Scenario:
30: y/o F presents with acute back pain since morning.
History Elements:
- HPI Pertinent findings
- Endorsing acute back pain with movement
- Endorsing hematuria
- Endorsing nausea, and vomiting
- Pain is 10/10 and radiating to the abdomen.
- Sexually active with husband, no protection or birth control
- Denies fever, and vaginal discharge.
- Denies trauma.
- Denies PMHx of kidney stones
- The patient did not take any pain medication.
PMH:
- No significant past medical history
PSH:
- No significant past surgical history
Physical Exam:
- Vitals:
- Blood pressure 140/90 mmHg, right arm
- Temperature: 99.0 F oral
- Heart Rate 105 RPM
- RR: 20 breaths per minute
Exam:
- General
- The patient appears in pain and hunched over.
- Lungs:
- Clear to auscultation b/l, no crackles or wheezing
- Heart:
- Normal S1 & S2 sounds, no murmurs appreciated.
- Abdomen:
- +Flank pain, Abdomen is Soft, non-tender, bowel sounds present in all 4 quadrants. No CVA tenderness.
- GU Exam:
- closed cervical os without cervical or adnexal tenderness on pelvic exam, negative for lesions/masses/discharge/blood
Differential diagnosis:
- Nephrolithiasis: The patient woke up with acute flank pain, but no radiation, and is endorsing nausea and vomiting. Physical exam is positive for flank pain, but negative for CVA tenderness.
- Pyelonephritis: The patient is c/o flank pain, and hematuria, and Pyelonephritis needs to be ruled out even though CVA tenderness is negative as Pyelonephritis can have serious complications
- Ovarian Torsion: The patient is also endorsing abdomen pain which can be radiating from kidney stones, but also ovarian torsion can cause flank pain.
- Ectopic Pregnancy: The patient is sexually active and does not use protection, and pain is occurring in the abdomen area, but unlikely..
Tests:
- Urine Analysis – Calcium oxalate, microscopic hematuria, no leukocytosis
- bHCG test – negative
- BMP – WNL
- CT without contrast scan of abdomen, and pelvis – bilateral staghorn caliculi less than 5cm.
Treatment:
- NSAIDs PRN for pain
- Zofran for nausea, and vomiting
- Plenty of fluids to help pass stones.
Pt. Counseling:
- Advise patient on self-care instructions such as taking NSAID as needed
- Drink plenty of fluids to help pass the stones.
- Given your kidney stones is less than 5cm no surgery will be needed, and the stones will pass
- Most kidney stones are usually caused by a diet high in sodium.
- Limit coffee, tea, and alcohol intake as this can cause stones to form.