Question - 2 - vuyyuru

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Q) A 36-year-old famale with chronic back pain is seen in the emergency department (ED) following a motor vehicle accident. Before coming to the ED, she vomited three times. She complains of acute pain in her right flank which radiates to her groin. "This pain is killing me," she says, "and it is quite different from my usual back pain." She has been taking ibuprofen and Percocet (oxycodone/acetaminophen) for at least five years. She denies fever or dysuria. Her blood pressure is 120/70 mmHg, pulse is 100/min, temperature is 36.7C (98F), and respirations are 14/min. Her mucous membranes are moist and pale. She appears to be in mild distress due to pain. Examination reveals right costovertebral tenderness. Lab investigations reveal the following:

Hemoglobin - 9.0 g/L
MCV - 70fl
Platelets - 200,000/mm3
Leukocyte count - 9500/mm3
BUN - 30 mg/dL
Serum creatinine - 1.8mg/dL
Serum calcium - 8.9 mg/dL

Urinalysis

Specific gravity - 1.006
Protein - 1+
Blood - gross
Nitrite - negative
Esterase - negative
WBC - 50+/hpf
RBC - too numerous to count
Casts - occasional WBC casts
Bacteria - none

Helical CT of her abdomen reveals mild dilatation of the right pelvicalyceal system, but no renal calculus is observed. Serum protein electrophoresis and urine Bence Jones protein are negative. What is the most likely diagnosis?

A. Pyelonephritis
B. Ureteric calculus
C. Analgesic nephropathy
D. Prerenal azotemia
E. Acute allergic interstitial nephritis

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