Snapshot A 30-year-old man presents to the emergency department with severe, colicky left flank pain of acute onset that radiates to the left groin. He also reports urinary frequency and urgency. Physical examination is significant for left-sided costovertebral angle tenderness. Urine dipstick is heme positive. Urinalysis also shows envelope-shaped crystals. A non-contrast abdominal CT is shown. Introduction Clinical definition calculi (stones) affecting the kidneys; however, these stones can also affect the ureter Epidemiology prevalence 12% in men and 7% in women risk factors hyperparathyroidism hypocitraturia sarcoidosis hyperoxaluria renal tubular acidosis type I nephrocalcinosis cystic fibrosis hyperuricosuria indwelling catheter urinary tract infections malabsorption (e,g., Crohn disease) horseshoe kidney obesity low fluid intake gout medications e.g., allopurinol, indinavir, acetazolamide, and topiramate Pathogenesis substance precipitation affecting the kidney and ureter e,g., hypercalciuria and low urine volume forms calcium cystals Prognosis small stones are more likely to spontaneously pass Nephrolithiasis Stones Stone Type Etiology Imaging Finding(s) Stone Shape Treatment Calcium Hypercalciuria e.g., idiopathic hypercalcemia Hypocitraturia precipitates calcium oxalate stones Ethylene glycol (antifreeze) Vitamin C abuse Crohn disease Urine alkalinization precipitates calcium phosphate stones Radiography radiopaque Computerized tomography radiopaque Envelope or dumbbell shape calcium oxalate Wedge-shaped prism calcium phosphate Hydrochlorothiazide Citrate Low-sodium diet Cystine Impaired cystine reabsorption in the proximal convoluted tubule this results in cystinuria Precipitates in acidic urine Diagnosis cyanide-nitroprusside test Radiography radiopaque Computerized tomography visible at times Hexagonal Dietary modification low sodium Urine alkalinization Chelating agents in refractory cases Struvite (magnesium ammonium phosphate) Urease-positive organisms such as Proteus mirabilis Staphylococcus saphrophryticus Klebsiella Urease-positive organisms subesequently alkalinize the urine this causes struvite stones due to precipitation Radiography radiopaque Computerized tomography radiopaque Can result in a staghorn calculi Coffin lid Removal of underlying infection Surgical removal of the stone Uric acid Hyperuricemia e.g., states of increased cell turnover and gout Precipitates in acidic urine Radiography radiolucent Computerized tomography minimally visible Rhomboid/rosette Urine alkalinization Allopurinol Adequate hydration prior to chemotherapy treatment Presentation Symptoms colicky flank pain pain may radiate to the groin or lower abdomen dysuria urgency and frequency Physical exam low abdominal tenderness costovertebral angle (CVA) tenderness Imaging Renal ultrasound indication in patients who are pregnant and children who are suspected to have nephrolithiasis modality abdomen and pelvis to visualize the kidney and bladder Non-contrast computerized tomography (CT) indication preferred imaging for most adults presenting with signs and symptoms concerning for nephrolithiasis modality abdomen and pelvis Studies Labs serum creatinine, uric acid, and ionized calcium should be obtained urine studies urinalysis/dipstick in order to