Renal Urological Case Study

Case Study

E.G. is a 41-year-old male presenting to the ED complaining of severe right back pain that started a couple of hours ago, right after he finished his daily run. He has a history of GERD, takes famotidine (Pepcid) 20 mg PO once daily at bedtime.

Subjective Data

Training for a marathon, running at least 10 miles a day, but today was so hot that he only made it 6 miles. Shortly after his run, the pain in his right back/side started. Pain level: 9 out of 10 scale, constant, nothing relieves it, and it does not worsen with movement. Denies any pain or numbness in his legs. While training, he has been supplementing his diet with protein shakes.

Objective Data

T: 99.6° F, P: 78, R:16, BP 122/80

No musculoskeletal pain or tenderness in the spine

Right flank tenderness

Based on the initial clinical manifestations and exam findings, the health care provider orders a urinalysis. At first, E.G. is unable to urinate, but after drinking several glasses of water, he is able to obtain a clean-catch urine specimen.

Diagnostic Studies-Urinalysis

Color: Dark, smoky color Specific gravity: 1.035

Odor: Foul pH: 6.2 (4.0-8.0)

Protein: None RBCs: 11/hpf (0-4/hpf)

Glucose: None WBCs: 3/hpf (0-5/hpf)

Ketones: None Casts: None

Bilirubin: None

Questions

1. Based on the data above, what do you suspect is occurring with E.G.? What assessment data led you to this conclusion?
2. What additional test(s) may be ordered to confirm this diagnosis?
3. E.G. has an ultrasound, and the presence of a large right renal calculus is confirmed. The health care provider orders E.G. IV Morphine sulfate for pain and recommends that he have a right extracorporeal shock-wave lithotripsy (ESWL). Explain this procedure.
4. What factors put E.G. at risk for developing a renal calculus?
5. What teaching should E.G. receive prior to his being discharged?
6. What nutritional instructions should E.G. be given to prevent recurrence of urinary calculi?

Renal Urological Case Study

Q1.

Based on the provided data, E.G. is likely experiencing a urinary tract issue, possibly involving the kidneys. The rationale supporting this conclusion includes the following;

• Severe right back pain radiating to the side, which suggests kidney involvement
• Microscopic blood in the urine, which indicates a urinary tract issue
• Dark, smoky urine color, depicting kidney problems
• Sudden onset of severe pain, which suggests a potential blockage, like kidney stones

Q2.

Based on the patient's symptoms and initial workup, the doctor might order tests to confirm a diagnosis. One of the tests is Imaging tests, which may be informed of an abdominal CT scan or Abdominal ultrasound (Caraiani et al., 2020). The former is the most commonly used imaging test to detect kidney stones. The test will provide images of the urinary tract, facilitating the visualization of tiny stones. Although abdominal ultrasound may not be as effective as a CT scan, it can be used to detect kidney stones through a non-invasive approach. Another test the doctor can request is blood tests to assess how the kidneys are filtering waste products from the blood. Abnormal results from either test will indicate kidney problems.  

Q3.

ESWL is a minimally invasive procedure used to break up large kidney stones. The term extracorporeal implies "from outside the body." The shock waves are produced by a machine outside the body targeting the stones. The term shock wave refers to the powerful pressure that can fragment the stones, while lithotripsy means "stone crushing."

The procedure starts with the patient being placed on a special table that allows the healthcare provider to locate the kidney stone. A lithotripter generates high-energy shock waves that are focused on the kidney stone, with the shock waves that pass through the body tissues harmlessly breaking the stone into smaller pieces (Torres-Alarcón et al., 2020). The smaller fragments then pass through the urinary tract and are expelled in the urine.

Q4.

Based on the information provided, certain factors might put E.G. at risk for developing renal calculus. One of the factors is dehydration. The case mentions that E.G.'s training regimen involves running 10 miles daily. Strenuous exercise can lead to dehydration, especially if fluid intake is inadequate (Armstrong, 2021). Dehydration concentrates urine, making it more likely for minerals to crystallize and form stones. Another factor is diet, as the case points to increased protein intake, which can increase urinary excretion of certain stone-forming substances.

Q5.

To recover smoothly from his ESWL surgery, E.G. should be informed about several critical areas before discharge. First, he must grasp the purpose and side effects of prescribed pain drugs like morphine sulfate and consider over-the-counter or heat therapy if necessary (Mohamed Kamel et al., 2023). It is also important to emphasize the need for fluid consumption, with water being the best choice, but clear broths or diluted juices also work. Another important part is monitoring for problems, such as fever, chills, nausea, vomiting, or increasing pain, and seeking medical assistance immediately. He should also be taught how to separate his urine with a filter and that collecting stone particles for examination can assist in identifying the stone type and guide prevention.

Q6.

E.G., should increase fluid intake to 2-3 liters per day, preferably water, to dilute urine and prevent stone formation. High-protein diets increase urinary stone excretion; hence, protein intake should be moderated (Zayed et al., 2023). E.G. should eat fish, chicken, and lentils for lean protein. E.G. should reduce oxalate-rich foods, including spinach, rhubarb, beets, almonds, and chocolate, for calcium oxalate stones, but should see a doctor before substantially reducing calcium intake to maintain bone health. E.G. should also cut red meat to prevent uric acid stones. Limiting sodium and sugary drink intake, eating a balanced diet, and exercising regularly are advised.

Matching the terms

Term: Description

Anuria: No urination or very little urination (less than 40-100 ml/day)

Dysuria: Painful urination

Enuresis: Involuntary urination, often at night (bedwetting)

Hematuria: Blood in the urine

Hesitancy: Delay in initiating urination

Oliguria: Decreased urine output (100-400 ml/day)

Polyuria: Excessive urination (large volume)

Urosepsis: A life-threatening condition caused by a urinary tract infection (UTI) that spreads into the bloodstream

Uremia: High levels of urea and other waste products in the blood due to kidney failure