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NephrolithiasisClinicalPresentation:History,PhysicalExamination,Complications

NephrolithiasisClinicalPresentation
Author:ChiragDave,MDChiefEditor:BradleyFieldsSchwartz,DO,FACSmore...
Updated:Aug07,2016

PhysicalExamination
Theclassicpresentationforapatientwithacuterenalcolicisthesuddenonsetof
severepainoriginatingintheflankandradiatinginferiorlyandanteriorly.Thepainis
usually,butnotalways,associatedwithmicroscopichematuria,nausea,and
vomiting.Dramaticcostovertebralangletendernessiscommonthispaincanmove
totheupperorlowerabdominalquadrantasaureteralstonemigratesdistally.
However,therestoftheexaminationfindingsareoftenunremarkable.
Abdominalexaminationusuallyisunremarkable.Bowelsoundsmaybehypoactive,
areflectionofmildileus,whichisnotuncommoninpatientswithsevere,acute
pain.Peritonealsignsareusuallyabsentanimportantconsiderationin
distinguishingrenalcolicfromothersourcesofflankorabdominalpain.Testicles
maybepainfulbutshouldnotbeverytenderandshouldappearnormal.
Unlikepatientswithanacuteabdomen,whousuallytrytolieabsolutelystill,
patientswithrenalcolictendtomoveconstantly,seekingamorecomfortable
position.(However,patientswithpyonephrosisalsotendtoremainmotionless.)The
classicpatientwithrenalcoliciswrithinginpain,pacingabout,andunabletolie
still,incontrasttoapatientwithperitonealirritation,whoremainsmotionlessto
minimizediscomfort.
Findingsshouldcorrelatewiththereportsofpain,sothatcomplicatingfactors(eg,
urinaryextravasation,abscessformation)canbedetected.Beyondthis,thespecific
locationoftendernessdoesnotalwayscorrelatewiththeexactlocationofthe
stone,althoughthecalculusisofteninthegeneralareaofmaximumdiscomfort.
Approximately85%ofallpatientswithrenalcolicdemonstrateatleastmicroscopic
hematuria,whichmeansthat15%ofallpatientswithkidneystonesdonothave
hematuria.Lackofhematuriaalonedoesnotexcludethediagnosisofacuterenal
colic.Tachycardiaandhypertensionarerelativelycommoninthesecases,evenin
patientswithnopriorpersonalhistoryofabnormalcardiacorbloodpressure
problems.
Feverisnotpartofthepresentationofuncomplicatednephrolithiasis.Thepresence
ofpyuria,fever,leukocytosis,orbacteriuriasuggeststhepossibilityofaurinary
infectionandthepotentialforaninfectedobstructedrenalunitorpyonephrosis.
Suchaconditionispotentiallylifethreateningandshouldbetreatedasasurgical
emergency.
Inpatientsolderthan60yearspresentingwithsevereabdominalpainandwithno
priorhistoryofrenalstones,lookcarefullyforphysicalsignsofabdominalaortic
aneurysm(AAA)(seeAbdominalAorticAneurysm).

ContributorInformationandDisclosures
Author
ChiragDave,MDResidentPhysician,DepartmentofSurgery(Urology),WilliamBeaumontHealthSystem
ChiragDave,MDisamemberofthefollowingmedicalsocieties:AmericanAcademyofFamilyPhysicians,AmericanCollegeofPhysicians,AmericanUrological
Association
Disclosure:Nothingtodisclose.
Coauthor(s)
SugandhShetty,MD,FRCSAssociateProfessorofUrology,OaklandUniversityWilliamBeaumontSchoolofMedicineAttendingPhysician,DepartmentofUrology,
WilliamBeaumontHospital
SugandhShetty,MD,FRCSisamemberofthefollowingmedicalsocieties:AmericanUrologicalAssociation
Disclosure:Nothingtodisclose.
KassemFarajOaklandUniversityWilliamBeaumontSchoolofMedicine
KassemFarajisamemberofthefollowingmedicalsocieties:AmericanMedicalAssociation,AmericanMedicalStudentAssociation/Foundation,AmericanUrological
Association,MichiganStateMedicalSociety
Disclosure:Nothingtodisclose.
SpecialtyEditorBoard
FranciscoTalavera,PharmD,PhDAdjunctAssistantProfessor,UniversityofNebraskaMedicalCenterCollegeofPharmacyEditorinChief,MedscapeDrugReference
Disclosure:ReceivedsalaryfromMedscapeforemployment.for:Medscape.
RobertEO'Connor,MD,MPHProfessorandChair,DepartmentofEmergencyMedicine,UniversityofVirginiaHealthSystem
RobertEO'Connor,MD,MPHisamemberofthefollowingmedicalsocieties:AmericanAcademyofEmergencyMedicine,AmericanCollegeofEmergencyPhysicians,
AmericanAssociationforPhysicianLeadership,AmericanHeartAssociation,MedicalSocietyofDelaware,SocietyforAcademicEmergencyMedicine,WildernessMedical
Society,AmericanMedicalAssociation,NationalAssociationofEMSPhysicians
Disclosure:Nothingtodisclose.
ChiefEditor
BradleyFieldsSchwartz,DO,FACSProfessorofUrology,Director,CenterforLaparoscopyandEndourology,DepartmentofSurgery,SouthernIllinoisUniversitySchool
ofMedicine

