A 56-year-old male was brought to the emergency room with a chief complaint was right flank pain.

History of present Illness:

One day prior to admission, the patient developed a change in the color of his urine from pale yellow to red in color. There was no associated fever, painful urination, or penile discharge. He decided to consult with his primary physician the following day.

One hour prior to admission, the patient developed severe right flank pain associated with nausea. Upon admission, the patient was noted by the ER physician to be in severe pain, with a pain scale of 9 from a visual analog pain scale from 1  to 10. On physical exam, patient had the following findings:

• Vital Signs BP: 140/90 mm Hg
• Heart rate: 110 bpm
• Respiration rate: 15 breaths per minute patient
• Temperature: 98.6 deg C
• All exam findings for the head, neck, heart, lungs, and abdomen were normal.
• On examination of the back, patient had tenderness on the right flank upon palpation.
• On examination of the genitalia, there was no penile discharge.
• Note of a 1 x 1 cm tophus on right big toe.

The following diagnostic exams were ordered

• CBC with WBC differential count
• Urinalysis
• Serum uric acid
• KUB x-ray
• MRI Scan abdominopelvic area

Past Medical History:

• Diagnosed with gout one year prior to admission
• On medication with allopurinol
• No heart and lung disease
• No diabetes or hypertension

Click here to review the results of the diagnostic exam.

Questions and topics for discussion:

1. After considering his signs, symptoms, findings, and diagnostic exams, what would be the clinical diagnosis in this patient? (1 pt)
2. What is causing the hematuria to occur?  (1 pt)
3. Why are his vitals (BP, HR, breathing) elevated? (1 pt)
4. What is causing the severe right flank pain? (1 pt)
5. How are the elevated levels of serum uric acid and positive uric acid crystals in the urinalysis related to your diagnosis? (1 pts)
6. What pain medication would you provide to this patient? Why would you choose this medication? (2 pts)
7. What treatment would you recommend for removing the cause of his pain?  Explain your answer.  (3 pts)

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