THE CASE ANALYSIS PROJECT

CONTENTS
Introduction 1
Submission dates and details 2
Assessment criteria 4
Structure of the report
1 Diagnosis 5
2 Patient presentation 5
3 Investigations 5
4 Sensitivity and specificity of one test 5
5 Disease details 6
6 Prognosis 6
7 Population burden of disease 6
8 Treatment objectives 6
9 Treatment given and the evidence base 7
10 Prescribing worksheet 7
11 Patient information leaflet 7
12 Prevention of disease 7
13 Possible future developments 7
14 Famous case(s) 8
15 References 8
Appendices
1 Case analysis project example – Calculus of Kidney 9
2 Information sources 20
3 Level of evidence for treatment 23
4 Prescribing worksheet 24
5 Certificate of Originality/Authenticity 26
1
INTRODUCTION
The aim of the Case Analysis Project (CAP) is to apply an epidemiological and public
health perspective to a common condition that you see on a clinical firm or in general
practice. It is written up as a simple case presentation with an emphasis on evidence-based
treatment and investigation. The information required can mainly be obtained from the
sources recommended and no mathematical calculations are needed.
The project report should be no longer than 2000 words (excluding prescribing worksheet,
famous cases and references) and detailed guidance on the structure of the report and a
sample of previously submitted coursework are given later on in this handbook. No tables
or graphs should be included.
The project is co-ordinated by a public health doctor/general practitioner from the Public
Health Research Institute. Major aspects include the descriptive epidemiology of the
condition, the sensitivity and specificity of one diagnostic test or clinical measurement, the
evidence base for treatment, and the potential for prevention.
Other aspects in the case report include completing a prescribing worksheet for one of the
drugs used in treatment, identifying a patient information leaflet if available and also
identifying current trials which may help the diagnosis and treatment of the condition in the
future.
Most of the information required can be obtained online and from basic textbooks.
An example of a Case Analysis Project is presented in Appendix 1. The condition discussed
is the Calculus of Kidney, and therefore we would exclude this diagnosis and the medication
used from the case reports that students present. The report contains an illustration of the
basic details required and is a report submitted recently which obtained a high grade.
Appendix 2 lists some important sources of information.
An initial lecture outlining the project will be given to each stream followed by two tutorials
around eight weeks later to ensure students are making satisfactory progress and to help
with any queries. The final submission date is around four weeks after the tutorials. With
three months to complete this short project and with proper planning we would expect
students to submit on time unless there are mitigating circumstances as defined and
approved by university rules. The submission dates and details are given in the next
section. To avoid any last-minute problems we would advise students to aim for completion
of the project by at least one week before the submission date. We recommend that you
keep thorough anonymised details and results for writing up the report. Having to go back to
find notes and results can be laborious and time consuming. Detailed writing up of the
projects should be done following the tutorials.
The CAP report will be graded ‘Excellent’/’Acceptable’/’Unacceptable’. As it is part of
the Community and Population Health course a satisfactory standard is especially
important in the sections asterisked below. Note that for some conditions there may not
be much detailed information available to complete all of the sections so you are strongly
advised to choose conditions, which are relatively common in the population and for
which a public health aspect is applicable. We do expect you to do a thorough search
of the literature (see Appendix 2) and to use up to date references. Medical knowledge
advances quickly and you must ensure that you are using the latest copies of textbooks,
guidelines and reviews.
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SUBMISSION DATES AND DETAILS
The initial CAP lecture is on Wednesday, 15th November 2017. Over the following three
weeks students will be asked to firstly identify a patient with a medical or surgical condition
that they wish to write up for their CAP report. Secondly, they should identify the test for
which they will examine the sensitivity and specificity when making the diagnosis.
Finally, students must identify a treatment regime, for which they will provide the evidence
base. To check that the condition is appropriate for the project and also to avoid large
numbers of students examining the same condition and/or test and treatment, students
should submit their project proposal using the link
https://www.surveymonkey.com/r/QLSS8PT by Friday, 08th December at 5:00pm.
Please note that failure to meet the deadline for the CAP proposal may contribute to failure of
the CAP overall.
Proposals should include:
1. your name, email address (so Dr. Heraclides can reply to you if necessary) and
stream
2. name of the condition you will be writing about
3. name of the diagnostic test you are assessing
4. name of the main treatment regime chosen
5. name of GP or Hospital Firm to which you observed this patient.
Please see below for an example:
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If too many students have chosen the same project (condition, diagnostic test, and treatment
regime) they will receive an e-mail within 7 days asking them to choose a different condition
and/or test and/or treatment. If any student is having problems identifying a case please
discuss this with Dr Alexandros Heraclides (CAP Lead for Cyprus).
Small group tutorials to review progress will be held, the first on Tuesday, 09th January 2018
and the second on Thursday, 01st February 2018. Exact times, locations and group
allocations will be notified in mid-December 2017. Detailed writing up of the projects should be
done after the tutorials.
Submission Instructions of final project:
The final project submission date is Wednesday, 28th February 2018 at 5:00pm.
Your project submission should consist of the following four documents:
1. CAP report
2. Patient Information leaflet
3. Prescribing worksheet
4. Certificate of Originality/Authenticity (the cover sheet is Appendix 5 of the CAP
Handbook and can be found as a separate word document on Moodle:
http://vle.sgul.ac.uk/course/view.php?id=2285)
The CAP report (document #1) must be submitted electronically via Turnitin, which will
automatically scan the report for plagiarism.
The other three documents (Patient Information leaflet, Prescribing worksheet, Certificate of
Originality/Authenticity) must be submitted electronically via email (cap@nicosia.sgul.ac.cy)
Your candidate number and initials of consultant/GP supervising the care of the patient, as
well as a word count should appear at the top right hand of the report.
Precise details on the submission procedure will be provided to you by email nearer the
submission date.
