– 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
- Diseases:
- 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 testÂ
– Investigations –
- Labs:
- U\A
- Serum electrolytes
- Kidney function
- Imaging:
- KUB or US for initial imaging
- CT (no contrast): gold standard
– Management –
- IVF
- Pain management (ketorolac)
- If < 5 mm -> might pass spontaneously
- 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
- Medical therapy:
- Potassium citrate -> alkalizing urine -> prevents stone recurrence
- Thiazides -> prevents calcium stones