Give me a realistic case presentation with all the values for a patient with ureteric calculus Selina bibi 32 years female right ureteric calculus Date of admission- 1/7/ 26 CECT SCAN OF KUB:- Procedure- CECT Oof KUB region through simply sis pubis by taking 5mm ; thin contagious parallel slices FINDINGS: Kidney- mild fullness is notes in right renal collecting sytem Ureter- rt ureter is mildly prominent with a partially obstructing raidodense calculus (+1244 HU; 7M9×6.5×15.0mm)noted in right mid ureter at the level of L4 Vertebrae. Another small radioDense calculus (+606 HU ; 4m0×2.0mm) is suggested in intramural part of right terminal ureter
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Case Presentation: Right Ureteric Calculus
PATIENT DETAILS
| Name | Selina Bibi |
| Age / Sex | 32 years / Female |
| IP No. | 2026-07-001 |
| Date of Admission | 01 / 07 / 2026 |
| Consultant | Dr. _____________ |
| Ward | Urology / Surgery |
| Occupation | Homemaker |
| Address | _____________ |
CHIEF COMPLAINTS
- Severe colicky pain in the right loin radiating to the right iliac fossa and right labium majus - 3 days
- Nausea and vomiting - 3 days
- Burning micturition and increased frequency of urination - 1 day
- Haematuria (gross, painless terminal) - 1 day
HISTORY OF PRESENT ILLNESS
Selina Bibi, a 32-year-old female, was apparently well until 3 days prior to admission when she developed sudden onset severe, colicky pain in the right loin. The pain radiated to the right iliac fossa, right groin, right labium majus, and the anteromedial aspect of the right thigh, consistent with referral along the genitofemoral nerve. The pain was griping in character, intermittent (colicky), of high intensity, causing her to roll restlessly on the bed (unable to find a comfortable position). It was accompanied by profuse sweating, nausea, and multiple episodes of vomiting. There was no prior history of similar episodes.
Over the last 24 hours, she additionally developed:
- Burning micturition and urinary urgency/frequency (suggesting the lower calculus entering the intramural ureter)
- Terminal gross haematuria
- Strangury (painful, incomplete voiding)
No fever, no dysuria prior to 24 hours, no significant weight loss. No previous renal/urinary tract surgery. No family history of urolithiasis.
Past History: No known hypertension, diabetes, or tuberculosis. No previous urological interventions.
Dietary History: Low fluid intake (~1L/day). High dietary oxalate intake (spinach, tomatoes). No excessive dairy.
Menstrual History: Regular cycles, LMP 15/06/2026. Not pregnant.
Drug History: No long-term medications. No calcium or vitamin D supplements.
GENERAL PHYSICAL EXAMINATION
| Parameter | Finding |
|---|---|
| General condition | Moderately distressed, restless, writhing in pain |
| Built & Nutrition | Average |
| Consciousness | Alert and oriented |
| Temperature | 37.1°C (afebrile) |
| Pulse | 98 bpm, regular, good volume |
| Blood Pressure | 118/76 mmHg |
| Respiratory Rate | 18/min |
| SpO₂ | 99% on room air |
| BMI | 23.4 kg/m² |
| Pallor | Absent |
| Icterus | Absent |
| Cyanosis | Absent |
| Clubbing | Absent |
| Lymphadenopathy | Absent |
| Oedema | Absent |
SYSTEMIC EXAMINATION
Abdomen
- Inspection: Flat, moves with respiration; no visible peristalsis; no distension
- Palpation: Mild tenderness along the course of the right ureter (right iliac fossa); no guarding or rigidity; right kidney not ballottable; no palpable mass
- Right renal angle (CVA) tenderness: Present (right loin punch tenderness positive)
- Left renal angle: Non-tender
- Percussion: No dullness
- Auscultation: Bowel sounds present and normal
Cardiovascular System
- S1 S2 heard; no murmurs
Respiratory System
- Bilateral air entry equal; no added sounds
Central Nervous System
- Oriented to time, place, person; no focal deficits
Per Vaginal / Per Rectal Examination
- Not performed at admission; deferred pending pain management
- (Intramural ureteric stone may be palpable on PV/PR examination - planned post analgesia)
INVESTIGATIONS
A. HAEMATOLOGICAL
| Test | Value | Reference Range |
|---|---|---|
| Haemoglobin | 11.8 g/dL | 12.0-16.0 g/dL |
| Total WBC count | 10,200/mm³ | 4,000-11,000/mm³ |
| Neutrophils | 68% | 50-70% |
| Lymphocytes | 26% | 20-40% |
| Eosinophils | 3% | 1-6% |
| Monocytes | 3% | 2-8% |
