Kidney Ureter BladderKUB

Spiral I

Study Guide

Shifa College of Medicine

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Table of Contents

1. Introduction

2. Theme 1: Patient with haematuria

3. Theme 2 : Patient with generalised edema

4. Theme 3: Patient with oliguria / decreased urine output

5. Theme 4: Patient with progressive rise in serum creatinine

6. Theme 5: Patient with electrolyte disorder

7. Theme 6: Patient with acid base disorder

8. Theme 7: Patient with difficulty in passing urine

9. List of Recommended Books

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ومسلمه مسلم كل على فريضة العلم طلبSeeking Of Knowledge Is an Obligation Upon

Every Muslim, Be It A Man or A Woman   (Mishkaat)

INTRODUCTION

This study guide includes KUB module for 1st spiral. The duration of the module is 4

weeks each. The module will be delivered around seven themes. Clinical cases have

been developed for each theme. These cases will be used as triggers to deliver the

respective objectives, using different learning strategies.

Learning Strategies:

Large group interactive sessions

These sessions are used to introduce the clinical theme and to discuss concepts in an

interactive manner utilizing audiovisual aids.

Small group discussions

Some of the objectives included in the curriculum, are discussed in small groups of 8-

10 students. These sessions involve a facilitator who mainly controls the process.

These discussions are structured as reading the case scenario by students,

brainstorming within the group about the application of the learnt knowledge, and

clarification of concepts by facilitator.

Problem based learning sessions

PBL is utilized as one of the learning strategies for some objectives. Three sessions

for one problem are conducted with an interval of 1-2 days. In the first session

students identify objectives related to that particular case, followed by self assigned

tasks and discussions in the subsequent sessions.

Integrated practical sessions

Students are divided into groups which perform relevant practical in basic sciences

and clinical skill laboratories.

Self directed learning

Sufficient time is allocated for self directed learning.

We hope that this study guide will help to organize your learning process during the module.

Good Luck!3

THEMES IN KUB

Theme 1: Patient with haematuria

Theme 2: Patient with generalised edema

Theme 3: Patient with oliguria / decreased urine output

Theme 4: Patient with progressive rise in serum creatinine

Theme 5: Patient with electrolyte disorder

Theme 6: Patient with acid base disorder

Theme 7: Patient with difficulty in passing urine

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THEME 1

PATIENT WITH HEMATURIA

Case 1Loin pain

(Addresses urinary calculi, painful haematuria, and UTI)

Presenting complaints:A 40 year male presents to the ER with history of severe pain in his right loin for 2 day. He also noticed that his urine had frank blood in it on two occasions. The pain radiated to the groin and right testicle. He had fever on day of admission. There is history of slight nausea and he vomited once before coming to the hospital.

Past history: No previous history of such pain. No history of Diabetes Mellitus, Hypertension, or any other significant illness. His uric acid had been checked in the past and was found to be high.

Family history: 2 of his brothers have been treated for kidney stones in the past.

Social History: He is a traffic warden. Non-smoker. Married having 1child.

Drugs: None

On examination:GPE: He is rolling in bed with pain. His BP is 160/100 mm Hg, pulse 110/ min. regular and temp is 1000 F. He appears pale and sweaty. Systemic examination: Abdominal examination shows slight tenderness in the right lumbar region. Bowel sounds reduced. There is no supra pubic mass or tenderness. Testicular examination is normal. Renal punch is positive on the right side.CVS: No abnormal finding.Respiratory System and CNS: UnremarkableInvestigations:CBC: Hb 14 gm/dl, WBC count 12,500 /cmm with 85% Polymorphs.S Creatinine: 0.7 mg/dl (0.5-1.0 mg/dl)Urine RE: Blood ++++, protein+, RBCs numerous/HPF, WBCs >25, Leukocyte esterase positive, bacteria +Further investigations: Next dayX-ray KUB, USG KUB, IVP.

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Critical Questions:

1. What are the structures present in right loin?2. Explain the pain in this patient on the basis of nerve supply of the structures

involved.3. How do you relate his problem with his serum uric acid concentration? 4. What biochemical changes do you see in the urine analysis of patients with

renal stones?

OBJECTIVES

Knowledge:1. Describe the gross features of Kidney and Ureters.2. Correlate the microstructure of the kidney and ureter to its functions.3. Identify the topography and relations of the kidney and ureter with the

surrounding structures.4. Describe development of the kidney and ureter and its associated anomalies.

