4-92
- Do a bimanual pelvic exam to check for adnexal tenderness.
- Check for costovertebral angle (CVA) tenderness. Lightly thump the right and left lower ribs in the back.
Increased tenderness suggests kidney pain. - Check for peritoneal signs. If pain increases with light tapping on the abdomen, shaking the abdomen,
striking the heel of the foot, or there is significant irritation of the abdominal contents, then bowel
inflammation/perforation (appendicitis, etc.) is suggested. - Light thumping over the right lower anterior chest wall would suggest gallbladder irritation. This, combined
with increased pain on eating, especially in young, overweight women is suggestive of gallbladder
disease.
Using Advanced Tools: Lab: Urinalysis may reveal casts, blood. Abdominal X-ray to assess for presence
of stones.
Assessment:
Severe side pain not related to position, which waxes and wanes, without evidence of an abnormal genital
exam or peritoneal signs strongly suggests ureteral stone.
Differential Diagnosis - any disease process between the lower chest and upper thigh can be considered.
Lower lobe pneumonia or pulmonary process - abnormal breath sounds
Abdominal causes (see Symptom: Abdominal Pain) - liver disease; cholecystitis/cholelithiasis
(gallbladder) diverticulitis including Meckel’s; appendicitis; mesenteric adenitis; abdominal aortic aneurysm.
Renal - waxing and waning pain excludes pyelonephritis, cysts, tumor or ischemic injury.
Musculoskeletal pain - this includes aches due to viral illness.
Inguinal hernia - distinguish by exam.
Urologic - Epididymitis - tender epididymis; testicular torsion - tender testis; congenital ureteropelvic junction
obstruction
Gynecologic - abnormal pelvic exam (see GYN Problems section): ectopic pregnancy, pelvic inflammatory
disease, torsion of ovary, ovarian cyst, tubo-ovarian abscess.
Plan
Treatment
Primary:
- Pain control (in order of preference): Ketorolac (Toradol) 30 mg IM q 6 h is highly effective in relieving
stone pain. Narcotics such as morphine sulfate 5-10 mg IM, Demerol 50-100 mg IM q3-4 h prn (can
combine with ketorolac)
Tylox 1-2 po q 4 h prn or Demerol 50-100 mg po q 4 h prn
If above are not available, NSAIDs such as ibuprofen 800 mg po tid or indomethacin 25-50 mg po tid
can help. - Hydration
- Antibiotics when fever is present in a suspected urinary stone patient: Either levofloxacin or IV
ampicillin plus IV gentamicin are acceptable (see pyelonephritis in UTI section). - Anti-emetics as needed
Primitive: None
Patient Education
General: Maintain good hydration.
Diet: Increased water and citrus juice intake may prevent further stone formation.
Prevention and Hygiene: See diet
Follow-up Actions
Return evaluation: All suspected stone patients need to eventually have an abdominal film taken to assess
the presence of stones.
Evacuation/Consultation Criteria: Evacuate ASAP patients with fever, persistent severe pain and persistent
vomiting. Refer patients with suspected stones for urologic consultation. Persistent symptoms require
evaluation with an IVP or CAT scan after evacuation.