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A 22-year-old woman presents with right lower quadrant (RLQ) pain [SOLVED]


A 22-year-old woman with severe right lower quadrant (RLQ) pain accompanied by dysuria, fever, shaking chills, and frequency.
She is sexually active with one partner and always uses condoms. Her last menstrual period was 5 days ago.

On physical examination, her temperature is 39°C and her heart rate is 120/min. Blood pressure and respirations are normal.
Abdominal examination reveals suprapubic tenderness with palpation. The patient complains of pain when percussion is performed with the ulnar surface of the fist over the right costovertebral angle (CVA). Pelvic examination is normal.

Which of the following is the most likely diagnosis?
a. Diverticulitis
b. Acute cystitis
c. Renal calculi
d. Pyelonephritis
e. Appendicitis


for each alternative that you choose its better to explain, one case will have 2 winners one first correct answer and one other best explained answer
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17 comments:

  1. d.Pyelonephritis
    Flank pain, abdominal or pelvic pain, nausea, vomiting, fever (≥37.8ºC), and costovertebral angle tenderness all are manifestations of acute uncomplicated pyelonephritis. Fever has been strongly correlated with the diagnosis of acute pyelonephritis.

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  2. drc ragab sedik said
    Rt pyelonepheritis is the best daignosis because the following:
    1-symptoms;dysuria,fever(high grade fever).
    2- symptoms;suprabupic pain.rt costoclavicular pain on examination

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  3. rt pyelonehritis
    fever chilling dysuria frequency all suggest pyelonephritis

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  4. d. Pyelonephritis
    In this case, fever (39C), Dysuria, Shaking chills and frequency of urination present patient has UTI.
    Tachycardia may be associated with fever,dehydration or sepsis condition.Flank or costovertebral angle (CVA) tenderness is most commonly unilateral over the involved kidney.Suprapubic tenderness usually ranges from mild to moderate without rebound. In this patient, abdominal rebound, rigidity, or guarding is not found. Patient is sexually active and the cause of infection may be due to poor hygiene and sexual intercourse.The most posiable causal organism is E Coli (90%).

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  5. the correct answer is pyelonehritis
    becouse of
    1-symptoms;dysuria,fever(high grade fever).
    2- symptoms;suprabupic pain.rt costoclavicular pain on examination

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  6. d. Pyelonephritis.
    High fever, costovertebral angle tenderness.

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  7. d.Pyelonephritis

    Systemic signs + signs of infection + severity + history.Closest dd is renal calculi but usually doesnt present with fever unless superimposed infection.

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  8. This comment has been removed by the author.

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  9. d. Pyelonephritis

    Data ( with )Pyelonephritis

    - fever < (39.4) ,shaking chills , tachcardia suggesting infection
    - suprapubic tenderness
    - dysuria, frequency -- > suggesting UTI
    - pain over the right costovertebral angle (CVA)
    i guess it is continuous pain and stays in one spot and increase by moving rather than wavy pain of renal stones

    So the Diagnosis most likely Acute Pyelonephritis but not chronic as in chronic cases theri e is associated hypertension resulting from renal damage


    Data (against) Acute cycstits

    - Rt CVA pain ( cycstits pain is lower abdomin and may be lower back )
    - Moderate fever

    Data (against) Diverticulitis

    - CVA pain & Suprapubic tenderness while Diverticulitis pain is lower left abdominal pain

    Data against ( appendicitis )

    - CVA pain while appendicitis pain begins near umbilicus and then moves lower and to the right and gets worse when moving around, taking deep breaths, coughing, or sneezing .
    - Moderate Fever ( while fever in appendicitis is low grade)

    Data (against) Renal Caculi

    - Suprapubic tenderness while in renal calculi it is flank tenderness
    - CVA pain which is wavy in character in renal calculi
    - Moderate fever while no fever except if associated infection in renal calculi cases

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  10. D. Pyelonepritis

    S> (+) severe right lower quadrant (RLQ) pain
    (+) dysuria,
    (+) fever,
    (+) shaking chills, and
    (+) frequency.
    (+) sexually active with one partner and
    always uses condoms.
    LMP: 5 days ago.

    O> BP: EN RR: EN Temp: 39°C HR: 120/min
    (+)suprapubic tenderness with palpation.
    (+)CVA Tenderness omplains of pain when percussion
    Pelvic examination is normal.

    Discussion:

    What to do:
    >>Examine urine for presence of gram-positive cocci (presumptively enterococci) or the more usual gram- negative rods, and send for culture and sensitivity.
    >>If the patient appears toxic, with a high fever or white count, nausea or vomiting to prevent adequate oral medicatication and hydration, or if the patient is pregnant or there is any sign of urinary obstruction or developing sepsis, he or she should be admitted to the hospital for intravenous antibiotics.
    >>For stable, otherwise healthy patients, start with a first dose of intravenous antibiotics in the ED (ampicillin 1000mg plus gentamicin 80mg, ceftriaxone 1000-2000mg, ofloxacin 200-400mg or ciprofloxacin 200-400mg), then discharge home on oral hydration and two weeks of oral antibiotics (trimethoprim 160mg plus sulfamethoxazole 800mg bid, ciprofloxacin 500mg bid, norfloxacin 400mg bid or ofloxacin 400mg bid x 14d).
    >>Instruct the patient to return to the ED for re-evaluation in 24-48 hours, and sooner if symptoms worsen. Most patients improve on this regimen, but the others will require hospital admission if they are not improving in two days.

    What not to do:
    >>Do not lose the patient to followup. Although lower UTIs often resolve without treatment, upper UTIs inadequately treated can lead to renal damage or sepsis.
    >>Do not miss an infection above a ureteral stone or obstruction.
    >>Crampy, colicky pain or hematuria with the symptoms above calls for an excretory urogram (IVP).
    >>Antibiotics and hydration alone may not cure an infected obstruction.

    NOTE:
    Although oral antibiotics are usually sufficient treatment for upper UTIs, there is a significant incidence of renal damage and sepsis as sequelae, mandating good followup or admission when necessary.
    By the same token, lower UTIs can ascend into upper UTIs, or it can be difficult to decide the level of a given UTI, in which case it should be treated as an upper UTI.
    Studies have shown tat a 14 day course of oral therapy is highly effective for the woman with clinical evidence of pyelonephritis without sepsis, nausea or vomiting. Quinolones such as ofloxacin (Floxin), ciprofloxacin (Cipro) and norfloxacin (Noroxin) are highly effective and probably the drugs of choice in this setting, except for pregnant women, for whom they are contraindicated. Trimethoprim-sulfamethoxazole (Bactrim, Septra) could also be used, although resistance of 5% to 15% of pathogens may be a more important factor in the selection of therapy for pyelonephritis than for cyctitis.

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  11. Hi, I have now 2 RA account, I collect them from my sites:
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    When someone download a book from site above I collect rapidpoint and after I convert them into RA just for you.

    Now let publish correct answer and winners, this was most simple case ;)

    Correct answer is:
    d. Pyelonephritis

    Winners:
    dr.hanaa (first correct answer)
    DR. DMDSANTOS (it was hard to decide a winner from sayarthein and Dr.BMW, but from my friends is suggested to DR. DMDSANTOS.

    Good luck next case

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  12. D\pyelonephritis :
    high grade fevrer , rigor with costovertebal tenederness in a female

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  13. -pyelonephritis in a female with fever, rigor with costovertebral tenederness.

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  14. d. Pyelonephritis

    bcz others is not associated wid this sign & symptom.

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  15. d.pyelonephritis

    ReplyDelete