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  #1  
Old 04-22-2012
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Question Costovertebral Tenderness!

A 22-year-old previously healthy female comes to the emergency department for acute-onset nausea, vomiting and colicky right-sided flank pain that radiates into her right inguinal region. She reports having normal menses 4 days ago, but did notice recent increased urinary frequency with burning sensation. She is extremely hungry, but unable to eat because of her flank pain. She denies sexual activity, history of sexually transmitted diseases (STDs), or vaginal discharge. She notes that she has had been told she has “kidney stones” before, but can't recall what type. Her temperature is 38.5°C (101.3°F), blood pressure (BP): 130/80 mm Hg, pulse: 110 beats/min, respiration rate (RR): 16 breaths/min, O2 saturation 97% on room air. As you are examining the patient, you notice that she nearly jumps off the table when you tap her right costovertebral region. Her abdominal examination is benign. Urinalysis is positive for blood and granular casts. Serum beta-human chorionic gonadotropin (β-HCG) is negative and serum creatinine is 1.0 mg/dL. Urine cultures are ordered. While waiting for the results, what is the most appropriate next step in diagnosis?

A. Computed tomography (CT) scan
B. Kidney, ureter, bladder (KUB) plain film
C. Meckel scan
D. Pelvic exam
E. Ultrasound

may i know what is this? PID or Renal stone? m so confused...
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  #2  
Old 04-22-2012
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D. Pelvic exam
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  #3  
Old 04-22-2012
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Why PID? Sounds absolutely like a stone to me - history of stones, physical exam, urine findings all point to obstructive nephropathy. I would order a CT scan to see where the stone is and how big it is.
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  #4  
Old 04-22-2012
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Positive giordano sign, plus fever plus a history of kidney stones deserve a ct scan,PID doesnt present like this, i would assume staghorn calculi
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  #5  
Old 04-22-2012
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its stone, most appropriate step in stone initial is KUB plain film if its -ve then go for CT scan, if pregnant lady present with then do U/S, if theres option of analgesic 1st we have to give analgesic even before dx test, read qs no asking for accurate test so no ct scan.
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  #6  
Old 04-22-2012
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This sounds to be: Pyelonephritis.

I think the best next step is: "Ultrasound".

don't miss this short video



best of luck.
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  #7  
Old 04-22-2012
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Quote:
Originally Posted by CraCIT View Post
This sounds to be: Pyelonephritis.

I think the best next step is: "Ultrasound".

don't miss this short video



best of luck.
It can be pyelonephritis, but the history of renal stones plus a fever would point to an infection by urease positive bugs that can cause staghorn calculi, besides I have never heard of a pyelonephritis that radiates to inguinal region (the pain that is) maybe im wrong but that is almost pathognomonic of either a kidney or ureteral stone, and the history of burning sensation when urinating would indicate a wrongly treated or not treated at all Lower urinary tract infection (by an urease positive bug)

Not saying im correct just explaining my reasoning behind my answer... But yeah im stuck between ultrasaound or CT scan though (which is what the question asks)
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  #8  
Old 04-23-2012
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This a typical scenario of renal stone, fever & urinary symptoms due to UTI. The CT is answer of choice, but i think KUB done first. So it's B.
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  #9  
Old 04-23-2012
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A. Computed tomography (CT) scan

Recurrent kidney stone causing infection pyelonephritis...CT for evaluation of stone and hydronehrosis...
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  #10  
Old 04-23-2012
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Nephrolithiasis possibly complicated by pyelonephritis. Send the patients to CT scanning for the purpose of diagnosing stone formation, since x-ray can carry up to a 20% false-negative rate.
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  #11  
Old 04-24-2012
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this is explan from qbank

Option B (Kidney, ureter, bladder (KUB) plain film) is correct. Kidney, ureter, bladder (KUB) would be the most appropriate initial diagnostic test as this demonstrate classic signs for acute nephrolithiasis. The majority of renal stones are calcium-based and thus radiopaque. Ammonium magnesium phosphate stones or struvite stones are also radiopaque.

Option A (Computed tomography (CT) scan) is incorrect. Computed tomography (CT) scan may be used to diagnosis renal stones, however, it is not an appropriate initial diagnostic test.

Option C (Meckel scan) is incorrect. Meckel scan is a nuclear scan utilizing technetium to localize Meckel diverticulum (functioning bleeding gastric mucosa). It would not be appropriate in the evaluation for nephrolithiasis or flank pain.

Option D (Pelvic exam) is incorrect. Pelvic inflammatory disease (PID) must always be an important consideration in a young woman. Ectopic pregnancy and other gynecologic emergencies may manifest as abdominal pain. With the onset of recent menses and negative human chorionic gonadotropin (HCG), however, it is prudent to obtain a plain film image with high clinical suspicion for nephrolithiasis.

