Vicky James and Owen Seagraves.
Vicky James and Owen Seagraves.
Urinary System Case Study
To help us understand how the urinary system functions, let’s meet two patients—Vicky James and Owen Seagraves. Each is visiting general practitioner, Dr. Pandit, to express some concerns about symptoms that seem, in some ways, to be very similar, and yet, in other ways, seem to indicate different disorders altogether.
Vicky is a third-grade teacher and an avid hiker. Owen is an athletic director at a small college. These two patients have never met, although in the small tourist town in which they both live, they happen to share the same physician—Dr. Pandit.
Dr. Pandit’s nurse calls Vicky into an examination room first. Vicky says she has not been feeling well lately. She primarily complains of blood in the urine but is also concerned about swollen ankles and back pain. The nurse takes her blood pressure and asks Vicky for a urine sample.
Unlike Vicky, Owen says at first that he has “no urinary symptoms” that he can identify, but that, instead, he has been having what he refers to as “gas pains that are getting worse and worse—I mean, excruciating.” He says that these pains also give him nausea. In addition, he has the same leg swelling Vicky reports but also complains of a rash.
Only when asked about elimination does Owen think to mention a “slight decrease” in urine output but an increase in the number of times he has to get up in the middle of the night.
The similarity of some of Vicky and Owen’s symptoms intrigues the nurse who takes their histories. After the remainder of her intake interview with her patients, the nurse muses that they both have flank pain and leg swelling and both mention that they are exhausted. However, one has weight loss and blood in the urine, whereas the other has less urine overall.
During pre-examination interviews, the nurse discovered that both Vicky and Owen have high blood pressure today.
The nurse also records that Vicky has a fever. She is curious to see how the Dr. Pandit will approach each patient’s symptoms.
Owen is having minimal difficulties with urination, but he does have troublesome side pains. Dr. Pandit suspects—among other things—that a blockage could be in Owen’s urinary system, perhaps a stone. In fact, evidence of a stone in the ureters often begins as side pain that eventually shifts to the lower back.
After color analysis, the next test Vicky’s urine undergoes is a pH test, which is used to determine to what degree the urine is acidic or alkaline (basic). The abbreviation pH stands for potential hydrogen. Urine pH may become alkaline with a bladder infection because the bacterial breakdown of urea releases ammonia, which is very alkaline.
In addition, one of the earliest signs of renal involvement in diabetes mellitus is the presence of an abnormal amount of albumin, a major blood protein in urine, a condition called albuminuria (albumin/o = albumin; -uria = urine condition). A special, sensitive urinalysis test can aid in detecting albumin. The presence of too much glucose (glyc/o), or sugar, in the urine is called glycosuria and is an indication of diabetes mellitus.
A urinary tract infection (UTI) is usually classified as either an upper UTI or a lower UTI. Upper UTIs are in the kidneys and ureters, and lower UTIs affect the bladder and urethra. In Owen’s case, not only is an infection present, but Dr. Pandit is also beginning to suspect Owen’s bigger problem is acute renal failure—possibly caused by an obstruction.
Renal failure is what its name indicates. The kidneys (ren/o) fail to excrete urine because of impaired filtration function. A large number of conditions, including high blood pressure, infection, and diabetes can lead to renal failure, which may be acute or chronic. The severity of renal failure can vary. The final phase of the chronic version is end-stage renal disease or chronic kidney disease (CKD), which can be fatal if not treated.
Owen’s particular inflammation occurs in the connective tissue that lies between the renal tubules, or the renal interstitium; this condition is called interstitial nephritis. In Owen’s case, this condition is a response to his recent administration of a penicillin medication for tonsillitis. The condition can also develop from the excessive use of aspirin and aspirin-type drugs. Signs and symptoms may include poor renal function, a fever and skin rash similar to the one shown in the illustration, and eosinophils in the blood and urine.
Dr. Pandit takes his patient off the offending drug to clear up the nephritis.
remember that Dr. Pandit suspects—among other possibilities—that Owen may have a urinary blockage. A blockage can be caused by long-term medication use or long-term use of an indwelling urinary catheter, which can produce scarring and thus cause a fibrotic narrowing of the urethra, called urethral stricture. The patient experiences diminished force, dysuria (painful urination), polyuria (urinary frequency), and hesitation.
Owen’s next test is scheduled, but before the day arrives, the pain in his side returns and is worse than ever. The pain is also now occurring in his back. Owen calls Dr. Pandit’s office to tell him that the pain is so bad he is sweating profusely and vomiting. Dr. Pandit tells Owen to get to the emergency department right away.
From these symptoms, Dr. Pandit quickly moves to confirm his earlier suspicion and takes action. Owen, indeed, has nephrolithiasis—that is, the condition (-iasis) of having kidney (nephr/o) stones (lith/o), or renal calculi.
Let’s return to our patient, Vicky.
Blood in the urine, along with symptoms such as pain in her back, swelling, high blood pressure, and fatigue, all suggest some sort of nephropathy, that is, a kidney disorder. Yet Vicky does not have a urinary tract infection, nor does she show evidence of having a kidney stone.
At one point, Dr. Pandit thought that the pain and a feeling of a lump in Vicky’s side might mean a nephroptosis—that is, a dropping or displacing (-ptosis) of the kidney (nephr/o) because of weak support. Her other symptoms, however, do not support that diagnosis.
Blood in the urine, pain, and/or a lump in the back (or side), along with leg and ankle edema, can all signal a number of disorders, of course; however, one of the more serious is renal cell carcinoma, or a cancerous tumor of the kidney (also called hypernephroma). In Vicky’s case, diagnostic sonography revealed renal cell carcinoma.
Being physically fit helps Owen make a quick recovery from the lithotripsy procedure. However, treatment is still far from over. Now that the primary cause—nephrolithiasis—has been treated, Owen, “happy and stone free,” can now be treated for secondary acute renal failure, a complication of his kidney stones. This treatment consists of the administration of the hormone erythropoietin to stimulate the production of red (erythr/o) blood cells (-poietin = substance that forms).
Now that his kidney stones have been treated, Owen’s treatment can focus on preventing the buildup of toxins by restricting his fluid intake, along with other dietary modifications. Owen is also given antibiotics and diuretics. The next focus is on bringing a potentially dangerous hyperkalemia (increased blood potassium) under control (Kal/i = potassium). Owen is intravenously (IV) administered calcium, glucose insulin, and oral potassium exchange resin. Finally, his blood pressure is brought back under control.
Soon Owen is back at work. Along with his regular exercise routine, he watches his sodium intake and has regained all of his former energy.
Six months later, life is looking much better for both Vicky and Owen. Both appear to be in good health after potentially life-threatening disorders. Vicky, of course, will continue to receive blood tests to check for kidney function at 3- or 4-month intervals for several years. Chest x-ray images, CT scans of the abdomen and chest, and other imaging tests will help monitor for any recurrence of the cancer.
When they both left Dr. Pandit’s office after follow-up visits, the nurse remarks, “Those two amaze me. Just think, not so many decades ago, recovery would have been a lot more difficult for both of them.”
Dr. Pandit nods, “And maybe out of reach.”
