- 64 year old female presented to the ED with blood in the urine and right-sided abdominal pain
- Pain started yesterday and is progressively worsening.
- Pain comes and goes, is “aching”, radiates to right groin
- Has noticed blood-tinged urine today
- Chronic “smoker’s” cough
- Review of systems otherwise negative
- Hypertension, well-controlled on lisinopril/hydrochlorothiazide
- Coronary Artery Disease, s/p DES to LAD 5 years ago, on aspirin, atorvastatin, metoprolol
- Menopause at age 49
- Former smoker (40 pack-year history), quit 5 years ago after stent
- Denies any illicit drug use
- Social alcohol consumption
Temp: 36.8° C, BP: 132/74 mmHg, HR: 95 bpm, RR: 12 rpm, SpO2: 95% on room air
- Abdomen tender to palpation in right upper and lower quadrants
- Right-sided flank tenderness
- Otherwise, normal exam (including genitourinary)
- CBC, CMP, PT/INR significant for a calcium level of 13.2 mg/dL, creatinine of 1.4 mg/dL
- Urinalysis shows 3+ blood, 2+ protein, no casts
- CT abdomen without contrast shows 6 mm obstructive renal stone at the right ureteropelvic junction with moderate right-sided hydronephrosis
What’s on your differential diagnosis?
What would you do next in the work-up for this patient?