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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 . 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

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  1. HKCEM College Tutorial A man with flank pain author Dr TW Wong Revised by Dr. Li Yu Kwan May 2013

  2. 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

  3. What would you like to know in the history? A B C is stable

  4. 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

  5. What are your ddx? Kidney-Ureter Hepatobiliary Colon Appendix Spine Lung base Skin Pain Site

  6. Now, a focussed exam... What to look out for?

  7. 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.

  8. Now, how do you control the pain? Narcotic e.g. Tramadol, Pethidine NSAID e.g. Toradol

  9. Our nurse has performed a urine dipstick test You can choose your scenario now: A C B

  10. Scenario A • Glucose ++ • Albumin + • WBC +++ • Nitrite ++ • RBC ++ Your provisional dx? Your next step?

  11. ?UTI ?acute pyelonephritis Admission?Further Ix? • KUB? • US? • Blood?

  12. Further investigation • KUB no stone seen • USG • no hydronephrosis • no stone • H’stix 8 mmol Pain has decreased, disposition?

  13. 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

  14. 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

  15. Consider admission to other specialties for complicated pyelonephritis • Anatomical abnormality e.g. horseshoe kidney • Immunocompromised • Recent instrumentation • Signs of obstruction • Pregnancy

  16. Scenario B • Glucose ++ • Albumin -- • WBC -- • Nitrite -- • RBC ++++ Your provisional dx and next step?

  17. KUB

  18. USG How to rule out complete obstruction?

  19. Ureteral jet

  20. Ureteral Jet (video)

  21. 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

  22. Another patient Left Right Dilatation of renal pelvicalyceal system suggestive of mild to moderate left hydronephrosis

  23. Another patient Severe hydronephrosis with cortical thinning

  24. Apart from stones, what else can cause colic and obstruction? Blood clot tumour clot papillary necrosis (DM)

  25. Ureteric Colic Disposal Plan? • Pain control • MSU • Refer urology for Ix • TCA prn

  26. Consider admission if… • Retractable pain and vomiting • Obstructive uropathy with urinary tract infection • Single or transplanted kidney with obstruction • Hypercalcaemic crisis • High grade obstruction

  27. Scenario C • Glucose ++ • Albumin + • WBC -- • Nitrite -- • RBC + Your provisional dx and action?

  28. KUB

  29. USG

  30. Patient still complains about the pain and looks pale... BP 90/- P 110/min What should you do now?

  31. 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?

  32. Further investigations. Which one first? Why? ECG CXR USG Progress

  33. US of Aorta 8 cm x 10 cm

  34. Further Investigation • ECG • sinus tachycardia • non-specific ST changes

  35. CXR • no cardiomegaly • no widened mediastinum • lungs are clear

  36. Diagnosis: Leaking AAA All elderly patients presenting with flank pain or renal colic should have AAA ruled out by US!

  37. KUB Any clues from KUB?

  38. Another patient

  39. How do you mx leaking AAA at ED? Get your senior! Inform surgical on-call Prepare for OT

  40. 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

  41. 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

  42. 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

  43. 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

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