Ryan Em C. DalmanMD MBA February 10, 2010

Patient History

 52-year-old  Female  Born on May 4, 1958  Roman Catholic  Lives in Antipolo City  Informant: Patient, good reliability

 Right Flank Pain

 Flank pain, left No precipitating event, took pain killers with partial relief No aggravating factor Constant and described as sharp and crampy No radiation Pain 5/10 Associated with painful urination No nausea, no vomiting, no fever, no blood in urine, no genital discharge 5 days PTA  Consult at Manila East Medical Center  CT stono – Nephrolithiasis R, Pelvocaliectasia R, Hydronephrosis R  For ESWL but d/c due to lack of schedule  Scheduled after 10 days 4 days PTA Symptom persisted

 Flank pain Took ibuprofen with no relief Radiation to the RLQ, 10/10 pain  No nausea, no vomiting, no change in bowel movement, no fever 6 hours PTA Consult Symptoms persisted

General: no weight loss, no change in appetite Cutaneous: no lesions, no change in color, no pruritus HEENT: with occasional headaches no redness no aural/nasal discharge no neck masses no sore throat

Cardiovascular: no easy fatigability, fainting spells, palpitation Gastrointestinal: no nausea and vomiting, no change in bowel movements, no acholic stools Endocrine: no polyuria, polydypsia, no heat/cold intolerance

Muskuloskeletal: no weakness, numbness on all extremities Hematopoietic: no easy bruisability, or bleeding

Hypertension on telmesartan 40mg OD (uBP 140/90) No Diabetes, Asthma, PTB No Cancer, Allergies, s/p ESWL 2x (2004 and 2008) s/p TAHBSO, non-malignant (2009) s/p appendectomy (high school)

 History of kidney disease (stone former), maternal  No hypertension, heart disease, cancer, stroke, diabetes, asthma, or allergies

 Business woman  Lives with her family in a subdivision  College graduate  Non-smoker  Occasional alcoholic beverage drinker  No substance abuse

Pertinent Physical Exam on Admission

 General Survey awake and not in cardiorespiratory distress In severe pain  Vital Signs afebrile at 37.2 o C RR 20 bpm HR 89 bpm Height:157cm weight:49kg BMI:19.9

 Skin Light brown No rashes, hemorrhages, scars Moist CRT 1-2 seconds

Head no lesions Eyes anicteric sclerae, pink palpebral conjunctiva pupils 2-3mm Ears no discharge, tenderness Nose septum medline, moist mucosa Throat mouth and tongue moist no TPC

Neck no cervical lymphadonapathy no nuchal rigidity Chest adynamic precordium no heaves, thrills, or lifts, PMI at 5 th ICS MCL regular rate, normal rhythm no murmurs Lungs symmetrical chest expansion, no retractions clear breath sounds

Abdomen flat, no lesions surgical scars: 9cm vertical on the hypogastrium, 5cm horizontal RLQ normoactive bowel sounds tympanitic on all quadrants direct tenderness on the RLQ no Murphy’s sign, rebound tenderness no masses, no organomegally Back CVA tenderness, right

History  52 year old female  CT stono - Nephrolithiasis  ESWL 2x  Flank pain with dysuria of 5 days  With radiation to the RLQ of 6 hrs, 10/10 pain  No history of trauma Physical Exam  Right CVA tenderness  RLQ tenderness  No obturator, psoas, and rovsing’s sign

Nephrolithiasis, Right Hypertension stage 1, uncontrolled

 Urinary Tract Infection  Musculoskeletal strain

 Definition: presence of stones in the kidney Harrison’s Internal Medicine, 18 th ed

 Prevalence rates: Male to female ratio – 3:1  Types of stones: Calcium oxalate and calcium phosphate (75 – 85%) Calcium salts (5 – 10%) Cystine (uncommon) Uric acid Struvite (common and potentially dangerous) Harrison’s Internal Medicine, 18 th ed

Kidneys must conserve water…. … but must also excrete materials that have low solubility Imbalance bet. Solubility and precipitation of salts!! Harrison’s Internal Medicine, 18 th ed

Insoluble materials Supersaturation Dec. in citrate levels dehydration Overexcretion of Caclium, oxalate, phosphate, cystine, or uric acid Harrison’s Internal Medicine, 18 th ed

Supersaturation reaches it’s maximum… Crystallization Harrison’s Internal Medicine, 18 th ed

 see movie

European Association of Urology 2008

 Diagnostics Plain CT Scan - A1 intravenous pyelography (IVP) – GS acute stone cholic KUB + US - B2a European Association of Urology 2008

 Pain relief European Association of Urology 2008

 Pain relief European Association of Urology 2008

 Spontaneous passage (80%) for stones </= 4mm in diameter  >/= 7mm spontaneous passage is very low  Overall passage rate of ureteral stone is: Proximal ureteral: 25% Mid-ureteral: 45% Distal ureteral: 70% European Association of Urology 2008

 Calcium Channel Blocker (nifedipine) An increase of 9% in stone-passage rates  Alpha blockers An increase of 29% in stone-passage rates European Association of Urology 2008

 Indications for Active Stone Removal Stone diameter >/= 6-7 mm Stone </= 6-7 mm residing in calyx European Association of Urology 2008

 Extracorporeal shock-wave lithotripsy (ESWL) European Association of Urology 2008

 ESWL sessions should not exceed 3-5x If not yet treated, a percutaneous method might be considered In case of infected stones or bacteriuria, antibiotic therapy should be given before ESWL and continues at least 4 days after Shorter intervals between treatment sessions are usually acceptable for stones in the ureter A frequency of Hz is acceptable and optimal European Association of Urology 2008

 Contraindications to ESWL treatment Pregnancy Severe skeletal malformations Severe obesity Aortic and/or renal artery aneurysms Uncontrolled blood coagulation Uncontrolled UTI European Association of Urology 2008

 Percutaneous Nephrolithotomy (PCNL)

 Retrograde intrarenal surgery (RIRS)

Antibiotic prophylaxis preoperatively to ensure sterile urine Stone extraction with a basket without endoscopic visualization of the stone should not be performed Nitinol baskets preserve tip deflection of flexible ureterorenoscopes and the tipless design reduces the risk of mucosa injury. They are therefore most suitable for use in flexible URS Stenting following uncomplicated URS is optional URS could become a reliable first-line treatment for lower pole stones </= 1.5cm Can be done when ESWL might be contraindicated European Association of Urology 2008

Open and laparoscopic surgery European Association of Urology 2008

 Chemolysis by percutaneous irrigation  10% hemiacidrin magnesium ammonium phosphate Carbonate apatite Brushite  Trihydroxylmethyl aminomethan solution Cystine stones Uric acid European Association of Urology 2008

Cochrane Studies  Patients with lower pole kidney stones who undergo PCNL have a higher success rate than ESWL whereas RIRS was not significantly different from ESWL. However, ESWL patients spent less time in hospital and the duration of treatment was shorter.

Cochrane Studies  In this review only one trial was found that looked at the effect of increase water intake on recurrence and time to recurrence. Increased water intake decreased the chance of recurrence and increased the time to recurrence. Further studies are needed.

Ryan Em C. DalmanMD MBA February 10, 2010