Renal Calculi or Kidney Stones an Important Medical Condition Discussion

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In the case of 34 year old female presenting with sudden excruciating 10/10 pain to her right flank area, accompanied by nausea which is subsiding a little now, I would suspect some urinary tract pathology, particularly nephrolithiasis. Nephrolithiasis is an increasingly common form of renal disease which is associated with a supersaturation of crystal deposition in the renal medulla varying in size, shape and contents. These deposits also referred to as renal calculi cause pain and injury to the ureters as they pass to the bladder and can also cause obstruction, leading to other renal complications. The majority of stones are composed of calcium oxalate, often mixed with calcium phosphate, however other stones include uric acid, cystine, struvite. Other differential diagnoses could include pyelonephritis, renal tumors, appendicitis, diverticulitis, pancreatitis, peptic ulcer disease, ovarian cysts, ectopic pregnancy, gallbladder disease, (Dave 2020).

In order to make a more definitive diagnosis, a detailed assessment and physical needs to be performed. The patient should be asked about pain quality, onset, duration, relieving factors, worsening factors, frequency and whether pain radiates to the abdomen and groin area as opposed to the upper abdominal quadrants. Questions also needs to be asked about the presence of urinary symptoms, pain quality with urination, frequency of urination, noticeable difference with urinary stream, decreased ability to urinate, presence of blood in the urine, or strong foul smelling urine. These will help to separate this diagnosis from GI related diseases and other urinary tract pathologies. The presentation of nephrolithiasis is strongly dependent on the factors like stone, size, location and stone type which may cause differing pain experience from one individual to another. It is typical for the patient to experience severe pain caused by movement of a stone from the renal pelvis into the ureter, which leads to ureteral spasm and possibly obstruction. Pain is sudden and starts in the flank area, and progresses downward and anteriorly into the genital region as the stone moves down the ureter. The pain is not usually aggravated or alleviated by change of position, and may be accompanied by chills, nausea, vomiting and diaphoresis. Hematuria is typically present, even if only microscopic. If the stone is lodged at the uretero-vesical junction, it can cause a sensation of urinary frequency and urgency. All symptoms are relieved quite abruptly when the stone moves out of the ureter into the bladder, and passes. The patient should also be asked about hydration status; if they have been out in high temperatures; diet high in calcium and protein; have recurrent UTIs, specially in women, as these are precipitating factors for renal calculi formation, (Dunphy, Winland-Brown, Porter & Thomas 2019).

Physical examination for this patient should entail abdominal inspection and palpation for abdominal distention and guarding. Percussion should be dome to flank area to assess for tenderness, and auscultation should be performed to assess for decreased or absent bowel sounds. Vitals should be taken to assess for fever, which may be present if there is obstruction which can cause acute infection. Blood pressure, heart rate and respiratory rates may be elevated as a pain response, (Dunphy, Winland-Brown, Porter & Thomas 2019).

The diagnostic test should include CBC to monitor infection, chemistry to monitor kidney function and hydration status. Urine should be analyzed for the presence of bacteria, WBCs, RBCs and minerals. Serum and urinary pH may provide insight regarding patient’s renal function and type of calculus, whether it be calcium oxalate, uric acid, or cystine. In addition to laboratory testing, radiologic testing like a non-contrast helical CT or a real US can accurately visualize the size and location of stones in the urinary tract, (Dunphy, Winland-Brown, Porter & Thomas 2019).

Acute management for nephrolithiasis, includes NSAIDs for pain management or narcotics if uncontrolled by NSAIDs. IV hydration should be initiated, especially in the presence of nausea and vomiting with anti-emetics given. Antibiotics should be given if infection occurs or with hydronephrosis. Alpha blockers, like tamsulosin should be given to help stone passage. If the stone is too large, typically more than 5mm, to be passed surgical management like, extracorporeal shockwave lithotripsy, stent placement, percutaneous nephrostomy, ureteroscopy, percutaneous nephrostolithotomy, open nephrostomy, or anatrophic nephrolithotomy, may have to initiated, (Dave 2020).

References

Dave, Chirag (2020). Nephrolithiasis. Medscape. Accessed June 16, 2021 from https://emedicine.medscape.com/article/437096-over…

Dunphy, M. L, Winland-Brown, E. J, Porter, O. B, & Thomas, J. D. (2019). Primary Care: Art and Science of Advanced Practice. (5th ed.). Philadelphia, PA: F.A. Davis Company.