Nephrolithiasis

  • nephrolithiaisumcomplicated MDM nephrolithiais
    • – Pertinent Diagnostics Contributory to MDM:
      • From eval:
        • still making urine,
        • gross hematuria,
      • Labs obtained, interpretated by me.
        • Upreg neg
        • No significant deragements outside of as expected.
        • Cr wnl therefore no indication of kindey damage.
        • Cr at baseline therefore no indication of kindey damage.
        • UA:
          • not c/w UTI
          • not suspected to have UTI though will follow up with UCx with standard institutionalf/u mechanism in placein
          • c/w UTI
          • microscopic hematuria, thereby making kidney stone more likely.
          • nomicroscopic hematuria, atypical for
        • CBC:
          • luekocytosis,
            • suspected to be 2/2 to demarginalizatio and not indicative of sepsis,
      • Imaging:
        • CT
          • non-con (given leading suspicion for nephrolithiasis):
            • shows hydronephrosis with nephrolithiasis.
          • with con(given leading suspicion for not for nephrolithiasis):
            • shows hydronephrosis with nephrolithiasis.
        • US,
          • ED performed US
            • by me:
              • hydronephrosis
                • on L
                • on R
              • no hydronephrosis,
          • Formal US obtained,
            • interpretted by radiology and by interpretted/correlated clinically to patient by me:
              • hydronephrosis
                • on L
                • on R
              • no hydronephrosis,
          • Imaging deferred given nephrolithiasis clinically diagnosis and eval is sufficiently consistent with nephrolithiasis for diagnosis.
      • – ED Course:
        • IVF,
        • analgesia,
          • with toradol,
          • with morphine,
          • with norco
          • d/w pt not to drive home and to excercise caution given requirement for sedating medications in ED.
        • flomax, first dose of flomax given in ED to minimize risks of syncope. D/w risks/benefits with pt and advised to exercise caution for possible syncope as known side effect.
      • Re-evaluation:
        • Pain well controlled.
      • Plan:
        • Trial for spontanous passage with strict return precautions concerning for inection (dysuria, fevers), worsening pain, or development of any new sx of lack of resolution of sx to return to ED and to f/u with PMD/urologist.
        • Rx:
          • ibuprofen,
          • flomax
          • norco for breakthrough pain,
            • ( Risks/benefits of medications that have sedating / impaired reaction time / impaired judgement side effects discussed with patient. Implored importance of not driving, being in place where fall risk could pose additional danger. Advised to exercise extreme caution to mitigate fall risk. Advised not to take concurrent sedating medications/etoh/substances/tylenol containing products. Pt verbally expressing understanding and agrees to abide by recs. Benefits of medications outweigh risk given pt agrees to exercise above precautions. )
        • MDM:
        • DIAGNOSIS:
          • nephrolithiasis,
            • uncomplicated
            • on left
            • on right
          • Suspect most likely uncomplicated nephrolithiasis given findings on imaging.
          • No evidence of concurrent urinary tract infection based upon patient's lack of urinary symptoms and also urine analysis not consistent with urinary tract infection.
          • Patient given IV fluids, morphine, Flomax, Toradol.
          • Plan for expectant management with trial for spontanesously passage.
          • Advised patient will need to follow up with primary care physician for urological consultation per discretion of PCP and also advised to return precautions.
      • – Evaluation was not sufficiently consistent the following entities to meet threshold for ED further diagnostics/interventions making risks outweigh benefit of further diagnostics/interventions for the patient i.e. not consistent with these conditions (consideration included but limited to these conditions):
        • No e/o infected stone.
        • Still passing urine.
        • Has ability for f/u with PMD and urology PRN.
        • Pain controlled.
        • Considered wide ddx however eval is not c/w gyncelogic etioloies (torsion, etc), GI etiologies, ID etiologies, MSK/neuro/back pathologies.
      • Dispo: home
    • GU pathology:
      • urinary tract infection,
      • pyelonephiritis,
      • nephrolithiasis,
      • GI pathology:
        • appendicitis,
        • colitis,
        • diverticulitis,
      • Gyn pathology:
        • torsion
        • ovarian cysts/ovarian pathology
        • pregnancy/ pregnancyrelated complications
      • Male specific pathology:
        • testicular pathology,
        • torsion,
        • epidimyitisfds
      • MSK:
        • MSK back pain
        • spinal cord pathology
    • – Ddx: (evaluation includes but was not limited to
    • – Working Diagnosis:
      • Evaluation for etiology of sx and provision of symptomatic relief.

Leave a Comment