Case Presentation 1

Okay ya’ll.

I know it’s been a hot minute. Sorry about that. BUT! I’ve seen the results of my polls and I will try to make more of these. This is my first attempt at adding quizzes to posts, so hopefully it is helpful in learning what the next steps are, what to order, and to help expand your differentials. I hope you learn you some things. THIS IS LONG. There are multiple things in here to learn/quiz about.

Also, it forces me to learn and re-learn this as well. Have fun!

Case:

23 y/o Female presents to the emergency room for severe left sided flank pain onset 3 hours ago. She was at home studying when her pain began. It is currently rated a “10/10”, is sharp, and feels like it radiates down to her L abdomen. She started having nausea and vomiting an hour ago which prompted her to come into the ED. No reported fevers. She denies any recent fall or trauma to the area. She has had similar symptoms previously.

PMHx: Kidney stones in the past, otherwise relatively healthy.

PSHx: tonsillectomy and adenoidectomy at age 5.

PE:

Vitals: HR is 107 BPM. RR is 14. Pulse ox is 98% on RA. Temp is 36.4’C.

General: In moderate distress due to pain. Walking around the room unable to sit still.

CV: Heart is tachycardic, but regular rhythm with normal S1 & S2. Radial pulses are 2+ and equal bilaterally.

Resp: Lungs are near to auscultation bilaterally. In no respiratory distress.

Abdomen: soft, non-distended. +CVA tenderness to left, none to right. Minimal tenderness to LLQ to palpation. No tympany. Bowel sounds present in all 4 quadrants.

Neuro: Alert and Oriented x3. CN II-XII grossly intact. All 4 extremities are neurovascularly intact with normal motor and sensation.

Let’s pause and take a look at things.

Well, let’s talk.

We have a young female, with flank pain, nausea, and vomiting who has had similar symptoms in the past. She has a family history of kidney stones. Otherwise, she is relatively healthy. On exam, she is afebrile but tachycardic, likely from pain. She has + CVA tenderness to her left side and minimal tenderness to her LLQ. Otherwise, her exam is normal.

We have an inkling that this is kidney stones. And in simple terms, we could consider that since this is the likely cause of her symptoms, we can do a workup and make sure there are no other concerning findings.

Results:

CBC showed an elevated WBC at 13.3, hemoglobin at 14, and platelets at 300,00.

BMP showed normal electrolytes except for a Ca of 15, and a creatinine of 2.0.

HCG was negative for pregnancy.

UA was negative for bacteria, WBC’s, leukocyte esterase, or nitrates. It was positive for blood.

CT showed the following:

Remainder of the CT results mentioned another stone in the UPJ, several in the bladder and not seen on the above image, but several renal calculi in bilateral kidneys. Hydronephrosis is present on the left. No other pelvic findings.

Okay, so I did you a solid and tried to wean the important information for you. I only gave you what you need to know in order to make the next steps. 

*Note* If you need help interpreting what the above means, let me help you. White count can be elevated from infection, inflammation, and stress. In general, infections tend to spike white counts. In something like severe sepsis, it is not uncommon to see a WBC of 20,000. But if it is slightly bumped (as in this case), it is likely due to inflammation/stress on the body. The hemoglobin and platelets are good here. If hemoglobin was down, we would want to look for bleeding. Same with platelets. Although platelets can be normal with a low hemoglobin, platelets can also be low with a normal hemoglobin indicating a clotting issue using up the platelets or issue making platelets.

For BMP, you need to know that creatinine tells us kidney function. In this case, her kidneys are not happy. Not happy kidneys = not good. She is young and healthy, so with some fluids and finding out the problem/fixing it, her kidneys should go back to normal. Just be aware that a bump in creatinine means kidney injury. Trending this number is important. Obviously, a high calcium is easy to spot. Well, an out of whack electrolyte in general is easy to spot.

As for the UA, we are worried about an infected stone. If you see stones AND a positive urinalysis, we worried. Infected stones involve more treatment and much more observation. We want to keep a closer watch. But she is afebrile, and UA is negative. So this is good stuff. Also, look for epithelial cells. If you see epithelial cells (like more than 0-1) the sample is contaminated. For positive/infected UA, your biggest answer is actually in the nitrates. Nitrate positive urine tells us more than bacteria or WBC. A true infected sample (like really bad UTI) would have all 3 likely. But if you are unsure, nitrate + will always yield a + UA. Whereas bacteria present can be falsely leading as if it is contaminated with skin cells (epithelial cells) then bacteria will be present. SO DON’T JUST LOOK AT THE BACTERIA PEOPLE.

Stop here and think about what all this information is pushing us towards.

We now know she has kidney stones, likely the cause of her pain given the hydronephrosis. But she has MANY kidney stones. Normal dehydration or medications likely wouldn’t cause this many at one time, at least not passing all at once. It is normal to have several in the kidney, but they may never leave the kidney or they may dissolve in the kidney. In this instance, many have passed.

