Surgery

Last updated on: September 9th, 2021

Stoned II

1


Clive, a 52-year-old store clerk, has had fever and right-sided abdominal pain since waking up today. He had a similar episode of pain without fever 11 months ago; at that time, he was found to have a 2 mm x 3 mm x 5 mm stone lodged in the right ureterovesical junction (UVJ). He was treated with medical expulsive therapy. After passage, the stone was found to be formed from magnesium ammonium phosphate. His co-morbidities include type 2 diabetes mellitus, hypertension, and dyslipidemia, all for five years. These are well-controlled on metformin, telmisartan, and rosuvastatin. He is not on any other medications. His family history is unremarkable. There is no history of allergies to drugs or foods. He does not smoke and only drinks socially.


On examination, Clive's BMI is 38.7 kg/m2. His temperature is 101 °F (38.3 °C). His vital signs are stable, with a blood pressure of 130/80 mmHg, pulse of 92/min, and a respiratory rate of 20 cycles/min. There is mild tenderness over the entire right side of the abdomen, without guarding or rebound tenderness. No other signs are present.


A full blood count is significant for a leukocyte count of 13,000/mm3 (normal: 4,500 -10, 000), with 85% neutrophils. Urinalysis shows 10-15 red cells (normal: 0-4) and 12-16 pus cells (normal: 0-4) per high powered field, with positive nitrite and leukocyte esterase tests. Serum creatinine is 0.9 mg/dL (normal: 0.5-1.5), and blood urea nitrogen (BUN) is 14 mg/dL (normal: 7-20). His capillary blood sugar is 230 mg/dL. An ultrasound scan shows a right-sided renal stone, with moderate to severe hydronephrosis. A noncontrast computed tomography (CT) scan shows a 20 mm x 22 mm stone in the lower part of the right renal pelvis, causing obstruction of the right urinary tract and moderate hydronephrosis.


The emergency department started Clive on narcotic analgesics and empirical antibiotics, after obtaining blood and urine cultures. They also converted him to an insulin regimen. He was then sent to your unit for urological management.