Nephrolithiasis

Nephrolithiasis

EBM - 11/19/09 Mark Lepsch

Department of Family Medicine

Real Life Case #1 • 28 year old man w/ family history of kidney stones presents to your clinic with severe pain radiating from his right CVA around the flank into the inguinal region. Thought for the day – What would the interpretive dance look like for this case?

Task #1 – What is your DDX?

Department of Family Medicine

Question #1 - Hematuria A Urine Dipstick analysis is performed in clinic. The results are: SG 1.030, Tr blood, Tr Prot, Tr LE, else neg. Using Inforetreiver, other handheld sources, or any member of the Level H consortium (Harper/Heim/Ham), please answer the following question: If the test for blood was negative – how would this change your thought process? A. Renal lithiasis is less likely. B. Renal lithiasis is impossible.

Department of Family Medicine

Question #2 - Imaging Using Inforetreiver, other handheld sources, or any member of the Level H consortium (Harper/Heim/Ham), please answer the following question: Given the information so far, what would be your imaging test of choice? A. Plain film (KUB)

C. Renal U/S

B. IVP

D. Stone protocol CT scan E. No imaging required

Department of Family Medicine

Level “H” Evidence – Beware… Question – Is this really what our newest attending does with Proteinuria?

Department of Family Medicine

Question #3 – Acute Management You diagnose a symptomatic renal calculi. You only have one prescription left on your pad.

Which medicine would you prescribe? A. Ketorolac

D. Other Narcotic

B. Other NSAID

E. Flomax

C. Demerol

F. Inhaled Sawin-ajuana

Department of Family Medicine

Question #4 – Prevention Two weeks later the patient is asymptomatic. You have recommended that they increase their water intake (>2L/day) for life. They wonder if there is anything else that can be done to prevent further stones. They happened to have caught the stone with the strainer that “Dr. Schmitty” gave them. It is a Calcium-oxalate stone. Which of the following do you prescribe? A. Avoid sodas (phosphoric acid), beer, and grapefruit juice B. Decrease protein intake C. Limit sodium intake D. HCTZ (to block calcium excretion) E. K-Mg-citrate

Department of Family Medicine

Nephrolithiasis - Overview PATHOLOGY 4 major types: (1) Calcium – 85%. Ca-oxalate, Ca-phosphate, or both. Stones are radioopaque. Associated with hypercalcemia. (2) NH4-Mg-Phos – 2nd most common. Radiolucent. Formed in alkaline urine by urease positive bugs such as Proteus or Staph. Can form large struvite calculi. (3) Uric acid – Strong association with hyperuricemia (gout). Seen with diseases that have increased cell proliferation (leukemia, myeloproliferative dx). (4) Cystine – secondary to cystinuria. HX Intense pain – patients are often agitated and can’t stop moving, as opposed to patients with peritonitis (who won’t move).

Department of Family Medicine

The End

Department of Family Medicine