Give me a realistic case presentation with all the values for a patient with yretic calculus
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I now have rich clinical data from multiple authoritative textbooks. Let me compile the full realistic case presentation.
Case Presentation: Ureteric Calculus
Patient Demographics
Name: Mr. A.K.
Age: 38 years
Sex: Male
Occupation: Software engineer (sedentary work)
BMI: 27.4 kg/m²
Presenting to: Emergency Department
Chief Complaint
Severe, sudden-onset right flank pain radiating to the right groin and testis for the past 6 hours.
History of Presenting Illness
Mr. A.K. was in his usual state of health when he developed a sudden-onset, severe, crampy pain in the right loin at 10:00 PM. The pain was colicky in nature, coming in waves, and was 9/10 in severity at its peak. It radiated from the right costovertebral angle anteriorly and downward toward the right iliac fossa, then to the right groin and right testis. The patient was unable to find any comfortable position - he was found writhing on the examination table. There was no posture that relieved the pain.
Associated symptoms included:
- Profuse diaphoresis
- Nausea and two episodes of non-bilious vomiting
- Mild dysuria and urinary frequency in the last hour (as the stone migrated distally)
- Gross hematuria noticed on voiding - patient described "pinkish-red urine"
- Right testicular retraction
He denies fever, chills, or rigors. No diarrhea. No trauma. Last bowel movement was normal.
Past History:
- One similar episode 2 years ago (right kidney stone, 4 mm, passed spontaneously)
- No known hypertension or diabetes
- No prior urological procedures or stents
Family History: Father had kidney stones at age 45.
Dietary History: Low fluid intake (~1 L/day), high protein diet (frequent red meat), high oxalate foods (spinach, nuts), low calcium diet (avoids dairy under mistaken belief it worsens stones).
Medications: None regular. Takes NSAIDs occasionally for back pain.
Allergies: No known drug allergies.
Physical Examination
| Parameter | Value |
|---|---|
| Temperature | 37.2°C (98.9°F) |
| Heart Rate | 104 bpm (tachycardia - adrenergic response to pain) |
| Blood Pressure | 148/90 mmHg (pain-driven hypertension) |
| Respiratory Rate | 18 breaths/min |
| SpO₂ | 99% on room air |
| GCS | 15/15 - fully alert and oriented |
General: Patient is diaphoretic, agitated, writhing in pain. Cannot find a comfortable position. No jaundice, cyanosis, or pallor.
Abdomen:
- Soft, non-distended
- Tenderness at right costovertebral angle (CVA tenderness ++)
- Mild right flank/iliac fossa guarding (+)
- Rebound tenderness: mild at right lower quadrant
- No palpable kidney mass or lump
- Bowel sounds: mildly reduced (reflex ileus)
- Murphy's sign: negative
Genitalia: Right testis retracted superiorly (cremaster spasm from genitofemoral nerve irritation). No scrotal swelling or tenderness on palpation of the testis itself.
Rectal Exam: Not performed acutely (stone not yet at intramural ureter level based on pain location).
Investigations
Urinalysis (Dipstick + Microscopy)
| Parameter | Value | Reference |
|---|---|---|
| Color | Pink-red (gross hematuria) | Yellow |
| Clarity | Turbid | Clear |
| pH | 5.8 | 4.5-8.0 |
| Specific Gravity | 1.028 | 1.005-1.030 |
| Blood (dipstick) | +++ | Negative |
| RBCs (microscopy) | 45-50 RBCs/HPF | 0-2 /HPF |
| WBCs | 8-10 WBCs/HPF | 0-5 /HPF |
| Protein | Trace | Negative |
| Glucose | Negative | Negative |
| Nitrites | Negative | Negative |
| Leukocyte esterase | Negative | Negative |
| Crystals | Calcium oxalate crystals (envelope-shaped) | None |
| Casts | Occasional RBC casts | None |
| Culture | Sent (negative at 48h) | Sterile |
Note: Hematuria may be absent if the ureter is completely obstructed. The absence of hematuria does not exclude a stone. - Harrison's Principles of Internal Medicine 22E
