A 37 year old man presents with severe left flank pain with radiation into his left testicle [This is very classic for kidney stone. Most commonly it radiates into groin or testicle. It also can radiate into abdomen as well]. He says he has had no history of similar pain but does recall his father getting similar attacks over the years. He says he can not find a comfortable position and has been vomiting all day.
On examination, he appears to be in severe pain, unable to lie down [This is in contrast to peritonitis or acute abdomen, where they often lie down and try not to move], and moves constantly. His testicles appear normal and are not tender. His urine shows hematuria [This is often present] but his kidney functions, electrolytes, amylase and lipase are all within normal limits.
At this time you will order:
1. Ultrasound [This does not detect stones in ureters and is not useful and may also not pick-up early obstruction] of kidneys
2. KUB [This does not detect uric acid stones and therefore is not worthwhile] plain films of abdomen
3. Helical CT [This is the right test but should be done without contrast as contrast may cover up the stone and prevent it from being seen] of abdomen with contrast
4. Non-contrast abdominal helical CT. This is the correct answer.
After review of the CT scan of abdomen you have decided that patient needs to be admitted. The reasons you have decided to admit this patient include all of the following except:
1. Bilateral kidney obstruction
2. Evidence of infection without ureteral obstruction or fever [This is the correct answer. This requires admission only if there is obstruction along with infection or if there is evidence of sepsis]
3. Severe pain despite oral analgesics
4. Solitary kidney obstruction
Further evaluation of kidney stone is indicated and includes:
1. Blood testing: BUN, Creatinine, urinalysis, uric acid, Calcium, electrolytes, and phosphorus.
2. 24 hour urine for uric acid, calcium, etc
3. Aanalyze the stone
Further recommendations in patients with kidney stones:
1. Drink about 2 liters of water per day or close to 8 glasses of water.
2. Uric acid stone can dissolve with making urine alkaline. This can be done with sodium bicarbonate.
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