Week 4 Case Study Summaries

8/1/2016 12:00 AM

Week 4

Once again, excellent work by you all!

Part 1

Mrs. Orndorf is a 28-year-old woman married for 3 years who has just returned from an outdoor camping trip with her husband, with symptoms of dysuria with a burning sensation, urgency to urinate, and frequent urination.  She said, “I have had similar symptoms three times over the last 2 years.  Pubic and low back discomfort awoke me two nights ago and that is why I am here.”  On physical examination, her temperature was 98.6° F, blood pressure was 114/64 mm Hg, pulse was 68 beats per minute, and the respiratory rate was 12 breaths per minute.  Other than a tender abdominal pelvic area, the examination was unremarkable.

·         What is your differential diagnosis?

·         According to the first item in your differential, what are the risk factors for this disorder?

·         What are some treatments for this disorder?

When we look at these symptoms the urinary tract is involved and possibly the reproductive system due to the finding of a tender abdominal/pelvic area. A burning sensation indicates the urethra is involved and urgency to urinate and indicates the bladder is involved. Thus, cystitis and urethritis are likely diagnoses.

Lower back pain is associated with a kidney stone. However, this would not account for a burning sensation or urgency to urinate. Also, kidney stones are usually very painful and blood pressure and respiration would likely be elevated. Pyelonephritis tends to present with fever and increased heart rate, and respiration. It also presents with lower back pain and abdominal tenderness. This presentation could represent early pyelonephritis. Atypical PID such as chlamydial could also present with some of these symptoms, but there is no vaginal discharge or fever.

DDx:

1.         Cystitis/Urethritis (UTI)

2.         Early pyelonephritis  

3.         Renal Stone

4.         Atypical PID

5.         Ectopic pregnancy

6.         Bladder Cancer

Here a tentative diagnosis can be made without any additional tests as the clinical presentation seems clear. One could be conservative and treat for cystitis/urethritis or be more aggressive and treat for early pyelonephritis.

Tests:  Urine Test Strip/Urinalysis, urine microscopy, complete blood with or without differential, microbiological culture of the urine.

Notable laboratory results from a dipstick urinalysis, microscopic examination, and urine culture: Color was dark yellow; trace blood; no casts; bacteria, especially E. coli, and WBCs were too numerous to count.

Because this patient has recurrent infection, schedule a follow up in about a week for an ultrasound. She may have an anatomical issue. CT abdomen/pelvis and voiding cystourethrogram can be used if kidney stone is suspected or if the patient comes back again with another UTI.

Typical bugs: E. Coli, Staph saprophyticus, Enterococcus, and other gram negative rods like Klebsiella & Pseudomonas. Other organisms to consider are yeast/fungi or odd bacterial infections in the elderly, diabetics, and those with chronic diseases and/or immunocompromised.

Treatment:

1st line: Nitrofurantoin ,Fosfomycin and Amoxicillin tend to be effective and have low toxicities.

2nd line: Trimethoprim-sulfamethoxazole (bactrim), ciprofloxacin

Longer duration with pyelonephritis.

If you are going to use Bactrim make sure the woman is not pregnant and is on birth control. Due to its anti-folate effects, this drug can cause anencephaly and spina bifida. With topoisomerase inhibitors like Cipro, cartilage and tendon damage is a possible major side effect and has also been found to be teratogenic in animal studies. Additional side effects for nitrofurantoin is pulmonary fibrosis and for Bactrim it is Steven-Johnsons Syndrome. Cipro may be used first line if we feel this is pyelonephritis. Once again we need to make sure the patient isn’t pregnant and is on birth control.

Part 2

A 56-year-old female comes into the clinic complaining of intermittent severe pain that radiates from the flank to the groin and sometimes to the inner thigh. Upon further questioning  she tell you that she has an urge to always go to the restroom and that she sometime sweats and feels nauseous. A urinalysis provides traces of blood, a few white blood cells and no bacteria.

• What is your differential diagnosis? Discuss in detail the pathophysiology of each item in your differential and how it might fit in describing this case.
• The x-ray comes back and there is nothing abnormal except a slightly dilated ureter. Does this change your differential or narrow it?
• How would you treat the pain in this case?

