1. CASE PRESENTATION (Evidence-based medicine)
By: Intern Sheena B. Fernando
Block O

2. General Data:
This is a case of A.E, 43 year-old male, married, Catholic, right-handed, from Taguig City who came in due to dysuria.

3. History of Present Illness
One week PTC -
(+) dysuria, (+) dribbling,
(+) flank pain on the left side,
VAS 8/10
Described as ‘parang namamanhid’
radiating to the left lower abdominal quadrant,
(-) frequency, (-) penile discharge,
(-)fever, (-) vomiting
(-) passage of urine sediments,
(-) nocturia, (-) straining, (-) urgency,
(-) retention
No consult done.
No medications taken.

4. 3 Days PTC - persistence of symptoms,
sought consult at private MD, prescribed with Ciprofloxacin 500mg/tab, 1 tab BID x 7 days, on Day 2 of treatment, Rowatinex tablet, 1 tablet TID x 7 days, HNBB (Buscopan) 10mg/tab, 1 tab TID x 5 days.
Temporary relief of symptoms.
KUB Ultrasound was done and showed Mild hydronephrosis with nephrolithiases left.

5. Few hrs PTC, persistence of symptoms
Consult at AMBU

6. Review of Systems
No weight loss, no headache, no easy fatigability, no loss of appetite, no jaundice
No cough, no colds, no difficulty of breathing, no chest pain
No orthopnea, no paroxysmal nocturnal dyspnea, no palpitation
No abdominal pain, no diarrhea, no change in bowel movement, no melena, no hematochezia, no hematemesis
No polyuria, polydipsia, polyphagia
No loss of consciousness, no seizures

7. Past Medical History (-) previous operation
(+) previous hospitalization due to AGE
1989, San Juan De Dios Hospital
(+) Hypertension since May 2008
HBP 160/110 UBP 120/90 with poor compliance to unrecalled medications
(-) DM, (-) PTB, (-) BA
(-) allergy to food and drugs

8. Family History

9. Personal and Social History
finished 3rd year HS
works as a family driver - his family’s source of income
drinks alcohol, once a week (beer, gin and hard drinks)
non-smoker
prefers to eat fatty and salty food
drinks water from NAWASA, unboiled, consuming 1 liter of water per day.

10. Sexual History Coitarche at 15 years old
With 3 nonpromiscuous sexual partners
(-) MSM

11. Physical Examination conscious, coherent, in pain Vital Signs:
BP= 140/90mmhg HR=84 bpm
RR=20cpm T= 36.5C BMI= kg/m2
SHEENT: dirty sclerae, pink palpebral conjunctivae, no nasoaural discharge, no cervicolympadenopathy, no TPC, PERTL 2-3 mm

12. CHEST: symmetric chest expansion, no retraction, clear breath sounds
CVS: adynamic precordium, distinct heart sounds, normal rate regular rhythm, no murmur
ABDOMEN: flabby, normoactive bowel sounds, nontender, (+) costovertebral angle ternderness left
EXTREMITIES: full and equal pulses, no cyanosis, no edema
GENITALIA: grossly normal genitalia, no discharge
DRE: good sphincteric tone, no skin tags, no masses, no tenderness, no blood on examining finger, empty rectal vault

13. Differential Diagnoses
DYSURIA
Infection
STI
Acute Pyelonephritis
Prostatitis
Complicated UTI
Structural
Testicular torsion
Obstruction 2o to mass
Obstruction 2o to prostate enlargement
Obstruction 2o to renal stones

14. Assessment Complicated UTI
Mild Hydronephrosis with Nephrolithiases, Left
Hypertension Stage II, uncontrolled

15. Plan Diclofenac 25mg/ml, 1 amp TIM was given Low salt, low fat diet
Dx: FBS, Crea, Na, K, TG, TC, LDL, HDL
12L ECG, Long Lead II
Urinalysis
Tx: Continue:
1. Ciprofloxacin 500mg/tab, 1 tablet BID for 5 more days
Start: 2. Diclofenac Na 50mg, 1 tab TID and PRN for pain on full stomach
3. Losartan + HCTZ 50mg/12.5mg 1 tab OD
TCB once with results at OPD DFCM after 1 week
Refer to Urology-Surgery OPD Basis
Advised

16. Diagnostic Dilemma
In adult patients with clinical symptoms of renal stones, what is the sensitivity and specificity of KUB- UTZ compared to CT scan in confirming the diagnosis, using a cross sectional study?

17. Adult patients with clinical symptoms of renal stones Intervention
Population
Adult patients with clinical symptoms of renal stones
Intervention
KUB UTZ
Comparison
CT scan
Outcome
Sensitivity and specificity in confirming the diagnosis
Method
Cross sectional study
KUB UTZ: Diagnostic Threshold - 30
Therapeutic Threshold – 80
Pre-Test Probability – 70%

18. Clinical Dilemma
In adult patients diagnosed with renal stones, is Rowatinex effective in facilitating passage of renal stones, using a randomized control trial?

19. Population
Adult patients with renal stones
Intervention
Rowatinex
Comparison
Placebo
Outcome
Effect in facilitating passage of renal stones
Method
Randomized control trial

20. Thank you!