Question

Exams ordered Results CBC with WBC differential count Urinalysis CBC within normal limits with no leukocytosis nor anemia RBCs too numerous to count No pus cells (+) uric acid crystals Slightly elevated Serum uric acid KUB (kidney ureter bladder) plain x-ray (radiograph) Abdominal Coronal MRI scan Abdominal Axial MRI Scan

Case Report:

A 56-year-old male anatomy professor at a well-known university in North Hollywood was brought to the emergency room at the UCLA Ronald Reagan Medical Center. His chief complaint was right flank pain.

History of present Illness:

One day prior to admission, the patient developed a change in the color of his urine from pale yellow to red in color. There was no associated fever, painful urination, or penile discharge. He decided to consult with his primary physician the following day.

One hour prior to admission, the patient developed severe right flank pain associated with nausea. His wife was brought him to the UCLA Ronald Reagan Medical Center. Upon admission, the patient was noted by the ER physician to be in severe pain, with a pain scale of 9 from a visual analog pain scale from 1 to 10. On physical exam, patient had the following findings:

• Vital Signs BP: 140/90
• Heart rate: 110/minute
• Respiration rate: 15/minute patient was afebrile
• All exam findings for the head, neck, heart, lungs, and abdomen were normal.
• On examination of the back, patient had tenderness on the right flank upon palpation.
• On examination of the genitalia, there was no penile discharge.
• Note of a 1 x 1 cm tophus on right big toe.

The following diagnostic exams were ordered:

• CBC with WBC differential count
• Urinalysis
• Serum uric acid
• KUB x-ray
• MRI Scan abdominopelvic area

He was immediately injected by IV with a strong analgesic to relieve the pain.

Past Medical History:

• Diagnosed with gout one year prior to admission
• On medication with allopurinol
• No heart and lung disease
• No diabetes or hypertension

Click here to review the results of the diagnostic exam.

Questions and topics for discussion:

1. What would be the clinical diagnosis in this patient? Please explain in detail the pathogenesis of this disease.
2. What are the clinical manifestations: signs, symptoms of this particular disease?
3. Discuss and explain the results of the CBC, serum uric acid, and urinalysis.
4. What do you see in the plain KUB and the coronal MRI scan of the abdomen where the 2 upper arrows are located? Identify this particular lesion, where is it located, and the specific organs involved.
5. Review the patient’s medical history. With this in mind, what is the specific type of lesion that you should expect to see and why?
6. On the axial scan of the abdomen, what is the organ pointed to by the three arrows? Is there anything wrong with this organ? If you answered yes, please explain in detail. What is a possible complication in this patient and the possible effect on the function of this organ in the long term?
7. What are the possible treatment options both medical and surgical for this particular patient?
8. Describe in detail the possible nursing intervention, especially with regards to diet and fluid intake.

Answer 1

Q.What would be the clinical diagnosis in this patient? Please explain in detail the pathogenesis of this disease.

A.The diagnosis is nephrolithiasis.(stone in right ureter) Urinary tract stone is usually caused by two thingsThe first phenomenon is supersaturation of the urine by stone-forming constituents, like calcium, uric acid. Crystals or foreign bodies can act as nidus, upon which ions from the supersaturated urine form microscopic crystalline structures. The resulting calculi give rise to symptoms due to occlusion or tissue damage when they become impacted within the ureter as they pass toward the urinary bladder. Majority of renal calculi contain calcium

What are the clinical manifestations: signs, symptoms of this particular disease?

Patient will experience acute abrupt sometimes severe pain in the flank,(Renal colic)Along with that infection and haematuria also may present.The pain refers to inferiorly and anteriorly.half of the patients have nausea and vomiting.

Discuss and explain the results of the CBC, serum uric acid, and urinalysis.

CBC in case of infection the total leukocyte count may increase or leucocytosis or neutropenia indicating as surrogate marker for infection in absence of fever or hypothermia .moreover level of uric acid to know the present status after allopurinol treatment.And urine test will reveal if there is heamaturia or probable uti (pus cells and bacteria)

What do you see in the plain KUB and the coronal MRI scan of the abdomen where the 2 upper arrows are located? Identify this particular lesion, where is it located, and the specific organs involved.

The image shows calcified stone (radioopaque ). presumably calcium stone located in the middle part of right ureter.Specific organ involved is right kidney (if obstruction /infection is there) and right ureter.

Q.Review the patient’s medical history. With this in mind, what is the specific type of lesion that you should expect to see and why?

Majority uric acid stone former in nephrolithiasis are associated with metabolic disease and also frequently gout(tophi), metabolic disease and Low or acidic pH . here patient is on allopurinol , to combat high uric acid level.

So we can expect here urate stone.