Practice this case based on how you are assessed in your OSCEs, and use the relevant sections for general revision. 🤓
Doctor Instruction:
You are a Junior Doctor working in the Emergency Department. Your next patient is Emma Smith – a 30-year-old female presenting with loin pain. Please take a history and perform an appropriate examination.
Patient History:
Emma Smith, a 30-year-old female, social worker
You are coming in today as you have had a sudden constant right loin pain radiating to the right groin in the past two days. You describe this as a severe sharp/dull pain. It is between 8-10/10 pain score. You tried ibuprofen and paracetamol with only little relief. No obvious trigger.
You feel nauseous but no vomiting. When it is painful, you do feel a bit hot and sweaty. No recorded temperature. You noticed pain passing urine (cannot see any blood), otherwise, no urinary symptoms. Urine output is normal – you last passed urine was yesterday. No labial/ anterior thigh pain. Bowels open normally with no loose stool or constipation (no blood). You have a regular male partner and are sexually active and you use a Mirena coil for contraception.
Ideas, Concerns, Expectations:
You think this is appendicitis, as your mum had this before. You are worried that your appendix might burst, which happened to your mum, who had emergency surgery. You hope to have your appendix removed as soon as possible and have your pain well-controlled.
Past Medical History:
Obesity
Hypertension
No previous history of renal stones
No past surgical history.
Drug History:
Ramipril 1.25mg OD
The Mirena coil was inserted two years ago.
NKDA
Family History:
Appendicitis from mother
Social History:
Lives with partner in a flat
Works as a social worker
Smoke five cigarettes a day for the past five years
Drink occasionally during special events
Independent at home
Examination Finding
The patient appears in agony, often twisting the body.
Right loin to groin tenderness, the abdomen is otherwise soft with no signs of peritonism. Right renal angle tenderness.
Bowel sound normal.
Genital examination is normal.
Differentials
Urolithiasis
UTI, e.g. pyelonephritis
Urinary Tract obstruction
Hydronephrosis
GI/ gynaecological pathologies e.g. acute appendicitis, ectopic pregnancy, ovarian cyst …etc.
Dissection of aortic aneurysm
Investigations
Bedside:
Basic observations
Urine dipstick – may show haematuria in urolithiasis, nitrite/ leucocyte positive in infection, pH (> 7: urea-splitting organism, e.g. Proteus spp, <5: uric acid stones)
Urine MCS
Urine Pregnancy Test
Bloods:
Routine Bloods e.g. U&E (measure renal function), FBC/CRP (infection), Calcium (hypercalcaemia), bHCG (ectopic pregnancy), coagulation screen if intervention is required/planned.
Imaging
Non-contrast CT KUB within 24 hours – the gold standard for diagnosing renal stones (first-line)
USS KUB (alternative to CT, e.g. pregnant women, young adults and children) If negative, low dose non-enhanced CT scan or MRI scan should be considered
Abdominal XR – calcium-based stone can be present on imaging; uric acid stones are radiolucent
Special Test:
If a stone is obtained, e.g. by encouraging the patient to attempt and catch the stone using a filter for analysis, the stone should be analysed to guide cause and reduce the risk of recurrence.
Management