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i-Human Molly Howard Case Study: Acute Right
Flank Pain (Ureteral Calculus) | 2025/2026 Ultimate
Guide to Pass First Try questions and answers with
rationals (100 Q&A).
Part 1: History Taking (HPI) - 25 Questions
1. Molly Howard is a 33-year-old female presenting with "severe
right-sided flank pain." According to the case, what is the most
critical element to clarify first in her History of Present Illness
(HPI)?
A. Her dietary habits over the last week
B. The onset, location, radiation, and characteristics of the pain
C. Her family history of kidney stones
D. The date of her last gynecological exam
Answer: B
Rationale: The HPI must completely characterize the pain using OLD
CARTS. For suspected renal colic, defining the onset (sudden vs.
gradual), location (flank), radiation (to groin), and character (colicky)
is the priority, as this pattern is nearly pathognomonic for a ureteral
calculus .
2. Molly describes her pain as "colicky." What is the best
description of colicky pain?
A. Constant, dull, and aching
B. Sharp, stabbing, and localized to one spot
C. Wavelike cramping that comes and goes in intensity
D. Burning sensation that radiates down the leg
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Answer: C
Rationale: Colicky pain is caused by smooth muscle spasm in a hollow
organ (like the ureter) trying to overcome an obstruction. It is
characterized by waves of intense cramping pain, which is classic for a
stone moving through the ureter .
3. The patient reports pain radiating to the groin. This pattern is
most characteristic of:
A. Pyelonephritis
B. A stone lodged in the proximal ureter
C. A stone migrating down the ureter toward the bladder
D. Appendicitis
Answer: C
Rationale: Pain radiation to the groin (or ipsilateral testicle/labia) is
referred pain along the genitofemoral nerve and indicates that the stone
is in the distal ureter, near the bladder. This is a key historical feature for
ureteral calculus .
4. Molly reports associated symptoms of nausea and vomiting. In the
context of renal colic, these symptoms are primarily due to:
A. Food poisoning from a recent meal
B. The shared nerve pathway (vagal stimulation) between the kidney and
the GI tract
C. Anxiety about the pain
D. A separate gastrointestinal illness
Answer: B
Rationale: The kidneys and GI tract share common nerve innervation
(celiac plexus). Severe pain from a kidney stone can stimulate this
plexus, leading to nausea, vomiting, and even ileus. This is a referred GI
response to the intense pain .
5. The patient reports dysuria and increased urinary frequency.
These symptoms are most helpful for:
A. Confirming the diagnosis of a kidney stone
B. Ruling out a urinary tract infection (UTI) as a contributing factor
C. Suggesting the stone may be located in the distal ureter near the
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bladder trigone
D. Diagnosing interstitial cystitis
Answer: C
Rationale: When a stone reaches the distal ureter, near the
ureterovesical junction, it can irritate the bladder trigone, causing urinary
urgency and frequency. Dysuria can also occur. These symptoms help
localize the stone's position .
6. Molly reports a low-grade fever of 100.2°F. What is the most
significant concern associated with fever in a patient with suspected
nephrolithiasis?
A. It confirms the diagnosis of a simple kidney stone.
B. It indicates the stone is passing successfully.
C. It raises suspicion for concurrent infection (pyelonephritis or
pyonephrosis).
D. It is a normal finding in all patients with renal colic.
Answer: C
Rationale: Fever in the setting of a stone and obstruction is a red flag. It
suggests an infection above the obstruction, which can rapidly progress
to urosepsis. This requires emergent intervention (drainage) .
7. Molly mentions she has had three UTIs in the last year. This
history is significant because:
A. It is unrelated to her current presentation.
B. Recurrent UTIs can be a risk factor or a consequence of kidney
stones.
C. It means she definitely has a UTI now.
D. It rules out a kidney stone.
Answer: B
Rationale: Stones can act as a nidus for bacteria, leading to recurrent
UTIs. Conversely, chronic infection with certain organisms (like
Proteus) can cause struvite stones. This history is important for
understanding her risk profile .
8. The patient reports a history of chlamydia in college. Why is this
a relevant piece of history for her current flank pain?
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A. Chlamydia causes kidney stones.
B. Untreated chlamydia can lead to urethral strictures or chronic pelvic
pain, which can mimic stone pain.
C. It is irrelevant information that should be ignored.
D. It means she is immune to future STIs.
Answer: B
Rationale: While chlamydia doesn't cause stones, a history of PID from
chlamydia can lead to chronic pelvic adhesions and pain. More
relevantly, it's a reminder of the importance of a sexual history and
ruling out other causes of pelvic/flank pain .
9. Molly states she missed a few of her oral contraceptive pills. What
is the single most important test this information mandates?
A. A pelvic ultrasound
B. A urine pregnancy test
C. A chlamydia test
D. A serum progesterone level
Answer: B
Rationale: Any reproductive-age female with missed OCPs and
abdominal/pelvic/flank pain must have a pregnancy test to rule out
ectopic pregnancy, which can present similarly. This is a non-negotiable
safety step .
10. The patient reports that Tylenol (acetaminophen) provided no
relief. This is most consistent with:
A. A musculoskeletal strain
B. Renal colic, which requires NSAIDs for prostaglandin-mediated pain
C. A tension headache
D. A placebo effect
Answer: B
Rationale: Renal colic pain is caused by prostaglandin release, which
increases ureteral pressure and smooth muscle spasm. NSAIDs (like
ketorolac or ibuprofen) are first-line because they inhibit prostaglandin
synthesis. Acetaminophen has no anti-inflammatory effect and is often
ineffective for this type of pain .
i-Human Molly Howard Case Study: Acute Right
Flank Pain (Ureteral Calculus) | 2025/2026 Ultimate
Guide to Pass First Try questions and answers with
rationals (100 Q&A).
