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Flank Pain




Hey whats going on guys, and welcome another case presentation.  Today I want to walk you through a presentation, and this patient presented with back pain.  Alright guys, so lets just get right into it today.  So, this was a 28 year old female that came in with some severe back pain, severe abdominal pain, she has nausea, she has vomitting, and its been present for the past day.  She’s taking 600 mg of motrin for the past day every 6 hours AND says there is no improvement at all.  Now, as soon as I walk into this room, I see this female kind of withering around.  She’s moving, she’s restless, and she’s in a lot of pain.  She’s hunched over and she’s grabbing her back.  So, this can be a few different things.  Now, her pain is more so in the flank area so its not so much spinal pain.  She denies any trauma and she denies lifting any thing heavy.   She says the pain just abruptly started this morning.  So, what am i going to do first?

The first thing Im going to do is relieve the pain, right?  Once we can get rid of the pain, we can get a better history, we can get a better physical, and we can really approach this patient a lot better than if we were trying to do anything before alleviating her symptoms.  The first thing I’m going to do or the first thing I did was I gave this patient torodol 60mg IM.  Another name for torodol is ketorolac. I also gave her reglan 10mg Im.  Another name for reglan is metoclopromide.  The reason for the reglan was for the nausea and the vomitting and the torodol was for the pain. Torodol is a type of NSAID thats used IM for the most part to relieve pain.

Now, just a little bit of an insight as to where I work.  I do work in a family practice setting. I don’t work in the ER emergency room.  I don’t work in the urgent care setting.  So seeing a patient like this might be a little bit intimidating for some working in family practice.  Now, I do get a lot of patients that are uninsured.  What does this mean?  This means a couple of things.  This means one, the patients can’t afford to go to the ER so they come in to us.  They come and see us, because they expect us to fix their problem.  Sometimes we can and sometimes we can’t.  Its knowing when to refer these patients to the emergency department thats the trick.  Cuz you don’t want to refer everybody that looks like they are in severe pain when all they need is pain medication, a good history, and a good physical to diagnose their issue.  Another thing is that these patients don’t know what urgent cares are.  A lot of these patients don’t even know that urgent cares exist, so again they walk in to see us.  Thirdly, these patients wait til the very last minute.  They don’t have health insurance and they don’t do their annual physical.  So when they come in to see us, they are pretty jacked up at that point, right?  So, anyway you need to know how to handle these types of situations regardless of the clinical setting that your working.  Just because your working in family practice doesn’t mean that your not going to get these types of patients that come in with acute pain.  Alright thats my little rant for today.  So, lets go over the exam.

So I did an abdominal exam, and the only place she had tenderness was in her right upper quadrant.  So, right upper quadrant meaning up here, you have a couple of things right.  We have a gallbladder and we have a kidney; basically those are the only two things up there.  Now, she didn’t have any rebound tenderness any where in the abdomen and she didn’t have any guarding any where in the abdomen.  And you know what, I just did a psoas and obturator also, because it takes two seconds.  She does not have appendicitis.  She also did not have a murphys sign.  A positive murphys sign is indicative of cholecystitis or cholelithiasis.  And the way you perform this type of exam is your going to palpate the right upper quadrant as the patient is taking in a deep breath.  IF that pain is so severe when you palpate, that she stops breathing, thats a positive murphys sign and thats indicative of cholecystitis or cholelithiasis.  She didn’t have a murphys sign at all.  She did have right CVA tenderness to palpation.  So she has right upper quadrant tenderness she’s got right CVA tenderness to palpation.  So, lets go over the differential diagnosis.

We need to exlude pyelonephritis, ectopic pregnancy, cholecystitis/cholelethiasis, and nephrolithiasis.  These are our top 4 working differential diagnosis.  Pyelonephritis, probably not right?  These patients are going to present with fever and they are going to present with urinary tract symptoms.  She did not have dysuria, she did not have increased urinary frequency and she did not have fever.  So, this makes pyelonephritis unlikely.  Although this patient did have right upper quadrant tenderness and right back pain, any female patient that is able to have a pregnancy needs to be ruled out for an ectopic pregnancy.  Every women with abdominal pain should have a pregnancy test done.  For liability reasons and the fact that ectopic pregnancy is life threatening.  Cholecystitis/cholelithiasis.  Does she have a stone in her gallbladder? Does she have inflammation of the gallbladder?  The fact that she had a negative murphys sign points us away from that diagnosis, but it is still possible, right?  Nephrolithiasis.  So she could have a stone in her ureter causing this intense pain.

Alright, so the labs that were going to do very quickly is going to be a pregnancy test.  Negative pregnancy test essentially rules out an ectopic pregnancy. Urine analysis.  She has hematuria.  She didn’t have any white blood cells.  She didn’t have any leukocytes.  She didn’t have any nitrates, so we can rule out pyelonephritis as well.  So, now were working with nephrolithiasis and cholecystitis.  Were looking more towards nephrolithiasis because she has blood in her urine which is present in the majority of patients presenting with nephrolithiasis.  She had a negative murphys which points us away from cholecystitis.  Now, I do work in family practice, but once a week we do have ultrasound and I was able to get an ultrasound on her to look at: one her gallbladder, and two to look for any stones.  The gallbladder was fine and she didn’t have stones in her gallbladder, but she did have a 6 mm stone found in her right ureter.  So she has nephrolithiasis.  Alright, so, she has a 6mm stone.

Stones under 10 mm will usually pass spontaneously.  Stones over 10 mm might not and these patients need to be referred to urology.  Stones that haven’t passed after a month should also be referred to urology for further workup.  So this patient has a 6 mm stone so we can essentially treat her here.  We control her pain and we control her vomitting and we give her some time for the stone to pass.  We just saved her thousands of dollars by not getting to excited and not getting to worked up and sending her off the the emergency room.  Alright guys, so this was a quick case of nephrolithiasis.  I hope you guys learned something valuable.  I hope this is something you can take to your own clinical practice and apply it to the real world.  Thank you so much for joining me, I appreciate you guys, and I will see you guys on the next clinical case presentation