neprolith1.ppt

8/11/2019 neprolith1.ppt

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Clinicopathologic CaseConference

PRESCILLA DIANA MONTANCESCIELO PELIGRINO

Department of Family MedicineChong Hua Hospital

Cebu City


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Objectives

To discuss the proper way of doingphysical examination of a patient with

kidney disease

To be able to discuss a case about

nephrolithiasis .


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General Data

Y. M. 31 years old

Male Married Korean

M. J. Cuenco Avenue, Cebu City


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3 weeksPTA

Patient started drinking protein supplements, 2 bottlesper day for body building.

MorningPTA

He had a sudden onset of colicky flank pain on bothsides with a pain scale of 8/10, radiating to theperiumbilical area, no anorexia, no vomiting, no fever.

He also noted hematuria, dysuria and oliguria. No medications taken. Persistence of the condition prompted consult and

was subsequently admitted.

History of Present Illness


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Family History

Paternal side: Diabetes, HypertensionMaternal Side: HypertensionNo Bronchial Asthma, No CAD, No CancerNo other heredofamilial diseases


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Personal and Social History

He is a known smoker for 5 pack yearsHe is an occasional alcoholic beverage drinkerconsuming 2 bottles per session.

No known Food and Drug Allergies


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Review of Systems

Skin: No pruritusHEENT: No Headache, No blurring of Vision, No Sorethroat

Respiratory System: No cough, no dyspneaCardiovascular System: No chest pain, no palpitationsGIT: no abdominal pain , no nausea and vomitingGUT: flank pain, dysuria, hematuria, oliguria

Extremities: body weakness


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Physical Examination

Awake, conscious,coherent, cooperativeV/S:

BP- 130/90mmHgTemp- 36.2 CPR- 70 bpmRR- 20 cpm

Wt: 72 kg; Ht- 158 cmBMI: 28.8


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Skin: No lesions, smooth texture, warm, good mobilityand turgor

HEENT: normocephalic,PERRLA, Neck- supple, nolymphadenopathy, Thyroid- no enlargement

Chest and Lungs:No deformity, Equal Chest Expansion, Clear Breath

Sounds,(-) rhonchi, (-) wheeze, (-) crackles

Heart: Adynamic precordium, PMI at 5th ICS MCL;

Distinct Heart Sound, no Murmurs


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Costovertebral Angle


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The Abdomen INSPECTION

-note for Scars, Striae, contour of the abdomen ( flat, rounded,protuberant, distended or scaphoid)

AUSCULTATION-Listen for bowel sounds and bruit

PERCUSSION-assess the amount and distribution of gas in the abdomen andto identify possible masses that are solid or fluid filled

PALPATIONLight Palpation - identify abdominal tenderness, muscular

resistance, and some superficial organs and masses.Deep Palpation.- delineate abdominal masses


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The Kidneys

Palpat ion of th e Lef t K idney

Move to the patients left side.

Place your right hand behind the patient just below andparallel to the 12th rib, with your fingertips just reachingthe costovertebral angle.Lift, trying to displace the kidney anteriorly.

Place your left hand gently in the left upper quadrant,lateral and parallel to the rectus muscle. Ask the patient to take a deep breath.


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Palpat io n o f the L ef t Kid n ey

At the peak of inspiration, press your left hand firmly anddeeply into the left upper quadrant, just below the costalmargin, and try to capture the kidney between your twohands.

Ask the patient to breathe out and then to stop breathingbriefly.

Slowly release the pressure of your left hand, feeling at

the same time for the kidney to slide back into itsexpiratory position.

A normal left kidney is rarely palpable.


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Palpat ion of th e Righ t Kid ney.

To capture the right kidney,return to the patients right side.Use your left hand to lift from inback, and your right hand to

feel deep in the left upperquadrant.Proceed as before.

A normal right kidney may bepalpable, especially in thin, well-relaxed women.


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ASSESSING COSTOVERTEBRAL ANGLETENDERNESS

Pressure from your fingertips maybe enough to elicit tenderness, butif not, use fist percussion.

Place the ball of one hand in thecostovertebral angle and strike itwith the ulnar surface of your fist.

Use enough force to cause a

perceptible but painless jar or thudin a normal person.