Part 1: History Taking (HPI) - 25 Questions
1. Molly Howard is a 33-year-old female presenting with "severe
right-sided flank pain." According to the case, what is the most
critical element to clarify first in her History of Present Illness
(HPI)?
A. Her dietary habits over the last week
B. The onset, location, radiation, and characteristics of the pain
C. Her family history of kidney stones
D. The date of her last gynecological exam
Answer: B
Rationale: The HPI must completely characterize the pain using OLD
CARTS. For suspected renal colic, defining the onset (sudden vs.
gradual), location (flank), radiation (to groin), and character (colicky)
is the priority, as this pattern is nearly pathognomonic for a ureteral
calculus .
2. Molly describes her pain as "colicky." What is the best
description of colicky pain?
A. Constant, dull, and aching
B. Sharp, stabbing, and localized to one spot
C. Wavelike cramping that comes and goes in intensity
D. Burning sensation that radiates down the leg
,2|Page
Answer: C
Rationale: Colicky pain is caused by smooth muscle spasm in a hollow
organ (like the ureter) trying to overcome an obstruction. It is
characterized by waves of intense cramping pain, which is classic for a
stone moving through the ureter .
3. The patient reports pain radiating to the groin. This pattern is
most characteristic of:
A. Pyelonephritis
B. A stone lodged in the proximal ureter
C. A stone migrating down the ureter toward the bladder
D. Appendicitis
Answer: C
Rationale: Pain radiation to the groin (or ipsilateral testicle/labia) is
referred pain along the genitofemoral nerve and indicates that the stone
is in the distal ureter, near the bladder. This is a key historical feature for
ureteral calculus .
4. Molly reports associated symptoms of nausea and vomiting. In the
context of renal colic, these symptoms are primarily due to:
A. Food poisoning from a recent meal
B. The shared nerve pathway (vagal stimulation) between the kidney and
the GI tract
C. Anxiety about the pain
D. A separate gastrointestinal illness
Answer: B
Rationale: The kidneys and GI tract share common nerve innervation
(celiac plexus). Severe pain from a kidney stone can stimulate this
plexus, leading to nausea, vomiting, and even ileus. This is a referred GI
response to the intense pain .
5. The patient reports dysuria and increased urinary frequency.
These symptoms are most helpful for:
A. Confirming the diagnosis of a kidney stone
B. Ruling out a urinary tract infection (UTI) as a contributing factor
C. Suggesting the stone may be located in the distal ureter near the
,3|Page
bladder trigone
D. Diagnosing interstitial cystitis
Answer: C
Rationale: When a stone reaches the distal ureter, near the
ureterovesical junction, it can irritate the bladder trigone, causing urinary
urgency and frequency. Dysuria can also occur. These symptoms help
localize the stone's position .
6. Molly reports a low-grade fever of 100.2°F. What is the most
significant concern associated with fever in a patient with suspected
nephrolithiasis?
A. It confirms the diagnosis of a simple kidney stone.
B. It indicates the stone is passing successfully.
C. It raises suspicion for concurrent infection (pyelonephritis or
pyonephrosis).
D. It is a normal finding in all patients with renal colic.
Answer: C
Rationale: Fever in the setting of a stone and obstruction is a red flag. It
suggests an infection above the obstruction, which can rapidly progress
to urosepsis. This requires emergent intervention (drainage) .
7. Molly mentions she has had three UTIs in the last year. This
history is significant because:
A. It is unrelated to her current presentation.
B. Recurrent UTIs can be a risk factor or a consequence of kidney
stones.
C. It means she definitely has a UTI now.
D. It rules out a kidney stone.
Answer: B
Rationale: Stones can act as a nidus for bacteria, leading to recurrent
UTIs. Conversely, chronic infection with certain organisms (like
Proteus) can cause struvite stones. This history is important for
understanding her risk profile .
8. The patient reports a history of chlamydia in college. Why is this
a relevant piece of history for her current flank pain?
, 4|Page
A. Chlamydia causes kidney stones.
B. Untreated chlamydia can lead to urethral strictures or chronic pelvic
pain, which can mimic stone pain.
C. It is irrelevant information that should be ignored.
D. It means she is immune to future STIs.
Answer: B
Rationale: While chlamydia doesn't cause stones, a history of PID from
chlamydia can lead to chronic pelvic adhesions and pain. More
relevantly, it's a reminder of the importance of a sexual history and
ruling out other causes of pelvic/flank pain .
9. Molly states she missed a few of her oral contraceptive pills. What
is the single most important test this information mandates?
A. A pelvic ultrasound
B. A urine pregnancy test
C. A chlamydia test
D. A serum progesterone level
Answer: B
Rationale: Any reproductive-age female with missed OCPs and
abdominal/pelvic/flank pain must have a pregnancy test to rule out
ectopic pregnancy, which can present similarly. This is a non-negotiable
safety step .
10. The patient reports that Tylenol (acetaminophen) provided no
relief. This is most consistent with:
A. A musculoskeletal strain
B. Renal colic, which requires NSAIDs for prostaglandin-mediated pain
C. A tension headache
D. A placebo effect
Answer: B
Rationale: Renal colic pain is caused by prostaglandin release, which
increases ureteral pressure and smooth muscle spasm. NSAIDs (like
ketorolac or ibuprofen) are first-line because they inhibit prostaglandin
synthesis. Acetaminophen has no anti-inflammatory effect and is often
ineffective for this type of pain .
