A 40-year-old Hindu married male complaining of sudden high fever for the last two days. He is also complaining of right flank pain with some burning on urination. Past medical history includes diabetes and hypertension. Current medications include metformin 500mg bid and lisinopril 10mg daily.

A 40-year-old Hindu married male complaining of sudden high fever for the last two days. He is also complaining of right flank pain with some burning on urination. Past medical history includes diabetes and hypertension. Current medications include metformin 500mg bid and lisinopril 10mg daily.

After thorough history and physical exam, I would diagnose this patient with nephrolithiasis. Patients that have nephrolithiasis present with if not all but some of the following symptoms acute, often severe flank pain, nausea and vomiting, hematuria which can be gross or microscopic, difficulty getting comfortable, pain that can radiate from the flank downward with referred pain to the groin and genitalia as the stone progresses down the ureter, urinary urgency and frequency, and fever and chills (Prochaska, Taylor, & Curhan, 2016). If the patient were obese this could be a contributing factor to nephrolithiasis, so knowing the patient’s current BMI would be important. Patients that have diabetes also have a higher incidence of having nephrolithiasis due to the urine being more acidic than that of someone whom does not have diabetes. During the assessment of the patient I would also inquire about his diet and does he consume a diet high in foods that contain oxalate. Research has shown that 80% of kidney stones are calcium oxalate and that it is more common in males than females (Nalini, Manickavasakam, & Walter, 2016).

Workup would include ordering a kidney, ureter, and bladder (KUB) film, it can visualize calcium oxalate stones, however a CT scan can be ordered if the KUB does not show any stones (Haewook, Segal, Seifter, & Dwyer, 2015). A urinalysis and urine culture and sensitivity should be obtained. A 24-hour urine can be ordered on someone with recurrent kidney stones. Ketorolac, which an NSAID, may be given for pain. Iv nausea medication may need to be given. IV fluids would be necessary. If it is found that the patient is going to be unable to pass the kidney stone, then the patient would set up for lithotripsy. If the kidney stone is too big and causing complications then the patient should be admitted to the floor for IV hydration, antiemetics, and pain management. This patient should probably be admitted to the hospital for observation and referred to urologist.

At home management would include increasing fluid intake, strain all urine, and keep stones and bring them back into the office to be tested, and eat a diet that that is either oxalate free or very low. Most patients do not require any type of surgical intervention, and they are able to pass the kidney stone on their own. The patient should be instructed to strain their urine. The patient would need to follow up in the clinic as soon as the stone passes and then have repeat scans to ensure that the whole stone has passed, or if he has trouble urinating. Cipro 400mg po should be given twice daily for 7 days. The patient can take Tylenol for fevers and pain, or some sort of mild opioid. Pyridium 200mg po three times a day for two days for dysuria.

Differential Diagnosis

1. Urinary Tract Infection: Urinary tract infections are the most common bacterial infection encountered in the ambulatory care setting. Patients present with symptoms such as urinary frequency, urgency, dysuria, suprapubic pain, and gross or microscopic hematuria (Grabe et al., 2015). Diagnosis confirmed after thorough history and physical exam, urinalysis, urine culture, and based on symptoms. Treatment would be aimed at having the patient increase their water consumption and then they should take Cipro 400mg po twice daily for 7 days. The patient can take Tylenol for fevers and pain. Pyridium 200mg po three times a day for two days dysuria.

2. Pyelonephritis: Pyelonephritis is an ascending infection of a bacterial pathogen infection the renal pelvis and kidney that primary presents as a UTI characterized by dysuria with flank pain, nausea, vomiting, and/or fever (Bae et al., 2015). A thorough history and physical will be important to help accurately diagnose the patient. Urinalysis should be ordered as well as a urine culture. Since the patient has a fever blood cultures should be ordered in the patient that is suspected to have pyelonephritis. KUB can be ordered or retrograde or antegrade pyelography in severe obstruction cases (Bae et al., 2015). This patient should be admitted to the hospital and given an initial dose of ciprofloxacin 400mg IV and then the patient should be given cipro 500mg po twice daily for 7 days. The patient should be instructed to push fluids and strain urine if the cause of obstruction is a kidney stone.

3. Interstitial Cystitis: Interstitial cystitis is a clinical syndrome consisting of suprapubic pain related to bladder filling and relieved by emptying bladder, accompanied by other symptoms such as increased daytimes and nighttime frequency, insidious onset, exercise, sexual activity, foods high in acid make the pain worse, lower abdominal tenderness, and tenderness in prostate exam (Hanno, Erickson, Moldwin, & Faraday, 2015). After thorough history and physical exam diagnosis could be made with symptoms. There is not a definitive test for interstitial cystitis. Having the patient keep a voiding diary can show voiding patterns. Cystoscopy can be done to confirm diagnosis. Urinalysis and urine culture should be ordered. The patient should avoid foods and activities that aggravate the bladder. Elmiron 100mg orally three times a day should be taken to help with bladder pain and irritation.

References

Bae, M., Park, C., Cho, Y., Joo, K., Kwon, C., & Park, H. (2015, April 2010). Effects of Diabetes Mellitus and HbA1c on Treatment Prognosis in Uncomplicated Acute Pyelonephritis. The Korean Journal of Urogenital Tract Infection and Inflammation, 10(1), 41-48. https://doi.org/https://doi.org/10.14777/kjutii.2015.10.1.41

Grabe, M., Bartoletti, R., Bjerklund, T., Cek, M., Koves, B., Naber, K., … Wagenlehner, F. (2015, March). GUIDELINES ON UROLOGICAL INFECTIONS. Urological Infections. Retrieved from https://uroweb.org/wp-content/uploads/18-Urological-Infections_LR.pdf

Haewook, H., Segal, A., Seifter, J., & Dwyer, J. (2015, July 31). Nutritional Management of Kidney Stones (Nephrolithiasis). Clinical Nutrition Research, 4(3), 137-152. https://doi.org/https://doi.org/10.7762/cnr.2015.4.3.137

Hanno, P., Erickson, D., Moldwin, R., & Faraday, M. (2015, May). Diagnosis and Treatment of Interstitial Cystitis/Bladder Pain Syndrome: AUA Guideline Amendment. Journal of Urology, 193(5), 1545-1553. https://doi.org/https://doi.org/10.1016/j.juro.2015.01.086

Nalini, S., Manickavasakam, K., & Walter, T. (2016, March). PREVALENCE AND RISK FACTORS OF KIDNEY STONE. Global Journal for Research Analysis, 5(3), 183-187. Retrieved from https://www.researchgate.net/profile/HNalini_Sofia/publication/299543144_PREVALENCE_AND_RISK_FACTORS_OF_KIDNEY_STONE/links/56fe82a108ae650a64f71f53/PREVALENCE-AND-RISK-FACTORS-OF-KIDNEY-STONE.pdf

Prochaska, M., Taylor, E., & Curhan, G. (2016, August 10). Insights Into Nephrolithiasis From the Nurses’ Health Studies. American Journal of Public Health. Retrieved from https://ajph.aphapublications.org/doi/full/10.2105/AJPH.2016.303319

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