A 26-year-old man comes to the emergency department due to sudden-onset severe, colicky right flank pain. He also has had dysuria, urgency, dark urine, and nausea but no vomiting. The patient has never before had these symptoms. Temperature is 37 C (98.6 F), blood pressure is 126/70 mm Hg, pulse is 90/min, and respirations are 18/min. Examination shows no abnormalities. Analgesics are administered with good control of pain. Noncontrast helical CT scan shows a 4-mm radiopaque stone in the right lower ureter. Laboratory studies show serum calcium of 9.8 mg/dL, serum creatinine of 0.9 mg/dL, and blood urea nitrogen of 15 mg/dL. Urinalysis shows hematuria but no casts. Which of the following is the most appropriate next step in management?

Question

A 26-year-old man comes to the emergency department due to sudden-onset severe, colicky right flank pain.  He also has had dysuria, urgency, dark urine, and nausea but no vomiting.  The patient has never before had these symptoms.  Temperature is 37 C (98.6 F), blood pressure is 126/70 mm Hg, pulse is 90/min, and respirations are 18/min.  Examination shows no abnormalities.  Analgesics are administered with good control of pain.  Noncontrast helical CT scan shows a 4-mm radiopaque stone in the right lower ureter.  Laboratory studies show serum calcium of 9.8 mg/dL, serum creatinine of 0.9 mg/dL, and blood urea nitrogen of 15 mg/dL.  Urinalysis shows hematuria but no casts.  Which of the following is the most appropriate next step in management?

Quizplus · Accepted Answer

Explanation: 11ec25c8_d20a_73d2_bc81_1b5c98a0340f_MD0003_00 This patient has acute flank pain and nausea due to ureterolithiasis, which is confirmed on CT scan. The majority of patients with uncomplicated kidney stones can be managed conservatively. Most stones ≤5 mm in diameter pass spontaneously; increased oral fluid intake (>2-2.5 L/day) is recommended to ensure adequate flow of dilute urine. Alpha blockers (eg, tamsulosin) can facilitate passage, especially for larger stones (6-10 mm). Stones ≥10 mm are unlikely to pass spontaneously and may warrant (outpatient) urologic evaluation to consider additional interventions (eg, lithotripsy). Regardless of stone size, urologic consultation and hospitalization is generally appropriate for patients with signs of urosepsis (eg, fever, altered mental status); acute kidney injury; complete obstruction; or refractory pain, nausea, or vomiting (Choice B). This patient has acute flank pain and nausea due to a 4-mm stone. There are no signs of urosepsis, renal function is normal, he is able to take oral fluids and medications, and his pain is well-controlled. The stone will likely pass spontaneously, and the patient can be discharged home with instructions to increase fluid intake and to strain the urine; straining urine for stone composition analysis is not by itself an indication for hospitalization (Choice D). (Choice A) Prolonged intravenous (forced) hydration is not proven superior to oral hydration for stone passage and is not needed for low-risk patients such as this one. Nonsteroidal anti-inflammatory drugs-which, in patients with nephrolithiasis, are as effective as opiates and associated with fewer side effects (eg, nausea)-would be appropriate in this patient with normal renal function. (Choice C) Dysuria is a classic symptom of urinary tract infection but is also common in lower ureterolithiasis. This patient has no fever or pyuria to suggest pyelonephritis, so he does not require observation or antibiotics. Educational objective: Most ureteral stones ≤5 mm in diameter pass spontaneously; increased oral fluid intake is recommended to ensure adequate flow of dilute urine. Alpha blockers can be used to facilitate passage of larger stones (6-10 mm). Urologic consultation is recommended for stones ≥10 mm and for refractory pain, anuria, acute kidney injury, or signs of urosepsis. References: Urinary stone disease: diagnosis, medical therapy, and surgical management. (http://www.ncbi.nlm.nih.gov/pubmed/29406057)

A 26-Year-Old Man Comes to the Emergency Department Due to Sudden-Onset