A 62-year-old woman is evaluated in the emergency department for right-sided flank pain, n… — USMLE Step 2 CK

A $62$ -year-old woman is evaluated in the emergency department for right-sided flank pain, nausea, and high fever that began $24$ hours ago. Her past medical history is significant for recurrent urinary tract infections. Temperature is $39.4^\circ\text{C}$ ( $102.9^\circ\text{F}$ ), blood pressure is $80/40\text{ mm Hg}$ , pulse is $128/\text{min}$ , and respirations are $26/\text{min}$ . Right costovertebral angle tenderness is present. Laboratory tests show a leukocyte count of $24,000/\text{mm}^3$ with $15\%$ bands and a serum creatinine of $2.3\text{ mg/dL}$ . Urinalysis reveals $4+$ leukocyte esterase, positive nitrites, and numerous bacteria. A noncontrast CT scan of the abdomen and pelvis shows a $12\text{-mm}$ calculus obstructing the right proximal ureter with associated severe hydronephrosis. Aggressive intravenous fluid resuscitation and broad-spectrum intravenous antibiotics are initiated, and a norepinephrine infusion is started to maintain mean arterial pressure. Which of the following is the most appropriate next step in management?

Percutaneous nephrostomy tube placementCevap
B
Ureteroscopy with stone extraction
C
Extracorporeal shock wave lithotripsy
D
Addition of an intravenous antifungal agent
E
Contrast-enhanced computed tomography of the abdomen

Cevap

Percutaneous nephrostomy tube placement

The patient presents with septic shock secondary to an obstructing ureteral stone, a true urologic emergency known as obstructive pyelonephritis. In this scenario, purulent urine is trapped under pressure in the renal pelvis, leading to rapid systemic bacterial dissemination. When a patient is hemodynamically unstable (requiring vasopressors), the immediate goal is purely 'damage control' through source drainage. Percutaneous nephrostomy tube placement by interventional radiology effectively drains the infected system under local anesthesia, stabilizing the patient. Once the infection is cleared and the patient is stable, definitive stone management can be planned.

Adım Adım Çözüm

Identify the patient's critical presentation.

The patient has the classic triad of flank pain, fever, and hemodynamic instability, complicated by an obstructing calculus confirmed on noncontrast CT.

Recognizing the severity of urosepsis dictates the urgency and type of surgical intervention required.

Determine the primary source of the instability.

The instability is driven by an undrained, closed-space infection (obstructive pyelonephritis).

Without rapid source drainage, isolated medical therapy (fluids, pressors, antibiotics) will ultimately fail to resolve the shock state.

Select the appropriate surgical intervention.

Percutaneous nephrostomy tube placement is chosen to emergently decompress the purulent urine.

Definitive stone removal is contraindicated in an unstable patient due to the risk of exacerbating the systemic infection, making immediate decompression the only viable step.

Anahtar Kavram

Patients with an obstructing urinary calculus and concurrent urosepsis require emergent decompression of the collecting system (e.g., via percutaneous nephrostomy), rather than definitive stone removal.

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