Skills:1. Take history of a patient with renal pain and ureteric colic.2. Examine the genitourinary system of a patient.3. Identify the microstructure of the different parts of the urinary system.4. Identify parts of the urinary tract on imaging modalities. 5. Counsel the patient regarding diet and fluid intake.Attitudes:1. Show respect to the patients and colleagues and faculty.2. Demonstrate the principles of good communication skills.3. Understand how to deal with patients in pain and distress.4. Demonstrate the principles of Consent

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Case 2Patient with painless haematuria

Presenting complaints:A 50 year old man presented with 3 episodes of reddish discoloration of urine for the last 1 month. There is no pain associated with this symptom. He has lost weight and has fever off and on. He has also had difficulty in passing urine for the last 7 days and has to strain at times and has noticed that he is passing less urine. Past history:Smoker for 35 years.

Social History: He has worked in a rubber factory for the last 20 years. He is married and supports his parents, wife and 3 children.

Drugs: He has been taking long term NSAIDs (ibuprofen) for osteoarthritis.

GPE: The patient looks emaciated and pale. BP is 130/85 mmHg, temperature is normal. There is no lymphadenopathy.Systemic examination: Abdominal examination reveals a mass arising from pelvis. It was tender to palpation and dull on percussion.CVS: No abnormal finding.Respiratory System and CNS: UnremarkableInvestigations: Hemoglobin 10 gm/dl, WBC and platelets normal, Na 135 mmol/L, K 4.5 mmol/L, BUN 80mg/dl, Creatinine 4.5 mg/dl. Urine RE examination shows Protein +, blood ++++, RBC numerous.Further investigations:USG KUB, CT scan abdomen and pelvis

Critical Questions:

1. What is the most likely cause of painless hematuria? 2. How does the development of urinary bladder take place?

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OBJECTIVES Knowledge:

1. Describe the gross features of urinary bladder and its relations with the surrounding structures.

2. Correlate the microstructure of the bladder to its functions.3. Describe development of the bladder and its associated anomalies.

Skills : 1. Take focused history of patient with haematuria

Hematuria, Pain

THEME 2 PATIENT WITH GENERALIZED EDEMA

CasePresenting complaints:A 16 year old boy presented to the clinic with complaint of progressive generalized body swelling for the past one year. Initially the swelling was limited to his face particularly around the eyes but for the past few weeks it has involved the entire body. Past History: Not significantSocial History: Student of 10th grade.Family history: Not significant for any chronic disease.GPE: Patient is appropriate for his age, height 168cm weight 84kg. Pulse 79/min, BP135/80mmHg, RR 20/min. Pedal edema+++.Systemic examination: significant ascites on abdominal examination.CVS: UnremarkableRespiratory System: Chest exam is suggestive of pleural effusion Investigations: Urine analysis with sp gravity of 1010, pH 6, protein ++++, blood nil, WBC 0-1, RBC 0-1, Serum creatinine 0.8mg/dl, serum Na:132 mEq/l, serum K: normal, albumin was 2g/dl, total protein 6.1g/dl. LDL cholesterol 200mg/dl.

Critical Questions:

1. How do you relate proteinuria with edema in this patient?2. What is the cause of pleural effusion in this patient?

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OBJECTIVES

Knowledge 1. Correlate glomerular and tubular structure to its function.2. Describe mechanism of urine formation.3. Discuss factors affecting the regulation of glomerular and tubular functions

(hormonal and non hormonal).4. Describe the mechanism of urine concentration and dilution.5. Correlate the mechanism of edema with its clinical presentation.6. Identify the sites of action of various diuretics.

Skills:1. Take focused history of a patient with edema.2. Examine a patient for peripheral edema.3. Perform urine routine analysis (by dipstick and microscopy)4. Interpret the results of urine analysis5. Perform estimation for urine protein.

Edema, Proteinuria, swelling

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THEME 3PATIENT WITH OLIGURIA/ DECREASED URINE OUTPUT

Case ARF

Presenting complaints:A 40 year old man is admitted with a 5 day history of passing less urine, following an acute episode of diarrhoea. The GI symptoms have now settled. He has now noticed a decrease in urine output for the last 4 days.

Past History: He is a known smoker (20 per day). He had an episode of fever with diarrhoea and vomiting 10 days ago. He had a routine medical checkup 4 months ago and all his lab investigations were normal. Drug History: He is taking NSAIDs and antibiotics for fever.

General physical examination: he is drowsy but arousable.Vitals: BP is 80/50 mm Hg, temperature: 37.6 0C, pulse: 110/min, respiratory rate: 24/min. Oral mucosa is dry, decreased skin turgor.Systemic examination: CVS: Unremarkable.Resp: Unremarkable.Abdomen: Unremarkable.CNS: Drowsy, no focal deficits on motor examination.