Option E (Ultrasound) is incorrect. Ultrasound would be a reasonable diagnostic test for hydronephrosis, acute obstructive nephropathy, or ureter dilatation. It would not, however, be appropriate as an initial diagnostic study.
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  #12  
Old 04-24-2012
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Quote:
Originally Posted by usmlepak View Post
its stone, most appropriate step in stone initial is KUB plain film if its -ve then go for CT scan, if pregnant lady present with then do U/S, if theres option of analgesic 1st we have to give analgesic even before dx test, read qs no asking for accurate test so no ct scan.
where did u get this info. i dont think it is n kaplan
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  #13  
Old 04-24-2012
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Default .

@ tyagee, its in kaplan qbank mcqs
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  #14  
Old 07-19-2012
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Quote:
Originally Posted by usmlepak View Post
its stone, most appropriate step in stone initial is KUB plain film if its -ve then go for CT scan, if pregnant lady present with then do U/S, if theres option of analgesic 1st we have to give analgesic even before dx test, read qs no asking for accurate test so no ct scan.
I think you are right about the pregnant person usmlepak. Checked with uptodate and they say the same; To avoid radiation, Pelvic US/ initially followed by Trans vaginal U/s for ureteric stones and then RX. IF still imaging is needed MR urography, low dose CT and limited IVP are other options.

As for non-pregnant women as in this case KUB followed by non-helical CT is the best option
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  #15  
Old 07-20-2012
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i would go with CT scan. see for stones and also any complications of pyelonephritis

CVA tenderness so not pid
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  #16  
Old 07-20-2012
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E. Ultrasound
Stone>>>obstruction>>>>>infection

USG is the first step in management of obstructive uropathy.
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  #17  
Old 07-20-2012
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This is weird, I think i've heard of Fish saying KUB is useless now.

Best initial is U/S, you'll catch most stones.

If you suspect urate stones then go for CT.
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  #18  
Old 07-21-2012
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Default CT in UW

I think i got a question in UW for a stone and the answer was CT
kub was mentioned in the answer choices
They don't do x-rays for stones anymore, that's for sure
if you will do ct anyway why the hell you wanna do x-ray first !
Be careful guys
there are questions in kaplan qbank which is clearly wrong
another e.g for a wrong answer to a question in qbank was
thyroid nodule with thyrotoxic features Next step?
and the answer was FNA !!!!!!!!
and there was TSH, Ultrasound, RAIU among the answer choices
and the answer is obviously TSH
I did solve 50% and I completely regret it !!
I highly recommend to not do it, It will destroy every single knowledge that you've got ! and makes you less confident
I think they didn't revise it for years, "ripping off people for some extra bucks" . after all they don't care about your score, they do care about the money

Best of luck for you guys
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Old 07-21-2012
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UW says "CT is more sensitive than KUB as KUB will miss small stones and gives no information about the obstruction "
US for the pregnant and will also miss small stones
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Old 07-21-2012
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Default Shall we come to a consensus ?

My head has been turned upside down and spun all around on this...

So for the sake of exam purposes...you are given a case where you suspect a urinary tract stone and you are asked....
WHAT IS THE BEST INITIAL TEST? .. What are you gonna put? Pregnant..I get it U/S...how about everybody else?
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Old 07-21-2012
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Quote:
Originally Posted by usmledee View Post
My head has been turned upside down and spun all around on this...

So for the sake of exam purposes...you are given a case where you suspect a urinary tract stone and you are asked....
WHAT IS THE BEST INITIAL TEST? .. What are you gonna put? Pregnant..I get it U/S...how about everybody else?
Ultrasound!
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  #22  
Old 07-21-2012
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Quote:
Originally Posted by zaiody View Post
UW says "CT is more sensitive than KUB as KUB will miss small stones and gives no information about the obstruction "
US for the pregnant and will also miss small stones

yes thats absolutely correct its CT .MTB also says the same .... x ray no longer used ... ct scan picks both radio opaque and lucent stones ....
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Old 07-21-2012
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Quote:
Originally Posted by Hitman View Post
yes thats absolutely correct its CT .MTB also says the same .... x ray no longer used ... ct scan picks both radio opaque and lucent stones ....
Do Ct or US is the best initial test???
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Old 07-21-2012
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Quote:
Originally Posted by usmledee View Post
Do Ct or US is the best initial test???
MTB says Ct is the most accurate ..... better than usg and X ray . here the qs asks the next step for diagnosis .its CT scan .... will accurately diagnose it .

so best initial test ?? should still be ct scan .... you have clear signs of stone and will be confirmed by CT ..... USG only for pregnant females .rest CT scan .
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