Renal Colic Approach

– History –

• CC: most likely will present as LUTS\flank pain:
  • Site (of pain, if any): where? Bi\uni-lateral? Radiates anywhere else (groin)?
  • Onset: first time? When? Sudden\gradual? Continues\intermittent? Worse\better?
  • Timing and frequency: day\night? How frequent?
  • Aggravating\relieving factors: position, medications?
  • Severity: 1-10 scale? Wakes you up from sleep? Interfering w\ ADL?

• Associated sx:
  • Constitutional: fever, chills, wt loss, loss of appetite, night sweats?
  • Urine: color, bloody (if yes; beginning\end\throughout, dark\fresh\mixed, clots), frothy, pneumaturia, fecaluria? Urethral discharge?
  • Voiding: hesitancy, straining, weak flow, intermittency, post-void dribbling, sensation of incomplete voiding?
  • Storage: frequency, urgency, urge incontinence, dysuria, nocturia?
  • GI: abdominal\flank\groin, N\V, diarrhea\constipation?

• PMHx:
  • Diseases:
    • Chronic ds (HTN, DM, DLP)
    • Kidney ds
    • Prev kidney stones
    • BPH
    • Malignancy
  • Medications
  • Surgery, hospitalization, trauma
  • Procedures, catheterization
  • Blood transfusions, IV drug use, tattoos
  • Allergies

• FMHx:
  • Similar complaint?
  • Same diseases as in PMHx?

• Social Hx:
  • Occupation, marital status, children?
  • Smoking, alcohol, recreational drugs?
  • Travel Hx
  • Diet, exercise

  

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– Abdominal Physical Exam –

• WIPE, blah blah 🙂
• “Take vital signs”
• Position: flat, arms on the side, pillow below the head
• Proper exposure: from xiphoid to mid-thigh
• General inspection of the pt and surroundings

1. Inspection: (stand at the end of the bed)

• Symmetry and contous
• Abdominal distention + flank fullness
• Scars, skin changes\discoloration, rashes, striae
• Obvious masses or swelling
• Dilated veins\caput medusa
• Visible pulsations
• Umbilicus (inverted\everted?}
• Hernia (ask pt to cough)

2. Palpation + percussion: (ask pt if they have any pain?)

• Superficial and deep: “abdomen soft and lax, no tenderness, no masses, no peritoneal signs”
  • Tenderness
  • Guarding\rigidity
  • Masses
  • Rebound tenderness
  • CVA tenderness

3, Auscultation:

• Bowel sounds
• Bruits: Aortic, renal, femoral

4. To complete:

• Digital rectal exam (PR)
• Genital exam
• Fecal occult blood test 

 

– Investigations –

1. Labs:
   • U\A
   • Serum electrolytes
   • Kidney function
2. Imaging:
   • KUB or US for initial imaging
   • CT (no contrast): gold standard

 

– Management –

1. IVF
2. Pain management (ketorolac)
3. If < 5 mm -> might pass spontaneously
4. Surgical therapy:
   • Size < 2 cm + upper ureter -> ESWL (extracorporeal shockwave lithotripsy)
   • Size < 2 cm + lower ureter -> ureteroscopy
   • Size > 2cm, staghorn, cysteine -> percutaneous removal or lithotripsy
5. Medical therapy:
   1. Potassium citrate -> alkalizing urine -> prevents stone recurrence
   2. Thiazides -> prevents calcium stones

 

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