Snapshot A 36-year-old woman presents to the emergency department with severe and colicky left flank pain that radiates to the left groin. She reports increased urinary frequency and urgency. She is sexually active with multiple men and uses condoms inconsistently. On physical exam, there is left-sided costovertebral angle tenderness and lower abdominal tenderness. Introduction Clinical definition calculi (stones) affecting the kidneys; however, these stones can also affect the ureter Epidemiology prevalence 12% in men and 7% in women risk factors hyperparathyroidism hypocitraturia sarcoidosis hyperoxaluria renal tubular acidosis type I nephrocalcinosis cystic fibrosis hyperuricosuria indwelling catheter urinary tract infections malabsorption (e,g., Crohn disease) horseshoe kidney obesity low fluid intake gout medications e.g., allopurinol, indinavir, acetazolamide, and topiramate Pathogenesis substance precipitation affecting the kidney and ureter e,g., hypercalciuria and low urine volume forms calcium cystals Prognosis small stones are more likely to spontaneously pass Nephrolithiasis StonesStone TypeEtiologyImaging FindingsStone ShapeTreatmentCalciumCalcium oxalate stones (most common)hypercalciuriahypocitraturiaethylene glycol (antifreeze)vitamin C abusecrohn diseaseCalcium phosphatein states of urine alkalinizatione.g., type I renal tubular acidosisRadiographyradiopaqueComputerized tomographyradiopaqueEnvelope or dumbbell shapecalcium oxalateWedge-shaped prismcalcium phosphateHydrochlorothiazideCitrateLow-sodium dietCystineImpaired cystine reabsorption in the proximal convoluted tubulethis results in cystinuriaalso results in decreased reabsorption of ornithine, lysine, and argininePrecipitates in acidic urineDiagnosiscyanide-nitroprusside testRadiographyradiolucentComputerized tomographyvisible at timesHexagonalDietary modificationlow sodiumUrine alkalinizationChelating agentsin refractory casesStruvite (magnesium ammonium phosphate)Urease-positive organisms such asProteus mirabilisStaphylococcus saphrophryticusKlebsiellaUrease-positive organisms subesequently alkalinizes the urinethis causes struvite stones due to precipitationRadiographyradiopaqueComputerized tomographyradiopaqueCan result in a staghorn calculiCoffin lidRemoval of underlying infectionSurgical removal of the stoneUric acidHyperuricemiae.g., states of increased cell turnover and goutPrecipitates in acidic urineRadiographyradiolucentComputerized tomographyminimally visibleRhomboid/rosetteUrine alkalinizationAllopurinolAdequate hydration prior to chemotherapy treatment Presentation Symptoms colicky flank pain pain may radiate to the groin or lower abdomen dysuria urgency and frequency Physical exam low abdominal tenderness costovertebral angle (CVA) tenderness Imaging Renal ultrasound indication in patients who are pregnant and children who are suspected to have nephrolithiasis modality abdomen and pelvis to visualize the kidney and bladder Non-contrast computerized tomography (CT) indication preferred imaging for most adults presenting with signs and symptoms concerning for nephrolithiasis modality abdomen and pelvis Studies Labs serum creatinine, uric acid, and ionized calcium should be obtained urine studies urinalysis/dipstick in order to check for red and white blood cells, nitrites, and urine pH urine culture stone composition analysis perform in patients who developed their first stone straining the urine Diagnostic criteria based on clinical presentation and confirmed by imaging Differential Urinary tract infections Acute pyelonephritis Groin hernia Complications Ureteral obstruction Ureteral stricture Urinary tract infection Renal deterioration
QUESTIONS 1 of 9 1 2 3 4 5 6 7 8 9 Previous Next Sorry, this question is for PEAK Premium Subscribers only Upgrade to PEAK Sorry, this question is for PEAK Premium Subscribers only Upgrade to PEAK Sorry, this question is for PEAK Premium Subscribers only Upgrade to PEAK Sorry, this question is for PEAK Premium Subscribers only Upgrade to PEAK (M1.RL.15.4671) A 49-year-old African American female with a history of chronic myeloid leukemia for which she is receiving chemotherapy presents to the emergency room with oliguria and colicky left flank pain. Her serum creatinine is 3.3 mg/dL. What is the preferred preventative therapy that could have been administered to this patient to prevent her complication of chemotherapy? QID: 107149 Type & Select Correct Answer 1 Diuresis 38% (27/72) 2 Acidification of the urine 15% (11/72) 3 Colchicine 22% (16/72) 4 Steroids 6% (4/72) 5 Dialysis 11% (8/72) M 3 Question Complexity C Question Importance Select Answer to see Preferred Response SUBMIT RESPONSE 1 Review Tested Concept Review Full Topic (M1.RL.15.4671) A 12-year-old boy presents with right flank pain and hematuria. His older brother has had several similar episodes in the past. Results of microscopic urinalysis are shown in Figure A. Which of the following tests can be used to help confirm the underlying diagnosis? QID: 107147 FIGURES: A Type & Select Correct Answer 1 Cyanide-nitroprusside test 67% (92/137) 2 Serum uric acid concentration 7% (9/137) 3 Urine uric acid concentration 17% (23/137) 4 Urine culture 6% (8/137) 5 Urease test 2% (3/137) M 2 Question Complexity D Question Importance Select Answer to see Preferred Response SUBMIT RESPONSE 1 Review Tested Concept Review Full Topic (M1.RL.13.25) Following passage of a calcium oxalate stone, a 55-year-old male visits his physician to learn about nephrolithiasis prevention. Which of the following changes affecting urine composition within the bladder are most likely to protect against crystal precipitation? QID: 101243 Type & Select Correct Answer 1 Increased calcium, increased citrate, increased oxalate, increased free water clearance 7% (6/88) 2 Decreased calcium, increased citrate, increased oxalate, increased free water clearance 8% (7/88) 3 Decreased calcium, decreased citrate, increased oxalate, increased free water clearance 5% (4/88) 4 Decreased calcium, increased citrate, decreased oxalate, increased free water clearance 74% (65/88) 5 Decreased calcium, increased citrate, increased oxalate, decreased free water clearance 2% (2/88) M 1 Question Complexity E Question Importance Select Answer to see Preferred Response SUBMIT RESPONSE 4 Review Tested Concept Review Full Topic (M1.RL.13.1) A 45-year-old Caucasian male with a history of chronic myeloid leukemia for which he is receiving chemotherapy presents to the emergency room with oliguria and colicky left flank pain. His serum creatinine is 3.0 mg/dL and is urine pH is 5.0. You diagnose nephrolithiasis. His kidney stones, however, are not visible on abdominal x-ray. His stone is most likely composed of which of the following? QID: 100955 Type & Select Correct Answer 1 Calcium oxalate 8% (6/74) 2 Calcium phosphate 3% (2/74) 3 Magnesium ammonium phosphate 0% (0/74) 4 Uric acid 80% (59/74) 5 Cystine 8% (6/74) M 1 Question Complexity D Question Importance Select Answer to see Preferred Response SUBMIT RESPONSE 4 Review Tested Concept Review Full Topic Sorry, this question is for PEAK Premium Subscribers only Upgrade to PEAK
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