Question

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

CLINICAL DIAGNOSIS:

This patient can be diagnosed as RIGHT RENAL CALCULI.

Renal calculi or kidney stones are solid masses made of crystals. It can be present in kidneys, ureter, bladder, urethra.

This patient has right flank pain , the kidneys are situated in the flank region . So the stone is in the kidney. Renal calculi is the most painful medical condition.

Pathophysiology: There are various types of kidney stones. In this patient it is uric acid stones because this patient is having the history of gout. Uric acid stones can occur in people with gout or those undergoing chemotherapy. And also this type of stones more common in men than in women.

Risk factors: includes,

1. age, sex, race

2. dehydration

3. obesity

4. diet with high levels of protein, salt or glucose

5. medications such as diuretics, calcium based antacids.

SIGNS AND SYMPTOMS:

1. severe pain

2. hematuria

3.nausea and vomiting

4. chills and fever

5. frequent need to urinate small amount of urine.

COMPLICATIONS:

Urinary destruction leads to kidney infection and kidney damage.

TREATMENT:

Medical:

1. Allopurinol for uric acid stones.

2. Sodium bicarbonate or sodium citrate to make the urine less acidic.

Surgical:

1.Lithotripsy

2. Tunnel surgery

NURSING INTERVENTIONS:

1. Collect complete history of the patient .

2. Physical assessment should be done

3. maintain interpersonel relationship with the patient

4. Educate the patient about his condition.

5. Administer intravenous fluid to prevent dehydration

6. provide 6- 8 glass of water

7. educate about the importance of water

8. describe about low purine diet

9. ask to take oxalate rich foods

10. administer medications.

11. Inform physician about patient's condition.