A 42-year-old man comes to the emergency department due to sudden-onset, severe left-sided… — USMLE Step 2 CK

A $42$ -year-old man comes to the emergency department due to sudden-onset, severe left-sided flank pain that radiates to his left groin. He has no significant past medical history. His temperature is $37.1^\circ\text{C}$ ( $98.8^\circ\text{F}$ ), blood pressure is $140/90\text{ mmHg}$ , pulse is $98\text{/min}$ , and respirations are $16\text{/min}$ . Physical examination reveals left costovertebral angle tenderness but a soft, non-tender abdomen. Laboratory studies show a normal leukocyte count and urinalysis is positive for microscopic hematuria but negative for leukocyte esterase and nitrites. A noncontrast CT scan of the abdomen and pelvis reveals a $4\text{-mm}$ stone in the left distal ureter with mild hydroureter. His pain improves significantly after receiving intravenous ketorolac. Which of the following is the most appropriate next step in management?

Discharge home with tamsulosin and encourage oral fluid intakeAnswer
B
Administration of intravenous broad-spectrum antibiotics
C
Extracorporeal shock wave lithotripsy
D
Placement of a percutaneous nephrostomy tube
E
Ureteroscopic stone extraction

Answer

The correct answer is to discharge the patient home with tamsulosin and encourage oral fluid intake.

The correct answer involves discharging the patient with medical expulsive therapy. Ureteral stones less than

5\text{ mm}

in diameter have a high likelihood (often

>80\%

) of spontaneous passage. Because this patient has well-controlled pain, normal renal function, and no evidence of urinary tract infection, he does not require hospital admission or immediate urologic intervention. An alpha-1 receptor blocker, such as tamsulosin, relaxes the smooth muscle of the distal ureter, facilitating stone passage.

Step-by-Step Solution

Evaluate the patient's clinical stability and signs of infection.

The patient is afebrile with normal vital signs, normal leukocyte count, and negative urinalysis for infection.

To rule out a urologic emergency such as an infected obstructing stone, which would require immediate decompression.

Assess the stone size and location from the imaging.

The CT scan shows a

4\text{-mm}

stone in the distal ureter.

Stone size and location are the primary predictors of spontaneous passage. Stones under

5\text{ mm}

have a high probability of passing spontaneously.

Determine the appropriate management strategy based on stone characteristics and patient status.

Medical expulsive therapy (alpha-blockers and hydration) in an outpatient setting is selected.

Conservative management is indicated for small, uncomplicated stones in patients with well-controlled pain.

Key Concept

Uncomplicated ureteral stones smaller than

5\text{ mm}

in stable patients with controlled pain should be managed conservatively with a trial of spontaneous passage using medical expulsive therapy.

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