Flank Pain

Cynthia Meneses; Jorden Cummings; Salma R. Imran; and Aruna Chhikara


  • General info: This case is related to a known hyperthyroid, chronic smoker with prior history of kidney stones who presents to you with flank pain. This is a problem based experiential learning that involves you (students) in the process of critical thinking. This will help you to develop problem solving skills and learn how to work in a team with people from different health profession backgrounds.
  • Student level: Undergraduate 2nd / 3rd year
  • Health professions involved: Medicine, Dentistry, Nursing, Nutrition, Psychology, Pharmacy.

Day 1 – Page 1

Case Info

David is a 32-year-old married man with a 3-year-old son. He has been a chronic smoker for the last 15 years and presents with his wife at the emergency unit with the complaint of right flank pain and difficulty in passing urine.

As a health care professional working in the emergency unit of the community hospital, you are responsible for developing an action plan for David.

Tutor Probes

  1. What information would you like to know about David? How would you go about gathering this information?
  2. What are some possible conditions that could cause right flank pain?
  3. What are some possible conditions that could cause difficulty with urination?
  4. Do you consider that second-hand smoking is more dangerous than smoking? Why?
  5. How would you asses a patient’s willingness to quit smoking?
  6. What advice would you give to your patient on how and why should they quit smoking?

Day 1 – Page 2

Case Info

David is a veterinarian at a busy practice – one of the few in the city that takes emergency patients 24 hours/day. He is often on his feet all day running from patient to patient. He has little time for breaks and mostly subsists on coffee and protein bars all day. His wife reports that he often spends his evenings responding to texts from his colleagues and patients.

David and his wife had a lot more free time before he started his practice. They travelled two or three times a year, they used to go on runs and long hikes and have enjoyable dinner parties with family and friends. Since the birth of their son and the practice has become busier, these activities have almost disappeared completely from their routine. David prefers to stay home on his down time and says he’s always too tired to make plans.

He was diagnosed with hyperthyroidism at the age of 27 and also has a history of kidney stones. He is worried if his stone has increased in size and is blocking his urine.

Tutor Probes

  1. How might David’s lifestyle be related to his physical presentation?
  2. How might David’s water intake and diet influence his symptoms?
  3. What do you know about hyperthyroidism?
  4. What tests are used to diagnose hyperthyroidism?
  5. What are signs and symptoms of hyperthyroidism?
  6. Are David’s eating habits responsible for hyperthyroidism?
  7. Is there a connection between hyperthyroidism and kidney stones?
  8. What are kidney stones? What are the different types of kidney stones and how do they form?
  9. Do you think kidney stones run in the family? If so, what type?
  10. How can David’s increased work pressures affect his family life?
  11. What concerns do you have with David loss of interest in being active and socializing? In what ways can this affect his marriage and family life? Are there any potential psychosocial explanations for this?
  12. Do you think David is stressed or depressed? How would you differentiate stress from depression?
  13. How does our body react to stress? Do you think our body responds differently according the level of stress?
  14. How would pursue a patient or a colleague/friend who you think is dealing with stress?

Wrap-up Questions

What health care professionals should David consult with to improve his overall health and well-being?

What types of challenges do health care professionals face in maintaining work-life balance?

Do you think career in health care is incompatible with work-life balance?

Day 2 – Page 1

Case Info

On questioning about his symptoms, David’s wife reports “He was fine last night. We had his favorite pasta for dinner and then went out for a drive. It was this morning. He was getting ready to go to a dentist appointment which he hasn’t been to in over a year, when he came out of the washroom and started to complain about heaviness and pain around his right kidney.”  She also explains that he had lithotripsy with the placement of a stent in his ureter 2 years ago for a left kidney stone and has been having on and off right sided flank pain since then. The doctors told him that he has a stone in his right kidney that is small, and it might pass in his urine someday.

He has been having troubles passing urine since then, and his symptoms have been getting worse over time. David reports that he has simply been too busy to get to the doctor.

Tutor Probes

  1. Why is it important to have regular dental visits?
  2. How is smoking related to oral health?
  3. What are some oral manifestations of thyroid gland disorders?
  4. How does oral health effect your overall wellness?
  5. What are the precautions that a dentist should follow while treating a patient with hyperthyroidism?
  6. What are the signs and symptoms associated with kidney stones?
  7. Describe the urine of a patient with kidney stones.
  8. What are the risk factors associated with the development of kidney stones?
  9. What are some possible oral manifestations associated with renal disease?
  10. What is lithotripsy? When can it be used to treat kidney stones? What other treatment options are available to treat kidney stones?
  11. How would you ask David about any changes he made or did not make to his lifestyle after his lithotripsy?

Day 2 – Page 2

Case Info

On examination, David looks pale and keeps rolling in pain. His right flank is very tender on palpation and his bladder looks distended. His temperature is fine with no other signs of infection. His wife adds that the doctors advised him to restrict milk intake and other forms of calcium because that is what caused the stone formation in his kidneys, but he never takes care of his diet and that he’s “been living off of Tylenol 3 for the past year or so.” David reports that he feels he might pass out from pain.

Tutor Probes

  1. How would you assess and intervene regarding David’s pain?
  2. Are there any concerns regarding how David has been managing his pain throughout these 2 years?
  3. What are some challenges in managing someone with chronic pain?
  4. How can dealing with chronic pain affect someone’s marriage or family life?
  5. What do you know about Canada’s opioid crisis?
  6. What are the early and late signs of infection?
  7. What are the dietary modifications to manage and prevent kidney stones?
  8. How do you identify patients warranting a urology consultation?
  9. What diagnostic tests and procedures would you perform on David to confirm your diagnosis?
  10. If a patient feels he might pass out from pain, what encouragement could you provide him to keep his morale high?
  11. What other disciplines might you involve or refer David to, given how he has been managing his pain for the past year?
  12. What ethical issues arise related to David’s report of how he has been managing his pain for the past year? Do you have a responsibility to assess David’s access to his pain medication?

Wrap-up Questions

As a health professional working with David, how can you motivate him to continue his journey in maintaining his health?

What should be included in patient education about kidney stones at the time of hospital discharge?

How can you help someone struggling with an addiction?

Should David receive any referrals to other health professionals as part of his health journey?


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Instructional Strategies in Health Professions Education Copyright © 2020 by Cynthia Meneses; Jorden Cummings; Salma R. Imran; and Aruna Chhikara is licensed under a Creative Commons Attribution-NonCommercial-ShareAlike 4.0 International License, except where otherwise noted.

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