Bedside examination is typically unremarkable (perhaps demonstrating some tenderness in the affected flank) - perhaps signs of dehydration from reduced fluid intake secondary to associated vomiting.
Urine dip - May display microscopic haematuria, or suggest infection (will need to send urine culture if positive for infection markers)
Pregnancy testing should be considered/performed in all women of child-bearing age presenting with abdominal pain, as unexpected pregnancies do occur, and ruptured ectopics can present with a wide variety of patterns of pain.
ECG - ECGs are performed in most patients that attend A&E, or are admitted to hospital. It is a quick, simple, inexpensive test that allows us to examine the heart rhythm, evaluate tachycardia, and can show signs of a number of conditions that otherwise might not be suspected.
Retrieval of the stone (If pt. notices passing the stone when urinating) à send for analysis
For patients with recurrent nephrolithiasis, 24-hour urine measurements allow risk factors to be identified and corrected
As ever, bloods provide a wealth of information that helps to delineate between all of our differentials, and are a quick, simple, and relatively safe and minimally-invasive test. Important tests here include:
•Full Blood Count
•Hb drop might suggest Perforated peptic ulcer/Ruptured AAA
•Raised WCC would suggest infection, such as Concurrent infection in Urolithiasis/Pyelonephritis/Lower lobe pneumonia
•If positive, would lend further weight to the infective picture
•Look at the renal function, which is often impaired in obstructive uropathy - this would be a post-renal cause of AKI
•Electrolytes may show a raised calcium
•Urate (along with Calcium)
•Help to analyse risk factors for stone formation
•LFTs - If on the Right Hand Side
AXR - Used in some centres for initial assessment. Disadvantages:
1.Not all stones are radio-opaque
2.High radiation exposure (much higher than a CXR, as a higher dose is needed to image through the denser abdomen)
Renal Tract USS - Often used concurrently in known stone disease ?hydronephrosis.
1.Often detect renal stones
1.Ureteric stones not often detected
Non-contrast CT KUB (CT Kidneys, Ureters, Bladder) - This is the Gold Standard as it has a high sensitivity and specificity in identifying stone disease AND concurrent assessment of alternative pathology.
Intravenous Urograms = injection of contrast and subsequent series of AXRS à demonstrate any filling defect. Rarely used due to having the following disadvantages:
1.High radiation exposure
2.The relative superiority of CT imaging
Ureteric colic - increased peristalsis around the site of the obstruction. Flank to pelvis. *It is possible to have no pain with a stone, especially if the stone is non-obstructing. The pain radiates down to the testis, scrotum, labia or anterior thigh.
This is a very common finding in Renal stones, occurring in the vast majority of cases, however it is usually microscopic (invisible), rather than macroscopic (visible), so the urine will still appear its normal colour, and this is likely to only be identified on urine dipstick testing.
Due to stasis of urinary flow, there may well be a concurrent infection, There is doubt about the aetiology here, and it may be that the concurrent infection predisposes to the stones, rather than the other way round.
•Rigors, fever, lethargy from infection
Loin->groin pain will have associated N&V
In terms of presentation, the most common symptoms are LUTS - hesitancy, poor or intermittent stream, straining, prolonged micturition, feeling of incomplete bladder emptying, post-micturition dribbling, frequency, urgency, urge incontinence, and nocturia.
Another potential presentation is with Transitional Cell Carcinoma of the Bladder, as chronic irritation of the bladder epithelium (as occurs with bladder stones) can predispose to the development of TCC bladder