check for red and white blood cells, nitrites, and urine pH urine culture stone composition analysis perform in patients who developed their first stone straining the urine Diagnostic criteria based on clinical presentation and confirmed by imaging Differential Urinary tract infections Acute pyelonephritis Groin hernia Treatment Medical analgesia, bed rest, and intravenous fluids indication considered first-line treatment for uncomplicated urolithiasis < 10 mm α-blockers or calcium channel blockers indication can be considered to facilitate the passage of ureteral stones appears to relax the ureter Operative extracorporal shock wave lithotripsy indication preferred for renal stones < 2 cm percutaneous nephrolithotomy indication preferred for renal stones > 2cm note flexible ureterorenoscopy can be an option if percutaneous nephrolithotomy cannot be done Complications Ureteral obstruction Ureteral stricture Urinary tract infection Renal deterioration
QUESTIONS 1 of 5 1 2 3 4 5 Previous Next Lab Values Blood Hematologic Cerebrospinal Sweat, Urine, and BMI Blood, Plasma, Serum Reference Range ALT 8-20 U/L Amylase, serum 25-125 U/L AST 8-20 U/L Bilirubin, serum (adult) Total // Direct 0.1-1.0 mg/dL // 0.0-0.3 mg/dL Calcium, serum (Ca2+) 8.4-10.2 mg/dL Cholesterol, serum Rec: < 200 mg/dL Cortisol, serum 0800 h: 5-23 μg/dL //1600 h: 3-15 μg/dL 2000 h: ≤ 50% of 0800 h Creatine kinase, serum Male: 25-90 U/LFemale: 10-70 U/L Creatinine, serum 0.6-1.2 mg/dL Electrolytes, serum Sodium (Na+) 136-145 mEq/L Chloride (Cl-) 95-105 mEq/L Potassium (K+) 3.5-5.0 mEq/L Bicarbonate (HCO3-) 22-28 mEq/L Magnesium (Mg2+) 1.5-2.0 mEq/L Estriol, total, serum (in pregnancy) 24-28 wks // 32-36 wks 30-170 ng/mL // 60-280 ng/mL 28-32 wk // 36-40 wks 40-220 ng/mL // 80-350 ng/mL Ferritin, serum Male: 15-200 ng/mLFemale: 12-150 ng/mL Follicle-stimulating hormone, serum/plasma Male: 4-25 mIU/mL Female: premenopause: 4-30 mIU/mL midcycle peak: 10-90 mIU/mL postmenopause: 40-250 pH 7.35-7.45 PCO2 33-45 mmHg PO2 75-105 mmHg Glucose, serum Fasting: 70-110 mg/dL2-h postprandial:<120 mg/dL Growth hormone - arginine stimulation Fasting: <5 ng/mLProvocative stimuli: > 7ng/mL Immunoglobulins, serum IgA 76-390 mg/dL IgE 0-380 IU/mL IgG 650-1500 mg/dL IgM 40-345 mg/dL Iron 50-170 μg/dL Lactate dehydrogenase, serum 45-90 U/L Luteinizing hormone, serum/plasma Male: 6-23 mIU/mL Female: follicular phase: 5-30 mIU/mL midcycle: 75-150 mIU/mL postmenopause 30-200 mIU/mL Osmolality, serum 275-295 mOsmol/kd H2O Parathyroid hormone, serume, N-terminal 230-630 pg/mL Phosphatase (alkaline), serum (p-NPP at 30° C) 20-70 U/L Phosphorus (inorganic), serum 3.0-4.5 mg/dL Prolactin, serum (hPRL) < 20 ng/mL Proteins, serum Total (recumbent) 6.0-7.8 g/dL Albumin 3.5-5.5 g/dL Globulin 2.3-3.5 g/dL Thyroid-stimulating hormone, serum or plasma .5-5.0 μU/mL Thyroidal iodine (123I) uptake 8%-30% of administered dose/24h Thyroxine (T4), serum 5-12 μg/dL Triglycerides, serum 35-160 mg/dL Triiodothyronine (T3), serum (RIA) 115-190 ng/dL Triiodothyronine (T3) resin uptake 25%-35% Urea nitrogen, serum 7-18 mg/dL Uric acid, serum 3.0-8.2 mg/dL Hematologic Reference Range Bleeding time 2-7 minutes Erythrocyte count Male: 4.3-5.9 million/mm3Female: 3.5-5.5 million mm3 Erythrocyte sedimentation rate (Westergren) Male: 