Possible differential diagnosis

1.            Kidney Stones

2.            Pyelonephritis

3.            Diverticulitis

4.            Cancer (unspecified)

5.            Abdominal Aortic Aneurysm

Kidney stones commonly cause urinary urgency, restlessness, hematuria, sweating, nausea, and vomiting. The pain that kidney stones cause are due to contractions of the ureter as it attempts to expel the stone. Kidneys stones are often in the renal pelvis or proximal portion of the ureter and cause pain that radiates to the groin. Kidney stones in the mid ureter tend to radiate pain to the flank, while lower lying kidney stones tend to cause an increase in urinary frequency. Hydronephrosis can be observed following the obstruction of urine flow through one or both ureters. The most common type of kidney stone is calcium oxalate (up to 80%) with calcium phosphate, uric acid, and struvite each accounting for 5-10%. Treatment includes alkalinization of urine, large intake of water and the use of diuretics. Lithotripsy can be used to break up the stones. In this procedure, high-intensity pulses of ultrasonic energy are used to cause fragmentation of the stones.

Part 3

A 60-year-old patient comes into your office with a history of hypertension and a myocardial infarction 13 years ago. You notice that both of her ankles are swollen and that her skin seems shiny. She first noticed her ankle swelling 9 months ago and it has gotten progressively worse. She has a smell of ammonia on her.  She also has a 2 year history of diabetes.

•What are at least five systemic effects of chronic kidney disease?

•How would you modify the diet and what is the rationale to the changes of the diet that you make?

Symptoms of kidney disease typically include:

•Nausea and vomiting

•Passing only small amounts of urine

•Swelling, particularly of the ankles, and puffiness around the eyes

•Unpleasant taste in the mouth and urine-like odor to the breath

•Persistent fatigue or shortness of breath

•Loss of appetite

•Increasingly higher blood pressure

•Muscle cramps, especially in the legs

•Pale skin

•Excessively dry, itchy skin

•In children: increased fatigue and sleepiness, decrease in appetite, and poor growth

The purpose of this diet is to keep the levels of electrolytes, minerals, and fluid balanced when you have chronic kidney disease or are on dialysis. People on dialysis need this special diet to limit the buildup of waste products. Limiting fluids between dialysis treatments is very important because most people on dialysis urinate very little (if at all).

Kidney Foundation Recommendations:

Take in enough calories each day to keep you healthy and prevent the breakdown of body tissue. Weigh yourself every morning to make sure you are meeting daily weight goal.

Low-protein diets may be helpful before starting dialysis. A moderate-protein diet (1 gram of protein per kilogram of body weight per day) is usually recommended. Once dialysis begins, more protein is needed. A high-protein diet with fish, poultry, pork, or eggs at every meal may be recommended. This will help you replace protein loss. 8 - 10 ounces of high-protein foods is recommended each day.

The minerals calcium and phosphorous will be checked often. Even in the early stages of chronic kidney disease, phosphorous levels in the blood can get too high. This can cause hypocalcemia due to the body extracting calcium from the bones, making patients more prone to fracture. Dairy also needs to be limited because of the large amounts of phosphorous. Some dairy foods are lower in phosphorous, including tub margarine, butter, cream cheese, heavy cream, ricotta cheese, brie cheese, sherbet, and nondairy whipped toppings. Calcium and vitamin D supplements may be needed to prevent bone disease. Phosphorous binders also help to control phosphorous levels. People with advanced kidney failure also have anemia and usually need iron supplementation.

Once dialysis begins, fluids need to be limited. Excess fluid buildup causes shortness of breath, which usually requires immediate medical attention. Ways to limit fluid intake includes limiting salt use and salty foods (also helps with BP control), freezing liquids in an ice cube tray and eat it like a popsicle (must keep count of cubes used daily), staying cool on hot days.

Check all labels for salt content per serving, ideally less than 100 mg of salt per serving.

Excess potassium can build up when the kidneys no longer function, potentially causing dangerous and potentially deadly heart arrhythmias. Potassium is found in many foods, including fruits and vegetables. Choosing the right item from each food group can help control your potassium levels. Fruits to avoid include bananas, oranges, orange juice, nectarines, kiwis, prunes/raisins/dried fruit, cantaloupe, and honeydew. Vegetables to avoid include asparagus, avocado, potatoes, spinach, squash, and tomatoes.