35-Year-Old Male with Abdominal Pain, Cramping, and Urinary Symptoms
A 35-year-old male presents to the ED with complaints of abdominal pain and cramping, along with pus and blood in his urine. He mentions a recent history of food poisoning-like symptoms, vomiting, and dysuria. Past medical history includes meth/ETOH abuse, rectal abscess, and recent vaccinations. Physical exam reveals lymphadenopathy and a penile lesion. Labs show leukocytosis, and a pelvic CT reveals retroperitoneal and inguinal adenopathy. The plan includes IVF, ondansetron, management of lymphadenopathy, and treatment for possible STIs. Follow-up for HIV testing is also planned.
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Presentation Transcript
THE CASE: 35 y/o male presents to the ED ..
CC abd pain/cramping pus & blood when urinates HPI 5 days ago, believed he had food poisoning c intermittent abd cramping, bloating, distention, vomiting Today vomited x 4, undigested food, not keeping anything down, no hematemesis Formed BM today, no diarrhea 6 days ago had 1 day of fever, none since Dysuria at initiation of urinary stream, pus from urethral opening of penis 2 months ago had lapchole at another hospital, with subsequent wound infection Denies F S C cough ST dyspnea CP
PMH Meth/ETOH abuse (last use few months ago) Rectal abscess + COVD boosted +flu IZ Meds/Allergies none/NKDA ROS neg x for HPI PE Vs 97.8 90 22 98% RA 101/68 HEENT L eye injected o/w nl LAN very large NT L>R inguinal LAN (2 cm), no cerv or ax LAN Resp nl CV nl Abd BS decrease, NT ND GU uncirc male chancre-like painless 1 cm ulcerative lesion, on a clear base with indurated borders at distal foreskin, no noted urethral discharge, testes/ NT no edema/masses Perianal: no lesions Skin No rash or trauma Neuro nl
Labs WBC 13 Hgb/Hct/plts nl 73% N 77 segs 10 monos no bands CMP/lipase nl UA 1.024 prot 100 RBC 241 WBC 2394 epi 4 bact none Urine tox + cannabinoids, meth, amph Hepatitis screen nl COV neg Bedside HIV 4th Gen Ag/AB neg Antitreponemal AB+ CT abd/pelvis Multiple retroperitoneal and B inguinal adenopathy (diff includes infectious, inflammatory vs malignant adenopathy. CCR. Hepatomegaly, s/p chole.
A/P 1. Abd pain/N/V/ leukocytosis- gastroenteritis-Rx IVF ondansetron, improving 2. Inguinal/RP lymphadenopathy-pt states lymph nodes were much bigger and have begun to resolve-infectious vs malignant- ? HIV f/u LAN bx if no improvement after abx, treating STI s 3. Pyuria/Purulent penile discharge-concern for CT/NG/trich given syphilis as below, will Rx for both multiple female sexual partners Rx IM Ceftriaxone 1 Gm x 1 in ED Rx Doxycycline 100mg PO BID x 7 days HIV AB pending
4. Primary syphilis- penile lesion c/w resolving chancre Rx Bicillin 2.4 million units IM in ED RPR pending 5. PSA + MJ, meth by snorting, denies IVDU ED course: ID consultation rec hospitalization and above Rx. Seen by hospitalist, rec blood cx, HIV RNA, but left AMA to meet his girl coming in from out of town after above meds and before these rec tests could be drawn.
Labs resulted after ED visit: Urine Cx neg HIV AB neg CT/GC + CT/+GC RPR reactive, 1:64
