CONCEPT MAP (CASE 3)

Clinical Profile
Physical Findings
- 42 y.o
- Female -BP- 120/80 (normal)
- Filipino -HR-82 bpm (normal)
- Admitted due to hematuria
-RR-19 cpm (normal)
- Urine is red in color with sandy particles per voiding
- Has urinary frequency - T-36.3 C (Afebrile)
- Has dysuria - Hypoactive bowel sounds
- Right flank pain - Hypogastric tenderness
- Recurrent right inguinal pain which resolves spontaneously - Has positive Kidney punch sign
- Occasional hypogastric pain
- No jaundice
- Hospitalized due to UTI and acute pyelonephritis
- Father had nephrolithiasis - Anicteric sclerae
- Non-hypertensive & non-diabetic - No bruit
- No weight loss - Negative Murphy’s sign
- No fever & chills - No direct and rebound
- No nausea & vomiting
- No cough & dyspnea
tenderness
- No melena or hematochezia - No edema
- No urinary urgency Pivot: Hematuria
- No abnormal vaginal discharge

Differential: Nephrolithiasis Differential: UTI secondary to STI Differential: Hemorrhagic Cystitis Differential: Autosomal
Dominant Polycystic Kidney
R/I: R/I: R/I: Disease
(+) Hematuria (+) Hematuria (+) Acute onset of hematuria
(+) Dysuria (+) Dysuria (+) Dysuria R/I:
(+) Urinary frequency (+) Pain in the hypogastric area (+) Hematuria
(+) Urinary frequency
(+) Unilateral flank pain (+) Flank pain (+) Flank pain
(+) Lower abdominal tenderness
(+) Lower abdomen tenderness (+) Inguinal pain
(+) Urinary frequency Risk Factor: Previous history of
(+) Recurrent pain that resolves R/O: UTI
spontaneously *Common among oncology patients
Risk factor: Recurrent UTI
(-) Urinary incontinence
Risk Factors: R/O:
R/O: (-) Fatigue (-) 15-29 y/o has higher risk
*Father had previous surgery due to (-) Fever (-) Nocturia (-) Progressive bilateral
nephrolithiasis. (-) Chills
*Low urine volume (Urine output 4-5x (-) Fever & chills formation of renal cyst
(-) Nausea & vomiting (-) Hypertension
per day amounting to approximately
(-) Foul smelling discharge (-) Family history of ADPKD
250cc per voiding)
(-) Cloudy urine (-) Multiple bilateral kidney cyst
(-) Sandy particles in the urine (-) Large kidney size
R/O:

-Cannot completely rule out

Differential: IgA Nephropathy

Differential: Pelvic Inflammatory Disease
R/I:
R/I: Admitting Diagnosis (+) Hematuria
(+) Hematuria (+) Flank pain
(+) Dysuria NEPHROLITHIASIS
(+) Hypogastric tenderness Risk Factors:
(+) Urinary frequency *Common among Asian

Risk Factors: *Recurrent UTI R/O:

-High blood pressure
R/O: -Edema of the hands and feet
-Foul vaginal discharge -Proteinuria
-Fever & chills
-Nausea & vomiting
PATHOPHYSIOLOGY:

Increased urinary super saturation

Crystal nucleation

Crystal growth

Crystal aggregation

Crystal cell interaction

Crystal retention within the kidney or renal collecting duct

Risk Factors:
Stone Formation
-Father was hospitalized due
to nephrolithiasis

-Low urine volume

-Previous UTI

Irritation of the lining Lodges stone to the

Blockage of the
of the kidney ureter
ureter
 

Causes injury to the

DYSURIA
local cells & Urine backs up
capillaries HYPOGASTRIC PAIN
into the kidney
URINARY FREQUENCY

HEMATURIA ↑Pressure in the kidney

Radiation to the genital area

Swelling of the
kidney & spasm of FLANK PAIN
the ureter INGUINAL PAIN
Nephrolithiasis possible results:
Laboratory:

1. CBC
2. Electrolytes
3. Crea
4. Urinalysis
5. KUB Radiograph
6. Abdominal and Pelvic Ultrasound

Test Patient’s Possible Result Normal Ranges (IM Units

Platinum)
CBC
 WBC 12.0* 4.5 – 11 X10ˆ3 /L
 RBC 3.2* 4.2 – 5.4 X 10^12 /L
 Hemoglobin 10.8* 12.0 – 16.0 g/dL
 Hematocrit 30* 38 – 47 %
Electrolytes
 Na 137 137 – 145 mmol/L
 K 3.7 3.5 – 5.1 mmol/L
 Cl 105 98 - 107 mmol/L
Blood Chemistry
 Creatinine 91 46 – 92 umol/L

*WBC indicating leukocytosis; RBC, Hgb, Hct indicating acute blood loss

Urinalysis

Parameter Patient’s Possible Result Normal Value

Color Red*
Transparency Turbid* Clear
Specific Gravity 1.020 1.016 – 1.022
pH 6.0 4.6 – 6.5
Sugar (- ) (-)
Protein /Albumin Trace* (-)
RBC TNTC* 0 – 5/hpf
WBC 5-11 0 – 5/hpf
Bacteria Moderate* (-)
Cast None
Crystals, Epithelial cells, Mucous few
threads
*Results show hematuria, mild proteinuria, with bacteriuria

RADIOGRAPHIC IMAGING

To assess composition and location of the kidney

stone
KUB radiograph 60% of all renal stones are radiopaque (Calcium
phosphate and calcium oxalate) and may be seen
anywhere along the urinary tract most especially
lodged in the 3 constrictions of the ureter.
 Cysteine calculi are faintly radiodense while uric
acid stones are radiolucent

More specific and sensitive than Xrays. Provide

picture of the kidneys and bladder and can identify
blockage or urinary flow and help identify stones.
Abdominal and Pelvic Ultrasound Highly effective at showing >5mm stones but poor
visualization in <3mm
Renal stones are hyperechoic and show posterior
acoustic shadowing.
Hydronephrosis shows a hypoechoic area of the
kidneys.