Investigations:Na 125 mmol/lit, K 3.5 mmol/lit, Bicarb 13 mmol/L, BUN 85mg/dl, Cr 7.0 mg/dl.Urine examination shows: Protein trace, Blood negative, WBC: 8-10/HPF, RBC: nil.

Critical Questions:

1. What is the possible cause of oliguria in this patient?2. How will you categorize acute renal failure in this patient?

3. What is the cause of drowsiness in above patient?

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OBJECTIVES Knowledge:

1. Differentiate between pre-renal, renal and post renal basis of acute renal failure.

2. Correlate various biochemical/electrolyte abnormalities with Acute renal failure

Oliguria, Drowsy, Renal

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THEME 4

PATIENT WITH PROGRESSIVE RISE IN SERUM CREATININE

Case

Presenting complaints:A 55 year old woman, known diabetic and hypertensive, is referred to the renal outpatient clinic. She complains of progressively increasing anorexia, nausea, shortness of breath on exertion and has recently noticed ankle swelling.

Past History:She has a history of ischemic heart disease, diabetic retinopathy and long standing hypertension which is also poorly controlled. She had a serum creatinine done 1 year ago which was 2.6 mg/dl.Family history:Her mother was also diabetic. Social History:She is a widow dependent on her son who is a cobbler.

On Examination:GPE:Clinically she looks pale; Pulse:110/min;BP is 160/100 mm Hg, Respiratory rate : 26/min;JVP is raised, ankle edema is positive.

Systemic examination: CVS: S1 +S2+A systolic murmur in apical region (flow murmur)Resp: Examination of chest reveals basal crackles.Abdomen: Unremarkable.CNS: Unremarkable.

Investigations: Hemoglobin 8 gm/dl, Creatinine 8.0 mg/dl, BUN 60, K 5.8 mEq/l, Na 130 mEq/l, and Bicarb 14 mEq/l. Her Cholesterol is 300 mg/dl, Triglyceride 300mg/dl, HDL 30mg/dl, and LDL 135 mg/dl.

She is started on hemodialysis shortly afterwards. She started to improve but gradually ran into problems of vascular access for hemodialysis. Peritoneal dialysis is not possible due to previous abdominal surgery. A question of renal transplantation arises.

Her prognosis is poor unless she has a kidney transplant. Her sister who is slightly mentally handicapped initially agreed to donate the kidney and is fully HLA matched and a highly compatible donor. There was some family pressure as well. There are no other donors at this time. For some reason her sister has now decided not to donate. She is saying that her sister should buy the kidney from someone as others have done in the village.

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Critical Questions:

1. What is the significance of Diabetes Mellitus, Ischemic heart Disease and Hypertension in progression of renal failure in this patient?

2. What are the important factors to be considered for kidney transplant in this patient?

OBJECTIVES

Knowledge:1. Correlate the functions of kidney with symptoms and biochemical changes in

patients with various stages of Chronic Kidney Disease. 2. Identify the basis of various investigations used in chronic kidney disease.3. Relate the concept of osmosis, convection and ultrafiltration to the process of

dialysis. 4. Identify psychosocial and ethical issues concerning patients with chronic

kidney disease and renal transplant.

Skills:1. Perform serum creatinine estimation2. Calculate creatinine clearance

Attitudes:1. Demonstrate awareness of psychosocial issues related to chronic kidney

diseases.2. Demonstrate the basic steps of breaking bad news to a patient with chronic

renal failure requiring dialysis. (SPIKE model for breaking bad news)

Dialysis, Renal, Creatinine

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THEME 5

PATIENT WITH ELECTROLYTE DISORDER

Case 1Presenting complaints:65 yrs old male presented in ER with history of altered sensorium for 2 days.

Presenting complaints: Patient is a diagnosed case of IHD and CHF for 5yrs and on treatment for that. Recently his physician increased the dose of certain medicines. His family noticed gradual mental state changes for the past 2 days.

Past History:H/O IHD and CCF

Family History:H/O HTN and IHD in the family.

