NSG 3370 WEEK 4 ASSIGNMENT 2 (DISCUSSION)

NSG 3370 WEEK 4 ASSIGNMENT 2 (DISCUSSION) A 56-year-old female comes into the clinic complaining of intermittent severe pain that radiates from the flank to the groin and sometimes to the inner thigh. Upon further questioning she tell you that she has an urge to always go to the restroom and that she sometime sweats and feels nauseous. A urinalysis provides traces of blood, a few white blood cells and no bacteria. • What is your differential diagnosis? Discuss in detail the pathophysiology of each item in your differential and how it might fit in describing this case. • The x-ray comes back and there is nothing abnormal except a slightly dilated ureter. Does this change your differential or narrow it? • How would you treat the pain in this case? Differential Diagnosis: Nephrolithiasis is due to an increase in excretion of stone-forming components such as calcium, oxalate, urate or cystine; the stones are called renal calculi (Sakhaee, Maalouf, & Sinnott, 2012). The prevalence of kidney stones in the U.S. population is 6-12% and has become a major health burden for those who suffer with “chronic kidney disease, nephrolithiasis-induced bone disease, increased risk of coronary artery disease, hypertension, type 2 diabetes mellitus, and the metabolic syndrome” (Sakhaee et al., 2012, p. 1848). Nephrolithiasis is more common in white males between ages 20-40, though the incidence in females is higher in the late 20’s and declines at age 50, but remains constant there after (Sakhaee et al., 2012). There are four different types of kidney stones, each are as follows: • Calcium – accounts for approximately up to 80% of all stones, that consist of calcium oxalate and phosphate, and can be cause by both genetic and environmental factors (McCance, Huether, Brashers, & Rote, 2013). • Uric Acid – is a type of stone that is created when the urine is persistently acidic; sometimes calcium may be found with this type stone (McCance et al., 2013). • Struvite – results from kidney infections, primarily contains magnesium-ammoniumphosphate and women tend to be more susceptible (McCance, Huether, Brashers, & Rote, 2013, p. 1344). • Cystine – is rare and from a genetic disorder that leaks cysteine through the kidneys and into the urine (McCance et al., 2013). Renal tumor or renal cell carcinoma (RCC) accounts for 2%–3% of all adult malignancies, representing the seventh most common cancer in men and the ninth most common cancer in women (Escudier et al., 2012). RCC is more common in patients with obesity, end-stage renal failure, acquired renal cystic disease and tuberous sclerosis (Escudier et al., 2012). RCC is due to genetics, autosomal, and hereditary. Symptoms are similar to kidney stones with complaints of flank pain, gross hematuria and palpable abdominal mass. Common risk factors with RCC is smoking and hypertension. The most common types of RCC is as follows: • Clear-cell RCC is the most frequent sub-type of sporadic RCC in the adult 70%–85%. The typical histological feature is the clear aspect of the cells due to glycogen and lipids in their cytoplasm. They are distributed in tubular and solid areas with a very prominent capillary stroma. The multilocular cystic RCC, composed entirely of numerous cysts lined by clear cells, probably is a variant of low aggressivity of this sub-type (Escudier et al., 2012). • Papillary RCC its name arises from the distribution of malignant cells around capillary cores (papillae) in 50%–70% of the tumor. In 73% of cases, they are type I (cells have scarce cytoplasm), and in 42% they are type II (eosinophilic cytoplasm). A strong expression of α-metylacil-CoA racemase is a typical feature (Escudier et al., 2012). • Chromophobe RCC just 5%–10% typical cells are polygonal with a clear delimitation of the cytoplasmic membrane (that gives them the appearance of a plant cell). The pale reticulated cytoplasm (chromophobe) is due to the presence of abundant cytoplasmic invaginated 150–300-nm diameter vesicles (Escudier et al., 2012). • Collecting duct RCC (Bellini tumors) is less than 1% of RCC are from the medullary distal nephron or Bellini ducts. The typical morphology of the cells is a high nuclear grade, eosinophilic cytoplasm, predominant tubular arrangement, desmoplasia and expression of high-molecular-weight cytokeratins. Medullary RCC is considered as an undifferentiated collecting duct carcinoma (Escudier et al., 2012). Interstial cystitis (IC) is known as a condition of discomfort and/or pain within the bladder and pelvic region. Studies have shown no true reason to what causes interstial cystitis, though researchers believe the causes maybe associated with other parts of the body or this maybe hereditary (NIH, 2013). Symptoms of IC maybe similar to those of bacterial infection, but without an organism (NIH, 2013). Further testing consists of uranalysis, urine culture, cystoscopy, and biopsy of the bladder wall and urethra. The patient may experience IC along with nephrolithiasis due to stones passing through the ureters and entering into the bladder. However, I find nephrolithiasis would be the primary fit for this case. The x-ray comes back and there is nothing abnormal except a slightly dilated ureter. Does this change your differential or narrow it? I would narrow it to nephrolithiasis; though it may be possible to a renal tumor, but a more definitive test would need to reveal such. Diagnosis for RCC would either need to be confirmed by CT and/or ultrasonography along with biopsy ((Escudier et al., 2012). Treatment for pain. Kidney stones can be very painful and depending on severity of pain and size will depend on treatment. For minor pain, Ibuprofen, Acetaminophen, or naproxen sodium would be appropriate. However, for severe pain an injection of Toradol IM and sending the patient home with Norco or Oxy IR may help relieve pain until the stone passes. Encouraging the patient to increase intake of oral fluids of water and juice will help assist with passing of small stones. If the patient experiences nausea oral Zofran can be prescribed. Escudier, B., Eisen, T., Porta, C., Patard, J. J., Khoo, V., Algaba, F., Mulders, P., & Kataja, V. (2012). Renal cell carcinoma: ESMO Clinical Practice Guidelines for diagnosis, treatment and follow-up. Annals of Oncology, 23(7), 65-71. doi: 10.1093/annonc/mds227 McCance, K. L., Huether, S. E., Brashers, Brashers, V. L., & Rote, N. S. (2013). Pathophysiology: The biologic basis for disease in adults and children. (7th ed.). St. Louis, MO: Mosby National Institute of Health. (2013). Interstial cystitis/painful bladder syndrome. Retrieved from: Sakhaee, K., Maalouf, N. M., & Sinnott, B. (2012). Kidney stones 2012: Pathogenesis, diagnosis, and management. The Journal of Clinical Endocrinology and Metabolism, 97(6), 1847–1860.