Long-Term Care: OSCE

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:

  1. 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.
  2. 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
  3. Ovarian Torsion: The patient is also endorsing abdomen pain which can be radiating from kidney stones, but also ovarian torsion can cause flank pain.
  4. 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.