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“truly stoned” A Case Discussion

“truly stoned” A Case Discussion. Ryan Em C. Dalman MD MBA - 070070. February 10, 2010. Case Presentation. Patient History. General Data. 52-year-old Female Born on May 4, 1958 Roman Catholic Lives in Antipolo City Informant: Patient, good reliability. Chief Complaint.

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“truly stoned” A Case Discussion

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  1. “truly stoned”A Case Discussion Ryan Em C. Dalman MD MBA - 070070 February 10, 2010

  2. Case Presentation Patient History

  3. General Data 52-year-old Female Born on May 4, 1958 Roman Catholic Lives in Antipolo City Informant: Patient, good reliability

  4. Chief Complaint Right Flank Pain

  5. History of Present Illness 5 days PTA Symptom persisted • Consult at Manila East Medical Center • CT stono – Nephrolithiasis R, Pelvocaliectasia R, Hydronephrosis R • For ESWL but d/c due to lack of schedule • Scheduled after 10 days 4 days PTA • Flank pain, left • No precipitating event, took pain killers with partial relief • No aggravating factor • Constant and described as sharp and crampy • No radiation • Pain 5/10 • Associated with painful urination • No nausea, no vomiting, no fever, no blood in urine, no genital discharge

  6. History of Present Illness Symptoms persisted 6 hours PTA Consult • Flank pain • Took ibuprofen with no relief • Radiation to the RLQ, 10/10 pain • No nausea, no vomiting, no change in bowel movement, no fever

  7. Review of Systems General: no weight loss, no change in appetite Cutaneous: no lesions, no change in color, no pruritus HEENT: with occasional headaches no redness no aural/nasal discharge no neck masses no sore throat

  8. Review of Systems Cardiovascular: no easy fatigability, fainting spells, palpitation Gastrointestinal: no nausea and vomiting, no change in bowel movements, no acholic stools Endocrine: no polyuria, polydypsia, no heat/cold intolerance

  9. Review of Systems Muskuloskeletal: no weakness, numbness on all extremities Hematopoietic: no easy bruisability, or bleeding

  10. Past Medical History Hypertension on telmesartan 40mg OD (uBP 140/90) No Diabetes, Asthma, PTB No Cancer, Allergies, s/p ESWL 2x(2004 and 2008) s/p TAHBSO, non-malignant (2009) s/p appendectomy (high school)

  11. Family History History of kidney disease (stone former), maternal No hypertension, heart disease, cancer, stroke, diabetes, asthma, or allergies

  12. Personal and Social History Business woman Lives with her family in a subdivision College graduate Non-smoker Occasional alcoholic beverage drinker No substance abuse

  13. Case Presentation Pertinent Physical Exam on Admission

  14. Physical Exam • General Survey • awake and not in cardiorespiratory distress • In severe pain • Vital Signs • afebrile at 37.2oC • RR 20 bpm • HR 89 bpm • Height:157cm weight:49kg BMI:19.9

  15. Physical Exam • Skin • Light brown • No rashes, hemorrhages, scars • Moist • CRT 1-2 seconds

  16. HEENT Head no lesions Eyes anictericsclerae, pink palpebral conjunctiva pupils 2-3mm Ears no discharge, tenderness Nose septum medline, moist mucosa Throat mouth and tongue moist no TPC

  17. Chest and Lungs Neck no cervical lymphadonapathy no nuchal rigidity Chest adynamicprecordium no heaves, thrills, or lifts, PMI at 5th ICS MCL regular rate, normal rhythm no murmurs Lungs symmetrical chest expansion, no retractions clear breath sounds

  18. Abdomen/ Perineum Abdomen flat, no lesions surgical scars: 9cm vertical on the hypogastrium, 5cm horizontal RLQ normoactive bowel sounds tympanitic on all quadrants direct tenderness on the RLQ no Murphy’s sign, rebound tenderness no masses, no organomegally Back CVA tenderness, right

  19. Salient Features History 52 year old female CT stono - Nephrolithiasis ESWL 2x Flank pain with dysuria of 5 days With radiation to the RLQ of 6 hrs, 10/10 pain No history of trauma Physical Exam Right CVA tenderness RLQ tenderness No obturator, psoas, and rovsing’s sign

