Hypothyroid case

Hypothyroid case

orders : cbc for anemia, ua, cxr, esr, ecg, serum
electrolytes(hyponatremia),
tsh which is elevated, t4 which is low, resin t3 or t4 uptake(low) riu :
low s. cholesterol, creatine kinase, LFT: increased, b sugar: hypoglycemia,
antimicrosomal n antithyroglobulin: increased in hashimotos

Management. levothyroxine, rx of anemia, consultn from endocrino thyroid specialist.

**A 29-year-old female dancer with no significant medical history comes to your office with several days of urinary frequency, burning, and urgency. In addition, she notes a cloudy discoloration of her urine. She uses no medications, has no allergies, and has not seen a physician for several years.

initial approach??how would you use the history and physical examination to help you localize the infection?
dysuria can occur because of infection at any level.
Temperatures above 102.2oF, nausea, vomiting, chills, and other systemic symptoms are more suggestive of pyelonephritis, although this is not specific. Pyelonephritis characteristically gives back pain and tenderness to palpation at the costovertebral angle. Cystitis often results in suprapubic pain and tenderness. Urethritis can give a urethral discharge that can be clear, white, or yellow. Clinically distinguishing between urethritis and cystitis is difficult

On physical examination this patient had a temperature of (100.4oF) and suprapubic tenderness. There was no back or costovertebral angle tenderness, and there was no discharge noted from the urethra.

Investigations??

urinalysis is the best initial test. Leucocyte esterase test on a dipstick is very sensitive and specific for detecting WBC. THis is quite useful as UTI is rare in the absence of WBC in urine.

Microscopy A single white cell visible on a high power field is suggestive of infection.

Gram stain A single bacterium visible on an unspun urine specimen viewed on a high power field correlates to growth on a culture of >100,000 bacteria/milliliter (ml) of urine. A urine culture growing >100,000 bacteria/ml of an organism from voided urine is strongly associated with the diagnosis of UTI. On a catheterized specimen, >100 bacteria per ml is considered positive, and any growth from a percutaneous aspiration of the bladder (suprapubic tap) is considered abnormal.

Imaging studies are not essential in the first infection in adults.

This patient had a urinalysis that was strongly positive for white blood cells and mildly positive for red blood cells and protein. A urine culture was deferred because the patient's income was not sufficient for health insurance, and she wished to defer the cost of a urine culture. Clinclly she was dx as cystitis.

What is the optimal treatment?

This patient is treated with two double-strength, trimethoprim/sulfamethoxazole tablets. She leaves the following morning for a series of dance performances along the eastern coast of the United States and does not return to her home for 6 weeks. The day following her return she calls your office for an urgent appointment because she has been having fever and dysuria for the past several days as well as nausea and vomiting. In your office you find a very ill-appearing woman with a temperature of 102.9oF with marked costovertebral angle tenderness. What is your assessment of this patient's current diagnosis, and what would you do to evaluate and treat her at this point?

admit the patient to the hospital and obtain a urinalysis, urine culture, and blood cultures.

intravenous antibiotics because of both the severity of symptoms and the nausea and vomiting.

Initially, the choice of antibiotics is largely empiric because a urine culture will take at least 24 hours to yield any growth and an additional 24 hours to speciate the organism and obtain sensitivities. Some guidance can be obtained from Gram stain.


What would be your choice for intravenous antibiotics at this time, and on what do you base the choice?

Initially, the choice of antibiotics is largely empiric because a urine culture will take at least 24 hours to yield any growth and an additional 24 hours to speciate the organism and obtain sensitivities. The choice can be guided somewhat by a knowledge of the most common bacteriology described above as well as a gram stain of the urine. Although it will not give the specific species, a gram stain will allow you to differentiate the gram-negative bacilli such as E. coli and Klebsiella from gram-positive cocci such as enterococcus and S. saprophyticus.

A urinalysis reveals 100 WBCs per HPF, 2+ protein, and 2+ blood. Gram stain of this patient's urine reveals gram-negative rods.

Many agents are active against gram-negative bacilli: third-generation cephalosporins (e.g., ceftazidime, cefotaxime, or ceftriaxone), ciprofloxacin, extended spectrum penicillins (e.g., ticarcillin, piperacillin, or mezlocillin), ticarcillin/clavulanate, or aztreonam would all likely be effective. Second-generation cephalosporins would also likely be adequate

The addition of an aminoglycoside in combination with any of the agents listed above is appropriate in those cases where a concomitant bacteremia, a very severe infection, or possibly a resistant organism is suspected.