knocking pain (+)

8. Lab Data 7/11 7/127/11 7/12 WBC: 20.19 Sugar: 187 <URINE> PTP 12.3 RBC:4.16BUN:14.7 KET : 2+ PTC 10.9 Hgb:12.9Cr:0.8 SG : 1.014 PT (INR):1.28 Hct:39.4Na:133 OB: 1+ PTTR :29.2 MCV:94.7K:3.9PH:6.0 PTTC : 28.3 MCH:31.0SGOT:22PRO:1+ MCHC:32.7SGPT:14URO:1.0 PLT:176CRP:251WBC:+/- Aerobic bac culture : - RDW-CV:13.4 Color: yellow/clear Anaerobic bac culture: - RDW-SD:46.6RBC:2-5 NEUT:89WBC:2-5 EOSIN :0 Epi:0-2 BASO: 0 Bacteria + LYMPH:5.7 Pregnant test: negative MONO:5.3

9. Initial Clinical Impression Suspect APNSuspect APN R/O intra abdominal abscessR/O intra abdominal abscess Plan Arrange abdominal CT with enhancementArrange abdominal CT with enhancement Pain controlPain control Antibiotics use (Avelox) for infection controlAntibiotics use (Avelox) for infection control

10. Uro consultation 7/12 01.47 am RLQ pain radiated to periumbilical areaRLQ pain radiated to periumbilical area PE: no right flank knocking painPE: no right flank knocking pain Echo: no obvious right hydronephrosisEcho: no obvious right hydronephrosis Assessment: Right APN unlikelyAssessment: Right APN unlikely Suggest: consult GYN (r/o PID)Suggest: consult GYN (r/o PID)

11. Image Finding

12. Clinical impression(2) Suspect an abscess or a hemorrhagic lesion in the right renal parenchyma.Suspect an abscess or a hemorrhagic lesion in the right renal parenchyma. Superimposed neoplasms cannot be excluded.Superimposed neoplasms cannot be excluded.

13. GS consultation 7/12 11:10am7/12 11:10am Pain area (RLQ)not compatible with CT finding  r/o other possible causesPain area (RLQ)not compatible with CT finding  r/o other possible causes No other associated problems over GI tractNo other associated problems over GI tract Suggest : contact uroSuggest : contact uro

14. GYN consultation 7/12 13.46 pm7/12 13.46 pm Sex behaviour (+)Sex behaviour (+) Sono: NGLSono: NGL PV:Cervix motion tenderness (-), bilateral adnexa tendernessPV:Cervix motion tenderness (-), bilateral adnexa tenderness PE: right flank pain. Lower abdominal tenderness(-)PE: right flank pain. Lower abdominal tenderness(-) Assessment: no OBY/GYN emergencyAssessment: no OBY/GYN emergency Suggest: contact uroSuggest: contact uro

15. Final plan Admit to Uro ward for further management.Admit to Uro ward for further management. Uro clinical impression: Right renal abscessUro clinical impression: Right renal abscess

16. The End! Thank you Very Much for your kind attention!Thank you Very Much for your kind attention!