A 35-year-old man presents to urgent care with severe right-sided flank pain and fever that began suddenly 4 hours ago. The pain is sharp, intermittent, and radiates toward the groin; it is unrelieved by over-the-counter medication. He reports associated nausea but no vomiting. He also reports dysuria over the past 24 hours and notes that his urine appeared pink this morning. This is his second episode of flank pain in the past 2 weeks, with the prior episode resolving spontaneously after several hours.
The patient has no significant past medical history, allergies, or prior episodes of kidney stones. He is not taking any medications but took ibuprofen for the pain. He reports that his father had kidney stones in his 40s. On physical examination, his blood pressure is 130/90 mm Hg, heart rate is 115 beats/min, and temperature is 102.2˚F. The patient appears uncomfortable, restless, and diaphoretic. He has soft abdominal tenderness over the right costovertebral angle, no guarding, and no rebound tenderness on abdominal examination. Which of the following symptoms is of greatest concern in this patient?
- Pain
- Family history of kidney stones
- Fever
- Dysuria and pink urine
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Answer: c. This patient’s high fever in the context of tachycardia and flank pain is a red flag and suggests possible obstructive pyelonephritis, which is a urologic emergency. The differential diagnosis of this patient includes obstructive pyelonephritis due to nephrolithiasis, complicated urinary tract infection (eg, urosepsis), ureteral obstruction from another cause or possible malignancy, or an abdominal aortic aneurysm, which is unlikely but critical to rule out. You obtain the following diagnostic studies on this patient: urinalysis, complete blood count with differential (to assess for leukocytosis), basic metabolic panel to evaluate kidney function and electrolytes, blood culture to rule out bacteremia and sepsis, and lactate levels. Your urgent care does not have computed tomography (CT) available, so you perform a bedside ultrasound.
What is the best next step in the management of this patient?
- Discharge the patient with oral antibiotics and pain medication, and schedule outpatient urology follow-up.
- Perform emergency percutaneous nephrostomy to relieve obstruction.
- Refer the patient to the emergency department (ED) for immediate surgical removal of the suspected kidney stone.
- Administer IV fluids, provide pain control, and refer the patient to the ED.
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Answer: d. You decided to implement an aggressive management plan for this patient due to his fever. You began IV fluids to support his kidney function and hemodynamics, IV acetaminophen to reduce his fever, and IV broad-spectrum antibiotics (ceftriaxone and metronidazole). With the IV in place, you pushed 30 mg ketorolac to alleviate his pain. While you waited for emergency medical services to arrive to transfer him to the ED, you told the patient that because you are unable to perform a CT in-house, he needed to have a noncontrast CT scan of the abdomen and pelvis to rule out obstructive pyelonephritis, ureteral obstruction, or other malignancy. At the ED, the patient had an urgent urology consult and was admitted for monitoring.
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Tracey Davidoff, MD, FACP, FCUCM, has practiced Urgent Care Medicine for more than 15 years. She is Board Certified in Internal Medicine. Dr. Davidoff is a member of the Board of Directors of the Urgent Care Association and serves as Co-Editor-in-Chief of the College of Urgent Care Medicine’s “Urgent Caring” publication. She is also the Vice President of the Southeast Regional Urgent Care Association and a member of the editorial board of the Journal of Urgent Care Medicine. At EB Medicine, Dr Davidoff is Editor-In-Chief of Evidence-Based Urgent Care, and co-host of the Urgentology podcast.
