Let's turn to another clinical case.
We have a 49-year old gentleman who presents to
clinic for further evaluation of a recent kidney stone
diagnosed in the emergency department one week prior
He has a history of hypertension
and gout both diagnosed 10 years prior.
He admits that he's not been very vigilant
about taking his medications on a regular basis
because his work schedule
has been pretty, pretty labored.
He's a construction foreman and
he works about 16 hours per day.
His physical exam is remarkable for central
obesity, elevated blood pressure at 148 over 90
and then erythematous tophaceous
painful joints involving his metacarpal joints,
his PIPs in the 2nd and 3rd digits in both of his hands.
So before we move on, what are some of the clinical
clues in the history and physical exam that can help us
with the cause of this patient's stone?
Let's take a look.
He has a history of gout, potentially uncontrolled because
remember he can't always take his medications regularly.
He's working as a busy construction
foreman, puts him at risk for stone formation
if he doesn't have adequate water intake.
And finally, his physical exam is very interesting.
It shows an inflammatory arthritis with involvement
of both the MCPs and PIPs along with tophi.
That's really suggest of gouty arthritis.
So taken together, the history and physical exams
suggest that this patient likely has uric acid stones.
So what should be done to evaluate this patient?
We want to do both the basic
and complete stone evaluation.
We're talk about what that means in the upcoming slides.
What are some of the important clues on physical
exam that can help us with his particular stone work-up?
Remember our patient had this tophaceous-looking gout,
very suggestive again of having underlying uric acid stones.
And this image shows this inflammatory arthritis involving
both the MCPs at the right and left upper extremities
and PIP involvement as well.