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Re: Case: 19 year old with back pain

 
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Re: Case: 19 year old with back pain - August 27, 2006 12:30:00 PM   
drbuddy

 

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Where would that get us?

(in reply to Dr.Wagner)
Post #: 41
Re: Case: 19 year old with back pain - August 27, 2006 2:41:00 PM   
Dr.Wagner


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jbird, I really like your question.

In this case, there were no radiating symptoms into the groin and no blood in the urine. While we didn't describe family history, those two factors alone were enough to rule out a stone. Sure, there is a possibility of a stone, but her presentaion was not quite the same presentation of a patient with kidney stones.
That being said, a flat film (KUB) really leads to nowhere...they simply are not helpful. An IVP is nice, but a tad outdated and still requires a "good read" to rule out a stone. Currently a spiral CT is the test of choice.

If there were blood or a significant history of stones, you would not be faulted to look for one.

If there was a stone AND pyelonephritis, the patient would need to stay in the hospital for IV antibiotics and possible stent placement by the urologist.

I have made this mistake once...patient got very ill.

It is important to note that the antibiotics are the most important portion of this equation...with or without a stone.

Thanks jbird.

_____________________________

Dr. Wagner DO
Moderator of Medical Complexity Forum

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Post #: 42
Re: Case: 19 year old with back pain - August 27, 2006 10:51:00 PM   
jbird007

 

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Buddy, I was concerned with the possibility of missing a stone which could have been the cause of the pyelonephritis. As Doc Wagner stated he had an experience with a very similar scenario.

Doc Wagner, your welcome and thanks!

Jbird

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Post #: 43
Re: Case: 19 year old with back pain - November 18, 2006 9:50:00 PM   
jbird007

 

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Question for Doc Wagner,

Through this discussion, you have stated spiral CT is the best dx test for eval of kidney stones. Do you know the relability of plain film x-ray to dx a kidney stone/s. The reason I ask is because 2 weeks ago I experienced symptoms of kidney stones or a UTI. I had severe throbbing excruciating rightsided backpain which sent me to my MD. UA showed some blood and slight elevated WBC. He scripted me Cipro, vicodin and valium and mentioned I had possible UTI and/or stone. The vicodon and valium helped in pain relief and spasms and after a week I was feeling fairly well.(btw I have limited health insurance, have always been very healthy and made a choice to only have catastrophic coverage with a 5k deduct). Two days ago excruciating pain started and it is now in my lower abdomen but moreso directly in my penis and towards the dital end. My urine stream is good and I am voiding normal with no signs of blood or cloudy urine. There is no pus or discharge from my penis. I took an A/P plain film x ray and it appears there is a calcification/ stone(8x4 mm) located in the bladder region(due to location and shape I am ruling out a phebolith.) I have read that sometimes kidney stones in the bladder radiate pain to the penis. Is this correct? So, I am faced with a dilemma. Wait it out and hope it passes or dissolves or see my MD. Or maybe something else is going on. The pain comes and goes and when it comes (on a scale on 1 to 10) it is a definite 10,000. I get pale as a ghost and I feel like passing out. The vicodin and valium does nothing. No fever. I feel like I need a blast of morphine, the pain is that bad. I am drinking apple cider vinegar, lemon juice and organic cranberry juice(no sugars). This is day 3 and things have not improved. I am hoping to avoid having to undergo any invasive instrumentation via the urethra, if you know what I mean. (cringe at the thought). And lithotripsy would be quite costly and they still may have to enter via urethra.

Your thoughts would be appreciated.

JBird

(in reply to Dr.Wagner)
Post #: 44
Re: Case: 19 year old with back pain - November 19, 2006 12:41:00 PM   
FLAOrthoPT

 

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From: West Palm Beach
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ouch, my first vote is think about getting insured. My next is get a rusty spoon and do some invasive procedures.