Submissions cannot be accepted after the above deadline. Failure to submit by the
deadline and/or projects with a high plagiarism score will automatically receive the
grade of Unacceptable (U).
The projects will be marked and returned to Registry and students are expected to have their
grades 4 weeks after submission. For those who fail to meet the required standard, two
further submissions will be allowed. Dates will be communicated by Registry to the
students concerned and also displayed on the Registry examination page. Dr Heraclides
will meet with any students whose report is judged unacceptable to give practical guidance
for the resubmission of the report.
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ASSESSMENT CRITERIA
All sections should be completed, even if there is little relevant information available, and
comply with the specified word limits. The report should be properly organised and
presented with correct spelling and punctuation. There should be logical progression and
linkage of ideas and credit will be given for evidence of critical thinking, interpretation of
information and the drawing of appropriate conclusions. Most importantly, the report should
indicate that the medical and especially epidemiological/statistical terms and methods
mentioned are correctly understood. References should be up to date and correctly cited,
indicating that the literature has been properly reviewed. Plagiarism both from published
sources and other student reports is strictly not allowed and students not abiding by this
rule may face consequences beyond failure of the specific project. All reports will be put
through plagiarism software which includes previously submitted CAP reports.
The marking will be according to the criteria as defined below:
Excellent (E) may include:
The requirements for an ‘Acceptable’ report are clearly met.
Excellent clarity of written expression.
Comprehensive review of literature with concise accurate critical analysis of the medical,
public health, statistical and prescribing aspects of the case.
Outstanding presentation and organisation of the report.
Acceptable (A) may include:
Major sections completed within specified word limits.
Case presented in a clear, comprehensible and logical way.
Literature review and referencing satisfactory and correctly presented.
Use of commonly available health statistics and evidence based medicine reports with an
understanding of their limitations.
Correct and appropriate use of epidemiological, medical and statistical terms.
Appropriate use of data with evidence of critical thinking and interpretation of diagnostic tests
and appropriate conclusions.
Appropriate information on the public health aspects of the case.
Unacceptable (U) may include:
Not submitted on time.
Failing the plagiarism check and plagiarism confirmed.
Poor organisation and structure of report.
Section not completed to a satisfactory standard.
Limited reading and research.
Limited critical analysis.
Significant errors in the content of the report – public health, epidemiological, statistical,
medical, pharmacological, which may affect patient safety.
Errors in spelling, grammar and presentation which substantially affect the understanding of
the report.
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STRUCTURE OF REPORT
The CAP report comprises 15 sections including references. The figures in brackets are the
maximum number of words for each section. The asterisked sections (*) of the CAP project
are considered key sections and will probably require the most research. The candidate
number, consultant or GP initials supervising the care of the patient and a word count
should appear at the top right hand corner of the first page of the report.
The report should be no longer than 2000 words, the sections with their allocated word
limits are given over the following pages. In keeping with other project work, students are
allowed to exceed this word limit for their reports by a maximum of 10% (applies also to
sub-sections word limit).
1. DIAGNOSIS
The main diagnosis should be given with the code from the International Classification of
Diseases (10th Revision). The coding system is available online. Use the 4 digit coding if
applicable. (50)
2. PATIENT PRESENTATION
A brief outline of the patient’s presentation with a summary of symptoms and signs and
previous medical and social history. (150)
3. INVESTIGATIONS
This section should comprise a concise summary of the investigations undertaken. You may
use accepted abbreviations and symbols as used in the latest editions of the Oxford
Handbook of Clinical Medicine and Lecture Notes in Clinical Biochemistry. Both of these
books are available in the library. (150)
4. SENSITIVITY AND SPECIFICITY OF ONE TEST *
Previous teaching on the course has discussed the concepts of sensitivity and specificity
of measurements and physical signs in medicine. In this section we are considering these
aspects in relation to diagnosis and not public health screening. Diagnostic information can
be from a wide range of sources including biochemical, haematological, radiological and
other imaging, histological, and clinical findings. Select one measurement or clinical finding
that was important in the diagnosis and give information on its sensitivity and specificity as a
diagnostic test. Marks will be deducted if sensitivity/specificity are reported for more than one
tests (you have to be precise and to the point). Additionally, do not forget that in order to
derive sensitivity/specificity and other diagnostic statistics, researchers compare the specific
test of choice to another test (i.e. gold standard, if available, or best accepted practice). Thus
sensitivity/specificity values are always relative to some other test and this other test should
be clearly mentioned each time. Sometimes the gold (or reference) standard is actually a
combination of test results. You should include actual reported values including the
confidence intervals (wherever available). Other information you may wish to report could
include the predictive value of the test or sign.
From your previous teaching you will know that sensitivity is the proportion of the subjects
with the disease who have a positive test for the disease (or the ability of a test to correctly
identify as positive those with the disease). The specificity is the proportion of subjects
without the disease who have a negative test (or the ability of a test to correctly identify as
negative those without the disease). Generally there is a tradeoff between the sensitivity and
specificity of a diagnostic test. It is obviously desirable to have a test that is highly sensitive
and highly specific but this is frequently not possible. In making a diagnosis we usually have
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to consider the results of several different tests. When you complete this section obtain your
information from properly referenced original scientific reports and do not just quote textbook
or other statements from general web-sites that do not quote the scientific reports on
which the figures are based. (150)
5. DISEASE DETAILS
Using one of the basic medical textbooks or your lecture notes briefly define the condition
and the causes and risk factors if known. Please mention if there are any occupational
factors linked to the condition. (200)
6. PROGNOSIS
Briefly describe the reported outcome of the condition – the case fatality rate or survival rate
if it can cause death and the natural history, including complications or disability, if it is not
usually fatal or resolves over time with or without treatment. (100)
7. POPULATION BURDEN OF DISEASE *
Information sources for this section are detailed in Appendix 2. This key aspect of the
project requires information on the incidence and prevalence of the condition and also a
summary of available general practice consultation rates and morbidity data, hospital
inpatient data and, if applicable, mortality data. Students are encouraged to find and
report UK data, although additional data from other parts of the world are also allowed. Data
from Cyprus would also be a welcomed addition. Information from the World Health
Organisation (or any other source of global health statistics) on the global burden of the
disease should also be included, if available. Comment on any trends noted in the disease
patterns. Remember also that not all cases present clinically for health care – there may be
undiagnosed cases in the community. Comment on this aspect – the so called ‘iceberg’
phenomenon – if it applies to the condition you have chosen.
