A fifty three year old male presented to the emergency room with left flank pain. After being administered with some pain relievers, the physician asked for a renal ultrasound scan to assess the kidney organs to rule out a renal pathology.
a. Ultrasound uses high frequency sound waves whch are transmitted using a transducer that is olaced against the skin. The sound waves are passed to the body which then bounce back to the transducer and produces echoes which are transformed to an image of the organ of interest. During a renal ultrasound, patient prepararion is required before the actual process of scanning. The preparation includes filling the bladder to mean that the patient is required to take atleast four glasses of water one hour before the examination. During the period of the examination, the patient is required to stay calm and not empty their bladder.
When the patient is ready, the patient has to agree to the consent form through signing it. The patient then takes off their personal clothing and put on the hospital gown and the patient should also remove jewellery. The patient should lie prone on the examination table and the conducive fel is applied to the body are of interest. The main positions for the renal ultrasound include; supine, prone and oblique. The transducer is then rubbed against the skin on the area where the ultrasound gel has been applied. The procedure involves no pain or any invasive processes although the gel that is used for the examination may feel cold.
b. The examination of the patient who had presented with the left flank pain differed a little bit with the routine examination. First, the positioning of the patient was oblique because the left kidney could be easily accessed in that position. For most ultrasound examinations, the patient is ususlly required to lie supine but in my case I had to device a position that would provide the best results. The oblique position improved the imaging strategy for the left kidney while fro the right kidney, the patient was positioned on supine position. Furthermore, when examining the urinary bladder, the patient was positioned supine to check the bladder thickness as well as the volume.
The images taken were of both kidneys and the urinary bladder. In each image taken there was the measurement of the size and also others showing the vascularization. The left kidney images also showed a measurement of the sizes of the kidney stones and their locations.
a. The left kidney appeared to have the urolithiasis and hydronephrosis but appeared normal in size and shape. The sonographic appearance of the left kidney stones included; echogenic focal areas with acoustic shadowing and did not pick any color of Doppler flow. The stones were three in numbe with two of them located on the middle pole of the left kidney and the other one in the upper pole of the kidney. The kidney stones were average in sizes with the largest having the measurement of 0.92cm by 0.8cm. The pulsed wave Doppler was further used to check if there was any other complication of the kidney. The left kidney did not show any signs of obstruction since the renal resistive index was of the normal range.
Concerning the hydronephrosis on the left kidney, the sonographic appearance was large hypoechoic areas at the middle of the kidney. The renal pelvis further showed some dilatation which extended to the kidney parenchyma. On the other hand, the right kidney appeared normal in size, shape, echo texture and echo pattern. The vascularization of the right kidney was also normal on color Doppler.
b. The primary differential diagnosis for the case mentioned above include; renal infarction. The mentioned condition is a likely primary diagnosis because the stones could cause the blockage of blood vessels which cause thrombus. The formation of thrombus defines the renal infarction which blocks the renal artery and could end up causing renal failure.
c. The pathophysiology of renal stones include the collection of crystals from the highly concentrated urines which then stick to the urothelium and eventually forms the stones.
The report from the radiologist demonstrated similar results as mine since the final diagnosis was left renal stones.
The patient was released with medications to help relieve the pain and to also help shrink the renal stones. In combination with the diagnosis, there were other laboratory tests ordered such as the calcium levels in the body and the urine PH to help in the clinical relation.
Apart from the control through diet where I advised the patient to moderate his sodium intake, I also suggested a follow-up scan to check the progress of the renal stones.
The four most likely differential diagnosis for a ptient with gross hematuria include;
Cystitis refers to the inflammation of the urinary bladders which could either swell, turn red or even cause some irritation. The most common cause of cystitis is the urinary tract infection which occurs when bacteria enters the bladder and that to reproduce hence causing the condition. The condition may also be cauased by some imbalance of bacteria in the body which then leafs to infection casuing inflammation. Apart from the infection, there are other possible causes like induction b certain medications, getting exposed to radiations and also the use of some hygiene products.
Cystitis mostly present in form of the increased urge to urinate, urine with a strong odour, appearance of blood in the urine, abdominal cramps and some feelings of bladder fullness every time.
Pyelonephritis is caused when there is an invasion of the ranl parenchyma by bacteria. The bacteria are transmitted to the kidneys through the ascension from the lower urinary tract. The bacteria can also reach the kidneys through the bloodstream. The bacteria can cause the gross pathology such as the formation of abscess and renal edema. The conditions above may cause scars which are irreversible and could eventually lead to renal insufficiency. On radiological diagnosis, pyeloonephrotos may appear as abnormal histological transformations to the renal system due to infection. The changes may include; fibrosis, interstitial inflammation, renal scarring, and tissue destruction.
Prostatitis referes to the inflammation or te infection of the prostate gland whereby an individual will present with a variety of clinical features. Prostatitis is a common urological condition in men mostly of ages fifty and below. Prostatitis could consists of acute and chronic bacterial prostatitis and the non-bacterial prostatitis. Majority of the acute bacterial prostatitis occur due to the ascension of the urethral infection. The infection can also occur from the lymphatic or direct spread from the rectum or from a bacterial sepsis. The organisms responsible for the condition include the E. Coli, Pseudomonas and Enterobacter. The other cause os the sexually transmitted infections like gonorrhea and chlamydia. The chronic bacterial prostatitis is thought to be due to the insufficient treatment of acute bacterial prostatitis.
Nephrolithiasis refers to the urinary stone disease which could be caused by some mechanisms. The major phenomenon is where the stones are formed from high saturated urine which contains the oxalate, uric acid, and calcium. The foreign bodies or the crystals get attached to the ions from the super concentrated urine to form some microscopic crystalline substances. The renal calculi formed will give rise to some symptoms like pain as they try to be passed to the urinary bladder.
The sonographic appearances of cystitis include the distension of the urinary bladder but with thickened and irregular walls. When the thickness of the urinary bladder walls in cystitis is measured, it could give a value more thhan 7mm. However, the normal wall thickness in a urinary bladder should be 3mm in a case where the bladder is fully distended and any value above the mentioned is termed as cystitis. In a case where the urinary bladder is not well-distended, the walls should not go beyond a measurement of 5mm.
Sonographic features of pyelonephritis include the altered echogenicity in the renal parenchyma where regions with edema will appear hypoechoic while those areas with hemorrhage appear as hyperechoic. There could also be appearance of some debris in the collecting system and on color Doppler, the vascularity is decreased. The other appearance is the enlargement of the kidney with some scattered echoes which are low leveled.
Similar to the pyelonephritis, prostatis appears as hypoechoic, irregular and thickened capsules. There is increased vascularity at the periphery of the prostate gland on color Doppler.
The sonographic appearance of the kidney stones or nephrolithiasis includes echogenic focal areas with acoustic shadowing and they do not pick any color of Doppler flow. Unlike pyelonephritis, the renal stones are hyperechoic. The stones appear as bright spots compared with the other renal parenchyma.
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