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HKCEM College Tutorial. A man with flank pain. author Dr TW Wong Revised by Dr. Li Yu Kwan May 2013. Triage . M 65 R flank pain for one day DM, HT Fu GOPD BP 160/100 P 100/min Temp 37.5° C. Triage Category III. What would you like to know in the history?. A B C is stable.

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a man with flank pain

HKCEM College Tutorial

A man with flank pain

author

Dr TW Wong

Revised by

Dr. Li Yu Kwan

May 2013

triage
Triage
  • M 65
  • R flank pain for one day
  • DM, HT Fu GOPD
  • BP 160/100
  • P 100/min
  • Temp 37.5° C

Triage Category III

targeted history
Pain:-

P- flank, loin

Q-colicky, sharp…

R- to groin, aggravate and relief by…

S- pain score 1-10

T- onset ? Sudden; last for...

Associated symptoms:

GU-- dysuria, freq../

M/Sk-- bone pain, pain with bending…

GI…

System Review:

fever

PH, Med, allergy

Targeted history
what are your ddx
What are your ddx?

Kidney-Ureter

Hepatobiliary

Colon

Appendix

Spine

Lung base

Skin

Pain

Site

now a focussed exam

Now, a focussed exam...

What to look out for?

physical exam
General

pallor, jaundice

uremic look

Abdomen

local tenderness

renal angle; spine…

Mass including hernia

BS

System survey

lung basalcrep

Skin eruption (herpes)

Physical Exam

*Remember referred pain from scrotal pathologies.

now how do you control the pain

Now, how do you control the pain?

Narcotic e.g. Tramadol, Pethidine

NSAID e.g. Toradol

our nurse has performed a urine dipstick test
Our nurse has performed a urine dipstick test

You can choose your scenario now:

A

C

B

scenario a
Scenario A
  • Glucose ++
  • Albumin +
  • WBC +++
  • Nitrite ++
  • RBC ++

Your provisional dx? Your next step?

uti acute pyelonephritis
?UTI ?acute pyelonephritis

Admission?Further Ix?

  • KUB?
  • US?
  • Blood?
further investigation
Further investigation
  • KUB no stone seen
  • USG
    • no hydronephrosis
    • no stone
  • H’stix 8 mmol

Pain has decreased, disposition?

disposition
Disposition
  • To EM/Observation ward for suspected pyelonephritis
  • Management
    • MSU C&ST
    • antibiotic
    • pain control
    • blood for CBC, RFT
  • For this patient with DM and male sex, consider admission to medical if poor DM control, high fever, clinical sepsis or obstructive uropathy is suspected
antibiotic of choices a e coc guideline
Antibiotic of choices (A&E COC guideline)
  • 2nd and 3rd generation cephalosporin, fluoroquinolones, or beta-lactam/ beta- lactamase inhibitor combinations
  • Fluroquinolone has better tissue concentration in the prostate
  • Give parenteral antibiotic if fever, chill, vomiting, abdominal pain or sign of bacteremia
  • Oral antibiotic can be started with clinical improvement, afebrile for 24-48 hr, with a treatment course of 14 days
consider admission to other specialties for complicated pyelonephritis
Consider admission to other specialties for complicated pyelonephritis
  • Anatomical abnormality e.g. horseshoe kidney
  • Immunocompromised
  • Recent instrumentation
  • Signs of obstruction
  • Pregnancy
scenario b
Scenario B
  • Glucose ++
  • Albumin --
  • WBC --
  • Nitrite --
  • RBC ++++

Your provisional dx and next step?

slide18
USG

How to rule out complete obstruction?

ureteral jet1
Ureteral jet
  • Evaluation of complete (distal) urinary obstruction
  • Typically 1 to 12 antegrade urinary jets per minute from both ureters
  • The detection of ureteral jets essentially excludes the possibility of a total obstruction
  • The ureteral jets are visualized due to the difference in specific gravity of the urine currently in the bladder and the urine entering from the ureter
another patient
Another patient

Left

Right

Dilatation of renal pelvicalyceal system suggestive of mild to moderate left hydronephrosis

another patient1
Another patient

Severe hydronephrosis with cortical thinning

apart from stones what else can cause colic and obstruction

Apart from stones, what else can cause colic and obstruction?

Blood clot

tumour clot

papillary necrosis (DM)

ureteric colic
Ureteric Colic

Disposal Plan?

  • Pain control
  • MSU
  • Refer urology for Ix
  • TCA prn
consider admission if
Consider admission if…
  • Retractable pain and vomiting
  • Obstructive uropathy with urinary tract infection
  • Single or transplanted kidney with obstruction
  • Hypercalcaemic crisis
  • High grade obstruction
scenario c
Scenario C
  • Glucose ++
  • Albumin +
  • WBC --
  • Nitrite --
  • RBC +

Your provisional dx and action?

patient still complains about the pain and looks pale
Patient still complains about the pain and looks pale...

BP 90/-

P 110/min

What should you do now?

resuscitation go back to abc
Resuscitation--go back to ABC
  • Oxygen by mask
  • 2 IV line inserted, cardiac monitor
  • no skin rash
  • chest clear
  • Abd tender (mainly right side), mildly distended.
  • Femoral pulses palpable.

What Ix will you perform now?

slide33

US of Aorta

8 cm x 10 cm

further investigation1
Further Investigation
  • ECG
    • sinus tachycardia
    • non-specific ST changes
slide35
CXR
  • no cardiomegaly
  • no widened mediastinum
  • lungs are clear
diagnosis leaking aaa

Diagnosis: Leaking AAA

All elderly patients presenting with flank pain or renal colic should have AAA ruled out by US!

slide37
KUB

Any clues from KUB?

how do you mx leaking aaa at ed

How do you mx leaking AAA at ED?

Get your senior!

Inform surgical on-call

Prepare for OT

mx of leaking aaa
Mx of leaking AAA
  • A,B
    • oxygen by mask to maintain SpO2
  • C
    • fluid resuscitation to keep SBP around 90 mmHg to maintain renal perfusion
    • X-match 6 units
    • judicious use of analgesic by titration
focused usg for evaluation of patients with flank pain
Focused USG for evaluation of patients with flank pain
  • Look for hydronephrosis/pyonephrosis for patients with suspected renal calculi and pyelonephritis
  • Signs of complete obstruction
  • Diagnosis of AAA for elderly patients
  • +/- diagnosis of biliary colic for right flank pain
summary
Summary

We have covered:

  • evaluate a patient with flank pain
  • the use of US/KUB in the diagnosis of flank pain
  • how not to miss a leaking AAA
reference
Reference
  • A&E COC clinical guideline No 23: Antibiotic use in A&E department
  • Urolithiasis in the Emergency Department. Emerg Med Clin N Am 29 (2011) 519–538
  • Genitourinary imaging in the Emergency Department. Emerg Med Clin N Am 29 (2011) 553–567