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truly stoned A Case DiscussionRyan Em C. DalmanMD MBA - 070070February 10, 2010

Case PresentationPatient HistoryGeneral Data52-year-oldFemaleBorn on May 4, 1958Roman CatholicLives in Antipolo CityInformant: Patient, good reliability

Chief ComplaintRight Flank Pain

History of Present IllnessFlank pain, leftNo precipitating event, took pain killers with partial reliefNo aggravating factorConstant and described as sharp and crampyNo radiationPain 5/10Associated with painful urinationNo nausea, no vomiting, no fever, no blood in urine, no genital discharge

5 days PTAConsult at Manila East Medical CenterCT stono Nephrolithiasis R, Pelvocaliectasia R, Hydronephrosis RFor ESWL but d/c due to lack of scheduleScheduled after 10 days

4 days PTASymptom persisted5History of Present IllnessFlank painTook ibuprofen with no reliefRadiation to the RLQ, 10/10 painNo nausea, no vomiting, no change in bowel movement, no fever 6 hours PTAConsultSymptoms persisted6Review of SystemsGeneral: no weight loss, no change in appetiteCutaneous: no lesions, no change in color, no pruritusHEENT: with occasional headaches no rednessno aural/nasal dischargeno neck massesno sore throat7Review of SystemsCardiovascular: no easy fatigability, fainting spells, palpitation Gastrointestinal: no nausea and vomiting, no change in bowel movements, no acholic stoolsEndocrine: no polyuria, polydypsia, no heat/cold intoleranceReview of SystemsMuskuloskeletal: no weakness, numbness on all extremities Hematopoietic: no easy bruisability, or bleedingPast Medical HistoryHypertension on telmesartan 40mg OD (uBP 140/90)No Diabetes, Asthma, PTBNo Cancer, Allergies,

s/p ESWL 2x (2004 and 2008)s/p TAHBSO, non-malignant (2009)s/p appendectomy (high school)

Family HistoryHistory of kidney disease (stone former), maternalNo hypertension, heart disease, cancer, stroke, diabetes, asthma, or allergiesPersonal and Social HistoryBusiness womanLives with her family in a subdivisionCollege graduate Non-smokerOccasional alcoholic beverage drinkerNo substance abuseCase PresentationPertinent Physical Exam on AdmissionPhysical ExamGeneral Surveyawake and not in cardiorespiratory distressIn severe painVital Signsafebrile at 37.2oC RR 20 bpmHR 89 bpmHeight:157cm weight:49kg BMI:19.9Physical ExamSkinLight brownNo rashes, hemorrhages, scarsMoistCRT 1-2 secondsHEENTHeadno lesionsEyesanicteric sclerae, pink palpebral conjunctivapupils 2-3mmEarsno discharge, tendernessNoseseptum medline, moist mucosaThroatmouth and tongue moistno TPCChest and LungsNeck no cervical lymphadonapathyno nuchal rigidity Chestadynamic precordiumno heaves, thrills, or lifts, PMI at 5th ICS MCLregular rate, normal rhythmno murmursLungssymmetrical chest expansion, no retractionsclear breath soundsAbdomen/ Perineum Abdomenflat, no lesionssurgical scars: 9cm vertical on the hypogastrium, 5cm horizontal RLQnormoactive bowel soundstympanitic on all quadrantsdirect tenderness on the RLQno Murphys sign, rebound tendernessno masses, no organomegally

BackCVA tenderness, right

Salient FeaturesHistory52 year old femaleCT stono - NephrolithiasisESWL 2xFlank pain with dysuria of 5 daysWith radiation to the RLQ of 6 hrs, 10/10 pain No history of trauma

Physical ExamRight CVA tendernessRLQ tendernessNo obturator, psoas, and rovsings sign

19Case DiscussionPrimary ImpressionNephrolithiasis, RightHypertension stage 1, uncontrolled History52 year old femaleFlank pain with dysuria of 5 daysWith radiation to the RLQNo history of traumaCT stono - NephrolithiasisPhysical ExamRLQ tendernessNo obturator, psoas, and rovsings signRight CVA tenderness21Differentials Urinary Tract Infection Musculoskeletal strainNephrolithiasisDefinition: presence of stones in the kidney

Harrisons Internal Medicine, 18th edStruvite These stones occur mainly in women or patients who require chronic bladder catheterization and result from urinary tract infection with urease-producingbacteria, usually Proteus species. 23NephrolithiasisPrevalence rates:Male to female ratio 3:1Types of stones:Calcium oxalate and calcium phosphate (75 85%)Calcium salts (5 10%)Cystine (uncommon)Uric acidStruvite (common and potentially dangerous)

Harrisons Internal Medicine, 18th edPathophysiologyKidneys must conserve water.

but must also excrete materials that have low solubilityImbalance bet. Solubility and precipitation of salts!!Harrisons Internal Medicine, 18th edImbalance between solubility and precipitation of salts.The kidneys must conserve water but must also excrete materials that have low solubility.

Balanced through: diet, climate and activity

25PathophysiologyInsoluble materialsSupersaturationDec. in citrate levelsdehydrationOverexcretion of Caclium, oxalate, phosphate, cystine, or uric acid Harrisons Internal Medicine, 18th ed26PathophysiologySupersaturation reaches its maximumCrystallizationHarrisons Internal Medicine, 18th ed27Pathophysiology see movieDiagnostics/workupEuropean Association of Urology 2008

Diagnostics/workup

European Association of Urology 2008Diagnostics/workupDiagnosticsPlain CT Scan - A1intravenous pyelography (IVP) GS acute stone cholicKUB + US - B2a

European Association of Urology 2008 In case of an acute stone colic, excretory urography (intravenous pyelography, IVP) has been established as a gold standard. During recent years, unenhanced helical computed tomography (CT) examinations have been introduced as a quick and contrast-free alternative (1,2,3). In randomized prospective studies, the specificity and sensitivity of this method for patients with acute flank pain was found to be similar to that obtained with urography (4,5-9). In selected cases, additional information regarding renal function may be obtained by combining CT with contrast infusion. One great advantage of CT is the demonstration of uric acid and xanthine stones, which are radiolucent on plain films. Another advantage is the ability of CT to detect alternative diagnoses (7,10). However, the advantage of a non-contrast imaging modality has to be balanced against the higher radiation dose given to the patient during CT investigation (3,5,11).31ManagementPain relief

European Association of Urology 2008ManagementPain relief

European Association of Urology 2008ManagementSpontaneous passage (80%) for stones /= 7mm spontaneous passage is very lowOverall passage rate of ureteral stone is:Proximal ureteral: 25%Mid-ureteral: 45%Distal ureteral: 70%European Association of Urology 2008ManagementCalcium Channel Blocker (nifedipine)An increase of 9% in stone-passage ratesAlpha blockersAn increase of 29% in stone-passage rates

European Association of Urology 2008ManagementIndications for Active Stone RemovalStone diameter >/= 6-7 mmStone