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56M no PMH p/w RUQ pain

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

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56M no PMH p/w RUQ pain

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  1. 56M no PMH p/w RUQ pain Jeremy Price, MSIV Albert Einstein College of Medicine July 19, 2013

  2. 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

  3. Physical Examination • Vital Signs • T 97.2°F • 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

  4. Physical Examination cont’d • 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 Murphy’s sign, normoactive BS, no organomegaly • Back: severe R CVA tenderness

  5. 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

  6. Labs • CBC: 8.1>12.6/37.7<224 • BMP: 137/3.6|104/23|21/1.0<146 • Alk Phos 83 / AST 22 / ALT27 • Amylase 155, Lipase 140 • And the urinalysis is…

  7. Labs cont’d • …negative

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

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

  10. 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?

  11. 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

  12. 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

  13. 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

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