Chief Complaint

"I have a sharp pain in my pelvis and my sides."

History of Present Illness

72 yo Caucasian female with a h/o type 2 diabetes, HTN, Hyperlipidemia, and recurrent UTIs
who presents to the ED c/o pelvic pain and bilateral side pain. She states the pain started about
4 days ago and has been progressively getting worse. Pt. rates pain 9/10 and describes it as a
sharp. Onset of pelvic pain started while the patient was sitting down on the couch watching tv.
Pt. stated she associated the pain with another UTI and stated she would wait until next week
to go see her PCP. Pt. continued to do her normal ADLs for a few days before the pain became
excruciating once it radiated to her sides, causing the pt. to come to the ED. Pt. has never had
pelvic pain or side pain this severe. Pt. states that she has been treated for multiple UTIs over
the years with symptoms such as dysuria, frequency, hematuria, and urgency. Pt. states she
noticed hematuria about a month ago, but decided not to follow up d/t it not being painful. Pt.
denies any recent trauma to pelvis, abdomen, or flank area. Pt. has a hx of smoking 2 packs per
day for the last 42 years. Pt. has been taking Actos to control her diabetes for the past year.

PMH

-Type 2 Diabetes

-HTN

-Hyperlipidemia

-Recurrent UTI

-GERD

Past Surgical History

-Appendectomy

-Tonsillectomy

Medications

-Norvasc 10 mg daily

-Actos 30 mg daily

-Lipitor 80 mg daily

-Cranberry tablet daily

-Ultram 50 mg Q 6hrs PRN

-Humalog sliding scale AC and HS

-Lantus 18 units Q evening.

-Multivitamin daily

-Calcium 500 mg daily

-Prilosec 20 mg daily

Social History

Pt. lives alone. Is widowed. Is able to complete own ADLs and IADLs. Drives, shops and does the
financing. Has 2 daughters that occasionally visit and help around the house. Pt. has a 42 year, 2
pack a day history of smoking. Denies illicit drug use, but admits to having occasional alcoholic
beverage.

Family History

Pt. father was a chronic smoker and alcoholic. Died of bladder cancer when he was 73 yo.
Mother was a type 2 diabetic with a history of HTN and afib. Died of a stroke at 64 yo.

Allergies

Cipro- Anaphylaxis

Norco- Rash

ROS

General- well nourished, obese, elderly female. Guarding pain to pelvis and bilateral flank area.
Denies shakiness, fever, chills, N/V, change in bowel patterns.

EENT- Denies vertigo, tinnitus, or hearing loss. Denies any eye pain or neck stiffness, c/o
occasional reflux that is controlled with medication.

Cardiovascular- No chest pain, SOB, or syncope.

Respiratory- No accessory muscles used, occasional non productive cough, denies hemoptysis
or SOB.

GI- No N/V/D, Occasional reflux controlled with medication. No changes in bowel habits.

GU- Painless hematuria, pelvic pain, no dysuria, frequency, or urgency. Recurrent UTIs. Flank
pain upon palpation.

MSK- No pain or stiffness to joints. No cramping.

Neuro- No confusion, no tingling or extremities, no numbness, no headaches.

Psyc- Cooperative and pleasant.

Physical Exam

Vital signs- T-98.7, BP 157/93, HR 108, RR 24, O2 sat 96% on room air.

General- Well nourished, obese, Elderly female

HEENT- PERRLA, External ears intact, nose patent, moist mucous membranes, normal cephalic.

Neck- Non palpable thyroid, trachea midline.

Lymph nodes- No palpable lymph nodes.

Cardio- Normal S1 and S2, regular rate and rhythm, no gallops, murmurs or rubs.

Pulmonary- No wheezes, crackles, or rhonci. Symmetrical expansion.

Skin- No rash or lesions. Warm, dry, no areas or breakdown.

Psyc- A&Ox4. Cognition intact. Pleasant and cooperative.

