1. Jeremy Price, MSIV Albert Einstein College of Medicine July 19, 2013
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:
R Flank pain:
Cholelithiasis
Nephrolithiasis
Acute cholecystitis
Urolithiasis
Cholangitis
Retroperitoneal hematoma
Acute hepatitis
Ruptured renal cyst
Perforated duodenal ulcer
Ureteral stricture
RLL pneumonia
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