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Difficulty: EasyDiagnostic Workup and Test Sequencing

A 45-year-old man comes to the emergency department due to the sudden onset of severe, colicky right flank pain that radiates to his right groin. He states the pain began 2 hours ago and is 10/10 in intensity. He is pacing around the examination room and cannot find a comfortable position. Vital signs show a temperature of 37.1°C (98.8°F), blood pressure of 145/90 mmHg, heart rate of 98/min, and respiratory rate of 18/min. Physical examination reveals right costovertebral angle tenderness, but the abdomen is soft and non-tender without rebound or guarding. Urinalysis demonstrates 30-50 red blood cells/hpf and no leukocyte esterase or nitrites. Which of the following is the most appropriate next step in the diagnostic evaluation for this patient?

  1. Non-contrast computed tomography of the abdomen and pelvisAnswer
  2. B
    Ultrasonography of the kidneys and urinary bladder
  3. C
    Magnetic resonance urography
  4. D
    Intravenous pyelography
  5. E
    Plain radiograph of the kidneys, ureters, and bladder (KUB)

Answer

Non-contrast computed tomography of the abdomen and pelvis
The correct answer is non-contrast computed tomography (CT) of the abdomen and pelvis. This patient's presentation of severe, acute-onset, colicky flank pain radiating to the groin, accompanied by pacing (inability to find a comfortable position) and microscopic hematuria, strongly suggests an acute ureteral stone (nephrolithiasis). In a non-pregnant adult, a non-contrast CT of the abdomen and pelvis is the diagnostic modality of choice. It offers the highest sensitivity and specificity, accurately identifying the size and location of the stone, as well as complications such as hydronephrosis.

Step-by-Step Solution

1
Identify the clinical syndrome based on the patient's presentation.
The patient has sudden, severe colicky flank pain radiating to the groin, inability to sit still, costovertebral angle tenderness, and microscopic hematuria.
These findings are highly characteristic of nephrolithiasis (kidney stones).
2
Determine the most appropriate guideline-concordant imaging modality to confirm the diagnosis.
Non-contrast computed tomography (CT) of the abdomen and pelvis is selected.
Non-contrast CT is the gold standard initial imaging study for suspected nephrolithiasis in non-pregnant adults due to its high sensitivity and specificity for identifying the stone size and location.

Key Concept

Diagnostic imaging sequencing for suspected nephrolithiasis in non-pregnant adults.
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Topics

Diagnostic Workup and Test Sequencing

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