Flank pain (oxford clin cases)

Question 1

What are some differentials when someone presents with acute flank pain?

Answer 1

Muscle sprain
Ureteric colic
Pyelonephritis
Testicular torsion
Leaking or ruptured AAA

Question 2

What 3 surgical emergencies do you need to rule out when someone presents with acute flank pain?

Answer 2

Pyelonephritis
Ruptured AAA
Testicular torsion

Question 3

Where will pain from kidney stones be?

Answer 3

Unilateral and radiating from loin to groin

Question 4

What will be the character of pain if there is a stone in the kidney vs the ureter?

Answer 4

Kidney= constant
Ureter= colicky

Question 5

How severe is pain for kidney stones?

Answer 5

Extremely severe, comparable to childbirth

Question 6

What other symptoms should you ask about when someone presents with flank pain and why?

Answer 6

Is there any fever- suggests infection
Is there dehydration- predisposes them to kidney stones
Is there any change in urination- dysuria, frequency, urinary obstruction, heamaturia etc
Is there nausea or vomiting- if yes rules out muscle strain, nerve root causes etc
Cloudy urine?- infection

Question 7

What should you ask about in pmx in someone with flank pain? Explain why

Answer 7

Have they has previous kidney stones- recurrence is not uncommon
Have they had recurrent UTIs- increases risk of stones
Have they had any kidney operations- if one kidney has been removed obstruction of the remaining ureter is a medical emergency
Do they have polycystic kidney disease- increases risk of stones
Do they have atherosclerotic disease- all increase risk of AAA leak/rupture

Question 8

What should you look for in the drug hx when someone has flank pain and why?

Answer 8

Are they on any drugs that crystallise the urine?- increases risk of blockage
Are they on diuretics- increases dehydration which increases risk of kidney stones

Question 9

What should you look for on examination of someone with flank pain and why?

Answer 9

Position- if its ureteric colic they won’t be able to lie still and will writhe, if its peritonitis they will lie completely still
Tenderness- flank tenderness in ureteric colic
Mass- expansile AAA
Temperature- indicates infection eg pyelonephritis
Lower limbs- an easily felt popliteal pulse might indicate AAA

Question 10

Can an AAA be ruled on via clinical examination?

Answer 10

No, you have to image it too

Question 11

What does acidic urine suggest?

Answer 11

Urate stones

Question 12

What does alkaline urine suggest?

Answer 12

Presence of bacteria that produce urease which can cause stones

Question 13

What do red or white cell casts in the urine suggest?

Answer 13

Red or white cells are coming from the kidney

Question 14

What do red cell casts in urinalysis indicate?

Answer 14

Glomerular damage

Question 15

What do white cell casts in urinalysis indicate?

Answer 15

Pyelonpehritis

Question 16

How commonly are white cell casts found?

Answer 16

Not common at all

Question 17

What 2 tests can be done on urine? When should they be done

Answer 17

Normal urinalysis (looks for haematuria, pH, WBC etc)- do if you suspect any urine pathology

Urine microscopy, culture and sensitivity (looks at the urine in more detail)- do if you urinalysis is abnormal

Question 18

What bloods would you do for someone with flank pain? Explain why

Answer 18

FBC- look for raised WCC
CRP/ESR- if raised indicates inflammation
U&Es- assess renal function
Serum calcium, phosphate and urate- should be checked in everyone with stones/suspected stones

Question 19

What is the first line investigation for suspected AAA?

Answer 19

Contrast CT abdomen

Question 20

What is the best imaging for stones/ flank pain in general and why?

Answer 20

Non contrast CT KUB- it will clearly show any stones and also allows good visualisation of the AAA

Question 21

In someone with flank pain, if you suspect pancreatitis what investigation should you request?

Answer 21

Serum amylase and lipase

Question 22

In someone with flank pain, if you suspect perforated peptic ulcer what investigation should you request?

Answer 22

Erect chest x ray

Question 23

How are kidney stones managed?

Answer 23

If there is no infection or complications they can be conservatively managed with analgesia, fluid intake and an alpha blocker/CCB (to relax ureters)

If infected, abx and monitoring are required

If the stone is small it may pass by itself so the patient can be sent home and asked to strain their urine and bring it back for analysis, if its large it may need to be removed

Question 24

How can kidney stones be removed?

Answer 24

Shock wave therapy- the stone is shocked so it breaks into smaller fragments that can be passed

Use a ureterorenoscope- up the urethra to remove, place a stent after as it can cause stricture

Question 25

When should someone with a kidney stone be admitted?

Answer 25

If there is evidence of urinary tract infection If there is evidence of renal failure If there is severe pain after analgesia If there are bilateral obstructing stones or unilateral obstructing stones in a patient with only one kidney

Question 26

What should patients with kidney stones be advised to do after discharge?

Answer 26

Increase fluid intake

Question 27

What patients should undergo further testing if they have kidney stones?

Answer 27

If they have a significant family hx of renal stones If they had multiple stones when they presented If they have recurrent stones

Question 28

How will acute pyelonoehritis present?

Answer 28

Flank pain Vomiting Fever Urinalysis showing hematuria, white cells, nitrates

Question 29

If all investigations for flank pain come back normal what could you suspect?

Answer 29

Back pain

Question 30

How can back pain be managed?

Answer 30

NSAIDs- if recommending them to patients advise them not to take them regularly or in combination Weight loss Build up strength of core muscles Back care- ensure the muscles are supported, don't do strenuous activity or bend down a lot etc

Question 31

NSAIDs are the first line treatment for kidney stones, but who can they not be given too?

Answer 31

Patients with asthma Patients with severe heart failure (especially COX-2) Previous or active peptic ulcers

Question 32

What 3 locations are kidney stones most likely to cause an obstruction?

Answer 32

Pelvoutreteric junction Pelvic brim Vesicoureteric junction

Question 33

Above what diameter should you operate on an AAA?

Answer 33

When they are above 5.5cm in diameter

Question 34

What are red flags for back pain?

Answer 34

``` Unintentional significant weight loss Fever Thoracic spine pain Sphincter problems Under 20 or over 50 Nerve root pain that doesn't resolve (in 6 weeks) Severe morning stiffness ```

Question 35

How do NSAIDs, opiates and paracetamol differ in how they combat pain?

Answer 35

``` NSAIDs= reduce inflammation at sight of pain Opiates= reduce transmission of pain signals to the brain Paracetamol= reduces the brains perception to pain ```

Question 36

How should you prescribe painkillers for severe pain and why?

Answer 36

In combination- they are more effective this way as they reduce pain in different ways Anticipating bouts of pain instead of as reactions to them