Clinical Case Homework

STUDENT:SHADY ABO HAMAD
GROUP:M1653
CLINICAL CASE
A 46-year-old male patient
Complaints: abnormal red urine color, visible for 2 days.
Medical history: The patient noticed a change in the color of the urine after eating red beet. The
patient was considered healthy prior to the onset of this symptoms. He had no any heart or liver
disorders before. An episode of red urine coloring occurred a year ago, the patient didn’t go to
the doctor.
Clinical examination: Skin is clean, pale pink. Edema is absent. Rhythmic, resonant heart
sounds. BP 120/80 mm / Hg, HR 79 b / min. Vesicular murmurs are heard on the entire lung
surface, rales are absent. The abdomen volume is enlarged due to adipose tissue; soft and
painless on palpation. Bilateral negative lumbar percussion.
Paraclinical examination:
Urinalysis: Color - red; relative density -1015; proteins are negative; small amount of flat
epithelium; leukocytes - 2-3 f/ v; erythrocytes - 15-20 f/ v , regular ; no casts were found.
Blood biochemistry: Total protein - 70g / l, creatinine - 60 mmol / l; urea - 5.8 mmol / l; glucose
- 4.8 mmol / l; cholesterol - 3.8 mmol / l; K - 4.0 mmol / l; Na - 132 mmol / l.
Renal USG: Kidneys are normally located, clearly outlined, normal thickness of renal
parenchyma. Both kidneys longitudinal dimensions are-12 cm, without hydronephrosis.
Deformation of the pelvicalyceal system. Echodense structure found in the right renal calyx.
Simple kidney X-ray: Staghorn calculi in the right kidney.
QUESTIONS
1. Make a presumptive diagnosis.
2. Justify on the presumptive diagnosis based on the symptoms / signs / syndromes described in
the clinical case study.
3. Name the additional clinical examinations / maneuvers necessary to confirm the diagnosis and
justify their use.
4. Indicate the necessary laboratory investigations to confirm the diagnosis and justify each of
them.
5. Indicate the instrumental investigations necessary to confirm the diagnosis and justify each of
them.
6. Make a differential diagnosis. Give arguments.
7. Make a definitive diagnosis. Give arguments.
8. Prescribe the therapeutic approach, drug and / or surgical treatment. Justify your answer.
9. Write the main drug prescription.
10. Outline the main messages in patient education / patient recovery strategy.
Answers
1.Diagnosis – kidney stones, acute renal failure
2. The presumptive diagnosis based on the symptoms
 Severe pain in the side and back, below the ribs

