A 45-year-old man comes to his physician after spending a second sleepless night with excruciating lower abdominal pain. The pain seemed to come in waves and was unrelieved by aspirin, tylenol, a six-pack of beer, or lying or standing in any position. He had not experienced any similar pain before. On physical examination there are no abnormal findings.

Questions:

1. What abnormal findings are present?

There is cloudiness with microscopic hematuria.

2. What is the differential diagnosis?

Hematuria can be due to numerous causes: inflammation, trauma, glomerulonephritis, calculi, instrumentation, neoplasms, etc.

3. What diagnosis do you suspect?

The severe pain suggests a renal calculus.

4. What other studies could be done?

Radiographic studies. A plain film will demonstrate about 80% of stones (those with calcium). An IVP may show a filling defect. The urine could be strained to catch a passed stone so that it could be sent for analysis. Uric acid stones suggest gout, magnesium ammonium phosphate stones suggest urinary tract infection.