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Morning Report

Erin Fuchs PGY2 January 15, 2014

Case/History
15 year old female who presents with acute onset worsening abdominal pain Had initially begun around 11am at school Ate lunch not all of it, but some, but pain continued to worsen Mom picked up after school, brought home, and pain has since continued increasing Presents to the ED at approximately 6-7PM with 10/10 right lower quadrant abdominal pain that radiates to her back. Since coming home from school she has had nausea and vomiting x2 secondary to pain

ROS: Positive for abdominal pain radiating to back, nausea/vomiting x2. Otherwise negative MEDS: Synthryoid, Advil (400mg day before), Excedrin Migraine ALL: NKDA PMH: Hypothryoidism, otherwise negative IMMS: UTD FHx: Negative for GI disorders or other chronic illnesses SHx: Not currently or ever sexually active; no concerns about STI or pregnancy; Regular periods; denies tobacco, alcohol, or illicit drugs

Physical Exam
WT: 41.9 kg, T 36, HR 80, RR 20, SpO2 RA GEN: Writhing on bed, cannot appear to find a comfortable position, occasionally crying HEENT: NCAT, PEERLA, EOMI, TMs clear, OP pink w/o exudate or erythema, MMM NECK: FROM, (-)cervical LAD CV: RRR, S1, S2, (-)murmur, 2+ radial pulses RESP: CTAB, (-)wheeze, rhonchi, crackles GI: BS+, soft, nondistended, negative HSM. TTP esp in RLQ and LLQ BACK: +Right flank pain EXT: WWP

15 year old female with acute onset right quadrant abdominal pain

DDx
Infectious Disease: Gastroenteritis Viral Illness Appendicitis Pneumonia Hepatitis Pharyngitis Gastrointestinal: Constipation Intraabdominal abscess Cholecystitis Pancreatitis Perforated ulcer Abdominal migraine IBD Primary Bacterial Peritonitis Meckels Diverticulum CV: Myocarditis Pericarditis

MISC: Trauma Adhesions Sickle cell syndrome vasoocclusive crisis Familial Mediterranean fever ENDO/RENAL: UTI Urolithiasis DKA Henloch SP HUS OB/GYN: Ovarian torsion Ruptured ovarian cyst Ectopic pregnancy Labor Pelvic Inflammatory Disease

Studies
CBC: WBC 5.7 (N65%, L26%, M7%), Hgb 12.2, Hct 35, Plts 185 CRP: <0.5 UA: Cloudy, sp 1.02, pH 7, trace prot, negative gluc, ket, nitritie, hgb, LE
WBC 5, RBC 0, Epi 10, neg bacteria

BMP: Na 138, K 4.3, Cl 105, CO2 19, BUN 12, Cr 0.73, Gluc 113, Ca 9.8 B-hCG: Negative
Urine Cx: <1000 mixed gram positive organisms

Imaging
US Appendix: Tubular structure projecting in right lower abdomen. This is believed to represent the distal right ureter rather than appendix, given dilatation of right renal collecting system and proximal ureter. No distal ureteral stone seen.

-> increased bladder distention


US Pelvis: Normal of uterus and ovaries; probable dilated right ureter. Suspicious for renal stone CT without contrast:
Mild pelviectasis of right kidney and ureterectasis of proximal right ureter. No renal or ureteral stone 3 calcifications in region of cecum and terminal ilium -> likely fecaliths. No dilated appendix. No etiology for abdominal pain seen.

Kidney Stones
Definitions: Urolithiasis: renal stones at any location within the urinary tract Nephrolithiasis: stones formed exclusively in the kidney Nephrocalcinosis: deposition of calcium salts in the renal parenchyma, including the tubular lumen, tubular epithelium, and interstitium Deposits usually are either calcium oxalate or calcium phosphate

Epidemiology
Ages 10-19 = 4% of total episodes of nephrolithiasis Boys more affected at younger ages (up to 10 yo) More common in Caucasians Most common stone:
Calcium oxalate (45-65%) Calcium phosphate (14-30%) Struvite (13%)

Presentation
Depends on age:
Younger kids dont often see radiating flank pain
Inverse relationship between age and pain (60, 40, 20% in adolescents, school-age, <5yrs) May be related to the frequency of stones lodged in the ureters (less likely in younger kids)

Hematuria (30-55%) Dysuria and Urgency (10%) consistent with UTI Nausea and vomiting (10%)

Evaluation/Diagnosis

Good History
Previous renal stone, family history, abnormalities, metabolic conditions, medications, recurrent UTIs

PE Labs
UA Ucx Serum Creatinine

Imaging
Abdominal X-ray Radiopaque stones Ultrasound limited to radiolucent stones and urinary obstruction Noncontrast CT most sensitive

Acute Management
Pain management
NSAIDs Opiods

Passage
Most <5mm pass spontaneously
Increase hydration Medications

Interventions

Prevention
2/3 patients developed 1 or more additional stones within 5 years Evaluate underlying risk factors:
Stone analysis Metabolic evaluation
Serum tests: Ca, Phos, HCO3, Cr, Mg, Uric Acid

Urine tests
24-hour urine collections

Interventions:
Fluid Intake Metabolic

References

Barr, Ronald. "Abdominal Pain in the Female Adolescent." Pediatrics in Review. 4.9 (1983): 281-289. Web. 15 Jan. 2014. Ferry, George. "Causes of acute abdominal pain in children and adolescents." UpToDate. Wolters Kluwer Health, 19 Aug 2013. Web. 15 Jan 2014. Fishman, Mary, Mark Aronson, and Mariam Chacko. "Chronic abdominal pain in children and adolescents: Approach to the evaluation." UpToDate. Wolters Kluwer Health, 19 Dec 2013. Web. 14 Jan 2014. Lendvay, Thomas, Jodi Smith, and F Bruder Stapleton. "Acute management of nephrolithiasis in children." UpToDate. Wolters Kluwer Health, 18 Jun 2013. Web. 15 Jan 2014. McKay, Charles. "Renal Stone Disease." Pediatrics in Review. 31.5 (2010): 179-188. Web. 15 Jan. 2014. Smith, Jodi, and F Bruder Stapleton. "Clinical featurs and diagnosis of nephrolithiasis in children. UpToDate. Wolters Kluwer Health, 03 Jun 2013. Web. 15 Jan 2014. Smith, Jodi, and F Bruder Stapleton. "Epidemiology of and risk factors for nephrolithiasis in children." UpToDate. Wolters Kluwer Health, 29 Aug 2013. Web. 15 Jan 2014. Smith, Jodi, and F Bruder Stapleton. "Prevention of recurrent nephrolithiasis in children. UpToDate. Wolters Kluwer Health, 03 Jun 2013. Web. 15 Jan 2014.

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