A 56-year-old male anatomy professor at a well-known university in North Hollywo

Question

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: What would be the clinical diagnosis in this patient? Please explain in detail the pathogenesis of this disease. What are the clinical manifestations: signs, symptoms of this particular disease? Discuss and explain the results of the CBC, serum uric acid, and urinalysis. 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. 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? 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? What are the possible treatment options both medical and surgical for this particular patient? Describe in detail the possible nursing intervention, especially with regards to diet and fluid intake.

Explanation / Answer

The clinical diagnosis in this patient would be KIDNEY STONE (NEPHROLITHIASIS). The symptoms of pain in right flank, tenderness in right flank, red color urine, nausea, high blood pressure, high heart rate, history of gout, uric acid test, KUB Xray, MRI scan points towards diagnosis of KIDNEY STONES.

PATHOGENESIS: Since the patient had Gout( condition with high serum uric acid levels), the Uric acid crystals was formed in kidney which developed into larger kidney stones in due course of time due to supersaturation of urine. There can be Other stones also like calcium oxalate, struvite stones, cysteine stones.

Clinical Manifestations: Pain and tenderness at the flank area, fever, chills, blood in urine, cloudy and foul smelling urine, nausea and vomiting, urgent need of urination, urinating in less amount, pain or burning during urination.

CBC gives information about RBC, WBC & PLATELETS. WBC count increases during infections. Due to kidney stone there can be case of urinary tract infection due to which WBC count can rise to fight the infection caused by bacteria. Serum uric acid test done here gives levels of uric acid in blood serum. If it is high then chances of forming kidney stone is more and there is also a chance of gout. Urinalysis is done here to see infection in urine, urine ph, creatinine levels, uric acid levels, levels of calcium, oxalate, citrate, phosphate, cysteine.

KUB X-ray and MRI scan shows deposition of stones.

Patient has a history of GOUT. In such condition there is high levels of serum uric acid and this high serum uric acid leads to formation uric acid crystals which forms stones. The kidney stones can be uric acid stones.

Medical treatment option: Medicines to dissolve the type of kidney stones, for example, allopurinol, citrates(sodium citrate), alkalizing agents( d- pencillamine), ursodeoxycholic acids, diuretics(thiazide type, furosemide), pain reliever (acetaminophen, Ibuprofen).

Surgical treatment: Shock wave lithotripsy, Ureteroscopy, Percutaneous nephrolithotripsy, Percutaneous nephrolithotomy, open surgery.

Nursing Intervention: Diet: Limit protein in diet, avoid red meat(leads to uric acid formation), limit salt intake, avoid mushroom, cauliflower, spinach, eat low fat diet.

Fluid: Drink lot of water which can aid in stone removal, Drink orange and lemon juices because citric acid in such juices help to dissolve the stone.

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