Complete Blood Count (CBC)
| Parameter | Value | Reference |
|---|---|---|
| Hemoglobin | 14.8 g/dL | 13.5-17.5 |
| Hematocrit | 44% | 41-53% |
| WBC | 12,200 cells/μL | 4,500-11,000 |
| Neutrophils | 78% | 50-70% |
| Lymphocytes | 16% | 20-40% |
| Platelets | 228,000/μL | 150,000-400,000 |
Mild leukocytosis (12,200) is expected from the pain/stress response; levels >15,000 with fever should prompt suspicion of concurrent infection/urosepsis. - Tintinalli's Emergency Medicine
Basic Metabolic Panel / Renal Function Tests
| Parameter | Value | Reference |
|---|---|---|
| Serum Creatinine | 1.0 mg/dL | 0.7-1.3 |
| BUN (Blood Urea Nitrogen) | 18 mg/dL | 7-20 |
| eGFR | 88 mL/min/1.73m² | >60 |
| Serum Sodium | 138 mEq/L | 136-145 |
| Serum Potassium | 4.0 mEq/L | 3.5-5.0 |
| Serum Chloride | 101 mEq/L | 98-107 |
| Bicarbonate | 24 mEq/L | 22-29 |
| Serum Calcium | 9.6 mg/dL | 8.5-10.5 |
| Serum Phosphate | 3.2 mg/dL | 2.5-4.5 |
| Serum Uric Acid | 6.1 mg/dL | 3.5-7.2 |
| Fasting Glucose | 94 mg/dL | 70-100 |
| Serum Albumin | 4.2 g/dL | 3.5-5.0 |
During acute obstruction, most patients have no rise in serum creatinine because the unobstructed kidney functions at up to 185% of its baseline capacity. - Tintinalli's Emergency Medicine
24-Hour Urine Metabolic Study (performed after acute episode resolved)
| Parameter | Value | Reference / Risk Threshold |
|---|---|---|
| Total Volume | 950 mL/day | >2000 mL recommended |
| Urine Calcium | 310 mg/day | <200 mg/day (hypercalciuria >250 mg/day in women, >300 mg/day in men) |
| Urine Oxalate | 52 mg/day | <40 mg/day |
| Urine Citrate | 220 mg/day | >450 mg/day (hypocitraturia <450) |
| Urine Uric Acid | 680 mg/day | <800 mg/day |
| Urine Sodium | 210 mEq/day | <100 mEq/day (reflects high salt intake) |
| Urine pH | 5.8 | Calcium oxalate unaffected; uric acid risk pH <5.5 |
| Urine Creatinine | 1,850 mg/day | Confirms adequate collection |
Metabolic abnormalities identified: hypercalciuria, hyperoxaluria, and hypocitraturia - a classic triad for recurrent calcium oxalate stone formation.
Serum PTH (Parathyroid Hormone)
| Parameter | Value | Reference |
|---|---|---|
| Intact PTH | 32 pg/mL | 15-65 pg/mL (normal) |
Primary hyperparathyroidism excluded.
Imaging
Non-contrast CT KUB (CT of Kidneys, Ureters, Bladder) - GOLD STANDARD:
- Stone location: Right distal ureter, 3 cm proximal to the ureterovesical junction (UVJ)
- Stone size: 6 mm in greatest dimension
- Stone density (Hounsfield Units): 980 HU (consistent with calcium oxalate)
- Degree of obstruction: Moderate hydronephrosis of right kidney (anteroposterior pelvis diameter 14 mm)
- Perinephric stranding: Present around right kidney (indicating obstruction-related edema)
- Ureteral dilatation: Right proximal and mid-ureter dilated up to 8 mm
- Left kidney: Normal, no stones, no hydronephrosis
- Bladder: Normal
- No free fluid, no aortic aneurysm
Helical CT is highly sensitive and allows visualization of uric acid stones (traditionally considered "radiolucent"). It detects stones as small as 1 mm. - Harrison's Principles of Internal Medicine 22E
KUB Plain X-Ray (done prior to CT):
- Faint opacity in right pelvis region, partly overlying sacrum - difficult to characterize without CT
Renal Ultrasound (bedside, done at triage):
- Right hydronephrosis (moderate)
- Right kidney AP pelvis 14 mm
- No direct visualization of stone in mid or distal ureter (limited by bowel gas)
Stone Analysis (after spontaneous passage, Day 2)
| Parameter | Result |
|---|---|
| Stone composition | Calcium oxalate monohydrate (whewellite) - 85%, Calcium oxalate dihydrate (weddellite) - 15% |
| Stone size recovered | 5.8 mm |
| Morphology | Envelope-shaped crystals on microscopy |
Diagnosis
Primary: Right ureteric calculus (distal ureter, 6 mm calcium oxalate stone) with moderate right hydronephrosis