The incidence is the fraction or proportion of a group initially free of the outcome which
develops the outcome over a given period of time. In other words, a measure of the rate at
which new cases occur in a population. The prevalence is the fraction or proportion of a
group possessing a clinical outcome or disease at a given point in time (i.e. existing cases)
and is measured by a single examination or survey of a group; this is known as the point
prevalence. Often the period prevalence is given instead, which is the % in the population
who had the problem in a fixed period of time, often 1 year. Both incidence and prevalence
should be reported per unit population (i.e. %, or per 1000, per 100,000, etc.), not as
absolute numbers. Please look for data that are from good quality medical surveys and not
just figures mentioned in general textbooks or patient information leaflets.
General Practice data are available from the sources listed in Appendix 2 and you should
try to find consultation rates, the number of patients with the condition that a GP might have
on their lists (for some conditions there are disease registers), prevalence and incidence
rates based on RCGP data and Qualities and Outcome Framework (QOF) data. It can be a
challenge to get up to date GP data, and 2007 seems one of the most recent years for data.
When using the Hospital Episode Statistics (HES) for hospital inpatient data read the
‘Field Descriptions’ because data are recorded in terms of Finished Consultant Episodes
(FCEs). Do not make the mistake of assuming that one FCE equals one person per annum.
A person may have several admissions within one year and several episodes within one
admission. Make sure you identify the table with the right level of detail. Many of you will
need the 4 digit ICD table rather than the 3 digit table.
Tables for Mortality Statistics by Cause for England and Wales are produced annually by
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the Office of National Statistics. These tabulate the number of deaths in a given year by sex,
age-group and 4-digit ICD code. Please present data using rates rather than numbers when
available as this obviously makes comparisons possible between and within populations.
(400)
8. TREATMENT OBJECTIVES
State simply the aims of treatment appropriate for the patient. (30)
9. TREATMENT GIVEN AND THE EVIDENCE BASE *
You should start this section by briefly outlining the treatment recommended for the
condition (i.e. NICE Guidelines or other source). Then report the main treatment for the
condition (treatment regime of choice) and report the evidence-base on its effectiveness,
based on original research publications. In addition, the level of the evidence should be
reported based on the grading scheme in Appendix 3. It is fine if the treatment regime
contains more than one drug, or combination of surgery and drugs, or simply surgery.
Important, this section should be more like a mini literature review of RCTs (or metaanalyses
of RCTs, if available) on the actual effectiveness of a specific treatment regime,
rather than simply an overview of Guidelines. Your basic text books, and Guidelines where
available, will usually reference the information and trials on which treatment is based and
the information sources (Appendix 2) will direct you to the main sources of medical evidence
(e.g. PubMed, Cochrane Library, etc.). You should always reference the primary source of
information (i.e. the original research study), not the secondary source (i.e. text book or
Guidelines). Comment briefly on how the treatment given to your patient varied from that
which you recommend. As with section 4, marks will be deducted if evidence is presented
for several different treatment regimes rather than just the treatment of choice. (300)
10. PRESCRIBING WORKSHEET
Select one of the drugs that has been used in treating this condition, or was already
being used by the patient, and complete the prescribing worksheet (Appendix 4;
attachment on Moodle). Here you can use any medication used by the patient, not
necessarily the actual treatment reported in section 9. Attach a copy with your
submitted reports. Again brief notes; information available from latest British National
Formulary. Please avoid using compound drugs i.e. more than one constituent in the
prescribing sheet.
(Word count not included in project)
11. PATIENT INFORMATION LEAFLET
Search the internet and local health libraries to see if there are patient information leaflets
related to the condition. There may be disease specific patient support groups which provide
information e.g. British Heart Foundation, Macmillan UK, Diabetes UK. Attach a copy of a
leaflet that you judge helpful (not included in word count) and comment briefly on why you
think it is good or not so good. Leaflets often cite useful references. If no patient information
was found please state this clearly, with a possible justification on the absence. Patient UK
is useful but often very basic. Leaflets from the UK are preferable, but could be used from
any part of the world, as long as the text is in English. (70)
12. PREVENTION OF DISEASE *
Primary prevention – are there documented measures that can reduce the risk of
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the population developing this condition?
Secondary prevention – are there initiatives to tackle the disease at its very early stages?
Are there screening tests to detect early disease? Do they satisfy the criteria for a useful
screening programme?
Tertiary prevention – are there other measures which can reduce the rate of progression or
complications for those who already have the disease?
In your report consider prevention measures under these individual headings. Many will
apply at a primary level but also secondary and tertiary. Make brief mention of this as you
work down the prevention levels and do not forget obvious preventive measures such as
reducing smoking, obesity, alcohol consumption, low activity levels, poor diet if these have
an effect on the condition you have examined. If a level of prevention is not applicable to the
condition that you have chosen then report this clearly in the section, with a simple
explanation on why it is not applicable. (200)
13. POSSIBLE FUTURE DEVELOPMENTS
Research to improve the diagnosis and management of disease is ongoing world-wide.
Look at websites which list current clinical trials (see Appendix 2) and identify some of
the main lines of investigation relevant to the condition you have treated. The web sites
have been carefully selected – do use them. (150)
14. FAMOUS CASE(S)
For interest – both yours and the markers – look on the internet to see if there are any well
known people (alive or dead) who have suffered from the condition. Any interesting or
unusual facts will also be well received.
