Case Study: Sudden Severe Pain

Some of the more common causes of flank pain include:

• a kidney infection
• a kidney abscess
• kidney stones
• dehydration
• a bladder infection
• shingles
• Tietze’s syndrome
• arthritis, especially spinal arthritis
• a spinal fracture
• disc disease
• a pinched nerve in the back
• a muscle spasm

Less common causes of flank pain include:

• kidney disease
• pneumonia
• pancreatitis
• appendicitis
• a blockage in the urinary tract
• an inflammatory bowel disease, such as Crohn’s disease
• a renal infarct, which occurs when a blood clot blocks the blood supply to the kidney
• shingles
• an abdominal aortic aneurysm

Scroll down to see the answer!

I'm including lab results again with normal values for your reference:

Laboratory Test Results:

• Na 139 meg/L (135-145)
• K 4.2 meq/L (3.5-5)
• Cl 103 (101-112)
• Mg 2.0 mg/dL (1.8-3)
• PO4 2.8 mg/dL (2.5-4.5)
• Ca 10.1 mg/dL (8.5-10.5 high normal)
• Uric acid 6.2 mg/dL (2.4-7.4 for males)

24-Hr Urine Collection

• Volume 1, 300 mL (1-2 L/24 hrs)
• Calcium 182 mg (100-300 mg/24 hrs)
• Citrate 130 mg (287-708 mg/24 hrs)
• pH 6.2 (5.0-6.5)
• Specific gravity 1.034 (1.016-1.022)
• Protein, total 110 mg (<165 mg/24 hrs)

CT Scan:

• 6-mm radiopaque stone in right mid-ureter
• 1-mm radiopaque stone in inferior calyx of left kidney

Urinalysis:

• The patient provided a urine sample in the ER.
• Significant numbers of RBC and WBC found in Microscopic analysis of the specimen

Questions:

• In addition to male gender and white race, identify other risk factors that have contributed to the urinary stone.
• What clinical findings support that this is not a uric acid stone?

Here are the responses from members who came to the Admin Help Desk to submit their diagnoses for the 6th Case Study Investigation (CSI).

A DOUBLE THUMBS UP to those with the correct FINAL diagnosis!

 spotangel

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 Renal calculi

Susie2310

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 My initial thought is kidney stone.

beckysue920

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 I think the patient is passing a kidney stone.

NRSKarenRN

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 Renal Calculi/Kidney stones/Urolithiasis/Nephrolithiasis

DextersDisciple

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Not looking for a zebra: extreme exercise without adequate water consumption+dark urine+hx kidney stones+flank pain-fever+labs WNL= Renal calculi 

Once again, we thank all who participated and we hope you enjoyed the CSI.

COMING SOON:  CSI installment #7 ... 

 

One in 10 people in the US will have a kidney stone at some point in their lives. Men have a lifetime risk of 19% compared to women’s risk of 9%. 

Clinical Course:

The stone passed spontaneously within three hours and the patient was released. Stone analysis revealed that the primary component was calcium oxalate. The urologist ordered a blood Chemistry panel and a 24-hour urine collection test.

Treatment and recommendations: 

If the stones had not passed, extracorporeal shock wave lithotripsy (ESWL) could be done. Surgery is also an option, or removal with a scope. 

Patients should focus on increasing fluids in diet as well as limit foods that are high in oxalate, protein and salt. The patient should also reduce the amount of vitamin C consumed since Excess vitamin C is excreted from the body as oxalate, a bodily waste product that can increase the amount of oxalate in the urine.

Foods high in oxalate: Spinach, leafy green vegetables, rhubarb, almonds, beets, navy beans, chocolate, okra, potatoes, nuts and seeds, soy products, tea, strawberries and raspberries.

Also be aware that gamma globulins can be nephrotoxic – their impact on the kidneys may have implications in D.C.’s future.

Medications:

To prevent calcium stones, thiazide diuretics or phosphate-containing preparation. Allopurinol is only useful for uric acid stones. For uric acid stones, an alkalinizing agent may help prevent uric acid stones.

Citrate is a powerful force in preventing calcium stones and D. C. has very low citrate, so adding potassium citrate pills would be helpful.

Answers to questions:

Risk factors for kidney stones:

• Increased levels of vitamin C
• Dehydration from running extra miles, not drinking enough, difficulty swallowing
• Personal history of kidney stones

Symptoms of kidney stones no matter the type include blood in the urine, urine that smells bad or is cloudy. Pain is often in the lower back, sides, abdomen or groin due to blockage inside the kidneys. They are often accompanied by fever and chills as well as nausea and vomiting. 

A uric acid stone would come with a high uric acid level, and D.C. has a normal uric acid level

The high pH of the urine and the low citrate levels are consistent with calcium oxalate stones. 

References

• Merck Manual Professional Version, Urinary Calculi: https://www.merckmanuals.com/professional/genitourinary-disorders/urinary-calculi/urinary-calculi
• Mayo Clinic Kidney Stones: https://www.mayoclinic.org/diseases-conditions/kidney-stones/symptoms-causes/syc-20355755