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Difficulty: MediumUrologic Surgery

An emergency medicine physician is evaluating a 54-year-old woman complaining of severe right-sided back pain, rigors, and vomiting that began 12 hours ago. Her temperature is 39.2°C (102.6°F), blood pressure is 88/55 mmHg, and pulse is 115/min. Physical examination reveals exquisite right costovertebral angle tenderness. Laboratory testing shows a leukocyte count of 18,000/mm³. Arrange the following management steps in the most appropriate chronological sequence for this patient.

  1. 1Obtain blood and urine cultures, then initiate broad-spectrum intravenous antibiotics
  2. 2Perform a noncontrast computed tomography (CT) scan of the abdomen and pelvis
  3. 3Perform emergent decompression of the upper urinary tract (via percutaneous nephrostomy or ureteral stent)
  4. 4Perform definitive stone removal (via ureteroscopy or shock wave lithotripsy)

Answer

The correct chronological sequence is: 1) Obtain cultures and initiate broad-spectrum antibiotics, 2) Perform a noncontrast CT scan, 3) Perform emergent decompression of the urinary tract, and 4) Perform definitive stone removal.
In a patient presenting with an infected, obstructing kidney stone (obstructive pyelonephritis), the physiological priority is treating the systemic inflammatory response and local infection before proceeding to structural interventions. Thus, antibiotics are given immediately. Once the patient is stabilized, a noncontrast CT is performed to delineate the stone's size and location. Because antibiotics cannot penetrate the stagnant, purulent urine proximal to the stone, emergent source control via a nephrostomy tube or ureteral stent is mandatory. Finally, definitive stone destruction is delayed until the patient has fully recovered from the infectious episode.

Step-by-Step Solution

1
Identify the clinical presentation and primary diagnosis.
The patient has severe flank pain, fever, hypotension, and leukocytosis, consistent with septic shock secondary to an infected obstructing kidney stone (obstructive pyelonephritis).
Recognition of sepsis in the setting of urolithiasis dictates immediate, life-saving sequence of management.
2
Determine the immediate resuscitative priority.
Administration of intravenous fluids, obtaining cultures, and starting broad-spectrum antibiotics.
Sepsis guidelines require systemic antibiotics within the first hour to prevent cardiovascular collapse.
3
Select the appropriate diagnostic imaging.
Noncontrast CT of the abdomen and pelvis.
Once stabilized, imaging is needed to confirm the level and size of the obstruction before surgical intervention.
4
Determine the emergent surgical intervention.
Urgent decompression via percutaneous nephrostomy or ureteral stenting.
Systemic antibiotics cannot effectively penetrate an obstructed, purulent collecting system; physical drainage is required for source control.
5
Plan definitive management.
Delayed definitive stone removal (e.g., ureteroscopy).
Attempting stone fragmentation during active infection can cause massive systemic bacterial dissemination.

Key Concept

Management of obstructive pyelonephritis (infected nephrolithiasis) requires immediate hemodynamic stabilization and antibiotics, followed by imaging and emergent urinary tract decompression, delaying definitive stone removal until the infection resolves.
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Urologic Surgery

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