Nephrolithiasis EBM 11172009 Mark Lepsch

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NephrolithiasisEBM - 11/17/2009Mark Lepsch
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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?

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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.
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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
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Level H Evidence Beware
Question Is this really what our newest
attending does with Proteinuria?
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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
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Question 4 Prevention
Two weeks later the patient is asymptomatic. You
have recommended that they increase their water
intake (gt2L/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
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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 cant stop
moving, as opposed to patients with peritonitis
(who wont move).
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The End