A 55-Year-Old Man With Recurrent Sharp Flank Pain

Jyoti Wadhwa, MBBS, MD; Madhavi Tripathi, MBBS, MD; Madhur Kumar Srivastava, MBBS


September 14, 2017

Physical Examination and Workup

Upon physical examination, his oral temperature is 98.6°F (37°C), his pulse is regular at 90 beats/min, his blood pressure is 136/80 mm Hg, and his respiratory rate is 16 breaths/min. The patient is noted to be uncomfortable as a result of his flank pain but is in no acute distress. The examination of his head and neck is normal. His lungs are clear to auscultation, and he has normal cardiac sounds. His abdomen is soft and nontender, with no palpable masses. Mild costovertebral angle tenderness is present on the right side. A neurologic examination does not reveal any abnormal findings.

The initial laboratory studies show hematuria, with 75-100 red blood cells per high power field, and a normal creatinine level of 0.8 mg/dL (70.72 µmol/L). An ultrasound is performed, which reveals a stone of 13 mm in size in the right renal pelvis. After being given intravenous ketorolac, his pain resolves, and he is discharged home.

Because of his recurrent nephrolithiasis, a follow-up is arranged with urology, at which time he undergoes further testing. A laboratory workup reveals a serum ionized calcium concentration of 6.1 mg/dL (1.53 mmol/L; reference range, 4.5-5.6 mg/dL) and a 24-hour urinary calcium of 390 mg/24 h (9.75 mmol/24 h; reference range, <300 mg/24 h). Parathyroid scintigraphy is performed (see Figures 1 and 2).

Figure 1.

Figure 2.


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