Also, she has no infected stone which is good based on the UA results and being afebrile.

However, her calcium is really high. Oh, and she has renal injury based on her creatinine numbers.

You go back to ask some more history…

After further questioning, she tells you that she had started having pain days ago, but since it resolved she didn’t think much of it until tonight when symptoms re-appeared and she started vomiting. She has also been fatigued “for a while” but feels it is stress related. She is usually constipated “all the time” but states this is relatively normal for her and has intermittent myalgias and bone pain.

The following labs you ordered returned:

PTH: Elevated

Phosphorus: decreased

Vit D: level within normal limits.

Medical Decision Making (Try to do this on your own first!):

This is a 23 y/o F who presented to the ED for severe L sided flank pain with N/V with a history of kidney stones. Upon further investigation, she had reported similar pain for days, in addition to chronic symptoms of constipation, fatigue, and myalgias/bone pain. She has a family history of kidney stones. On exam, she is afebrile, with + CVA tenderness to her L and LLQ pain. Studies showed multiple stones present in the GU system with hydronephrosis, but no urinary infection. Her WBC is slightly elevated, likely due to pain and stress response. Her calcium and PTH were elevated. Her kidney function was elevated as well, likely multifactorial with stones, hydronephrosis, and hypercalcemia. She was given pain medication, and started on IVF, calcitonin, and bisphosphonates. She will be admitted for further management to medicine with consult to urology.

Let’s talk about causes of hyperparathyroidism!

Hyperparathyroidism can be caused from many reasons (see images below for difference between the types). In layman’s terms, PTH from the parathyroids causes an increase in calcium resorption and circulation in the body. Whereas calcitonin decreases circulating calcitonin. I’ve added added a handy dandy brief pic/flow chart on how PTH works. It’s the basics, but should help jog your memory!

Primary hyperthyroidism is a problem with the main gland itself. In this case, that would be the parathyroid gland. Something regarding the gland itself is causing the issue. Such as hyperplasia (enlarged), adenoma (benign tumor), or carcinoma (cancer/something like small cell lung carcinoma which secretes PTHrp or parathyroid hormone-related protein which mimics PTH in the body). Long story short, the cancer creates a peptide similar to PTH, and it circulates in the body mimicking things and the body responds as if it were PTH. But that’s a different discussion.

Secondary is as it sounds; the cause is secondary or outside of the gland itself. Can be from many causes. Renal failure is probably the biggest one. Basically, another part of the chain above is not working properly. Due to this, the body increases PTH to try to increase the calcium levels that the body desperately needs.

There is also tertiary. Long story short, this is basically also due to renal failure, but long term effects of it.

So in her case, she had primary hyperparathyroidism. We know this because we also checked her phosphorus and vitamin D levels. Sure, we could say her kidneys caused it, but this is less likely given her young age and no prior medical problems. We would have to trend her creatinine to know for sure, but the above two levels may also be normal in this state.

While admitted…

Urology saw the patient to place a ureteral stent to her left ureter to help pass her obstructed stone. This will also help with her hydronephrosis.

As an astute med student now looking at the case, you think endocrine should be involved. As a healthy young woman with primary hyperparathyroidism and a family history of a “syndrome”, but no other clues, you are considering a neuroendocrine cause. You think it is MEN syndrome, particularly MEN1.

MEN Syndromes: There are 3 types. They are genetic mutations and run in families. Typically, you are diagnosed when a child or when young as you present with symptoms by this point. (I’ve changed this case a bit from what I actually saw hence why this patient is older here). Tumors develop on multiple endocrine glands and cause excess of hormones. Tumors can be benign or cancerous and it is important to check other endocrine glands as well. Although there is an easy chart/way to remember MEN syndromes for testing purposes on exams, in real life there is more cross-over between the endocrine glands.

Back to the case…

Because of the concern for MEN1, she also underwent imaging studies to evaluate her pituitary gland, parathyroids, and pancreas.

CT brain showed no tumors or hyperplasia of the pituitary gland.

CT abdomen/pelvis showed no abnormal findings.

Thankfully in our case, there are no other glands affected at this time. We would need to do a genetic screen on her and her family members to confirm MEN syndrome type 1, but that can be done at a later time.

Treatment for hyperparathyroidism is as follows:

• Surgical therapy is the most common/gold standard. So a parathyroidectomy would need to be done and then the patient would need to be on hormone replacement with her calcium and vitamin D levels monitored.
• Medically includes hydration and exercise, along with moderating calcium and vitamin D intake. Although this is not recommended unless the patient is not a surgical candidate.

At this point, I’m not going to go into the whole surgical aspect and the actual surgery portion for this case. You are welcome to look up a total versus a subtotal parathyroidectomy though!

Well. That was long. And also hard to actually create. I know it isn’t amazeballs by any means but I do hope it helped you figure out how you should be thinking! Until next time. Cheers!