Integrative case 01
Emergency department visit for acute flank pain
Objectives
- Recognize the clinical features of renal colic.
- Develop differential diagnoses.
- Select complementary tests.
- Identify warning signs.
- Recognize an infected urinary obstruction.
- Define when urgent urological intervention is needed.
Stage 1
Arrival at the emergency department
A 46-year-old male patient presents with severe right flank pain of 3 hours' duration.
The pain had a sudden onset, is 9/10, and is colicky. The patient is restless and cannot find a position that relieves the pain.
The pain had a sudden onset, is 9/10, and is colicky. The patient is restless and cannot find a position that relieves the pain.
What additional information do you consider important?
Stage 2
Differential diagnosis
With the information available, what is the most likely diagnosis?
Stage 3
Physical examination
138/82
BP mmHg
92
HR bpm
36.8°C
Temp.
98%
SatO₂
Patient alert and restless from pain. Abdomen soft and depressible, with no guarding or signs of peritoneal irritation. Positive right costovertebral angle percussion. External genitalia unremarkable.
Are there currently any clinical signs suggesting an infectious emergency?
Stage 4
Complementary tests
What tests would you request? (choose all that you consider necessary)
Stage 5
Management
Does this patient need urgent urological intervention?
The case moves forward
Two hours later...
39.1°C
Temp.
118
HR bpm
96/58
BP mmHg
18.700
White blood cells
Creatinine 1.7 mg/dL. Elevated CRP. Urine: pyuria +++, positive nitrites.
Did your management change?
Solitary kidney
History of left nephrectomy. Previous creatinine 1.1 mg/dL, current creatinine 2.6 mg/dL.
Would you keep outpatient management?
Refractory pain
Afebrile patient with normal renal function, but he continues to have 10/10 pain and vomiting despite treatment.
Is he still a good candidate for outpatient management?
Dangerous diagnosis
A 72-year-old patient, a smoker with hypertension, with sudden severe flank pain, pallor, and BP 82/55 mmHg.
Before diagnosing renal colic, what diagnosis can you not afford to miss?
Case completed
Final assessment
0/100
Key takeaways
- The diagnosis of renal colic combines clinical findings and appropriate tests.
- NSAIDs are the first-choice analgesic in renal colic if there are no contraindications (EAU); pain that is refractory despite adequate treatment is an indication to consider urinary drainage or ureteroscopy.
- Stone disease + infection + obstruction is a urological emergency.
- In an infected urinary obstruction, priority should be given to draining the urinary tract and treating the infection.
- Potentially serious differential diagnoses should always be considered.
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