60 yo F with flank pain, nausea/vomiting

Case and content by Brandon Fainstad, MD
Edits, updates and graphics by Yilin Zhang, MD


OBJECTIVES:

  • Evaluate a patient with flank pain


CASE:

A 60 year old woman presents to the ED with nausea, emesis and L sided flank pain for 18hrs. The pain is constant, improved when leaning forward and aggravated with inspiration. She denies fevers but reports chills and rigors. She denies SOB, productive cough, dysuria, hematuria, diarrhea. She admits to chronic tooth pain, a small draining boil on her R buttock. Her PMH is significant for COPD, depression, hemochromatosis and nephrolithiasis. She only takes NSAIDS and APAP as needed for pain and reports following recommended doses. She was previously homeless but is currently living in the basement where there was recently confirmed mold infection. She moved from the southeast United States a year ago and denies any other domestic or international travel. She smokes tobacco but denies any IV drug use.

Physical Exam

T37.1C, HR 110, BP 120/65, SaO2 95% RA, RR 24
GEN: leaning forward in moderate distress
HEENT: red and swollen gingiva w/o palpable fluctuance. Multiple missing teeth
PULM: tachypneic, shallow breathing, no wheezing, CTAB
CV: tachycardic, regular, no murmurs, non-elevated JVD, good distal pulses
GI: soft, non-distended, mild tenderness over LUQ/lower ribs.
Skin: <1 cm boil over R buttock with small amount of sanguinous drainage, no surrounding erythema or induration
GU: no CVA tenderness


What is your differential based on her history and physical? 


Labs

BMP notable for BUN 45, Cr 0.7
CBC notable for WBC 25 (88% PMNs)
Venous lactate 1.7
LFTs nml
UA: trace ketones, small blood and 1+ hyaline casts

CXR


What are your next steps in diagnosis and management? 


What is your interpretation of the CT chest findings in the setting of this patient’s presentation? Reveal to show findings and differential if focusing on “option 2” objectives. 


CASE CONTINUED:

What are septic pulmonary emboli (SPE)? (~2-3 min) 

What are typical CT findings of septic pulmonary emboli (SPE)? (~1-2 min) 


OUTCOME:

What is complicated versus uncomplicated bacteremia? (~5 min) 


What are additional antibiotic options for the treatment of MRSA bacteremia? (~1-10 min)


TAKE HOME POINTS:


REFERENCES:

  1. Lin, M. Y., K. Rezai, and D. N. Schwartz. “Septic Pulmonary Emboli and Bacteremia Associated with Deep Tissue Infections Caused by Community-Acquired Methicillin-Resistant Staphylococcus Aureus.” Journal of Clinical Microbiology 46.4 (2008): 1553-555.
  2. Cook, Rachel J., Rendell W. Ashton, Gregory L. Aughenbaugh, and Jay H. Ryu. “Septic Pulmonary Embolism.” Chest 128.1 (2005): 162-66.
  3. Liu, C, et al. 2011. “Clinical Practice Guideline by the Infectious Diseases Society of America for the Treatment of Methicillin-Resistant Staphylococcus aureus Infections in Adults and Children.” Clinical Infectious Diseases. 53(3):e18-e55.
  4. Holland, TL, et al. 2014. “Clinical Management of Staphylococcus aureus Bacteremia:  A Review.” JAMA. 312(2): 1330-1341.
  5. Weerakkody, Yuranga. “Septic Pulmonary Emboli.” Radiopaedia Blog RSS. Radiopedia.org, 03 June 2016. Web. 15 June 2016.