Abdomen- Non tender upon palpation, slight distention noted, no masses. BS active in all 4
quadrants. Flank pain.

Extremities- Warm, dry, ROM WNL, Hand grips and leg presses bilaterally equal and strong,
pulses all 2+.

MSK- No joint pain or stiffness. ROM WNL. Able to bear weight and walk. Gait steady.

Neuro- A&Ox4. PERRLA. Cranial nerves 1-12 intact.

LABS

NA- 140

K- 5.6

Cl- 103

BUN- 38

Cr-2.6

Glucose- 146

Calicum- 9.0

WBC- 9.4

RBC- 2.64
HBG- 8.1

HCT- 57%

PLT- 155

Problem List

1. Pelvic pain

2. Flank Pain

Assessment
This is a 72 yo female with a history of recurrent UTIs, HTN, diabetes, hyperlipidemia, and
GERD. Presents to the ED with a 4 day history or progressive worsening of pelvic pain.

Differential DX of Pelvic pain

1. Bladder Cancer
Bladder cancer begins most often in the cells that line the inside of the bladder, Usually affecting
older adults. Most bladder cancers are treatable d/t them being dx at an early stage. The most
common type of bladder cancer in the united states is transitional cell carcinoma. This type of
cancer occurs in the cells that line the inside of the bladder. Risk factors for bladder cancer
include smoking d/t harmful chemicals going into your urine. Smoke from a cigarette gets
excreted through the urine which will damage the cells of the bladder. Elderly have an increased
risk of developing bladder cancer, being a man, exposure to certain chemicals, Previous cancer
treatment, recurrent UTIs, family history of bladder cancer, and some diabetic meds such as
Actos. Taking Actos for more than a year can increase your risk of developing bladder cancer. A
pt. that presents with a bladder infection will usually have painless hematuria, frequency,
urgency, pelvic pain, back pain, anemia from the hematuria, elderly, and hx of recurrent UTIs,
smoking and family history. Dx is done by cystoscopy with biopsy. The cystoscopy is a scope
that is inserted into the urethra and into the bladder to view and masses/tumors and abnormal
cells. A biopsy may be done during the cystoscopy in order to further evaluate the tissue of the
bladder for abnormal cell growth indicative of bladder cancer.

Differential DX of Flank Pain

1. AKF
Occurs when the kidneys are unable to filter waste products from your blood. Unable to excrete
the waste products can cause a dangerous amount of waste build up in the blood. This develops
rapidly over a few hours. It can be fatal and requires critical treatment, but it can be reversed.
You can have acute kidney failure when you have a condition that slows blood flow to your
kidneys, experience direct damage to your kidneys, and obstruction of urine drainage. Risk
factors include being hospitalized, advancing age, PAD, diabetes, HTN, heart failure, kidney
disease, and liver disease. Signs and symptoms include decreased urine output, fluid retention,
SOB, fatigue, confusion, coma, and flank pain. Dx includes urine output studies, lab values such
as BUN and Cr, Urine test, Image testing, and biopsy of kidney.
Plan
Bladder Cancer
Based on evidence and assessment this patient is very likely to have a bladder cancer dx. Pt. has
multiple risk factors such as advancing in age, Taking Actos for more than a year, recurrent
UTIs, 42 year, 2 pack a day smoking history, and Pts. father died of bladder cancer just one year
older than the pt. currently is. Symptoms such as painless hematuria for the last month, pelvic
pain, and anemia support this dx. Blood levels and cystoscopy with biopsy to confirm dx ASAP.
AKF
Based on evidence and assessment it is very likely that the pt. has developed AKF secondary to
bladder cancer. The pt. presents with multiple symptoms such as flank pain, increased BUN and
Cr levels. Pt. is at a high risk of developing AKF d/t obstruction of urine drainage with a disease
such as bladder cancer. Redraw kidney blood levels, Urinalysis, and CT of kidney to confirm dx.