Question of the Week # 45

A 45 y/o woman presents to the Emergency room with complaints of severe flank pain and nausea. Patient’s past medical history reveals chronic smoking and occupational exposure to aniline dyes. Physical examination reveals mild right costo-vertebral angle tenderness. The patient is afebrile. Labarotory investigations reveal urine dipstick positive for blood but negative for leucoesterase and nitrite. Urinalysis reveals numerous RBCs per HPF. There are no RBC casts or WBC casts. Urine HCG is negative. The next step in managing this patient’s condition  is:

  • A) Start intravenos antibiotic therapy
  • B) Non Contrast CT scan
  • C) Contrast enhanced CT Scan
  • D) CT urogram and Cystoscopy
  • E) Ultrasonography

9 Responses

  1. B … for kidney stone

  2. aniline dye and smoking bladder cancer D

  3. this women has flank pain which means she has kidney pathology….but her exposure to smoking and aniline dye puts her at increased risk of bladder pathology…….at the end you treat her symptoms, so i will go with kidney pathology …so ‘B’ shud be the answer.

  4. Ans. B

    This patient’s clinical features as well as hematuria on urinalysis suggest renal colic from possible urolithiasis. Non Contrast CT is the best and first imaging test of choice in evaluating renal calculi ( do not choose plain x-rays or ultrasound. Ultrasound is optimal only in pregnant patients). The patient is at risk for bladder cancer however, her current symptoms of acute painful hematuria suggest a renal colic not a bladder malignancy.

    A. is not correct as this patient has no evidence of pyelonephritis or UTI ( absent wbc casts, absent wbcs or fever, no leucoesterase or nitrite on dipstick).

    C. is incorrect because CT urogram involves administration of contrast after a initial non contrast study. A non contrast CT is sufficient in most cases to evaluate the presence of stones ( except Indinavir stones in HIV positive patients on HAART where a contrast CT is preferred). Cystoscopy is not needed as acute flank pain with hematuria in this patient favors renal calculus more than a bladder cancer.

    D. IVP is incorrect since non contrast CT is the best test to visualize the stones.

    E. is incorrect because Non contrast CT is better than ultrasound in visualizing the renal calculi

  5. wow,amazing ques

  6. D

  7. Yes, cancer is PAINLESS hematuria, reading comprehension is key

  8. E

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