71 y/o febrile male with left flank pain for 24 hours

Ddx: Kidney stone, Pyelonephritis, shingles

First Examine patient to see if they are stable. If they are not, take measures to stabilize
before taking H/P.

Kidney stone
History: Confirm that the chief complaint is left flank pain. Ask patient to describe pain.
Expected findings are a colicky pain that has come and gone over the last 24 hours that is
extremely painful that radiates to the groin. Ask about any changes in urinary frequency or if
they have noticed any change in color of their urine. Ask about normal fluid intake. Next,
question about past surgical history, relevant medical history, sexual history and confirm
current medication and allergies.
Physical Exam:
Abdomen: Assess for visible pulsations or masses, palpate the abdomen to assess pain,
note if the abdomen is soft, listen for normal active bowels sounds. Expect a positive Lloyds
test
Pelvic: Examine penis for possible urethritis
Labs: BMP, CBC, UA
Imaging: Abdominal X-ray (KUB) should allow visualization of most stones. If the problem seems
severe or complicated, or KUB does not yield visualization of stone, a CT without contrast
should be ordered. It allows better visualization of the stone, possible determination of type of
stone, assess for signs of urinary obstruction, and show hydronephrosis (uptodate). A skilled US
can also be used.
Management: Instruct patient to consume lots of fluid and strain urine for passage of stone.
The patient can be started on pain control medication if needed. Analysis of stone should be
performed after it passes. If the stone does not pass within a few days or is to large to pass,
alternate therapy should be used. Option include Percutaneous nephrolithotomy,
ureteroscopy, and shock wave lithotripsy. In these cases, the patient would need to be properly
consented to the procedure. If an operation is indicated a PIV would be started.

Pyelonephritis
History: Confirm that the chief complaint is left flank pain. Ask patient to describe pain. Expect
patient to describe a constant pain that has become worse. Ask about if patient has had UTIs in
the past. Ask if there is any dysuria, suprapubic pain or hematuria. Next, question about past
surgical history, relevant medical history, sexual history and confirm current medication and
allergies.
Physical Exam:
Abdomen: see kidney stone. (+/-) Lloyds sign.
Pelvic: see kidney stone
Labs: Urine culture, UA, BMP, CBC
Imaging: depending on how sick the patient is a CT without contrast is warranted to detect
processes that may delay response to therapy, or to dx a complication of infection like abscess
(uptodate).
Management: If the pyelonephritis is determined to be complicated then the patient should be
admitted to the hospital to watch for complication like sepsis and renal failure. Regardless of
the it is complicated or uncomplicated, oral antibiotics for 1-2 wks should be started as soon as
possible. Adjustments to antibiotic regiment can be made once urine culture is read.

Shingles
History: See kidney stones/pyelonephritis. Confirm patient had varicella zoster in past.
Physical exam:
Abdomen: See kidney stones/pyelonephritis. Inspect the abdomen for rash.
Labs: BMP, CBC, UA
Imaging: none
Management: Antiviral medication should be started to help prevent future lesions from
appearing and lessen severity and duration of current lesions.