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Jeremy Price, MSIV Albert Einstein College of Medicine July 19, 2013 56M no PMH p/w RUQ pain

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Case RUQ pain x3 days, began gradually now 10/10 and constant, sharp, radiating around to the back, accompanied by nausea, vomiting x1. Denies fever, dysuria, frequency, hematuria, change in bowel habits. PMH: none PSHx: none Meds: none Allergies: NKDA SH: denies toxic habits FH: non-contributory

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Physical Examination Vital Signs T 97.2F BP 130/74 P 56 R 18 97% on RA General: AAOx3, thin middle-aged Hispanic male lying on stretcher in obvious discomfort HEENT: mmm, no scleral icterus Neck: supple, no LAD, no JVD

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Physical Examination contd CV: S1, S2, RRR, no m/r/g Resp: CTAB, good air entry, no wheezes Abd: soft, nondistended, mildly tender to palpation in RUQ, negative Murphys sign, normoactive BS, no organomegaly Back: severe R CVA tenderness

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Differential Diagnosis RUQ pain: Cholelithiasis Acute cholecystitis Cholangitis Acute hepatitis Perforated duodenal ulcer RLL pneumonia R Flank pain: Nephrolithiasis Urolithiasis Retroperitoneal hematoma Ruptured renal cyst Ureteral stricture Pyelonephritis Perinephric abscess Ruptured AAA

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Labs CBC: 8.1>12.6/37.7

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Labs contd negative

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Imaging CT abdomen and pelvis without contrast: Mild right hydronephrosis secondary to an obstructing 5x3mm stone in the proximal ureter

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Final Diagnosis/Treatment Urolithiasis Patient treated with IV Ketoralac and morphine for pain, and NS for hydration Discharged with Motrin, Percocet, and Flomax

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ED Management of Kidney Stones Pain control: ketorolac 30mg IV (caution in renal insufficiency) and morphine 0.1mg/kg x1 then titrated for further relief IV hydration...hastens stone passage or exacerbates pain?

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Forced versus Minimal Intravenous Hydration in the Management of Acute Renal Colic: A Randomized Trial 43 ED patients with nephrolithiasis randomized to either forced IV hydration (2L NS over 2 hours) or minimal IV hydration (20mL NS per hour) Stone size was equivalent between groups Pain and spontaneous stone passage rates were recorded and analyzed No difference in narcotic requirement, hourly pain score, or stone-passage rate between groups Conclusion: Maintenance fluids are sufficient to treat dehydration

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Disposition Discharge to home if adequate pain control is established in ED, normal creatinine; follow-up with urology Send home with strainer Discharge medications: Ibuprofen 600mg PO q6h, Percocet for breakthrough pain, Tamsulosin (Flomax) 0.4mg PO daily (effective for distal ureteral stones) Admit: intractable pain, unable to tolerate PO, renal failure, urosepsis, renal transplant, single kidney, comorbid conditions

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Things To Know 10-20% of patients with nephro-/urolithiasis can have clean urinalysis Fluids for dehydration, not for stone passage Test of choice: noncontrast CT of abdomen/pelvis Discharge with Ibuprofen, Percocet, and Flomax For stones >4 mm, progressive decrease in the spontaneous passage rate; unlikely to pass if 10mm