Renal & Urinary System


{"ops":[{"insert":{"image":"\/storage\/case-images\/cs\/S23_F1.jpg"}},{"insert":"\n\n"},{"insert":"The day is drawing to close, and you cannot help but glance at your watch every now and then.\n"}]}


{"ops":[{"insert":"All of sudden, your pager buzzes. You have a referral from the emergency department (ED).\r\n\r\n\u0022.... just 15 minutes left\u0022, you grumble to yourself, as you step out of the ward.\n"}]}


{"ops":[{"insert":{"image":"\/storage\/case-images\/cs\/S23_F3.jpg"}},{"insert":"\n\n"},{"insert":"When you walk into the ED, the doctor on call brings you up to speed on the new patient.\n"}]}


{"ops":[{"insert":"Andr\u00e9, a 6-year-old boy, has had severe left-sided abdominal pain for around an hour.\r\n\r\nThe pain was episodic, with each episode lasting between two to three minutes. He had also vomited twice. He is not febrile, and there is no history of urinary or bowel symptoms or recent trauma.\n"}]}


{"ops":[{"insert":{"image":"\/storage\/case-images\/cs\/S23_F5.jpg"}},{"insert":"\n\n"},{"insert":"Andr\u00e9 had three similar attacks over the last year, although none of these lasted for more than a few minutes each. He had not been shown to a doctor on those occasions.\r\n\r\nHe also had urinary tract infections (UTIs) twice, at ages two and four respectively. These resolved with antibiotic therapy and had not been investigated further.\n\nHe is not on any medications and has no known allergies.\n"}]}


{"ops":[{"insert":{"image":"\/storage\/case-images\/cs\/S23_F6.jpg"}},{"insert":"\n\n"},{"insert":"\u0022His vitals are stable. On abdominal examination, there was tenderness in the left hypochondrium and lumbar region, and a ballotable left kidney - which is why we paged you\u0022, the doctor concludes.\n\nYou thank him, and after introducing yourself to Andr\u00e9\u0027s parents, proceed to reconfirm the findings yourself.\n"}]}


{"ops":[{"insert":{"image":"\/storage\/case-images\/cs\/S23_F7.jpg"}},{"insert":"\n\n"},{"insert":"You obtain a thorough history, but no new facts come to light.\r\n\r\nAbdominal examination confirms the presence of tenderness over the left hypochondrium and lumbar region, and that the left kidney is ballotable.\n"}]}


{"ops":[{"insert":{"image":"\/storage\/case-images\/cs\/S23_F8.jpg"}},{"insert":"\n\n"},{"insert":"You perform a bedside ultrasound scan, and note that the left renal pelvis and calyces are severely dilated, although the renal parenchyma appears normal. The left ureter does not seem to be dilated, and no stone shadows are present.\r\n\r\nThe right kidney and ureter appear normal.\n"}]}


{"ops":[{"insert":{"image":"\/storage\/case-images\/cs\/S23_F9.jpg"}},{"insert":"\n\n"},{"insert":"The clinical and imaging findings point towards a provisional diagnosis of ureteropelvic junction obstruction (UPJO) complicated by moderate hydronephrosis.\r\n\r\nAndr\u00e9\u0027s parents look confused and shocked when you brief them on this possibility. You stress the need for admission and further urgent investigations, to which they immediately agree.\n\nWhile the ED staff busies themselves with the relevant administrative work, you consider Andr\u00e9\u0027s immediate management. Relieving his pain is the most urgent priority.\n"}]}


{"ops":[{"insert":"How will you alleviate the pain?\n"}]}
1. Intramuscular (IM) morphine
2. Intravenous (IV) morphine
3. Rectal diclofenac