Secondary:
- Ureteric colic (right)
- Hypercalciuria
- Hyperoxaluria
- Hypocitraturia
Management
Acute Phase (ED Management)
-
Analgesia:
- IV Ketorolac 30 mg stat (NSAID - first-line for renal colic; reduces ureteral spasm and prostaglandin-mediated pain)
- IV Morphine 4 mg PRN for breakthrough pain
-
Anti-emetics: IV Metoclopramide 10 mg for nausea/vomiting
-
IV Fluids: Normal saline 500 mL bolus (correction of dehydration from vomiting; excessive IV fluids do not accelerate stone passage)
-
Medical Expulsive Therapy (MET):
- Tamsulosin 0.4 mg orally once daily (alpha-1 blocker; relaxes smooth muscle of distal ureter, improves passage rate for stones 5-10 mm; particularly effective at the UVJ)
-
Urine straining: Instructions to strain all urine to capture stone for analysis
-
Monitoring: Urine output, vital signs, repeat creatinine if no passage in 24-48h
Criteria for Urgent Urological Intervention (none present in this patient):
- Fever + obstruction (urosepsis - medical emergency)
- Solitary kidney with obstruction
- Bilateral ureteral obstruction
- Complete obstruction >4 weeks (risk of irreversible renal damage)
- Intractable pain/vomiting despite medications
- Rising creatinine
Follow-Up (Outpatient - Recurrence Prevention)
Given the metabolic profile (hypercalciuria + hyperoxaluria + hypocitraturia):
- Fluid intake: Increase to >2.5 L/day (target urine output >2 L/day)
- Dietary calcium: Normalize intake to 1,000-1,200 mg/day (low-calcium diet paradoxically increases stone risk by increasing intestinal oxalate absorption)
- Reduce dietary oxalate: Reduce spinach, nuts, chocolate, rhubarb
- Reduce sodium and animal protein: High sodium increases urine calcium excretion; animal protein lowers citrate and raises uric acid
- Potassium citrate 20 mEq twice daily: Raises urine citrate, alkalinizes urine, chelates calcium
- If hypercalciuria persists on diet: Consider Hydrochlorothiazide 25 mg/day
Differential Diagnoses Considered and Excluded
| Diagnosis | Reason Excluded |
|---|---|
| Acute appendicitis | No fever, no peritonism; pain moved from loin to groin (classic colic); CT showed no appendiceal pathology |
| Ruptured AAA | Patient young (38y), no hemodynamic instability, CT confirmed no aneurysm |
| Acute pyelonephritis | No fever, no rigors, urine culture negative, no costovertebral tenderness distinct from colic |
| Epididymo-orchitis | Testicular retraction explained by cremaster spasm; testis non-tender on examination |
| Musculoskeletal pain | Visceral quality, radiation pattern, hematuria, CT positive - excluded |
| Ovarian pathology | N/A (male patient) |
Prognosis and Patient Education
- A 6 mm distal ureteric stone with medical expulsive therapy has approximately 60-70% chance of spontaneous passage (stones <5 mm pass ~68-90%, stones 5-10 mm pass ~40-70%).
- Without dietary and fluid modification, the 5-year recurrence rate is ~50% and up to 67% when radiographically detected stones are included. - National Kidney Foundation Primer on Kidney Diseases 8e
- Patient counselled on family history (father affected) doubling genetic predisposition.
- Long-term risk of hypertension, CKD, and cardiovascular disease if recurrent stone disease goes unmanaged.
Sources:
- Harrison's Principles of Internal Medicine 22E (2025) - Clinical Presentation, Diagnosis, Stone Risk Factors
- S Das: A Manual on Clinical Surgery 13th Edition - Ureteric Calculus, Symptoms and Signs
- Tintinalli's Emergency Medicine: A Comprehensive Study - Pathophysiology, Clinical Features, Emergency Management
- National Kidney Foundation Primer on Kidney Diseases, 8e - Epidemiology, Acute Renal Colic, Metabolic Work-Up
- Brenner and Rector's The Kidney, 2-Volume Set - Renal Stone Disease, Metabolic Risk
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