Flank Pain Flashcards

1
Q

Differentials of acute flank pain?

A
Muscular sprain
Nepholithiasis/ureteric colic
Leaking/rupturing AAA
Spinal pathology (fracture, metastases, disc prolapse)
Testicular torsion
Pyelonephritis
Perforated peptic ulcer
Renal cancer
Abscess
Basal pneumonia

Think gynea aswell

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2
Q

What questions will ask in a patient with presenting complaint of flank pain?

A
SOCRATES
Fever, rigors, night sweats
Nausea/vomiting - Visceral
Haematuria
Lower urinary tract symptoms - UTI/Ureteric obstruction
Cloudy or offensive smelling urine
Leg weakness - Spinal
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3
Q

What are the surgical emergency in a patient with flank pain ?

A

Leaking/ruptured AAA
Testicular torsion
Pyelonephritis
Perforated peptic ulcer

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4
Q

What are the important things in someone PMH/DH when they present with flank pain?

A

Previous kidney stones

Recurrent cystitis - Predisposes to stones of the struvite type

Atherosclerotic disease - AAA
Long standing back pain - MSK

Kidney disease - Polycystic kidneys predisposes to pyelonephritis

DH - Indinavir, aciclovir and acetazolamide

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5
Q

What position do those with ureteric colic tend to adopt?

A

Unable to sit still and thus tend to writhe in pain

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6
Q

What tests should be performed in someone with suspected ureteric colic?

A

Urinalysis

Urine microscopy, culture and sensitivity

Bloods - FBC, U&Es, CRP, Serum Ca, phosphate and urate

Imaging - CT-KUB

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7
Q

When should a patient with a kidney stone be admitted?

A

There is evidence of an upper urinary tract infection (proximal to the obstruction)

Evidence of renal failure

Refractory pain (despite analgesia)

Bilateral obstructing stones (or one if only one kidney)

Elderly, child or otherwise unwell (for closer monitoring)

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8
Q

What is the initial management for kidney stones

A

Analgesia and encourage fluid intake

Maybe add a medication to relax the smooth muscle of the ureter. Either an alpha-blocker (tamsulosin) or a CCB (nifedipine)

Follow up 2-3weeks

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9
Q

What is the initial management for kidney stones >0.5cm?

A

Lithotripsy - Extracorporeal shock wave lithotripsy

Ureterorenoscopic removal - Commonly require a post-operative ureteric stent

Percutaneous nephrolithotomy

Stenting

Antibiotic cover

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10
Q

What is the longer term management of individuals with kidney stones?

A

Increase fluid intake

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11
Q

Which organism most commonly causes pyelonephritis?

A

E. coli

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12
Q

What is the management for MSK back pain?

A

Maintaining activity and exercise

Regular analgesia

Build up core muscles

General back care

(Surgery no better than conservative management)

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13
Q

What are the different types of kidney stones? How might you treat them?

A

Calcium (75-85%) - Oxalate, phosphate or mixed

  • Hypercalcinuria (exclude hyperparathyroidism)
  • Hyperuricosuria can be be given allopurinol
  • Hypocitraturia can be give potassium citrate

Struvite (10-20%)(ammonium magnesium phosphate)
- Most common in women and are secondary to infection with urease-producing bacteria

Urate (5-10%) - Urate crystals from the presence acid urine

Cystine (1%) - Secondary to cystinuria (a rare autosomal recessive disorder)

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14
Q

What are the radiological findings would you look for in a patient with suspected kidney stones?

A

The stones themselves

Hydronephrosis and/or hydroureter due to obstruction

Perinephritic fluid

Soft-tissue rim - Stone may be surrounded rim of soft tissue

Tail sign - Soft tissue opacity extends away from stone like a tail (Consistent with pelvic phlebolith not ureteric stone)

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15
Q

What are the complications of kidney stones?

A

Ureteric stricture

Acute or chronic pyelonephritis

Renal failure

Intrarenal perinephric abscess

Xanthogranulomatous pyelonephritis (chronic bacterial pyelonephritis characterised by the destruction of renal parenchyma and the presence of granulomas and abscesses)

Urine extravassation into the pelvic cavity

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16
Q

Where are renal tract stones most likely to cause obstruction?

A

PUJ
The pelvic brim
The vesico-ureteric junction

17
Q

At what diameter is surgical intervention advisable for an unruptured AAA?

A

AAA diameter is greater than 5.5cm

AAA diameter growing >1cm per year

Symptomatic AAA

18
Q

What is the ‘psoas sign’ on abdominal radiographs?

A

When one of the two psoas shadows on the abdominal radiograph is not visible

This can represent an AAA

Can also represent other abdominal pathology (eg acute pancreatitis) or be present in healthy individuals

19
Q

What are the Red Flag in back pain that warrant referral?

A

Sphincter problems
Patients unable to self-care or walk

Weight loss
Fever
Back tenderness to palpation
Thoracic spinal pain
Violent trauma

50yo
Severe morning stiffness
Structural deformity
Nerve root pain