p2
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1]A 27-year-old primigravid woman at 29 weeks' gestation comes to the emergency department because of a 24-hour history of increasingly severe right-sided abdominal pain and no appetite. She has vomited twice over the past 4 hours. She has not had vaginal bleeding. Her temperature is 38.2 C (100.8 F). Examination shows exquisite tenderness of the right lateral flank and the fundus. There are no peritoneal signs. Bowel sounds are absent. The fetal heart rate is 144/min. Laboratory studies show: Hematocrit 37% Leukocyte count 16,000/mm3 Serum Total bilirubin 1.1 mg/dL Amylase 32 U/L Lactate dehydrogenase 110 U/L Urine WBC 3•5/hpf Which of the following is the most likely diagnosis? A ) Abruptio placentae B ) Appendicitis C ) Cholelithiasis D ) Colitis E ) Pyelonephritis
2]
A 42-year-old woman comes for a follow-up examination.
Two weeks ago,
her blood pressure was 152/94 mm Hg during a routine
visit. Her blood
pressure today is 150/94 mm Hg, pulse is 76/min, and
respirations are
14/min. Examination shows no other abnormalities.
Serum studies show:
Na+ 142 mEq/L
Cl– 105 mEq/L
K+ 4 mEq/L
HCO3– 26 mEq/L
Urea nitrogen (BUN) 12 mg/dL
Glucose 101 mg/dL
Creatinine 0.8 mg/dL
An ECG shows no abnormalities. Which of the following
is the most
appropriate next step in management?
A
) Measurement of plasma renin activity
B
) Serum lipid studies
C
) 24-Hour urine collection for measurement of
metanephrine level
D
) Echocardiography
E
) Captopril renal scan
confusion with B OR E EXPLANATIONS PLEASE
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| cool doctor
Forum Junior
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Posts: 231
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1.appendicitis
pylo is possible DDX but the her UA is not showing the classical findings
2.B
she has other RF for CVD (HTN) so this is an indication to do lipid levels in women between 20-45y
why would u choose E with normal labs??
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| doyoudig
Forum Guru
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Posts: 613
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cool doctor, why not C for the 1st question ? thx
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| p2
Forum Senior
Topics: 41
Posts: 52
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can u tell me classical UA FINDINGS OF PYELONEPHRITIS
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| SmokyWaters
Forum Elite
Topics: 6
Posts: 447
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first is abruptio placentae...
there is no tenderness of fundus in appendicitis and fetal heart rate shouldn't change as well
UA findings of pyelonephrtis = should have leucocytosis thats the most consistent finding
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| SmokyWaters
Forum Elite
Topics: 6
Posts: 447
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2nd is B .. thats fine..
choose the cheapest 
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| cool doctor
Forum Junior
Topics: 1
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for abruptio you must have severe bleeding
this pt have 24 hours of pain w\o bleeding.this cant be abruptio
C. how can u explain the high WBC for the stones? beside there should be some RBC in cholelithiases
as for the fundus tenderness, I think the appendix is displaced upword and that explains the site of the pain.
my humbe opinion
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| cool doctor
Forum Junior
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for pylo the urine WBC should be very high and usually there r WBC casts.
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| p2
Forum Senior
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but in concealed abruptio no bleeding
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| sherry39
Forum Junior
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b..mother has increased temp showing infectin
b
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| shahnaz.r
Forum Junior
Topics: 7
Posts: 77
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1] B. Classic presentation of appendicitis in pregnancy:
-RUQ or rt. lateral flank pain[appendix displaced upward by the gravid uterus]
- N/V,low grade fever, absent or diminished bowel sound,Leucocytosis,
-absence of PV bleeding and uterine contartion, normal FHR.
2] B =lipid profile.
This patient dosn't have any indication that tells us to go for further investigation for her HTN. We just need to find out what other CVS risk factors she has.
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| inkspot
Forum Guru
Topics: 33
Posts: 623
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A: The question stem says no peritoneal irritation. so i guess no appendicitis. wbc count is normal for pregnancy. should have been more since all are inflamations. ( also some one mentioned appendicitis as infection . no it doesnt have to be infection. -itis = inflamation)
i think its an early stage of placental abruption. concealed bleeding in which the HCT has fallen as well and there is fundal pain.
A. the patient has essential HTN. Her serum Na is elevated. it could be increased salt intake or secoundry adrenal issue. so better check the renin levels.
any one agree with me ?
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| gray
Forum Newbie
Topics: 2
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b and b.
temperature likely append
normal Na Level
sodium 135 - 148 mEq/L
where is do you get abnormal Na from inkspot
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| inkspot
Forum Guru
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i misread it !
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| dr ruman
Forum Elite
Topics: 32
Posts: 368
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this is really simple
its is ACUTE PYELO NEPHRITIS
supporting feature:1: flank pain with no sign of peritonitis(appendicitis and abruptio should have sign of perotinitis wether concealed or pobvious bleeding)
2:WBC in urine
3:acute pyelonephritis can cause paralytic ileus i.e, absent bowel sounds without any sign and symtom of peotinitis(reference UW notes)
4:serun LDH level can be bit raised in ac.pyelo
5>any nausea vomiting with fever and flank tenderness with fever is pyelonephritis in pregnanant untill proven otherwise(reference KAPLAN gyane notes)
hope i explained
for 2nd question,all lab normal ,so test to do is LIPID LEVEL to see wether she be happy with diet alone or need medication for HTN
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| gray
Forum Newbie
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I thought normal wbc count in urine is less than 10.
The current ‘normal’ parameter for white blood cells (WBCs) is <10. This will be replaced by a new ‘normal’ parameter of <40. WBC counts above 40 will be reported as an absolute number.
The current ‘normal’ parameter for red blood cells (RBCs) is <10. This will be replaced by a new ‘normal’ parameter of <140. RBC counts above 140 will be reported as an absolute number.
( new figures for automated system.)
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| WaqasQureshi
Forum Senior
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A and B
its abruptio placentae
there is tenderness of FUNDUS .. usual timing of abruption is also consistent, there is concealed bleeding plus signs of compromised fetal circulation INCREASED HEART RATE. the leuks are within Normal limits in urine. Rules out PYELONEPHRITIS plus there is no tenderness in pyelonephritis infront of the abdomen
as for second: lipid profile as everything is within normal limits except the hypertension
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| anp
Forum Newbie
Topics: 6
Posts: 46
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1) B as loss of apetite(more in favour of appendicitis) and position suggesting displacement due to pregnancy.For concealed abruptio-she should have feeble FHS and atleast some dark coloured vaginal discharge. I think normal FHR is 120 to 160,so the foetus here has a normal heart rate and dosnt look compromised.For Pyelonephritis she should have had high fever with chills ,dysuria,plenty of pus cells and few RBCs.
2) B
Edited by anp on 03/04/08 - 09:18 AM
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| Jcala
Forum Junior
Topics: 14
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B
B
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| aspire
Forum Senior
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Posts: 158
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1. E-Pyelonephritis
2.B-Serum lipid studies.
OMG! Some one clear up the confusion and the right answer please? P2?
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