Social History:Retired army officer; Ex-smoker

Drug history:ON diuretics,ACE-inhibitors,Aspirin,statins,b-blockers

On Examination:GPE:Elderly sick looking man, drowsy but arousable to verbal commands.BP 110/70, pulse 70/min, temperature 98.7 F.SYSTEMIC EXAMINATIONRESPIRATORY: fine crackles in the mid zone on the right side.CVS: S1+S2+S3ABDOMEN: soft,non-tender, mild hepatomegalyCNS: drowsy but arousable, no focal deficitLab investigation: CBC: TLC 11000/cmm, Hb 16g/dl, Platelets 3,50,000Serum sodium 112 mEq/LSerum Potassium 3.9 mEq/L Bicarb 24 mEq/L Chloride 100 mEq/L Serum Creatinine 1.5mg/dlBUN 30mg/dl Urine Na >30 mEq/L

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Critical Questions:

1. How do decreased serum sodium levels cause altered sensorium?2. What cause serum sodium levels to fall in this case?3. What do you think is the mechanism of action of ACEI on renal tubules and

correlate the renal effects with the effects on the brain of this patient?4. What do you understand is the relationship between serum sodium levels and

ECF osmolality?

OBJECTIVES

Knowledge:

1. Correlate the transport of water and other substances across urinary tubules with its derangements.

2. Describe the mechanism of regulation of ECF volume and osmolality.

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Case 2Presenting complaints:50year old diabetic lady was admitted to the hospital with complain of left hip pain after a fall in her room. The pain was so much that she was not able to move her left lower limb. X-Ray revealed left femoral neck fracture. After fixation of fracture patient felt better but 2 days later she developed decreased urinary output.

Drug History: Heparin 5000units SC twice a day, diclonefec Na 75mg twice a day and cefazolin 500mg 4 times a day beside insulin for blood sugar control

EXAMINATIONMiddle aged lady conscious and alert but in agony due to painVITALSB.P 140/90mmHgPulse 100/minTemp 98 F

SYSTEMIC EXAMINATIONRESPIRATORY: UnremarkableCVS: UnremarkableABDOMEN: UnremarkableCNS: UnremarkableLOCAL: Unable to move left lower limb due to severe pain

Investigations:Labs on admission were unremarkableAfter one day chemistry revealedS. Na 133mEq/LS.K 5.9mEq/LS. Creatinine 1.4mg/dlS. Bicarbonate 19mEq/LECG revealed tall T wave in chest leadsX=ray revealed fracture of left femur neck.

Critical Questions:

1. What do you think is the cause of acute renal shut down in this patient?2. What are the effects of hyperkalemia on the body?3. What do you think is the mechanism of production of tall tented T-waves in

ECG?4. How does increased potassium levels affect the potential changes in the cell

membrane that lead to changes in the ECG?5. Why is hyperkalemia lethal if left untreated?

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6. Give the mechanism of arrthymias generated by the changes in the serum level of potassium.

7. How does the body maintain normal potassium levels?

OBJECTIVES

Knowledge:1. Describe renal handling of potassium (Normal excretion and absorption) 2. Recall effects of different hormones on renal tubules and body tissues affect-

ing potassium level3. Able to enumerate causes of hyperkalemia and hypokalemia4. Identify the consequences of altered potassium levels

Altered sensorium, Electrolytes, Renal

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THEME 6

Patient with Acid base disorder

Case 1

Presenting complaints:A 50 year old lady with underlying recent hip fracture with Open reduction and internal fixation (ORIF) , develops sudden onset of dyspnoea 1 week after surgery.

Investigations: Arterial Blood Gases show: PH 7.46; PCO2: 30; PO2: 50; O2 saturation: 82%Na: 140 mEq/l, K: 4.0 mEq/l, Cl: 101 mEq/l, HCO3: 24 mEq/l, BUN: 10 mg/dl, Creatnine: 0.8mg/dl, glucose: 100 mg/dl

Critical Questions:

1. Interpret the Arterial Blood Gases given in this case?2. What are the natural buffers in the body?3. What do you think is the cause of dyspnoea in this patient?4. How will the acid base disorder in this patient be corrected?

Case 2

Presenting complaints: A 60 year old male with severe diarrhoea of 24hr duration comes to ER. He has decreased urine output.

Examination:BP: 80/55 mm of Hg Investigations:PH: 7.2, PCO2: 29, PO2: 75, O2 saturation: 94%Na 132 mEq/l, K: 3.3 mEq/l, Cl: 106 mEq/l, HC03:14 mEq/l, BUN: 28 mg/dl, Cr: 1.3 mg/dl, glucose: 100mg/dl

Critical Questions:

1. How does the diarrhea lead to decreased urinary output in this patient?2. What metabolic derangements can be seen in this patient?

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3. How will the body respond to correct these metabolic derangements?4. Which hormones will be released by the body in order to maintain the normal

concentration of sodium and potassium and extracellular volume in this case?

Case 3Presenting complaints:A 20 year old diabetic male presents with obtundation and volumedepletion in the ER.

