H.B. is a 56-year-old, married, white college professor who woke up to severe and intensifying pain in his left flank region this morning. He presented to the emergency room in severe acute distress with significant anxiety, pallor, and diaphoresis. He could not sit still on the ER bed but continued to move around, constantly repositioning himself. Groans from pain were constant. He developed nausea from the pain and vomited twice. The ER nurse gave him promethazine hydrochloride IV for nausea. Since he reported an allergy to meperidine, he was also given morphine IV for pain.

• Tonsillectomy for chronic earache and sore throat, age 6
• Non-Hodgkin's T cell-rich B-cell lymphoma, age 48, treated with 6 monthly sessions of CHOP, currently in remission
• IgG immunodeficiency disorder; possibly secondary to lymphoma or chemotherapy, age 52
• Zenker diverticulum, age 52
• Renal stones: ages 35, 43, 52 (all passed spontaneously)

Other than a skin allergy with meperidine, the patient has no other known allergies. He does not smoke or drink. He gets very little exercise and lately has not been compliant with instructions from his PCP to remain hydrated. He is taking rabeprazole daily for acid reflux associated with Zenker diverticulum (ZD). ZD also interferes with his ability to swallow. He is receiving gamma globulin infusions as needed for his immunodeficiency condition, usually once every 5-6 weeks. He is taking one chewable multivitamin tablet daily and one chewable 500-mg vitamin C tablet every day to help boost his immune response.

Vital Signs

T = 98.4°F; BP = 130/86 sitting, right arm;
P = 90; RR = 16; Ht = 5' 11", Wt = 182 lbs.

HEENT

• Conjunctiva clear
• Fundi are without lesions
• Nasal mucosa is pink without drainage
• Oral mucous membranes are moist
• Pharynx is clear and pink

• Pale, cool, and clammy without lesions or bruises
• Surgical scars from lymph node biopsies on lower abdomen and groin region
• Surgical scars on the back from removal of several sebaceous cysts and biopsy for suspected melanoma (biopsy was negative for cancer)

Neck

• Supple with no lymphadenopathy or thyromegaly
• 2-cm sebaceous cyst noted in the dorsocervical region
• No bruits auscultated

• Chest expansion is symmetric and full
• Diaphragmatic excursions are equal
• Lung sounds are clear to auscultation

Heart

• Regular rate and rhythm
• No murmurs, gallops, or rubs

Abdomen

• Non-distended
• Bowel sounds are present and normoactive
• No hepatomegaly or splenomegaly
• No tenderness or masses
• No bruits auscultated

• Cool
• No edema
• Peripheral pulses full and equal

Neurological

• Alert and oriented but anxious
• Strength 5/5 in all extremities
• DTR 2 + bilaterally
• Sensory intact to touch

CT Scan

• 6-mm radiopaque stone in left mid-ureter
• 1-mm radiopaque stone in inferior calyx of right kidney

Urinalysis

• The patient voided a urine sample in the ER, and microscopic analysis of the specimen revealed significant numbers of RBC and WBC.

The stone passed spontaneously within three hours and the patient was released. Stone analysis revealed that the primary component was calcium oxalate. The urologist ordered a blood chemistry panel and a 24-hour urine collection test.

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Abbreviations

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Abbreviations

Renal system physiology

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Renal system physiology