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NephrolithiasisClinicalPresentation:History,PhysicalExamination,Complications

BradleyFieldsSchwartz,DO,FACSisamemberofthefollowingmedicalsocieties:AmericanCollegeofSurgeons,SocietyofLaparoendoscopicSurgeons,Societyof
UniversityUrologists,AssociationofMilitaryOsteopathicPhysiciansandSurgeons,AmericanUrologicalAssociation,EndourologicalSociety
Disclosure:Nothingtodisclose.
AdditionalContributors
DavidSHowes,MDProfessorofMedicineandPediatrics,ResidencyProgramDirectorEmeritus,SectionofEmergencyMedicine,UniversityofChicago,Universityof
Chicago,ThePritzkerSchoolofMedicine
DavidSHowes,MDisamemberofthefollowingmedicalsocieties:AmericanAcademyofEmergencyMedicine,AmericanCollegeofEmergencyPhysicians,Societyfor
AcademicEmergencyMedicine
Disclosure:Nothingtodisclose.
RichardHSinert,DOProfessorofEmergencyMedicine,ClinicalAssistantProfessorofMedicine,ResearchDirector,StateUniversityofNewYorkCollegeofMedicine
ConsultingStaff,ViceChairinChargeofResearch,DepartmentofEmergencyMedicine,KingsCountyHospitalCenter
RichardHSinert,DOisamemberofthefollowingmedicalsocieties:AmericanCollegeofPhysicians,SocietyforAcademicEmergencyMedicine
Disclosure:Nothingtodisclose.
SandyCraig,MDResidencyProgramDirector,CarolinasMedicalCenterAssociateProfessor,DepartmentofEmergencyMedicine,UniversityofNorthCarolinaatChapel
HillSchoolofMedicine
SandyCraig,MDisamemberofthefollowingmedicalsocieties:AlphaOmegaAlpha,SocietyforAcademicEmergencyMedicine
Disclosure:Nothingtodisclose.
StephenWLeslie,MD,FACSFounderandMedicalDirector,LorainKidneyStoneResearchCenterAssociateProfessorofSurgery,CreightonUniversitySchoolof
Medicine,ChiefofUrology,CreightonUniversityMedicalCenter
StephenWLeslie,MD,FACSisamemberofthefollowingmedicalsocieties:AmericanCollegeofSurgeons,AmericanUrologicalAssociation,NationalKidney
Foundation,OhioStateMedicalAssociation
Disclosure:Nothingtodisclose.
JStuartWolf,Jr,MD,FACSDavidABloomProfessorofUrology,AssociateChairforUrologicSurgicalServices,Director,DivisionofEndourologyandStoneDisease,
DepartmentofUrology,UniversityofMichiganMedicalSchool
JStuartWolf,Jr,MD,FACSisamemberofthefollowingmedicalsocieties:CatholicMedicalAssociation,EndourologicalSociety,EngineeringandUrologySociety,
SocietyofLaparoendoscopicSurgeons,SocietyofUniversityUrologists,SocietyofUrologicOncology,AmericanCollegeofSurgeons,AmericanUrologicalAssociation
Disclosure:Nothingtodisclose.

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