Investigations:PH: 7.20, PCO2:10, HCO3:7, PO2 76, O2 saturation 92%. Na 140 mEq/l, K: 5.6

mEq/l, Cl: 102 mEq/l, BUN 50mg/dl, Creatnine: 1.8 mg/dl, plasma glucose 400mg/dl

Critical Questions:

1. Interpret the Arterial Blood gases given in this case?2. What is your diagnosis?3. What do think will be the effect of plasma glucose of 400 mg/dl in this man?4. What is the cause of volume depletion in this case?5. What is the renal threshold for glucose reabsorption?

OBJECTIVES

Knowledge:1. Discuss the basis of Acidosis(metabolic/respiratory) and Alkalosis (meta-

bolic/respiratory)2. Identify the role of various buffering systems in acidosis and alkalosis.3. Interpret arterial blood gas reports in normal and various acid base disorders.4. Identify basis of anion gap and its clinical application in analyzing metabolic

acidosis.

Arterial Blood Gases, Buffers, Dyspnoea, Metabolic19

THEME 7PATIENT WITH DIFFICULTY IN PASSING URINE AND INCONTINENCE

Case

Presenting complaints:A 53y old male, comes to urology clinic with severe burning, increased frequency of urination and urgency for last 6 days. For the last 1year he had to strain to begin urination. The stream has gradually become weaker and he has a sense of incomplete emptying of bladder. For last 3 months he also has to wake up many times at night to void. Sometimes he dribbles and passes urine before reaching the toilet. This has been causing day time fatigue.

Past history: well controlled diabetes mellitus - 10years.

Family history: Diabetes Mellitus

Social history: Businessman Drugs: Glibenclamide Tablet, 5mg, one daily

Examination: GPE: Temperature: normal; Pulse: 70/min; BP is 130/90 mm Hg, Respiratory rate: 16/min

Systemic examination: CVS: Unremarkable.Resp: Unremarkable.CNS: Unremarkable Abdomen:He has some supra pubic tenderness; no urethral discharge; normal external urethral meatus, testicles normal size non tender Rectal Examination: rectal tone and perianal sensations are normal, enlarged prostate with rubbery feel, rectal mucosa is mobile, median groove palpable, upper limit cannot be reached, no nodule or indurated area.

Investigations: Urine examination: WBC: 1-2 /HPF, RBC: few, Bacteria: nil, Leukocyte Estrase: negative, Nitrite: negativeUltra sound: weight of prostate is about 50g; urinary volume: pre void 405 ml, post void 100ml; kidneys: normal size.Serum Creatinine is normal.

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Critical Questions:

Q. 1. How will you explain his symptom of straining while urination on the basis of prostatic anatomy?2. Compare normal micturition reflex with incomplete emptying of bladder in this patient.

OBJECTIVES

Knowledge:

1. Describe gross and microscopic structure of prostate gland and urethra.2. Describe the development of prostate and urethra and associated anomalies.3. Correlate symptoms of the lower urinary tract to its structure and function.4. Discuss control of micturition and its derangements.

Urination, Urgency, Dribble, Prostate

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RESOURCE MATERIAL

Text book of Medical Physiology/Arthur C. Guyton & John E. Hall, 12th Edition

Human Physiology/Sherwood, 6th Edition.

Ganong’s Review of Medical Physiology 23rd Edition

Last’s Anatomy Regional and Applied, 11th Ed.

Keith L Moore, Clinically Oriented Anatomy 6th Ed.

Moore & Persaud, The Developing Human clinically oriented Embryology 8th Ed.

Wheater’s Functional Histology. A Text and Colour Atlas 5th Ed.

Biochemistry- Lipincotts illustrated Reviews 4th Ed.

Marks Essentials of Medical Biochemistry 2nd Ed.

Original article:

Endo F, MatsuuraT, Yanagita K, and Matsuda I. Clinical Manifestations of Inborn Errors of the Urea Cycle and Related Metabolic Disorders during Childhood. J Nutr 2004;134:1605S-1609S.

NOTE: Please do not restrict yourself to textbooks, make sure to look for the latest Best Available Evidence and also consult other reference books.

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PERSONS TO CONTACT

Dr. Riffat ShafiAssistant Professor, PhysiologyTeam leader (KUB)Ext: 3365e-mail: shafiriffat@hotmail.com

Dr. Ayesha MohiyuddinAssistant Professor, BiochemistryExt: 3386e-mail: aishamohyuddin@gmail.com

Dr. Tatheer ZahraAssistant Professor, AnatomyExt: 3770e-mail: drtatheer@gmail.com

GLOSSARY

Following online medical dictionaries can be referredwww.nlm.nih.gov/medlineplus/mplusdictioary.htmlwww.online-medical-dictionary.orgwww.medterms.com

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