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A 38-year-old man presents to A&E with sudden onset of severe right-sided flank pain radiating to his right testicle and groin. He is pacing the room, unable to sit still. He has vomited twice. Urinalysis: blood ++, leucocytes negative, nitrites negative. Temperature 37.2C.
Questions
a) What is the most likely diagnosis and what bedside observation supports it? (2 marks)
Diagnosis: Ureteric colic (renal colic) from a urinary stone.
The patient is restless, pacing, and unable to sit still — this is the hallmark of visceral pain from ureteric spasm. In contrast, a patient with peritonitis (e.g. appendicitis) lies perfectly still because movement worsens pain.
b) What is the gold standard investigation, and what is its sensitivity? (2 marks)
CT KUB (non-contrast CT of kidneys, ureters, and bladder) — the gold standard. 97% sensitive and 96% specific for urinary stones. Identifies all stone types (including radiolucent uric acid), stone size and location, and degree of hydronephrosis.
c) Outline the initial management. (3 marks)
- NSAIDs first-line: diclofenac 75 mg IM/IV (equal efficacy to opioids, fewer side effects).
- Anti-emetic: ondansetron 4 mg IV (for nausea/vomiting).
- Hydration: oral or IV.
- Strain all urine to catch the stone for analysis.
d) If CT shows an 8 mm stone in the distal ureter, what treatment options are available? (3 marks)
- Medical expulsive therapy: tamsulosin 0.4 mg OD + hydration for 4 weeks (50% chance of spontaneous passage for 5-10 mm stones).
- Ureteroscopy with Holmium laser lithotripsy (if medical therapy fails or patient prefers definitive treatment). Success rate over 90% for distal ureteric stones.
- JJ stent may be placed post-procedure for 1-2 weeks.