(No word count: 100 sufficient)
15. REFERENCES
Please use the Vancouver reference system and a maximum of 25 references.
A guide to the Vancouver reference style is in the library and also available on line.
(http://www.southampton.ac.uk/library/resources/documents/vancouverreferencing.pdf)
Please ensure that you examine the papers and documents cited and do not use subreferencing.
When referring to textbooks please give page numbers.
For references from the Internet, please put date accessed. Use the correct full reference
and not just a brief web address or a medical website reference. Information should be
from the scientific and medical literature and not from web-sites that provide medical
information without clearly identifying the studies on which it is based.
(Not in word count)
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APPENDIX 1: CASE ANALYSIS EXAMPLE – CALCULUS OF KIDNEY
‘T’ YEAR CASE ANALYSIS PROJECT
1. Diagnosis
Calculus of kidney – ICD 10: Chapter 14: Code N20.0
Please note – the patient described in the next section was diagnosed with calculus of kidney with a
concurrent pyelonephritis, however this report considers only the former.
2. Patient presentation
Mrs MC, a 42 year-old lady, presented to A&E with a four day history of left-flank pain. The pain began as a
dull ache and developed into an uncomfortable colicky pain. She also reported feeling “feverish”, nauseous,
shivering and having a “very severe” headache. The severity of headache prompted her to attend A&E. She
did not experience haematuria.
She had never experienced similar symptoms before, has no personal or family history of renal problems,
and reports asthma as her only medical condition. She lives with her boyfriend, is employed as a customer
services manager, and has never smoked. She drinks 10 alcohol units per week.
On examination (2 days after admission) she is alert and appears well. Her abdomen is soft and tender in
the left quadrants. A nephrostomy drainage tube exits her left-flank into a drainage bag which contains
100mL of a light-red liquid.
3. Investigations
The following investigations were performed around the time of admission:
x Urine dipstick was positive for blood
x FBC showed a low haemoglobin concentration of 94g/L (women: 115-160) and an elevated whitecell
count of 25.4 x109
/L (4-11)
x U&Es were all normal
x CRP was elevated to 361 mg/L (<10)
x Mid-stream urine (MSU) for Microscopy, Culture and Sensitivities (MCS) had been sent but
results were not yet available.
x Non-contrast abdominal CT reported as follows: “1.2 cm ovoid obstructing calculus in left PUJ
[pelvi-ureteric junction] region. Dilation of left renal pelvis to 1.3cm (5mm on right side). Left
kidney is swollen – suspected inflammatory change”.
The above results were considered to be consistent with a renal calculus with concurrent pyelonephritis,
and on this basis Mrs MC was admitted under urological surgery care.
4. Sensitivity and specificity of one test
Current guidelines advise that an initial ultrasound assessment should be followed by Non-Contrast
Computed Tomography (NCCT) imaging – the gold-standard technique – in the diagnosis of acute flank pain
(1).
To minimise radiation exposure it is recommended that patients with a BMI below 30 kg/m2 should receive
reduced-dose NCCT (2). A meta-analysis of studies published between 1995 and 2007 reports the sensitivity
of this technique as 96.6% (95% confidence interval [CI]: 95.0%-97.8%) and specificity of 94.9% (95% CI:
92.0%-97.0%) (3). The overall sensitivity and specificity of NCCT (regular- and low-dose radiation) in the
detection of renal stones are reported as 98% and 97% respectively (2).
A meta-analysis that evaluated the use of ultrasonography in the detection of kidney stones could not be
identified. However one prospective observational study reported a sensitivity of 76.3% (95% CI: 59.4%-
88.0%) and specificity of 78.3% (95% CI: 66.4%-86.9%) to stones that were subsequently identified on CT
(4).
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5. Disease details
Calculus of kidney (or “kidney stones” or “nephrolithiasis”) is a condition caused by crystal aggregates
becoming lodged in the kidney. These crystals form when urine becomes supersaturated such that a
component of the urine can no longer remain in solution. Most stones are formed from calcium oxalate
(75% of cases) (5)
Small stones (<5mm) will typically pass freely. Larger stones can be deposited in kidney, the bladder or
anywhere in between. Most common sites are a) the uretero-pelvic junction, b) where the ureter crosses
the pelvic brim, and c) where the ureter enters the bladder (5).
Patients typically experience excruciating colicky loin pain, often described as “the worst pain they have
felt”. They may also present with nausea, vomiting, haematuria and proteinuria (5).
The most common cause is dehydration. Other risk factors include high dietary intake of fatty foods or
oxalates (such as rhubarb, nuts and tea) and medical conditions such as hyperparathyroidism or
hypercalcaemia. Anatomical abnormalities such as horseshoe kidney also increase risk. 50% of cases are
believed to be secondary to hereditary disorders. Working in a hot environment (such as kitchen work) is
thought to be an occupational risk factor (6).
6. Prognosis
Urinary tract stones will either pass spontaneously or will require intervention. One recent study showed an
overall spontaneous passage rate of 86% (7). The same study reported a mean time to stone passage of 6.8
days for stones less that 2mm in size and 21.8 days for stones 6 to 8mm in size.
Larger and more proximally located stones are less likely to pass spontaneously. One study published by the
European Association of Urology (8) showed a spontaneous passage rate of 68% for stones less than 5mm,
and 47% for stones between 5mm and 10mm.
7. Population burden
Incidence
A report (9) by the Oxford Stone Group calculates an annual incidence of 166/100,000 in UK population,
however this figure is based on Hospital Admission Statistics (HSE) and hence excludes both asymptomatic
patients, and symptomatic patients that were not admitted. It is reasonable to assume that the “iceberg”
phenomenon applies to kidney stones given that a large proportion will pass without medical intervention.
Prevalence
A symptomatic kidney stone is an acute event and is as such not amenable to a meaningful measurement of
prevalence.