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Post #: 45
Re: Case: 19 year old with back pain - November 21, 2006 12:32:00 PM   
Dr.Wagner


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From: Indianapolis
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Would like to state I am not in the business of evaluating the care of other physicians...so I react painfully to this question. (disclaimer)

Through this discussion, you have stated spiral CT is the best dx test for eval of kidney stones. Do you know the relability of plain film x-ray to dx a kidney stone/s. The reason I ask is because 2 weeks ago I experienced symptoms of kidney stones or a UTI. I had severe throbbing excruciating rightsided backpain which sent me to my MD. UA showed some blood and slight elevated WBC. He scripted me Cipro, vicodin and valium and mentioned I had possible UTI and/or stone. The vicodon and valium helped in pain relief and spasms and after a week I was feeling fairly well.(btw I have limited health insurance, have always been very healthy and made a choice to only have catastrophic coverage with a 5k deduct). Two days ago excruciating pain started and it is now in my lower abdomen but moreso directly in my penis and towards the dital end. My urine stream is good and I am voiding normal with no signs of blood or cloudy urine. There is no pus or discharge from my penis. I took an A/P plain film x ray and it appears there is a calcification/ stone(8x4 mm) located in the bladder region(due to location and shape I am ruling out a phebolith.) I have read that sometimes kidney stones in the bladder radiate pain to the penis. Is this correct? So, I am faced with a dilemma. Wait it out and hope it passes or dissolves or see my MD. Or maybe something else is going on. The pain comes and goes and when it comes (on a scale on 1 to 10) it is a definite 10,000. I get pale as a ghost and I feel like passing out. The vicodin and valium does nothing. No fever. I feel like I need a blast of morphine, the pain is that bad. I am drinking apple cider vinegar, lemon juice and organic cranberry juice(no sugars). This is day 3 and things have not improved. I am hoping to avoid having to undergo any invasive instrumentation via the urethra, if you know what I mean. (cringe at the thought). And lithotripsy would be quite costly and they still may have to enter via urethra.

First and foremost...men, statistically, don't get UTI's. The urethra is too long (in most cases), unless you are 1. elderly 2. have BPH 3. have an indwelling catheter.
Men do get prostatitis and epidydimitis. But cystitis in a healthy male, very uncommon.
Both of the above cause testicular pain and sometimes pain with bowel movements.

Now, a plain film has a poor sensitivity for the detection of stones (probably 50-60% if that good) and the rule of thumb, is that if you are going to get ANY test, make it the best test (spiral CT).
Next, a stone that is less than 5mm has a 90% chance of passing. If you believe your stone is larger than that, you have only a 10% or less chance of passing said stone.

Lastly, I do not prescribe pain meds for UTIs, because the appropriate treatment is antibiotics and that should treat the UTI...so he/she must have been thinking something else...but I can tell you, 7days of pain is ABNORMAL.

You need a CT scan...and you likely have a kidney stone. A kidney stone PLUS cystitis is an automatic admission to the hospital for IV antibiotics. This will prevent pus in the urethra or abcsess formation behind the stone .

and yes, pain radiating from the flank to the groin is the referral pattern for ureteralithiasis.

_____________________________

Dr. Wagner DO
Moderator of Medical Complexity Forum

(in reply to Dr.Wagner)
Post #: 46
Re: Case: 19 year old with back pain - December 20, 2006 11:09:00 PM   
jbird007

 

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Doc Wagner. It was a kidney stone. On Dec 13th I delivered a 6x10mm kidney stone and she shot out like a bullet. I practically passed out but dove quickly into the toilet to retrieve it. LOL! Two days before it passed it decreased my urination to a very light dribble. It was my decison to wait it out although the docs thought I was crazy. It was lodged at the neck of the bladder/proximal urethra. Vicodin and valium helped when I got the terrible pain episodes. I was drinking H2O by the gallons, raw apple cider vinegar, and 2 ozs lemon juice mixed in olive oil. It is a reddish brown color with slated edges and resembles a calcium oxylate stone (from the pictures I looked at). It was sent off to confirm its composition. All said, it took about 6 weeks to pass. The most pain was when it passed from the kidney through the ureter. After that, I had no pain for about 2 weeks and thought maybe it broke up or dissolved. It must have been hanging out in my bladder but not giving me too many problems until I started to get this odd terrible pain in the tip of my penis. It was terrible. Thank God for pain meds and I finally passed it without any roto-rooter gouging-crushing-basket-thingy tools. All is well!

J

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Post #: 47
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