 Pain that radiates to the lower abdomen and groin
 Pain that comes in waves and fluctuates in intensity
 Pain on urination
 Pink, red or brown urine
 Urinating small amounts
3. Additional clinical examinations:
 Radiologic studies
 Ultrasound
 CT scan
 Nuclear medicine
 Retrograde pyelography
 Anterograde nephrostonegrams
Imaging. Imaging tests may show kidney stones in your urinary tract. Options range from
simple abdominal X-rays, which can miss small kidney stones, to high-speed or dual energy
computerized tomography (CT) that may reveal even tiny stones.
Other imaging options include an ultrasound, a noninvasive test, and intravenous urography,
which involves injecting dye into an arm vein and taking X-rays (intravenous pyelogram) or
obtaining CT images (CT urogram) as the dye travels through your kidneys and bladder.
4. The necessary laboratory investigations to confirm the diagnosis
 Blood testing. Blood tests may reveal too much calcium or uric acid in your blood.
Blood test results help monitor the health of your kidneys and may lead your doctor to
check for other medical conditions.
 Urine testing. The 24-hour urine collection test may show that you're excreting too many
stone-forming minerals or too few stone-preventing substances. For this test, your doctor
may request that you perform two urine collections over two consecutive days.
 Analysis of passed stones. You may be asked to urinate through a strainer to catch
stones that you pass. Lab analysis will reveal the makeup of your kidney stones. Your
doctor uses this information to determine what's causing your kidney stones and to form a
plan to prevent more kidney stones.
5. The instrumental investigations necessary to confirm the diagnosis
 Radiologic studies
 Ultrasound
 CT scan
The patient have symptoms that suggest a kidney stone, special X-rays or scans of the kidneys
and the tubes (the ureters) draining urine from the kidneys may be done. These tests may start
with an X-ray and ultrasound scan. A CT scan may also be needed. These tests are used to detect
a stone, to find out exactly where it is and to check that a stone is not blocking the flow of urine.
6. Differential diagnosis
 The diagnosis and initial management of urolithiasis have undergone considerable
evolution in recent years. The application of non-contrast helical computed tomography
(CT) in patients with suspected renal colic is one major advance. The superior sensitivity
and specificity of helical CT allow urolithiasis to be diagnosed or excluded definitively
and expeditiously without the potential harmful effects of contrast media. Initial
management is based on three key concepts: (1) the recognition of urgent and emergency
requirements for urologic consultation, (2) the provision of effective pain control using a
combination of narcotics and nonsteroidal anti-inflammatory drugs in appropriate
patients and (3) an understanding of the impact of stone location and size on natural
history and definitive urologic management.
 Urolithiasis should always be considered in the differential diagnosis of abdominal pain.
The classic presentation of renal colic is excruciating unilateral flank or lower abdominal
pain of sudden onset that is not related to any precipitating event and is not relieved by
postural changes or nonnarcotic medications. With the exception of nausea and vomiting
secondary to stimulation of the celiac plexus, gastrointestinal symptoms are usually
absent.
 The pain of renal colic often begins as vague flank pain. Patients frequently dismiss this
pain until it evolves into waves of severe pain. It is generally believed that a stone must at
least partially obstruct the ureter to cause pain. The pain is commonly referred to the
lower abdomen and to the ipsilateral groin. As the stone progresses down the ureter, the
pain tends to migrate caudally and medially.
 Distal ureteral stones may be manifested by bladder instability, urinary frequency,
dysuria and/or pain radiating to the tip of the penis, or the labia or vulva. Increasingly,
however, calculi are encountered in asymptomatic patients and are found incidentally on
imaging studies or during the evaluation of microhematuria.
 Symptoms similar to those of renal colic can be caused by noncalculus conditions. In
women, gynecologic processes that must be considered include ovarian torsion, ovarian
cyst and ectopic pregnancy. In men, symptoms of testicular processes, such as a tumor,
epididymitis or prostatitis, may mimic the symptoms of distal ureteral stones.
 Other general causes of abdominal pain, such as appendicitis, cholecystitis, diverticulitis,
colitis, constipation, hernias or even arterial aneurysms, may elicit similar discomfort.
Symptoms mimicking those of urolithiasis also occur with urologic lesions such as
congenital ureteropelvic junction obstruction, renal or ureteral tumors, and other causes
of ureteral obstruction.
7. Definitive diagnosis –Kidney Stones
8+9. The therapeutic approach, drug and / or surgical treatment/drugs
Medication: Pain relief may require narcotic medications. The presence of infection requires
treatment with antibiotics. Other medications include:
 allopurinol (Zyloprim) for uric acid stones

 thiazide diuretics to prevent calcium stones from forming
 sodium bicarbonate or sodium citrate to make the urine less acidic
 phosphorus solutions to prevent calcium stones from forming
 ibuprofen (Advil) for pain
 acetaminophen (Tylenol) for pain
 naproxen sodium (Aleve) for pain
Lithotripsy
Extracorporeal shock wave lithotripsy uses sound waves to break up large stones so they
can more easily pass down the ureters into your bladder. This procedure can be
uncomfortable and may require light anesthesia. It can cause bruising on the abdomen
and back and bleeding around the kidney and nearby organs.
Tunnel surgery (percutaneous nephrolithotomy)
A surgeon removes the stones through a small incision in your back. A person may need this
procedure when:
 the stone causes obstruction and infection or is damaging the kidneys
 the stone has grown too large to pass
 pain can’t be managed
Ureteroscopy
When a stone is stuck in the ureter or bladder, your doctor may use an instrument called a
ureteroscope to remove it.
A small wire with a camera attached is inserted into the urethra and passed into the bladder. The
doctor then uses a small cage to snag the stone and remove it. The stone is then sent to the
laboratory for analysis.
10. The main messages in patient education
 Proper hydration is a key preventive measure. The doctor recommends drinking enough
water to pass about 2.6 quarts of urine each day. Increasing the amount of urine you pass
helps flush the kidneys.
 The patient can substitute ginger ale, lemon-lime soda, and fruit juice for water to help
you increase your fluid intake. If the stones are related to low citrate levels,
citrate juices could help prevent the formation of stones.
 Eating oxalate-rich foods in moderation and reducing your intake of salt and animal
proteins can also lower risk of kidney stones.
 Doctor may prescribe medications to help prevent the formation of calcium and uric acid
stones.

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STUDENT:SHADY ABO HAMAD

 Severe pain in the side and back, below the ribs

4. The necessary laboratory investigations to confirm the diagnosis

7. Definitive diagnosis –Kidney Stones

8+9. The therapeutic approach, drug and / or surgical treatment/drugs

 allopurinol (Zyloprim) for uric acid stones

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