Nonetheless, one American study (10), published by the European Association of Urology, states an overall
“prevalence” of 8.8%. This figure was estimated from the survey question “have you ever had kidney
stones?” and hence perhaps represents a lifetime prevalence (up to the time of assessment) of
symptomatic stones, rather than a point prevalence of disease.
General practice morbidity data
The Royal College of General Practitioners reports (11) that in 2007 the age standardised person prevalence
rate of calculus of kidney and ureter was 8/100,000. In 2001 the equivalent rate was 6/100,000, with a
linear increase in the intervening years. The prevalence rate amongst women was only 60% that of men.
The 65-74 age group had the greatest rate of 15/100,000, while all age groups below 15 years had a rate of
zero.
Hospital inpatient data
Hospital Episode Statistics data reveals that there were 43,017 admissions for calculus of kidney (as a
primary diagnosis) in the 2014-15 period (12). The total number of Finished Consultant Episodes was
45,855. Of these 65% were male and the mean age was 51. 23% were emergency cases. The mean length of
stay was 2 days. The total number of diagnoses (including both primary and otherwise) was 75,518 – hence
around 32,000 diagnoses were non-primary.
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UK mortality data
129 deaths were recorded in 2014 with an underlying cause of calculus of kidney (13). Of these 48 were
male and 81 were female. Around 85% of cases were in the >65 years age group.
Global trends in incidence and prevalence
Several studies report a global increase in incidence of kidney stones. One meta-analysis (14) of twenty
countries found this increase to be independent of sex, race and gender and suggested dietary factors and
global warming to be driving the trend. A second study (15) of Icelandic patients quantified an increase in
annual incidence from 108/100,000 to 138/100,000 over a 24 year period starting in 1985. WHO data was
not identified.
8. Treatment objectives
Initial treatment of acute renal colic should manage symptoms of pain and nausea (16). Mrs MC was also
treated for pyelonephritis, however this report focuses on her pain management.
9. Treatment given and evidence base
This section discusses the selection of first-line analgesia in acute renal colic – it should be noted that Mrs
MC also received antibiotic and surgical treatment (nephrostomy) for the pyelonephritis that accompanied
her stone.
The National Institute of Clinical Excellence (NICE) guidelines recommend 75mg diclofenac, given
intramuscularly, for the rapid relief of severe renal colic. If dicloclofenac (a Non-Steroidal AntiInflammatory
Drug – NSAID) is contraindicated than an opioid analgesic such as morphine should be
considered (16). The European Association of Urology also recommends diclofenac, but suggests
administration via oral tablet or suppository (1).
The NICE guidelines are based on a Cochrane review of twenty trials from nine countries involving 1,613
participants comparing the outcomes of treating renal colic with NSAIDs versus opioids (17). This is
considered Grade 1 evidence for treatment. The review found that both NSAIDs and opioids each lead to a
significant reduction in patient-reported pain scores. However the majority of trials within the review
showed a higher incidence of adverse events with opioids, in particular there was a significantly higher
incidence of vomiting. Opioids were also found to carry a greater risk of requiring further “top up”
analgesia.
When NSAIDs are contraindicated and an opioid is given, it is recommends that pethidine is not selected as
this is associated with a higher rate of vomiting than other opioids (17). The Cochrane review did not
examine the outcomes of individual drugs within the NSAID class, or routes of administration.
In practice, the analgesia prescribed for Mrs MC was oral codeine (a weak opioid) – this was perhaps due to
her having a lower level of pain than typically experienced with kidney stones.
10. Prescribing worksheet
A prescribing worksheet for diclofenac has been completed and included as an appendix to this document.
11. Patient information leaflet
The British Association of Urological Surgeons publish information on their website (18) aimed at patients
with kidney stones. A copy of the content is attached.
The text is well-written with accessible language, and guides the reader through many aspects of the
condition. It outlines symptoms that should prompt a reader to visit their GP, explains what to expect at
such an appointment and covers the variety of treatment options available.
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12. Prevention of disease
Primary prevention
Adequate hydration is the most significant factor in the primary prevention of nephrolithiasis – increased
fluid intake will dilute the urine and hence reduce risk of crystal formation. A reduced fat, protein and
sodium diet can also reduce occurrence (1).
Secondary
No secondary-prevention screening tests or programmes were identified.
Tertiary prevention
Recurrence of renal stones is common. Following an initial stone, the recurrence rate at five years is 50%
and at ten years is 80% (1). As such interventions to reduce recurrence risk are an important management
aspect. There is of course a natural overlap with primary preventions measures.
Prevention of recurrence is largely based on lifestyle and dietary advice (16):
x Increasing fluid intake to produce 2-3 litres of urine each day.
x Eating a balanced diet, including plenty of fruit and vegetables.
x Reduce salt intake.
x Maintain a healthy weight.
x Avoid fructose-containing soft drinks (which are associate with increased urate levels).
Patients with calcium stones should also avoid (16):
x Excessive oxalate-rich foods (such as rhubarb, spinach, cocoa and strawberries).
x Excessive animal protein.
x Excessive sodium.
x Calcium supplements should be avoided – but dietary calcium should not be restricted.
Those with uric acid stones should avoid excessive intake of urate-rich foods such as liver, kidney and
poultry skin.
13. Possible future developments
215 studies are returned by a simple search for (“kidney stones” OR “nephrolithiasis”) on the
clinicaltrials.gov website. The majority of studies focus on optimising medical and surgical management of
stones, but several also consider identification of risk factors and stone prevention. A selection of are as
follows:
Prevention
x Prevention using novel dietary supplementation – including the use of lemon juice in patients with
calcium oxalate stones.
