OSCE Case

John S. is a 46 year old male with the complaint of back pain since yesterday

History Elements:

  • Onset: pain began suddenly around 4PM yesterday (it is 11:30AM now) after he returned home from the beach, doesn’t remember exactly what he was doing when the pain began 
  • Location: pain is located in the right flank 
  • Radiation: pain radiates to the abdomen in the RLQ and right groin 
  • Duration: the pain comes and goes (intermittent) and lasts anywhere from 5-30 minutes 
  • Character: the pain is crampy and colicky, and feels sharp when it’s most severe 
  • Alleviating/Worsening: he tried taking 2 tablets of 325mg Tylenol, with no effect. Nothing seems to be making the pain better. Nothing in particular makes it worse 
  • Timing: The sharp pain alternates with dull pain, which has been ongoing since yesterday and getting worse and worse 
  • Severity: right now the pain is 10/10! 
  • Also complaining of nausea, 3 episodes of vomiting (bilious, most recent episode 4 hours ago), dysuria, urinary frequency, and urinary urgency 
  • Denies hematuria or pyuria, no changes in urine
  • Denies fever, chills, night sweats 
  • Denies weight loss of changes in appetite 
  • Denies penile discharge or testicular pain
  • Denies blood in stool
  • Patient is sexually active with wife only, uses barrier protection, denies hx of STIs
  • Pain does not change with flexion, extension, or other movement 
  • Pain is absent on left side 
  • Denies injury, trauma, excessive exercise
  • Denies constipation or diarrhea
  • Is having regular bowel movements and passing gas regularly 
  • No personal history of kidney stones
  • Family history: negative for CVD/cancer/DM, father has had 3 episodes of kidney stones 
  • Social History: construction worker, spends most days outside, doesn’t drink so much water

Physical Exam:

  • Vital Signs: BP 132/84, HR 98 / regular, RR 18 / unlabored, T 98.7F, SPO2 98% / room air, BMI normal 
  • General Appearance: A/O x 3, writhing in pain, lying in left decubitus, in acute distress 
  • Heart: regular rate and rhythm
  • Lungs: Lungs clear bilaterally
  • Abdomen: No masses / hernias, no guarding, bowel sounds normoactive,no bruits, tympanic throughout, soft / non-tender / non-distended, no rebound, Murphy’s sign / McBurney’s point, Rovsing sign all negative, CVA tenderness + to right side
  • Genitourinary: uncircumsized penis with no erythema/discharge/blood at the urethral meatus, no lesions/masses on penis or scrotum, testes nontender with no masses/swelling
  • Muskuloskeletal: Spinous processes and paravertebral muscles nontender to palpation, tender to palpation of right flank at L3-L4, muscle strength 5/5 in all extremities, full passive and active range of motion intact, straight leg raise test negative bilaterally 

Differential Diagnosis:

  • Appendicitis 
  • Nephrolithiasis
  • Pyelonephritis 
  • Lower/uncomplicated UTI 
  • Musculoskeletal pain (e.g. muscle strain)
  • Inguinal Hernia

Tests

Labs:

  • Urinalysis: microscopic hematuria (1+ blood), pH 6.5, color/clarity pale yellow and clear, glucose negative, ketones negative, protein negative, bilirubin negative, leukocyte esterase negative, nitrite negative, 
  • Urine Microscopy: casts negative, white blood cells negative, red blood cells+
  • Urine culture: pending  
  • CMP: Na+ 140, K+ 4.1, BUN 22, Cr 1.1,BUN/Cr 20, glucose 99, calcium 9.4, albumin 4.2, alk phos 57, ALT 21, AST 25, bilirubin 1.2 
  • CBC: hgb 14.3, hct 43, plt 345, wbc 6.4

Imaging:

  • US right kidney: no hydronephrosis, no masses/cysts 
  • CT of abdomen/pelvis without contrast: 3mm partially obstructing stone at right ureterovesical junction, no significant hydronephrosis/fat-stranding 

Treatment

  • Ketorolac 15 mg IV q6h PRN for pain 
  • Aggressive hydration as tolerated
  • Metoclopramide 15 mg PO PRN for nausea/vomiting 
  • Flomax 0.4 mg PO x 3 days 
  • Monitor pt for 6 hours, and plan to discharge if pain resolves and urine culture negative for bacterial infection. Discharge with prescription for Ketorolac 10mg PO q4-6hs x 5 days. 

Patient Education

  • Instruct patient to strain urine until stone passes
  • Follow up with PCP in 1 week – confirm passage of stone, stone content, and bloodwork based on stone content 
  • Patient should return to ED if symptoms worsen, develops fever, gross hematuria, worsening pain, or stone does not pass within 2 weeks 
  • Advise patient to drink adequate amounts of water, especially if working outside in heat all day