Clinicopathologic Case

Conference
PRESCILLA DIANA MONTANCES
CIELO PELIGRINO
Department of Family Medicine
Chong Hua Hospital
Cebu City
Objectives
To discuss the proper way of doing
physical examination of a patient with
kidney disease

To be able to discuss a case about
nephrolithiasis .
General Data
Y. M.
31 years old
Male
Married
Korean
M. J. Cuenco Avenue, Cebu City


3 weeks
PTA
Patient started drinking protein supplements, 2 bottles
per day for body building.
Morning
PTA
He had a sudden onset of colicky flank pain on both
sides with a pain scale of 8/10, radiating to the
periumbilical 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
Past Medical History
Non-hypertensive, Non-asthmatic, Non-Diabetic
2004- Hospitalized in Korea due to flank pain
No previous Surgeries


Family History
Paternal side: Diabetes, Hypertension
Maternal Side: Hypertension
No Bronchial Asthma, No CAD, No Cancer
No other heredofamilial diseases
Personal and Social History
He is a known smoker for 5 pack years
He is an occasional alcoholic beverage drinker
consuming 2 bottles per session.
No known Food and Drug Allergies




Review of Systems
Skin: No pruritus
HEENT: No Headache, No blurring of Vision, No Sore
throat
Respiratory System: No cough, no dyspnea
Cardiovascular System: No chest pain, no palpitations
GIT: no abdominal pain , no nausea and vomiting
GUT: flank pain, dysuria, hematuria, oliguria
Extremities: body weakness

Physical Examination
Awake, conscious,coherent, cooperative
V/S:
BP- 130/90mmHg
Temp- 36.2 C
PR- 70 bpm
RR- 20 cpm
Wt: 72 kg; Ht- 158 cm
BMI: 28.8
Physical Examination
Skin: No lesions, smooth texture, warm, good mobility
and turgor
HEENT: normocephalic,PERRLA, Neck- supple, no
lymphadenopathy, 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


Costovertebral Angle
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 and
to identify possible masses that are solid or fluid filled

PALPATION
Light Palpation - identify abdominal tenderness, muscular
resistance, and some superficial organs and masses.
Deep Palpation.
- delineate abdominal masses
The Kidneys
Palpation of the Left Kidney

Move to the patients left side.
Place your right hand behind the patient just below and
parallel to the 12th rib, with your fingertips just reaching
the 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.

Palpation of the Left Kidney

At the peak of inspiration, press your left hand firmly and
deeply into the left upper quadrant, just below the costal
margin, and try to capture the kidney between your two
hands.
Ask the patient to breathe out and then to stop breathing
briefly.

Slowly release the pressure of your left hand, feeling at
the same time for the kidney to slide back into its
expiratory position.

A normal left kidney is rarely palpable.

Palpation of the Right Kidney.

To capture the right kidney,
return to the patients right side.
Use your left hand to lift from in
back, and your right hand to
feel deep in the left upper
quadrant.
Proceed as before.

A normal right kidney may be
palpable, especially in thin, well-
relaxed women.
ASSESSING COSTOVERTEBRAL ANGLE
TENDERNESS
Pressure from your fingertips may
be enough to elicit tenderness, but
if not, use fist percussion.

Place the ball of one hand in the
costovertebral angle and strike it
with the ulnar surface of your fist.

Use enough force to cause a
perceptible but painless jar or thud
in a normal person.
Physical Examination
Abdomen:
flat, active bowel sounds ,soft and nontender;
no masses or hepatosplenomegaly (-) tenderness
GUT: (-) Kidney punch sign
Musculoskeletal: (-) fracture
Extremities:
No edema
Capillary refill time < 2 seconds



Physical Examination
I- Mental Status Exam: Alert, Conscious, Coherent
II- Cranial Nerve Exam:
CN I- intact
CN II- intact, Pupil- reactive
CN III, IV, VI- full range EOM
CN V- Intact, Corneal Reflex- Present
CN VII- Symmetric, Can crease forehead, (-) nasolabial
flattening
CN VIII- able to hear whispered voice
CN IX, X- Gag reflex- Intact
CN XI- Able to shrug Shoulder
CN XII- Tongue midline at rest and with protrusion




Physical Examination
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, temperature
sensations


V- Motor



V- Reflexes
Primary Impression
Nephrolithiasis
DIFFERENTIAL DIAGNOSIS
Acute Cholecystitis
Acute Appendicitis
Acute Pancreatitis
KUB Ultrasound
Relative increase in renal parenchymal echogenicity
which may relate to :
1. Normal variance or UTI (40%)
2. Early, nonspecific medical renal disease (60%)
- Low density (uric acid, oxalate, xanthine or matrix
calculi, both kidneys, non-obstructing at
present.
- Non-ectatic ureters
- Structurally unremarkable urinary bladder but with
significant amount of post void residual urine
89.9ml (N= <60ml)
CBC
WBC 14.86
Hgb 17.2
Hct 51.9
Plt 179
Differential Count:
S 83.8
L 8.4
M 6
E 0.9
B 0.2
Urinalysis
Yellow, cloudy
pH 8.0
0Sp.gr. 1.025



Chemical Characteristics

Protein
Result
30
Reference Range
negative
Glucose negative negative
Ketone Negative Negative
Urobilinogen 2 Up to 2
Leukocyte 25 negative
Blood/hb 250 negative
Bilirubin negative negative
Nitrite negative negative
Urinalysis

Microscopic Findings
Result Reference Range
Red blood cell 3829 0-11
White blood cell 78 0-11
Bacteria 170 0-111
Squamous
Epithelial cells
13 0-11
Cast 0 0-1
Chemistry Result Reference
BUN 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
Nephrolithiasis
One of the most common urological problems
~13% of men and 7% of women will develop
a kidney stone during their lifetime with
increasing prevalence
Types of stones:
1. Calcium stones
2. Uric acid stones
3. Cystine stones
4. Struvite stones
Calcium stones
More common in men
3
rd
- 4
th
decade - average age of onset
~50% first time stone formers will form
another within 10 year
1 stone every 2-3 years
Average rate of new stone formation in recurrent
stone formers

Uric acid stones
- 5-10% of kidney stones
- common in men
- of patients with uric stones have gout
- usually familial whether or not gout is
present
Cystine Stones
Uncommon
Comprising ~1% of cases in most series of
nephrolithiasis

Struvite Stones
Common
Potentially dangerous
Occur mainly in women or patients who
require chronic bladder catheterization and
result from UTI with urease-producing
bacteria Proteus sp.
Can grow to large size and fill renal pelvis
and calyces staghorn appearance
Manifestations of Stones
Usually asymtomatic and is usually an
incidental finding
A common cause of isolated hematuria
DDx: benign and malignant neoplasm and
renal cysts
Only become symptomatic when stones
enter the ureter or occlude the UPJ, UVJ
and pelvic brim pain and obstruction
Passage of Stone

Passage of Stone
Pain may remain in flank or spread
downward and anteriorly toward the
ipsilateral loin, testes or vulva
Frequency, urgency and dysuria
Presence of stone in the portion of
The ureter within bladder wall
May be confused with UTI
Majority of ureteral stones
<0.5cm will pass spontaneously
Pathogenesis of Stones




Thank you