Risk factors
x Assessment of kidney stone risk following bariatric surgery – which is of significance given
increasing prevalence of both obesity and nephrolithiasis.
x Effects of over-the-counter dietary supplementation on kidney stone risk
Management
x Using high-fidelity CT scanning to accurately assess the architecture of a stone to assess its likely
response to shock-wave lithotripsy.
x Feasibility of moving kidney stones using ultrasonic propulsion.
x Comparison of devices for the surgical removal of stones.
x Identification of renal stone clinical scenarios suited to treatment with oral alkalinisation.
x Medical expulsion of kidney stones using for example Tamsulosin (often used for enlarged
prostate)
13
13
14. Famous cases
As expected from such a common condition, the list of famous (and infamous) sufferers of kidney stones is
long. At the more glamourous end of the spectrum – Alfred Hitchcock, Roger Moore and Kiefer Sutherland
are all reportedly kidney stone sufferers (19).
Some additional facts and figures of note (19)(20):
x A 1.1 Kg stone was removed from Sandor Sarkadi of Hungary in 2009 – it measured 17cm at its
widest point.
x The most kidney stones passed naturally by a single patient is 5,704.
x In 2006 William Shatner sold his kidney stone for $75,000
x In 1655 a Dutch Blacksmith, Jan De Doot, was said to have performed surgery on himself to
remove a bladder stone. He made an incision below the scrotum and directly into the bladder
before plucking the stone out. The outcome was not described.
14
14
15. References
1. Türk C, Knoll T, Petrik a, Sarica K, Skolarikos a, Straub M, et al. Pocket Guidelines on urolithiasis. Eur
Urol. 2014;40(4):362–71.
2. Fulgham PF, Assimos DG, Pearle MS, Preminger GM. Clinical effectiveness protocols for imaging in
the management of ureteral calculous disease: AUA technology assessment. J Urol. Elsevier Inc.;
2013;189(4):1203–13.
3. Niemann T, Kollmann T, Bongartz G. Diagnostic performance of low-dose CT for the detection of
urolithiasis: a meta-analysis. AJR Am J Roentgenol. 2008;191(2):396–401.
4. Moak JH, Lyons MS, Lindsell CJ. Bedside renal ultrasound in the evaluation of suspected
ureterolithiasis. Am J Emerg Med. Elsevier Inc.; 2012;30(1):218–21.
5. Hoda S a, Hoda RS. Robbins and Cotran Pathologic Basis of Disease. 8th ed. 2010. 962-963 p.
6. Bultitude M, Rees J. Management of renal colic. Bmj. 2012;345(aug29 1):e5499–e5499.
7. Tchey D-U, Ha YS, Kim WT, Yun SJ, Lee SC, Kim WJ. Expectant Management of Ureter Stones:
Outcome and Clinical Factors of Spontaneous Passage in a Single Institution’s Experience. Korean J
Urol. 2011;52(12):847–51.
8. Preminger GM, Tiselius HG, Assimos DG, Alken P, Buck C, Gallucci M, et al. 2007 Guideline for the
Management of Ureteral Calculi. Eur Urol. 2007;52(6):1610–31.
9. Turney BW, Reynard JM, Noble JG, Keoghane SR. Trends in urological stone disease. BJU Int.
2012;109(7):1082–7.
10. Scales CD, Smith AC, Hanley JM, Saigal CS. Prevalence of kidney stones in the United States. Eur
Urol. 2012;62(1):160–5.
11. Royal College of General Practioners. Weekly Returns Service Annual Prevalence Report 2007
[Internet]. 2007 [cited 2015 Dec 18]. Available from: http://www.rcgp.org.uk/clinical-andresearch/~/media/Files/CIRC/CIRC-76-80/BRU_Annual_prevalence_report_2007.ashx
12. Health and Social Care Information Centre. Hospital Episode Statistics, Admitted Patient Care –
England, 2014-15: Diagnosis [Internet]. 2015 [cited 2015 Dec 18]. Available from:
http://www.hscic.gov.uk/catalogue/PUB19124/hosp-epis-stat-admi-diag-2014-15-tab.xlsx
13. Office of National Statistics. Mortality Statistics: Deaths Registered in England and Wales (Series
DR), 2014 [Internet]. 2014 [cited 2015 Jan 1]. Available from:
http://www.ons.gov.uk/ons/rel/vsob1/mortality-statistics–deaths-registered-in-england-andwales–series-dr-/2014/rft-table-5.xls
14. Romero V, Akpinar H, Assimos DG. Kidney stones: a global picture of prevalence, incidence, and
associated risk factors. Rev Urol. 2010;12(2-3):e86–96.
15. Edvardsson VO, Indridason OS, Haraldsson G, Kjartansson O, Palsson R. Temporal trends in the
incidence of kidney stone disease. Kidney Int. Nature Publishing Group; 2013;83(1):146–52.
16. The National Institute of Health and Care Excellence. Renal or ureteric colic – acute, Clinical
Knowledge Summary [Internet]. 2015 [cited 2015 Dec 18]. Available from:
http://cks.nice.org.uk/renal-or-ureteric-colic-acute#!scenario
17. Holdgate a, Pollock T. Nonsteroidal anti-inflammatory drugs (NSAIDs) versus opioids for acute renal
colic. Cochrane Database Syst Rev. 2005;(2):CD004137.
18. Patients: I think I might have… Kidney Stones [Internet]. [cited 2015 Dec 18]. Available from:
http://www.baus.org.uk/patients/conditions/6/kidney_stones
19. Wikipedia. List of kidney stone formers [Internet]. [cited 2015 Dec 18]. Available from:
https://en.wikipedia.org/wiki/List_of_kidney_stone_formers
20. Nguyen MN. Famous Kidney Stoners [Internet]. 2012 [cited 2015 Dec 18]. Available from:

13 Famous Kidney Stoners

15
15
Appendix: Prescribing worksheet
Drug name: Diclofenac
Medication history
a) What other drugs is the patient currently taking (name/dose/times per day)?
