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an 82-year-old from assisted living, is brought in to see you
an 82-year-old from assisted living, is brought in to see you. She has deteriorated in the last 3 days and has become mildly confused, making mealtimes difficult, as the patient has begun refusing food. Sophie has a low-grade temperature. Her caregiver has noted that she frequently grabs at her abdomen and groans as if in pain, and there may have been blood in her last void, an hour ago. There is no one to confirm when the patient's last BM was. Sophie has been a relatively healthy lady. Her PMH is significant for lumbar disc disease, and PSH is positive for a cholecystectomy. Upon physical examination, you find that she has left, lower quadrant abdominal pain with palpation that appears to radiate to her left flank. By the time you assessed for CVA tenderness, Sophie was groaning with any attempted physical examination, even straight leg raises.
questions :
Identify three differential diagnoses. Provide your rationale and determine what you think is the most probable diagnosis, providing a brief description of the pathophysiology. Think outside the box. Don't let them all be related to the same body system.
Expert Solution
Answer:
3 differential diagnosis for Sophie:
1. Acid peptic disease- Sophie can be suffering from gastritis. There may have been blood in her last void. This can be because of gastritis or bleeding gastric ulcer. Nausea is also common in APD. Her food intake is reduced. This also commonly occurs in acid peptic disease. One more point making me to think about acid peptic disease is her accomodation in assisted living. She can be under some mental stress, which can be one reason for acid peptic disease.
2. Lumbar disc prolapse with radiculopathy- upper lumbar disc involvement can give rise to symptoms like that of Sophie. She is known case lumbar disc disease in the past. So again same pain may have started. Straight leg raising test is painful in lumbar disc prolapse, which is also present in Sophie.
3. Left ureteric calculi- left ureteric calculi may give rise to same set of symptoms. Left lower quadrant pain radiating to flank is typically seen in left ureteric calculi. Mild fever can be suggestive of low grade infection in urinary system due to calculi.
Out of these 3 differential diagnosis, I think Sophie is suffering from left ureteric calculi as fever is not present in other two differential diagnosis.
Pathophysiology of renal calculi- due to reduced water intake and presence of concentrated urine in excretory system, the calculi may be formed in urinary system. These calculi can be present in kidneys, ureter, urinary bladder or urethra. These calculi cause severe spasmodic pain and associated symptoms like nausea, vomittings, fever, burning micturation etc. Loin to groin pain is typically seen in ureteric calculi because of typical nerve supply of ureter. This pain radiates from flank to groin. Considering this pathophysiology and presenting symptoms of Sophie, I think she is suffering from left renal calculi specifically left ureteric calculi.
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