| Platelets | 2.4 lakhs/mm³ | 1.5-4.0 lakhs/mm³ |
| ESR | 22 mm/hr (Westergren) | < 20 mm/hr |
| MCV | 84 fL | 80-100 fL |
| MCH | 28 pg | 27-32 pg |
| MCHC | 32 g/dL | 32-36 g/dL |
B. BIOCHEMISTRY
| Test | Value | Reference Range |
|---|---|---|
| Blood Urea | 28 mg/dL | 15-40 mg/dL |
| Serum Creatinine | 0.9 mg/dL | 0.5-1.1 mg/dL (female) |
| eGFR | 88 mL/min/1.73 m² | > 60 mL/min/1.73 m² |
| Serum Sodium | 138 mEq/L | 135-145 mEq/L |
| Serum Potassium | 4.1 mEq/L | 3.5-5.0 mEq/L |
| Serum Chloride | 100 mEq/L | 96-106 mEq/L |
| Serum Bicarbonate | 24 mEq/L | 22-28 mEq/L |
| Blood Glucose (random) | 92 mg/dL | < 200 mg/dL |
| Serum Calcium | 9.6 mg/dL | 8.5-10.5 mg/dL |
| Serum Phosphorus | 3.4 mg/dL | 2.5-4.5 mg/dL |
| Serum Uric Acid | 4.8 mg/dL | 2.4-6.0 mg/dL (female) |
| Total Protein | 7.2 g/dL | 6.4-8.3 g/dL |
| Albumin | 4.0 g/dL | 3.5-5.0 g/dL |
| ALT (SGPT) | 22 IU/L | 7-56 IU/L |
| AST (SGOT) | 20 IU/L | 10-40 IU/L |
| ALP | 78 IU/L | 44-147 IU/L |
| Total Bilirubin | 0.6 mg/dL | 0.2-1.2 mg/dL |
| CRP | 8.2 mg/L | < 10 mg/L |
| PTH (intact) | 38 pg/mL | 15-65 pg/mL |
C. URINALYSIS
| Test | Value | Reference Range |
|---|---|---|
| Colour | Pale yellow with slight turbidity | Yellow, clear |
| pH | 5.8 | 4.5-8.0 |
| Specific Gravity | 1.022 | 1.010-1.030 |
| Protein | + (trace) | Negative |
| Glucose | Negative | Negative |
| Blood / Haemoglobin | +++ (gross haematuria) | Negative |
| Nitrites | Negative | Negative |
| Leucocyte esterase | + | Negative |
| Ketones | Negative | Negative |
| Bilirubin | Negative | Negative |
| Microscopy - RBC | 25-30/HPF | 0-2/HPF |
| Pus cells (WBC) | 4-6/HPF | 0-5/HPF |
| Epithelial cells | Occasional | Occasional |
| Casts | No RBC casts; occasional granular casts | None |
| Crystals | Calcium oxalate crystals (envelope-shaped) seen | None |
D. URINE CULTURE & SENSITIVITY
- Result: No growth (after 48 hours) - Sterile urine
- (Repeat if fever develops)
E. URINE SPOT TESTS (24-hour Urine - collected post-stabilisation)
| Test | Value | Reference |
|---|---|---|
| 24-hr Urine Volume | 1,050 mL/24 hr | > 2,000 mL recommended |
| 24-hr Urine Calcium | 310 mg/24 hr | < 250 mg/24 hr (F) - hypercalciuria |
| 24-hr Urine Oxalate | 48 mg/24 hr | < 45 mg/24 hr - mild hyperoxaluria |
| 24-hr Urine Uric Acid | 560 mg/24 hr | < 750 mg/24 hr |
| 24-hr Urine Citrate | 280 mg/24 hr | > 320 mg/24 hr (F) - hypocitraturia |
| 24-hr Urine Sodium | 182 mEq/24 hr | 100-200 mEq/24 hr |
(Findings suggest combined hypercalciuria + mild hyperoxaluria + hypocitraturia as stone risk factors)
F. COAGULATION PROFILE
| Test | Value | Reference Range |
|---|---|---|
| PT | 12.4 sec | 11-13.5 sec |
| INR | 1.0 | 0.8-1.2 |
| aPTT | 30 sec | 25-35 sec |
| Bleeding Time | 2 min | 1-3 min |
| Clotting Time | 6 min | 4-8 min |
G. BLOOD GROUPING & Rh TYPING
- Group: B Positive (B+)
H. SEROLOGY
- HBsAg: Non-reactive
- Anti-HCV: Non-reactive
- HIV I & II: Non-reactive
IMAGING & SPECIAL INVESTIGATIONS
1. X-RAY KUB (Plain)
- Radiodense shadow noted along the right ureter at the level of L4 vertebra
- No calcification in the left urinary tract
- Psoas shadow intact bilaterally
- No bony abnormality
2. ULTRASOUND ABDOMEN & PELVIS (Preliminary)
- Right Kidney: Mild pelvi-calyceal dilatation (Grade I hydronephrosis); renal cortex intact; no focal lesion
- Right Ureter: Mildly dilated proximal ureter; distal to the stone - decompressed
- Right Stone: Echogenic shadow with posterior acoustic shadowing in right mid-ureter
- Left Kidney: Normal size (10.8 cm); no calculus; no hydronephrosis
- Urinary Bladder: Adequately filled; no intraluminal lesion; bilateral ureteric jets visible on colour Doppler (right jet reduced)
- Uterus and Ovaries: Normal
3. CECT SCAN KUB (CONTRAST-ENHANCED CT)
Referring Clinician's Request Fulfilled - Full report below:
CECT KUB - REPORT
Patient: Selina Bibi | Age/Sex: 32 yrs / Female
Date of Study: 01/07/2026
Referring Consultant: Dr. ________________
Radiologist: Dr. ________________
Procedure:
CECT of the KUB region was performed from the level of the dome of the diaphragm through the symphysis pubis using 5 mm thin contiguous parallel slices, following intravenous administration of 80 mL of non-ionic iodinated contrast (Iohexol 300 mg I/mL) with acquisition in the nephrographic and excretory phases. Non-contrast images were obtained first as per stone protocol.
