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November 2011: Abdomen

A 25 year old floorhand presents to the sickbay with a complaint of right lower back pain that started approximately 3 days ago.  The pain is described as sharp and stabbing, about  8-9/10 on the pain scale, radiates down to his groin but has no discernable alleviating factors.  The pain comes and goes without any specific exacerbating factors.  He first noticed the pain as he was getting out of his bed 3 days prior.  The patient denies any specific trauma but notes that he has been lifting more weight than usual on deck.

On review of symptoms, he admits to nausea without vomiting, decreased appetite, and dark colored urine.  He has not been drinking more or less than usual.  He has no significant past medical or surgical history, is not taking any medications, and is not allergic to any medications.

Vitals:

  • Temp: 99.1
  • Pulse: 112
  • Respirations: 16
  • Blood pressure: 152/95
  • O2 Sat: 98% on room air
  • BMI:  27

Physical Exam:

  • Alert and Oriented, appears uncomfortable, NAD
  • HEENT: atraumatic, normocephalic, PERRL, EOMI
  • Heart: tachycardic, no murmurs appreciated
  • Lungs: Clear to auscultation
  • Abdomen: soft, non-tender, non-distended, normal bowel sounds
  • Back: normal range of motion, no spinal point tenderness, mild right CVA tenderness
  • Extremities: muscle strength 5/5 (upper and lower)
  • Genital: normal external genitalia, no testicular tenderness, no hernia appreciated
  • Gait: normal

 

Lab Work

  • Urinalysis
    • Color- dark yellow
    • Clarity- clear
    • Specific gravity- 1.020
    • pH- 6.0
    • Glucose – negative
    • Bilirubin – 1+
    • Blood – 2+
    • Urobilinogen – 0.2 EU
    • Protein – 1+
    • Ketones – 10+
    • Nitrite – negative
    • Leukocyte esterase – negative

How would you approach this patient?

Diagnosis: Nephrolithiasis

Treatment

  • Oral hydration (IV normal saline if the patient is not able to drink)
  • Monitor urine output and strain urine if you suspect stone
  • Pain control with NSAIDS such as ketorolac or narcotic medications such as vicodin or morphine as directed
  • Patient should remain in sickbay until transport arrives for CASEVAC

Discussion

Once you suspect that the patient may indeed have a kidney stone it is very important that he be sent in for further evaluation.  Hydration and pain control are paramount while the patient is in the offshore environment.  Obstruction is a dangerous complication and can be seen with stones measuring 5mm and greater.  Another complication of nephrolithiasis is infection which should be suspected in urine with pH greater than 7.5 and/or leukocyte esterase positive.  Patients should be encouraged to stay well hydrated to both increase urine flow and to decrease the solutes in the urine to reduce the risk of stone formation.

Return to Work

  • Symptoms should be completely resolved
  • Stones should be passed
  • Patient is no longer requiring pain medications

 

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