  20. Case Discussion

  21. Primary Impression Nephrolithiasis, Right Hypertension stage 1, uncontrolled

  22. Differentials Urinary Tract Infection Musculoskeletal strain

  23. Nephrolithiasis Harrison’s Internal Medicine, 18thed Definition: presence of stones in the kidney

  24. Nephrolithiasis Harrison’s Internal Medicine, 18thed • Prevalence rates: • Male to female ratio – 3:1 • Types of stones: • Calcium oxalate and calcium phosphate (75 – 85%) • Calcium salts (5 – 10%) • Cystine (uncommon) • Uric acid • Struvite (common and potentially dangerous)

  25. Pathophysiology Imbalance bet. Solubility and precipitation of salts!! Harrison’s Internal Medicine, 18thed Kidneys must conserve water…. … but must also excrete materials that have low solubility

  26. Pathophysiology Supersaturation Dec. in citrate levels dehydration Overexcretion of Caclium, oxalate, phosphate, cystine, or uric acid Harrison’s Internal Medicine, 18thed Insoluble materials

  27. Pathophysiology Crystallization Harrison’s Internal Medicine, 18thed Supersaturation reaches it’s maximum…

  28. Pathophysiology see movie

  29. Diagnostics/workup European Association of Urology 2008

  30. Diagnostics/workup European Association of Urology 2008

  31. Diagnostics/workup European Association of Urology 2008 • Diagnostics • Plain CT Scan - A1 • intravenous pyelography (IVP) – GS acute stone cholic • KUB + US - B2a

  32. Management European Association of Urology 2008 Pain relief

  33. Management European Association of Urology 2008 Pain relief

  34. Management European Association of Urology 2008 • Spontaneous passage (80%) for stones </= 4mm in diameter • >/= 7mm spontaneous passage is very low • Overall passage rate of ureteral stone is: • Proximal ureteral: 25% • Mid-ureteral: 45% • Distal ureteral: 70%

  35. Management European Association of Urology 2008 • Calcium Channel Blocker (nifedipine) • An increase of 9% in stone-passage rates • Alpha blockers • An increase of 29% in stone-passage rates

  36. Management European Association of Urology 2008 • Indications for Active Stone Removal • Stone diameter >/= 6-7 mm • Stone </= 6-7 mm residing in calyx

  37. Management European Association of Urology 2008 Extracorporeal shock-wave lithotripsy (ESWL)

  38. Management European Association of Urology 2008 • ESWL sessions should not exceed 3-5x • If not yet treated, a percutaneous method might be considered • In case of infected stones or bacteriuria, antibiotic therapy should be given before ESWL and continues at least 4 days after • Shorter intervals between treatment sessions are usually acceptable for stones in the ureter • A frequency of 1-1.5 Hz is acceptable and optimal

  39. Management European Association of Urology 2008 • Contraindications to ESWL treatment • Pregnancy • Severe skeletal malformations • Severe obesity • Aortic and/or renal artery aneurysms • Uncontrolled blood coagulation • Uncontrolled UTI

  40. Management PercutaneousNephrolithotomy (PCNL)

  41. Management Retrograde intrarenal surgery (RIRS)

  42. Management European Association of Urology 2008 • Retrograde intrarenal surgery (RIRS) • Antibiotic prophylaxis preoperatively to ensure sterile urine • Stone extraction with a basket without endoscopic visualization of the stone should not be performed • Nitinol baskets preserve tip deflection of flexible ureterorenoscopes and the tipless design reduces the risk of mucosa injury. They are therefore most suitable for use in flexible URS • Stenting following uncomplicated URS is optional • URS could become a reliable first-line treatment for lower pole stones </= 1.5cm • Can be done when ESWL might be contraindicated

  43. Management European Association of Urology 2008 Open and laparoscopic surgery

  44. Managament European Association of Urology 2008 • Chemolysis by percutaneous irrigation • 10% hemiacidrin • magnesium ammonium phosphate • Carbonate apatite • Brushite • Trihydroxylmethylaminomethan solution • Cystine stones • Uric acid

  45. Management European Association of Urology 2008

  46. Management European Association of Urology 2008

  47. Management European Association of Urology 2008

  48. Management Cochrane Studies Patients with lower pole kidney stones who undergo PCNL have a higher success rate than ESWL whereas RIRS was not significantly different from ESWL. However, ESWL patients spent less time in hospital and the duration of treatment was shorter.

  49. Prevention Cochrane Studies In this review only one trial was found that looked at the effect of increase water intake on recurrence and time to recurrence. Increased water intake decreased the chance of recurrence and increased the time to recurrence. Further studies are needed.

  50. “truly stoned”A Case Discussion Ryan Em C. Dalman MD MBA - 070070 February 10, 2010

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