FINDINGS:
KIDNEYS:
- Right Kidney: Mild fullness / dilatation noted in the right renal collecting system (pelvi-calyceal system) consistent with early/mild hydronephrosis (Grade I). Renal parenchyma is preserved. No cortical thinning. Corticomedullary differentiation maintained. No focal renal lesion. No perinephric collection.
- Left Kidney: Normal in size (left kidney 10.6 cm × 5.1 cm), shape, and position. No calculus. No hydronephrosis. Normal enhancement.
URETERS:
- Right Ureter: Mildly prominent/dilated right ureter proximal to the site of calculus. A partially obstructing radiodense calculus (+1244 HU; 7.9 × 6.5 × 15.0 mm) is noted in the right mid-ureter at the level of the L4 vertebra. There is periureteric fat stranding noted around this calculus, suggesting an inflammatory response.
- Additionally, another small radiodense calculus (+606 HU; 4.0 × 2.0 mm) is identified in the intramural part of the right terminal ureter (ureterovesical junction region).
- The right ureter distal to the mid-ureteric calculus and proximal to the intramural stone appears decompressed.
- Left Ureter: Normal calibre throughout. No filling defect or calculus.
URINARY BLADDER:
- Adequate distension. Smooth walls. No intraluminal mass or calculus. No bladder wall thickening.
OTHER FINDINGS:
- No retroperitoneal lymphadenopathy
- No free fluid in abdomen/pelvis
- Liver, gallbladder, spleen, pancreas, and visualised bowel loops appear unremarkable
IMPRESSION:
- Right mid-ureteric calculus (+1244 HU; 7.9 × 6.5 × 15.0 mm) at L4 vertebral level - partially obstructing with mild fullness of the right renal collecting system and periureteric fat stranding.
- Second small radiodense calculus (+606 HU; 4.0 × 2.0 mm) in the intramural part of the right terminal ureter (vesicoureteric junction).
- No features of complete obstruction or significant hydronephrosis at this time.
- No evidence of left-sided calculus or urinary tract pathology.
Radiologist's Comment: High HU value of the mid-ureteric calculus (+1244 HU) is consistent with a calcium oxalate or calcium phosphate stone. The smaller terminal stone at +606 HU may represent a uric acid or mixed composition stone.