Gentamicin IV 320mg IV every 24 hours for 5 days
Piperacillin/tazobactam IV 4g piperacillin + 500mg tazobactum IV every 8 hours for 5 days
Salbutamol 2 puffs of metered dose inhaler, as required, 100mcg per puff
b) Do they have any allergies? No.
c) Have they previously used the intended drug? No.
d) Note the following (special circumstances)
x Age: 42
x Liver function – normal/abnormal? Normal.
x eGFR/creatinine? Creatinine 57 μmol/l which is within reference range
x Male or female? Female.
x If female, pregnant/breast feeding/childbearing potential: Not known to be pregnant or
breastfeeding, of child bearing-age.
Drug information
1. What licensed indications are there for taking this drug? pain and inflammation in rheumatic disease
(including juvenile idiopathic arthritis) and other musculoskeletal disorders; acute gout; postoperative pain.
2. Why is this patient taking this drug? Acute renal colic
3. What other drugs are there for this indication? Other analgesics (other NSAIDs or opioids)
4. What are the contraindications to taking this drug?
Absolute
x Ischaemic heart disease
x Cerebrovascular disease
x Peripheral arterial disease
x Mild to severe heart failure
x Active gastro-intestinal bleeding
x Hypersensitivity to aspirin or any other NSAID
x Severe renal impairment
Relative
x Elderly – who risk serious side-effects and fatalities
x History of cardiac failure, left ventricular dysfunction, hypertension, oedema, and in patients with
other risk factors for cardiovascular events
5. Does the patient have any of these contraindications? No
6. Should the drug dose to be modified due to special circumstances: No
7. Is the patient at risk of drug interactions – if yes what? No
16
16
Putting it together
8. What drug dose/route of administration/dose frequency would you choose?
75mg diclofenac, given intramuscularly for immediate pain relief (as recommended by NICE) – followed by a
further 75mg after 30 mins if required.
9. What advice would you give to the patient about:
i. Starting and stopping? This is a one-off injection to relieve their immediate pain. Ongoing
analgesia will then be discussed.
ii. Side effects? They may experience an upset tummy, feel nauseous or experience diarrhoea.
iii. Special requirements when taking drug? None
iv. Monitoring? Any worsening of the patient’s asthma should be immediately reported, as it may be
related to the NSAID.
v. How much is this drug costing the NHS per month? A single 75mg dose of Voltarol® (Novartis) costs
99p.
17
17
STUDENT NOTES
18
APPENDIX 2- INFORMATION SOURCES
In your earlier studies you will have been introduced to the library and have probably
undertaken searches using Ovid and Pub Med. Google and Wikipedia also identify useful
references although their accuracy will need checking. For journal articles the most reliable
are those published in peer-reviewed general or specialist journals.
Official sources of routinely collected data will be an important component in assessing the
burden of disease and can nearly all be accessed from Department of Health and other
official web sites.
The library has obtained copies of the following textbooks which are relevant to diagnostic
testing.
Polmear A Evidence-Based Diagnosis in Primary Care. London: Elsevier, 2008
McGee S. Evidence-Based Physical Diagnosis, 2nd edn. St. Louis: Saunders, 2007
Katz DL Clinical Epidemiology and Evidence-Based Medicine. London:Sage, 2001
Useful internet sites (active at time this handbook was prepared) include:-
For disease definition:
http://www.who.int/classifications/icd/en/ ICD 10 – list chapter and code
For official statistics:
http://www.statistics.gov.uk
https://www.ons.gov.uk The Office for National Statistics (ONS) has access to sites that
report Hospital Episode Statistics, General Practice Morbidity data and UK Mortality
Statistics. (These may also come up by Google searching).
http://www.content.digital.nhs.uk/ NHS digital
https://www.gov.uk/guidance/phe-data-andanalysis-tools Public Health England
http://www.who.int/research/en/ WHO Data and statistics
http://www.thames-cancer-reg.org.uk/ Thames Cancer Registry- local cancer statistics
http://globocan.iarc.fr/Pages/summary_table_pop_sel.aspx GLOBOCAN: Global and
country-specific incidence and mortality for major cancers.
http://www.apho.org.uk/ Association of Public Health Observatories.
For hospital admissions (inpatient data)
For hospital admissions, see hospital episode statistics (HES data)
http://content.digital.nhs.uk/hesdata –These report both Finished Consultant Episodes
(FCEs) in England and admissions for all diseases. Do read the definitions carefully to
19
understand the data. You will almost certainly want to look at the admitted patient care
tables. Depending on the disease you are studying you will need the 3 digit or (more
likely) 4 digit ICD tables. The spreadsheet containing the relevant data can be found in
the following link:
http://digital.nhs.uk/media/27815/Hospital-Episode-Statistics-Admitted-Patient-CareEngland-2014-15-Diagnosis/Any/hosp-epis-stat-admi-diag-2014-15-tab
A simple search for ‘Mortality Statistics’ (www.ons.gov.uk) should enable you to find
the most up to date report in the DR (Death Report) series. Deaths are reported by
sex, age group and 4-digit ICD 10 Code and so you should find information if your
described condition can prove fatal.
For conditions related to public health (eg alcohol related, smoking related, sexual
health, infections etc) look for more details on the Public Health England website:
https://www.gov.uk/guidance/phe-data-and-analysis-tools
For cancer registration data:
https://www.ons.gov.uk/peoplepopulationandcommunity/healthandsocialcare/condition
sanddiseases/bulletins/cancerregistrationstatisticsengland/2015
For global health and global disease burden look at World health organization (WHO)
data: http://www.who.int/healthinfo/en/
For general practice morbidity data:
http://www.rcgp.org.uk/clinical-and-research/~/media/Files/CIRC/CIRC-76-
80/BRU_Annual_prevalence_report_2007.ashx
The above link relates to data collected in 2007; it is the latest currently available. It
summarises the data on the “annual person prevalence” (i.e. persons consulting at least
once in that year for a specified disease or group of diseases) reported by practices
contributing to the Weekly Returns Service (WRS) of the Royal College of General
Practitioners. Please note that in this report, ICD9 codes are used (and not ICD10).
