Question

1. Henry is a 60 year-old, white college man who woke due to intense and worsening pain in his right flank this morning. He came to your emergency room in a state of distress, with diaphoresis (sweating) and pallor (pale appearance). He was unable to sit still or become comfortable in the ER cot, groaning and stating that he was nauseated. His past medical history includes diabetes, gout, and controlled hypertension. He takes medications for his diabetes, gout, and hypertension; he reports no difficulties in affording his medications and does not have difficulties in taking them as prescribed. His vital signs are as follows: temperature mildly elevated at 99.5℉, BP mildly elevated at 138/85, heart rate increased at 110, Respiratory rate normal at 20. His height is 5’9”, and his weight is 205 pounds; his BMI is 30.3

   • What two main diagnoses do you suspect for Henry? Provide supporting evidence using his clinical manifestations.
   • What risk factors does Henry have for the diagnoses you have chosen? List two risk factors for each diagnosis, and briefly explain how that increases an individual’s risk for that disease.
   • What tests do you suspect will be ordered to confirm Henry’s diagnosis, and what value do they add to confirming or excluding your chosen diagnoses? Include at least three tests.

Answer 1

• The 2 main diagnosis based on patient symptoms are:

1. renal calculi : renal calculi is the formation of stone in kidney. The stones are usually composed of calcium, uric acid or oxalate.
Symptoms like flank pain, high temperature(99.5F) and nausea indicates presence of renal calculi.
2. Pyelonephritis: it is the bacterial infection of kidney. This results in pain over the side of kidney involved, fever due to infection and nausea.
Acute flank pain on right side, nausea and fever seen in the patient support the diagnosis.
• The two risk factors that are associated with renal calculi are:

1. Gout : goit results in high levels of uric acid in blood. This uric acid accumulates in the kidney resulting in stone formation.
2. Diabetes : diabetes results in impaired perfusion of kidney. This causes ions like calcium, urate and oxalate to accumulate in the kidney resulting in stone formation.
Two risk factors associated with pyelonephritis are:

1. diabetes : diabetes causes impaired flow of blood to kidney as well as impaired renal perfusion with oxygen. This causes accumulation of toxins and metabolites in the kidney which serves as a favourable environment for bacterial growth and infection.
2. Hypertension: increased blood pressure results in impaired kidney functions. Constantly high levels of blood pressure results in impaired kidney perfusion. This results in accumulation of harmful substances in kidney resulting in infection of kidney.
• The three diagnostic tests include:

1. urinalysis

urine should be tested for presence of bacteria, WBC, RBC, leucocyte esterase test or nitrate test.
Presence of bacteria, wbc, rbc, positive leucocyte esterase test and nitrate test indicates pyelonephritis.
Crystals of calcium oxalate, urate or cystine indicate renal calculi.

2. Computed tomography

CT of the kidney involves looking for hemorrage, abscess, obstructions , inflammatory masses or infections. Renal calculi can also be seen on CT.
Presence of abscess or infection confirms pyelonephritis whereas presence of stones confirms renal calculi.

• ultrasonography of kidneys may reveal abscess, focal renal infection points or renal calculi.
Renal stones confirm renal calculi and presence of infectious foci in kidney parenchyma confirms pyelonephritis.