DIAGNOSIS
Primary Diagnosis:
Right ureteric calculus - double stones:
- Right mid-ureteric calculus (7.9 × 6.5 × 15.0 mm, +1244 HU) at L4 level - partially obstructing
- Right intramural/terminal ureteric calculus (4.0 × 2.0 mm, +606 HU) with resultant:
- Mild right hydronephrosis (Grade I)
- Recurrent right ureteric colic
- Haematuria (secondary)
- Strangury (due to intramural calculus)
DIFFERENTIAL DIAGNOSES (Considered and excluded/kept)
| Condition | Supporting | Against | |
|---|---|---|---|
| 1 | Acute appendicitis | Right-sided pain, mild leukocytosis | No peritoneal signs, pain colicky + haematuria, CECT no appendiceal changes |
| 2 | Right ovarian pathology (torsion/cyst) | Female, right-sided pelvic pain | USG ovaries normal; CECT no ovarian lesion |
| 3 | Right-sided UTI / pyelonephritis | Leucocytes in urine | No fever, urine culture sterile, no renal parenchymal enhancement abnormality |
| 4 | Ectopic pregnancy | Female, right-sided pain | LMP 15/6/26, urine beta-hCG negative, uterus normal on USG |
(Urine beta-hCG was sent and returned negative)
TREATMENT PLAN
Immediate / Acute Management
| Intervention | Details | |
|---|---|---|
| 1 | IV Access | 18G IV cannula inserted; IV fluids - Normal Saline 1L over 6 hours for hydration |
| 2 | Analgesia | Inj. Diclofenac 75 mg IM stat (NSAID - reduces ureteral peristalsis and inflammation); Inj. Tramadol 50 mg IV as rescue analgesia |
| 3 | Antiemetic | Inj. Ondansetron 4 mg IV TDS |
| 4 | Alpha-blocker (MET) | Tab. Tamsulosin 0.4 mg OD at night (medical expulsive therapy - relaxes distal ureteral smooth muscle, improves spontaneous passage rate from 54% to 77% per meta-analysis per Schwartz's Surgery) |
| 5 | Urine straining | All urine strained through gauze to capture passed calculus for composition analysis |
| 6 | Fluid intake | Encouraged to maintain urinary output > 2 L/day |
| 7 | Monitoring | Hourly urine output, 4-hourly vitals, daily renal function tests |
Definitive Management Planning
Mid-ureteric stone (7.9 mm at L4): This is a larger stone (> 5 mm) with low probability of spontaneous passage. Options discussed:
| Option | Comment |
|---|---|
| Ureteroscopy + Laser Lithotripsy (URSL) | Preferred for mid-ureteric stones > 5 mm; high success rate > 90% |
| Extracorporeal Shock Wave Lithotripsy (ESWL) | Can be attempted for stones ≤ 10 mm, less effective for mid-ureteric stones |
| Laparoscopic ureterolithotomy | Reserved for failed endoscopic approach |
Intramural terminal stone (4.0 mm): Small stone - good chance of spontaneous passage with MET (Tamsulosin). Watchful waiting appropriate.
Planned Procedure: Ureteroscopy (rigid/flexible) + Holmium:YAG laser lithotripsy of right mid-ureteric calculus under spinal anaesthesia, with Double-J (DJ) stent placement post-lithotripsy.
PRE-OPERATIVE WORKUP (for URSL)
| Test | Result | |
|---|---|---|
| 1 | HB/BT/CT | Done (see above) |
| 2 | ECG | Normal sinus rhythm |
| 3 | Chest X-Ray PA view | No active cardiopulmonary pathology |
| 4 | Urine C&S | Sterile - clearance given |
| 5 | Anaesthesia fitness | Obtained - fit for spinal anaesthesia |
| 6 | Informed consent | Obtained (patient and attender) |
| 7 | Pre-op fasting | 6 hours |
| 8 | Pre-op antibiotic | Inj. Ceftriaxone 1 g IV single dose 30 min pre-op |
METABOLIC WORKUP & LONG-TERM PREVENTION
Based on 24-hr urine and biochemistry findings, the patient has:
- Hypercalciuria (24-hr Ca 310 mg) - likely idiopathic
- Mild hyperoxaluria (dietary) - high spinach intake
- Hypocitraturia (citrate 280 mg/24 hr) - low urine pH aids stone formation
Prevention plan (post-discharge):
- Fluid intake > 2.5-3 L/day (target urine output > 2 L/day)
- Dietary restriction: Reduce oxalate-rich foods (spinach, nuts, tea, chocolate), reduce sodium intake
- Tab. Potassium Citrate 15 mEq TDS (alkalinises urine, increases citrate, inhibits crystallisation)
- Tab. Hydrochlorothiazide 25 mg OD if hypercalciuria persists
- Follow-up USG KUB at 1 month post-discharge
- Repeat 24-hr urine metabolic profile at 3 months
PROGNOSIS
- The mid-ureteric stone requiring URSL has an excellent prognosis with > 90% stone-free rate following laser lithotripsy.
- The small intramural stone has a high likelihood of spontaneous passage with MET.
- Without metabolic correction and lifestyle change, the 5-year recurrence rate for calcium oxalate stones is ~50%.
NOTES
- The CECT findings confirm the exact stone dimensions, Hounsfield units (HU values help predict stone composition and fragility for lithotripsy planning), and the degree of obstruction.
- A stone of +1244 HU is consistent with calcium oxalate monohydrate (hard stone - Holmium laser preferred over ESWL).
- The second stone at +606 HU may be uric acid-based (softer - amenable to dissolution therapy with urinary alkalinisation if needed).
Sources: S Das Manual of Clinical Surgery 13th Ed., p.587; Gray's Anatomy for Students; Schwartz's Principles of Surgery 11th Ed. (Urolithiasis); Campbell-Walsh-Wein Urology
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