Unfortunately the 10 yearly National RCGP Morbidity Surveys have not been carried out
since the 1991-92 survey.
20
General practice data relating to conditions that are part of the GP Quality and Outcomes
(QOF) framework are available on NHS digital website http://www.content.digital.nhs.uk/
(search Quality and Outcomes Framework)
Also check the Research & Surveillance Centre Weekly Returns Service Annual
Report for GP incidence data on specific conditions.
http://www.rcgp.org.uk/clinical-and-research/our-programmes/research-andsurveillance-centre.aspx
These reports also contain general practice data and are linked to the ‘hscic’site –
Health and Social Care Information Centre’ websites For some major conditions data
are available from the Qualities and Outcomes Framework (Quof) reports which are
on the HSCIC web site. Unfortunately the 10 yearly National RCGP Morbidity
Surveys have not been carried out since the 1991-92 survey. Please see link below:
http://www.content.digital.nhs.uk/catalogue/PUB22266/qof-1516-rep-v2.pdf
Additional useful information sites
http://www.thecochranelibrary.com/ – this contains the Cochrane Database of Systematic
Reviews and also the Central Register of Controlled Trials
http://www.library.nhs.uk/ NLH is an excellent source of good quality information and a
means of keeping up to date with developments in the NHS
http://www.nice.org.uk/ National Institute for Health and Clinical Excellence (NICE)
This organisation has produced around 110 guidelines on various clinical subjects
http://www.york.ac.uk/inst/crd/ NHS Centre for Reviews and Dissemination – another
source of information on health matters.
https://cks.nice.org.uk Clinical Knowledge Summaries (formerly Prodigy). For general
practitioners, nurses and pharmaceutical advisers. This source may have patient
information leaflets.
http://www.eguidelines.co.uk/ Guidelines – summarising clinical guidelines for primary
care (3 times yearly update). (They may now be charging and therefore not easily
available.)
http://intute.ac.uk/ A site maintained by a group of UK universities and is useful for specific
searches such as patient information leaflets and also medical conditions. (Funding
withdrawn July 2010 but still useful.)
http://www.cks.nhs.uk/ Clinical Knowledge Summaries (formerly Prodigy). For general
practitioners, nurses and pharmaceutical advisers. This source may have patient
information leaflets.
http://www.tripdatabase.com Medical search engine on evidence-based medicine
(EBM) and clinical guidelines (BMJ subscription may be required) library should
enable access
http://www.clinicalevidence.com Another source of evidence-based reports
21
Information on UK screening programmes:
https://www.gov.uk/government/groups/uk-national-screening-committee-uk-nsc UK
National Screening Committee.
http://www.screening.nhs.uk/uknsc UK National Screening Committee.
Additional Information:
http://www.isrctn.com/ – ISRCTN registry is a primary clinical trial registry that accepts
all clinical research studies and supports transparency in clinical research – BioMed
Central – The Open Access Publisher
http://www.ClinicalTrials.gov US National Institutes of Health register of trials
* The internet references were correct on checking May 2017 but some may
have altered or been withdrawn subsequently.
22
APPENDIX 3– RATING LEVEL OF EVIDENCE FOR TREATMENT
1.Evidence obtained from systematic review of meta-analysis of
randomised controlled trials.
2.Evidence from at least one randomised controlled trial.
3.Evidence obtained from at least one well-designed controlled study without
randomisation.
4.Evidence obtained from at least one other type of well designed quasiexperimental
study.
5.Evidence obtained from well-designed non-experimental descriptive
studies, correlation studies and case studies.
6.Evidence obtained from expert committee reports or opinions and/or clinical
experience of respected authorities (no studies cited).
(Modified from NICE (2001) The Guideline Development Process-Information for National
Collaborating Centres and Guideline Development groups. London. NICE.
23
APPENDIX 4 – PRESCRIBING WORKSHEET
Drug name
Medication history
a) What other drugs is the patient currently
taking (name/dose/times per day)?
b)Do they have any allergies?
If yes – what happened?
c)Have they previously used the intended drug?
If yes – what happened?
d)Note the following (special circumstances)
Age
Liver function – normal/abnormal?
eGFR/creatinine?
Male or female?
If female, pregnant/breast feeding/childbearing potential?
24
Drug information
1.What licensed indications are there for taking this drug?
2.Why is this patient taking this drug?
3.What other drugs are there for this indication?
4.What are the contraindications to taking this drug?
5.Does the patient have any of these contraindications?
6.Should the drug dose to be modified due to special circumstances (d)? if yes –
how?
7.Is the patient at risk of drug interactions – if yes what?
Putting it together
8.What drug dose/route of administration/dose frequency would you choose?
9.What advice would you give to the patient about:
i) Starting and stopping?
ii) Side effects?
iii) Special requirements when taking drug?
iv) Monitoring?
v) How much is this drug costing the NHS per month?
25
I certify that this report is written entirely in my own words, except that:
Any text copied directly from another source is acknowledged and is enclosed in
quotation marks.
I understand that the use of plagiarism is an Examination Offence and is grounds for
failure of an assignment and/or disciplinary action.
I am aware that plagiarism detection software is now available and can be used for assessing
plagiarism in students’ work and that I may be required to provide my essay in an electronic
format.
I certify that I was actively involved in the clinical management of the patient described.
He/she was under the clinical care of
……………………………………..………………………………………………………………. IN CAPITALS
Consultant (Specialty/Hospital)
or General Practitioner (Practice)
at……………………………………………………………………………………………… IN CAPITALS
at the time this case was seen and treated.
Signed: ……………………………………………………………………………
Name:……………………………………………………………………………………….
(please print)
Candidate Number: ………………………………………………………………………
Date: …………………………………………2018
CASE ANALYSIS PROJECT 2017/18
CERTIFICATE OF ORIGINALITY/AUTHENTICITY