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Oxford Clinical Cases > Flank Pain > Flashcards

Flank Pain Flashcards

1
Q

List the differential diagnosis for flank pain.

A 
Muscular sprain
Ureteric colic 
Spinal pathologies (fractures, metastases, disc prolapse)
Leaking/ruptured AAA 
Testicular torsion 
Pyelonephritis
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2
Q

List some gynaecological diseases that could cause flank pain.

A

Ectopic pregnancy

Ovarian torsion

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3
Q

List some other abdominal pathology that could present atypically with flank pain.

A

Pancreatitis
Diverticulitis
Appendicitis

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4
Q

Describe the type of pain caused by ureteric colic.

A

Unilateral (almost always)
Waxing and waning (colicky)
Extremely severe
Loin to groin

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5
Q

Describe the type of pain caused by nerve impingement.

A

Shooting pain that radiates down the legs

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6
Q

What does pain that radiates down the leg suggest?

A

Lumbar nerve root compression

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7
Q

Which surgical emergency can present with acute flank pain?

A

Leaking AAA

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8
Q

What type of pathology tends to be associated with nausea and vomiting?

A

Visceral pathology (e.g. ureteric colic, biliary colic, appendicitis)

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9
Q

Why is it important to check for signs of persistent dehydration on examination?

A

Persistent dehydration predisposes to concentrated urine and the formation of kidney stones

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10
Q

Why is it important to perform a urine dipstick test in patients with ureteric colic?

A

70-90% of patients with ureteric colic have microscopic haematuria

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11
Q

List some symptoms of UTI.

A

Urgency
Frequency
Dysuria

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12
Q

List some common obstructive symptoms.

A

Hesitancy
Reduced flow
Dribbling
Incomplete emptying

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13
Q

What does cloudy, offensive-smelling urine suggest?

A

Infection

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14
Q

State another symptom that may indicate that spinal pathology is the cause of the flank pain.

A

Leg weakness

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15
Q

List some key features of the past medical history.

A 
Previous kidney stones 
Recurrent cystitis 
Atherosclerotic disease 
Longstanding back pain 
Kidney disease (e.g. polycystic kidney disease predisposes to pyelonephritis)
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16
Q

List some drugs that predispose to the formation of kidney stones.

A

Aciclovir
Indinavir
Acetazolamide

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17
Q

Name an inherited condition that increases the risk of forming kidney stones.

A

Cystinuria

18
Q

Describe the appearance of a patient with:
Ureteric Colic
Peritonitis

A
  • Ureteric Colic
    Writhing in pain and unable to stay still
  • Peritonitis
    Rigid and motionless
19
Q

What can you do during the examination to figure out whether spinal pathology is the cause of the flank pain?

A

Test range of movement and feel for tenderness over the vertebrae

20
Q

What examination should be performed if spinal pathology is suspected?

A

Lower limb neurological examination

21
Q

What examination should be performed if AAA is suspected?

A

Peripheral vascular examination

22
Q

Why is the finding of a popliteal artery aneurysm significant?

A

50% of patients with popliteal artery aneurysms also have AAA

23
Q

Why is it important to perform urinalysis in patients with flank pain?

A

Microscopic haematuria is a common feature of kidney stones

24
Q

What clues may the pH of the urine suggest?

A

Acidic – urate stones can cause urine to be acidic

Alkaline – suggests the presence of urease-producing bacteria (e.g. Proteus, Pseudomonas)

25
Q

What are red cell casts and what do they suggest?

A

Sausage-shaped clumps of red cells found on urine MC&S
They suggest that the red cells are coming from the kidneys rather then the ureters/bladder)
The presence of red cell casts suggests that there has been glomerular damage

26
Q

What do white cell casts suggest?

A

Pyelonephritis

27
Q

Why should patients be told to try and retain the stones if they pass them?

A

They can be send for analysis, which could reveal clues about the aetiology of the kidney stones

28
Q

List some blood tests that would be performed in a patient with suspected ureteric colic.

A 
FBC
CRP
U&Es
Creatinine
Serum calcium, phosphate and urate
29
Q

Why is it important to check the serum calcium, phosphate and urate levels in a patient with ureteric colic?

A

It can give information about the aetiology of kidney stones

30
Q

List two types of imaging that are useful for investigating patients with flank pain.

A

Bedside ultrasound

Non-contrast CT-KUB

31
Q

What is a disadvantage of using bedside ultrasound to investigate flank pain?

A

It shows AAA but it does not show whether the AAA is leaking or not

32
Q

List some reasons for admitting patients with kidney/ureteric stones.

A 
Evidence of upper urinary tract infection 
Evidence of renal impairment/failure 
Refractory pain 
Bilateral obstructing stones 
Elderly/child
33
Q

Which drugs can be used to ease the passage of kidney stones?

A

Tamsulosin

Nifedipine

34
Q

Management of kidney stones is largely dependent on its size. What size kidney stones have a good chance of passing spontaneously?

A

< 5 mm

35
Q

List some surgical methods of removing stones.

A

Ureteroscopic lithotripsy (URS)
Percutaneous nephrolithotomy (PCNL)
Extracorporeal shockwave lithotripsy (ESWL)
JJ Stenting

36
Q

Describe the typical presentation of acute pyelonephritis.

A

Dull flank pain, high fever and urinalysis suggestive of UTI

37
Q

Pyelonephritis can occur secondary to what other urinary tract pathology?

A

Secondary to obstruction caused by a kidney stone

38
Q

What organism most commonly causes pyelonephritis?

A

Escherichia coli

39
Q

List the sepsis 6 guidelines.

A 
High-flow oxygen
Take blood cultures 
Broad-spectrum antibiotics
IV fluid challenge
Measure serum lactate and haemoglobin
Monitor urine output
40
Q

What symptoms and signs would suggest that an intrarenal or perinephric abscess has developed?

A

Persistently high fever, bacteraemia, very high WCC, severe tenderness on examination or failure to improve with therapy

41
Q

Describe the typical presentation of an AAA.

A

Elderly with a past medical history of hypertension

Presents with sudden-onset, sharp flank pain

42
Q

Describe the management of an AAA.

A 
Urgent CT abdomen to confirm the bleed 
Large bore IV access 
X-match 10 units of blood 
Insert a urinary catheter 
Notify vascular surgeon

Oxford Clinical Cases (28 decks)

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