0-15 mm/hFemale: 0-20 mm/h Hematocrit Male: 41%-53%Female: 36%-46% Hemoglobin A1c ≤ 6 % Hemoglobin, blood Male: 13.5-17.5 g/dLFemale: 12.0-16.0 g/dL Hemoglobin, plasma 1-4 mg/dL Leukocyte count and differential Leukocyte count 4,500-11,000/mm3 Segmented neutrophils 54%-62% Bands 3%-5% Eosinophils 1%-3% Basophils 0%-0.75% Lymphocytes 25%-33% Monocytes 3%-7% Mean corpuscular hemoglobin 25.4-34.6 pg/cell Mean corpuscular hemoglobin concentration 31%-36% Hb/cell Mean corpuscular volume 80-100 μm3 Partial thromboplastin time (activated) 25-40 seconds Platelet count 150,000-400,000/mm3 Prothrombin time 11-15 seconds Reticulocyte count 0.5%-1.5% of red cells Thrombin time < 2 seconds deviation from control Volume Plasma Male: 25-43 mL/kgFemale: 28-45 mL/kg Red cell Male: 20-36 mL/kgFemale: 19-31 mL/kg Cerebrospinal Fluid Reference Range Cell count 0-5/mm3 Chloride 118-132 mEq/L Gamma globulin 3%-12% total proteins Glucose 40-70 mg/dL Pressure 70-180 mm H2O Proteins, total < 40 mg/dL Sweat Reference Range Chloride 0-35 mmol/L Urine Calcium 100-300 mg/24 h Chloride Varies with intake Creatinine clearance Male: 97-137 mL/minFemale: 88-128 mL/min Estriol, total (in pregnancy) 30 wks 6-18 mg/24 h 35 wks 9-28 mg/24 h 40 wks 13-42 mg/24 h 17-Hydroxycorticosteroids Male: 3.0-10.0 mg/24 hFemale: 2.0-8.0 mg/24 h 17-Ketosteroids, total Male: 8-20 mg/24 hFemale: 6-15 mg/24 h Osmolality 50-1400 mOsmol/kg H2O Oxalate 8-40 μg/mL Potassium Varies with diet Proteins, total < 150 mg/24 h Sodium Varies with diet Uric acid Varies with diet Body Mass Index (BMI) Adult: 19-25 kg/m2 Calculator ( ) xy AC 7 8 9 ÷ 4 5 6 × 1 2 3 - 0 . = + Sorry, this question is for PEAK Premium Subscribers only Upgrade to PEAK Sorry, this question is for PEAK Premium Subscribers only Upgrade to PEAK Sorry, this question is for PEAK Premium Subscribers only Upgrade to PEAK Sorry, this question is for PEAK Premium Subscribers only Upgrade to PEAK You have 100% on this question. Just skip this one for now. Take This Question Anyway (M2.RL.17.71) A 31-year-old obese Caucasian female presents to the Emergency Department late in the evening for left lower quadrant pain that has progressively worsened over the last several hours. She describes the pain as sharp and shooting, coming and going. Her last bowel movement was this morning. She has also had dysuria and urgency. Her surgical history is notable for gastric bypass surgery 2 years prior and an appendectomy at age 9. She is sexually active with her boyfriend and uses condoms. Her temperature is 99.5 deg F (37.5 deg C), blood pressure is 151/83 mmHg, pulse is 86/min, respirations are 14/minute, BMI 32. On physical exam, she has left lower quadrant tenderness to palpation with pain radiating to the left groin and left flank tenderness on palpation. Her urinalysis shows 324 red blood cells/high power field. Her pregnancy test is negative. What is the next best step in management? Review Topic | Tested Concept QID: 104613 Type & Select Correct Answer 1 A KUB (kidneys, ureters and bladder) plain film 0% (0/0) 2 Intravenous pyelogram 0% (0/0) 3 Transvaginal ultrasound 0% (0/0) 4 Noncontrast CT scan 0% (0/0) 5 Exploratory laparoscopy 0% (0/0) L 2 Question Complexity C Question Importance Select Answer to see Preferred Response SUBMIT RESPONSE 4