Patient: [Patient Name]
MRN: [Medical Record Number]
Date: [Date of Encounter]
Chief Complaint:
Renal colic (severe pain in the flank or abdomen radiating to the groin)
(may be present or absent depending on stone location and activity)
Hematuria (blood in the urine)
Other associated symptoms (e.g., nausea, vomiting, urinary urgency or frequency)
History of Present Illness:
Onset, duration, location, and character of pain (sharp, cramping, radiating)
Frequency and severity of episodes (first time vs. recurrent)
Passage of any urinary stones (describe size and color if possible)
Presence of hematuria (gross or microscopic)
Urinary symptoms (urgency, frequency, burning)
Risk factors for nephrolithiasis (e.g., family history, dehydration, certain diets, medical conditions)
Past Medical History:
Underlying medical conditions (e.g., chronic kidney disease, gout, hyperparathyroidism, recurrent urinary tract infections (UTIs))
Prior surgeries or procedures (including urologic procedures)
Medications (diuretics, steroids)
Social History:
Diet (high in sodium, protein, oxalate)
Fluid intake
History of tobacco use (increases risk of kidney stones)
Family History:
First-degree relative with nephrolithiasis
Physical Exam:
Vital signs: Assess for fever (suggestive of infection), tachycardia (rapid heart rate), hypotension (low blood pressure) during renal colic.
Abdominal examination: Palpate for flank tenderness (may be unilateral
depending on stone location).
Genitourinary examination: Gross hematuria may be visible.
Laboratory Tests:
Urinalysis: Red blood cells (RBCs), white blood cells (WBCs) (may indicate infection or inflammation), nitrites (suggestive of infection).
Urine culture: To rule out urinary tract infection (UTI) as a source of flank pain or hematuria.
Serum electrolytes: Assess for dehydration, electrolyte imbalances
(e.g., hypercalcemia contributing to calcium stones).
Kidney function tests: Serum creatinine and Blood Urea Nitrogen (BUN) to assess kidney function (derangements may suggest underlying kidney disease).
Imaging Studies:
Imaging is often essential to confirm the presence, location, and size of kidney stones. The choice of imaging study depends on several factors, including availability, radiation exposure, and patient factors.
KUB (kidney, ureter, and bladder) X-ray: Initial imaging study to identify radiopaque stones (most common type).
Non-contrast CT scan: More sensitive than KUB for detecting stones and providing detailed anatomic information. However, carries radiation exposure risks.
Ultrasound: Readily available, radiation-free, but may miss some stones and may not visualize the ureters well.
Assessment:
Nephrolithiasis: Confirmed by presence of a kidney stone on imaging studies.
Stone location (renal, ureteral): Impacts treatment decisions and prognosis.
Stone size: Larger stones may be more difficult to pass spontaneously and may require intervention.
Pain control: Assess the severity of pain and response to initial measures.
Hydration status: Dehydration can worsen stone passage.
Differential Diagnoses:
Consider other causes of flank pain, especially early in the presentation:
Appendicitis
Pelvic inflammatory disease (PID)
Musculoskeletal pain
Peptic ulcer disease
Plan:
The treatment plan will depend on the severity of symptoms, stone location and size, and presence of complications. Possible elements include:
Pain management: Medications (NSAIDs, opioids) to control pain during renal colic.
Hydration: Encourage increased oral fluids to promote stone passage.
Medical expulsive therapy: Medications to relax the ureter and facilitate stone passage (alpha-blockers). Only used for small stones in the distal ureter.
Lithotripsy: Shockwave therapy to break down stones into smaller fragments for easier passage.