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Abdomen:flat, active bowel sounds ,soft and nontender;no masses or hepatosplenomegaly (-) tenderness

GUT: (-) Kidney punch signMusculoskeletal: (-) fractureExtremities:

No edema

Capillary refill time < 2 seconds


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Physical ExaminationI- Mental Status Exam: Alert, Conscious, CoherentII- Cranial Nerve Exam:

CN I- intactCN II- intact, Pupil- reactive

CN III, IV, VI- full range EOMCN V- Intact, Corneal Reflex- PresentCN VII- Symmetric, Can crease forehead, (-) nasolabialflatteningCN VIII- able to hear whispered voiceCN IX, X- Gag reflex- IntactCN XI- Able to shrug ShoulderCN XII- Tongue midline at rest and with protrusion


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III- Cerebellar : can do finger-to-nose test,pronation-supination test, heel-knee-shin test, (-)Rombergs, ( -) tandem walk, wide-based walking

IV- Sensory: Intact light touch, pain, temperaturesensations


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V- Motor

V- Reflexes


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Primary Impression

Nephrolithiasis


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DIFFERENTIAL DIAGNOSIS

Acute Cholecystitis Acute Appendicitis

Acute Pancreatitis


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KUB UltrasoundRelative increase in renal parenchymal echogenicitywhich may relate to :

1. Normal variance or UTI (40%)2. Early, nonspecific medical renal disease (60%)

- Low density (uric acid, oxalate, xanthine or matrixcalculi, both kidneys, non-obstructing atpresent .

- Non-ectatic ureters- Structurally unremarkable urinary bladder but with

significant amount of post void residual urine89.9ml (N=


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CBCWBC 14.86Hgb 17.2

Hct 51.9Plt 179Differential Count:

S 83.8

L 8.4M 6E 0.9B 0.2


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UrinalysisYellow, cloudypH 8.00Sp.gr. 1.025Chemical Characteristics

ProteinResult30

Reference Rangenegative

Glucose negative negative

Ketone Negative Negative

Urobilinogen 2 Up to 2Leukocyte 25 negative

Blood/hb 250 negative

Bilirubin negative negative

Nitrite negative negative


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Urinalysis

Microscopic Findings

Result Reference RangeRed blood cell 3829 0-11

White blood cell 78 0-11

Bacteria 170 0-111

SquamousEpithelial cells

13 0-11

Cast 0 0-1


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Chemistry Result ReferenceBUN 12.8 7-18

crea 1.3 0.6-1.5

sodium 140 134-148

potassium 3.8 3.3-5.3

Uric acid 7.3 3-8

Total Calcium 9.1 8.4-10.4


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Nephrolithiasis

One of the most common urological problems~13% of men and 7% of women will developa kidney stone during their lifetime withincreasing prevalenceTypes of stones:1. Calcium stones

2. Uric acid stones3. Cystine stones4. Struvite stones


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Calcium stones

More common in men3 rd- 4 th decade - average age of onset~50% first time stone formers will formanother within 10 year1 stone every 2-3 years

Average rate of new stone formation in recurrentstone formers


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Uric acid stones

- 5-10% of kidney stones- common in men

- of patients with uric stones have gout- usually familial whether or not gout ispresent


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Cystine Stones

UncommonComprising ~1% of cases in most series ofnephrolithiasis


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Struvite Stones

CommonPotentially dangerous

Occur mainly in women or patients whorequire chronic bladder catheterization andresult from UTI with urease-producingbacteria Proteus sp.Can grow to large size and fill renal pelvisand calyces staghorn appearance


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Manifestations of Stones

Usually asymtomatic and is usually anincidental finding

A common cause of isolated hematuriaDDx: benign and malignant neoplasm andrenal cysts

Only become symptomatic when stonesenter the ureter or occlude the UPJ, UVJand pelvic brim pain and obstruction


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Passage of Stone


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Passage of Stone

Pain may remain in flank or spreaddownward and anteriorly toward theipsilateral loin, testes or vulva

Frequency, urgency and dysuriaPresence of stone in the portion of

The ureter within bladder wall

May be confused with UTIMajority of ureteral stones


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Pathogenesis of Stones


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