Clinicopathologic Case

Department of Family Medicine
Chong Hua Hospital
Cebu City
 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
• Patient started drinking protein supplements, 2 bottles
per day for body building.
• 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
 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
(-) rhonchi, (-) wheeze, (-) crackles

 Heart: Adynamic precordium, PMI at 5th ICS MCL;
Distinct Heart Sound, no Murmurs

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

-Listen for bowel sounds and bruit
-assess the amount and distribution of gas in the abdomen and
to identify possible masses that are solid or fluid filled

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 patient’s 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
 Ask the patient to breathe out and then to stop breathing

 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 patient’s right side.
 Use your left hand to lift from in
back, and your right hand to
feel deep in the left upper
 Proceed as before.

A normal right kidney may be
palpable, especially in thin, well-
relaxed women.
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
 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, (-)
Romberg’s, (-) tandem walk, wide-based walking
 IV- Sensory: Intact light touch, pain, temperature

 V- Motor

 V- Reflexes
Primary Impression
 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
- Non-ectatic ureters
- Structurally unremarkable urinary bladder but with
significant amount of post void residual urine
89.9ml (N= <60ml)
 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
 1.025

Chemical Characteristics

Reference Range
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
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
 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
- 4
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
- ½ of patients with uric stones have gout
- usually familial whether or not gout is
Cystine Stones
 Uncommon
 Comprising ~1% of cases in most series of

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 