A 55-year-old man presented with a 6-month history of intermittent gross hematuria that was initially painless but later associated with colicky pain in the right loin radiating to the groin. On examination, a 6x6 cm non-tender, movable intra-abdominal mass was palpated in the right lumbar region. Other examinations were normal. A provisional diagnosis of hydronephrosis with renal cell carcinoma was made.

1. 55 YEARS OLD PRESENT WITH
GROSS HEMATURIA

2. Patient Profile

3. • Intermittent blood mixed urine for 6 months.

4. According to the statement of the patient, he was
reasonably well about 6 months back. Then he noticed
passage of blood mixed urine which is gross, total,
episodic and initially painless but later associated with
pain in the right loin which is colicky in nature, mild
to moderate in severity, radiate to loin to groin, no
aggravating factor but releived by taking some
medication.

5. He had 3 episode of blood mixed urine which last
for 2-4 days and resolves sponateously. He passes
thread like cloted blood with urine sometimes but no
history of passes fleshy material through the urine.
He has no history of clot retention. Patient has no
history of fever with chill and rigor. Patient has no
history of increased frequency of micturition,
urgency, dysuria or evening rise of temperature.

6. He has no history of per-urethral catheterization or
instrumentation. There is no history of anorexia,
weight loss, cough, chest pain, haemoptysis,
hematomesis, jaundice, melena or bone pain. There
is no history of blood transfusion. Patient bowel
habit is normal.

7. There was no history of asthma, tuberculosis,
ischemic heart disease, stroke etc. There was no
previous history of jaundice or blood transfusion.

8. • Patient is married, has 2 sons and 1 daughter. He
has 3 sisters and 4 brothers. All of them are
apparently healthy.
• There is no history of cancer in the family

9. • There was no history of any surgery or
intervention or per urethra catheterization.

10. • Patient is immunized according to EPI schedule.

11. • He has no history of allergy to any drugs or foods.

12. • Smoker for 35 years, usually smokes 10-15 sticks
per day.
• Non-alcoholic
• Occasionally chews betel nut and betel leaf
• No history of drug abuse.
• No H/O extra marital exposure.

13. • Belongs to a family of lower middle class socio-
economic condition
• Lives in a brick-built house
• Drinks water from an arsenic-free tube-well
• Uses sanitary latrine.

15. • Appearance : Ill-looking,
anxious.
• Body built : Average.
• Nutritional status : Below
average.
• BMI – 18.4 (height- 172
cm, weight – 52 kg)
• Co-operation : Co-
operative.
• Decubitus : on choice.
• Anaemia : Absent
• Jaundice : Absent
• Cyanosis : Absent
• Clubbing : Absent
• Koilonychia : Absent
• Leukonychia : Absent
• Dehydration : Absent
• Oedema : Absent
•

16. • Pulse : 88
beats/minute
• BP : 130/80 mm Hg
• Resp Rate : 16
breaths/minute
• Temperature : 98º F.
• Body Hair Distribution :
Normal
• Skeletal Deformity : Absent
• Thyroid Gland : Normal.
• JVP : Not raised.
• Lymph node : Not
palpable

17. Genitourinary system examination
• Both renal angles are non-tender, left kidney is not
palpable.
• But there is an intraabdominal lump in right lumber
region which is non-tender, approximately 6X6 cm in
size, reniform in shape, smooth surface, cystic in
consistency, ill defined margin, moves with respiration
and ballotable, free from anterior abdominal wall and
underlying structures and separated from the liver.
There is vertical band of resonance over the lump.

18. • SP region –
• Not full.
• Non-tender.
• Hernial orifices - Are intact.
External urethral meatus normal
penis
Palpable part of urethra
scrotum
testies
epididymis
Palpable part of vas
perinium

19. • Abdomen:
• on inspection
abdomen is scaphoid in
shape, flank is normal,
umbilicus is centrally
placed & inverted. There
are some scratch mark
present over the
abdomen. There is no
engorged vein, visible
peristalsis, visible cough
impulse. Groin and
external genitalia are
normal.

20. • Palpation
• Temperature : Normal
• Tenderness : Absent
• Muscle guard : Absent
• Liver and spleen: Not palpable
• Kidneys : Not palpable or ballotable.

21. • Percussion
Shifting dullness :
Absent
Fluid thrill :
Absent
Upper border of liver
dullness: Right 5th
intercostal space
• Auscultation
Bowel sound : present
Bruit : not
present
• Digital rectal examination:
Nothing abnormality
detected (no nodule or
mass is palpable)

26. Md. Rohomot Ali , 55 years old, male, muslim, married,
Businessman from Zingira, Keranigonj, Dhaka presented
to me with the complain of passage of hematuria which
is gross, total, episodic and initially painless but later
associated with pain in the right loin which is colicky in
nature, mild to moderate in severity, radiate to loin to
groin, no aggravating factor but releived by taking some
medication.

27. He had 3 episode of blood mixed urine which last for
2-4 days and resolves sponateously. He passes thread
like cloted blood with urine sometimes but no history
of passes fleshy material through the urine. He has no
history of clot retention. He has no history lower
urinary tract symptom. Patient has no history of fever
with chill and rigor. He has no history of per-urethral
catheterization or instrumentation.

28. There is no history of anorexia, weight loss, cough,
chest pain, haemoptysis, hematomesis, jaundice,
melena, bone pain or blood transfusion. Patient is
non-alcoholic but smoker and maintains middle
socioeconomic condition.
On general examination all parameter are within
normal limit.

29. On genitourinary system examination Both renal
angles are non-tender, left kidney is not palpable.
But there is an intraabdominal lump in right lumber
region which is non-tender, approximately 6X6 cm
in size, reniform in shape, smooth surface, cystic in
consistency, ill defined margin, moves with
respiration and ballotable, free from anterior
abdominal wall and underlying structures and
separated from the liver. There is vertical band of
resonance over the lump.

30. urinary bladder was not palpable, hernia orifice are
intact.
EUM, penis, palpable part of urethra, scrotum,
testes, epididymis and perineum are normal. On
digital rectal examination nothing abnormality.
Other systemic examination reveals normal.

31. Provisional diagnosis
• Hydronephrosis with Renal cell carcinoma.

32. Differential diagnosis
• Hydronephrosis with right Urinary tract stone
• Hydronephrosis with Upper tract transitional cell
carcinoma
• Adult polycystic kidney disease.