Urology Case Study Example

CONSULTATION

Apparently this patient presented to the emergency room last night about midnight with excruciating left flank pain radiating down into the left groin and testicle, chills, nausea, vomiting, and slight urinary burning, all of about 2 hours’ duration, and a stat urine in the ER showed 60 to 80 red cells.  Apparently he was given Stadol 2 mg IM for analgesia and some IV fluids, and he had an emergency IVP run which showed a radiopaque stone measuring about 0.5 cm partially blocking the left ureter at a point about 3 cm below the UP junction.  There was moderate hydronephrosis without appreciable dilatation of the caliceal system, and some dye was getting down into the distal ureter.  I have reviewed these films, and they show normal urinary tract anatomy on the right and on the left, except as noted.

When I examined him about 10 a.m., he was still in considerable distress, although noticeably obtunded by a dose of Demerol given about one-half hour prior to my visit.  He was sufficiently alert, however, to give a good clear history.  Apparently this man has had 2 previous episodes of left-sided ureteral colic followed by spontaneous passage of stones, once while on military service in Turkey and once since then, but on neither occasion were the stones preserved for analysis.

His general health is good, and he takes no medicine.  He has never had a urinary tract infection.  There is no known family history of renal lithiasis, gout, or bone or joint disease.  However, he is adopted.  He is 41 years of age, married, with
2 daughters, and is employed as a manager of a bowling alley.

EXAMINATION

Temperature is 99.2, pulse 100, blood pressure 150/80.  Physical examination is quite benign except that he is pale, sweating, restless, and in considerable distress and tender at the left CVA and in the left upper quadrant over the kidney and ureter.  External genital examination is unremarkable.  I did not attempt to do a rectal examination as he has an IV running, even though he is now taking oral fluids and he is not nauseated.  He is voiding painlessly, and his urine is being strained.  I did not see his urine, but according to the patient and the attendant, it is not grossly bloody.

DIAGNOSIS

Left ureterolithiasis with partial ureteral obstruction and hydronephrosis.

RECOMMENDATIONS

1. Continue analgesia and hydration.

2. Continue straining urine and preserve any solid material passed for chemical analysis.

3. Clean-voided midstream urine for culture and sensitivity.

4. After this had been obtained, start Cipro 500 mg q.12h. orally.

5. He is now about 12 hours post onset of symptoms, but there is still a good statistical chance that he will pass his stone spontaneously.  We are going to get another IVP at 4 p.m., and if he is still obstructed, I think we had better attempt to bring this stone down with a snare before he gets enough local edema to obstruct completely or gets into trouble with a red-hot ascending pyelonephritis.

6. In any event, he needs a biochemical diagnosis of his problem, and depending on that, he may need dietary or drug prophylaxis against future calculus disease.

Thank you for the privilege of collaborating in the care of this patient.

FOOTNOTE

Line 11 (Page 1).  Alternative:  60-80.

Lines 12, 42 (Page 1).  Alternative:  I.M., I.V.

Line 14 (Page 1).  Decimals rather than fractions are used with metric measurements.  A zero is placed before the decimal point in measurements of less than 1 for clarity.  One-half centimeter is written as 0.5 cm.

Line 37 (Page 1).  Temp was expanded to temperature.