Labs on kidney stone/pyelo?

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turkeyjerky

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I just wanted to quickly poll you guys on this. Do you typically get labs, ie a bmp to check the renal function, on patients presenting w/ typical symptoms of a kidney stone or uncomplicated pyelonephritis?

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Unilateral ureteral stone = labs (other than UA) are very low yield. What are they going to tell you?

Bilateral obstruction (very rare) = labs definitely are needed (and urgent/emergent urology consult).

A patient with only one kidney and an obstruction = labs needed (and urgent/emergent urology consult).

Pyelonephritis is totally different. Again, a unilateral pyelonephritis should not affect renal function at all. Whether or not labs are needed has more to do with the overall condition of the patient. Vomiting, dehydrated, septic, getting admitted? Obviously, get labs.

Uti, plus "maybe there's early pyeolo" but probably not and is going home, labs are going to be low yield. Maybe a CBC is helpful (maybe).

Again, why would a unilateral pyeolo or ureteral obstruction affect renal function? That's the question.
 
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1. to assess hydration status, electrolytes, glucose, and cr/gfr... etc

2. if you don't do it and they come back everyone will think you're stupid even if you're practicing good medicine.

3. to tell the patient "we checked your kidney function and it's normal".

4. this is an ER, I am here to r/o emergencies, not save the healthcare system money. all while practicing appropriate medicine of course...

5. patients with true symptoms of pyelo/utero-obstruction often have other associated symptoms (severe ttp, n/v, hematuria) which make assessment of other abd pathology necessary. lfts/lipase

6. only thing JDs and the public care about is the number of tests you do.

7. patients expect it.

these are kind of bs reasons that could apply to anything.. but I think in most patients presenting for emergent evaluation of acute abd pain which you attribute to a GU disorder should have blood work.

sure I dc lots of uncomplicated pyelo (ie, UA positive w/ mild cva ttp) but anyone w/ sig VS abnormalities/comorbidities/riskfactors/bad clinical presentation (ie >90% of our population) is going to get a blood draw.
 
In general, I do--reference the recent medical-legal threads, but I tend to overtest. I can try and overthink it, or I can document a normal set of labs and vitals. On at least a certain subset of these patients, they're going to return and it's difficult to predict which ones will come back sicker.

Worst case scenario, I find that they've doubled their creatinine (most commonly due to vomiting/dehydration from pain) and I give them some fluids and admit for observation. No sweat off my back and an easy admit
 
If I didn't think that Peter Rosen would crawl over shards of glass to testify against all of us in exchange for a bounty of riches, I might consider testing less ....
 
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Yes. Order the labs.

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Uncomplicated unilateral stone? No.

Pyelonephritis? Always.
 
Uti, plus "maybe there's early pyeolo" but probably not and is going home, labs are going to be low yield. Maybe a CBC is helpful (maybe).

I agree that labs will probably be low yield (well, bloodwork anyway, the HCG and UA are high yield). But don't you think a BUN/Cr is more useful than a WBC in this patient? If they clinically have pyelo, how does a WBC anywhere between 4 and 25 (where >99% will be) help you?
 
I agree that labs will probably be low yield (well, bloodwork anyway, the HCG and UA are high yield). But don't you think a BUN/Cr is more useful than a WBC in this patient? If they clinically have pyelo, how does a WBC anywhere between 4 and 25 (where >99% will be) help you?
That's why I wrote "maybe" in that response. Twice.
 
How are you guys making this diagnosis of "uncomplicated unilateral stone"?
Hx, CT, U/S?

If I am getting an imaging study, I'm almost always getting labs?
The main reason I don't get labs is to get the patient out of the dept faster.

If the patient presents with known stone, pain the same as prior, etc.
I usually just check a urine and give symptomatic tx in those cases.
That is until my attending has a completely different plan.
 
How are you guys making this diagnosis of "uncomplicated unilateral stone"?
Hx, CT, U/S?

If I am getting an imaging study, I'm almost always getting labs?
The main reason I don't get labs is to get the patient out of the dept faster.

If the patient presents with known stone, pain the same as prior, etc.
I usually just check a urine and give symptomatic tx in those cases.
That is until my attending has a completely different plan.

In an otherwise healthy patient with a Hx of stones, who presents with unilateral flank pain that is similar to prior stones and no fever I do a UA and provide pain control. If the pain responds and the UA shows no infection, I discharge without further workup.

1st time stones will get a scan.
Infection on UA, intractable pain, fever, or history concerning for other pathology (AAA, retrocecal appendix, etc) will get a scan + labs.
 
I always do a UA. Pretty often I will do a CT KUB. Sometimes I will do a bedside US, and occasionally an XR (if urology wants one). Most of the time I will not do any blood testing unless they have tachycardia or a fever.
 
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Honestly I see about one to two people a year with rapidly increasing creatinine from unilateral stones. Why does it happen, no frickin' clue. Does it matter in getting them admitted, yes. CBC is useless in uncomplicated stones. Pyelonephritis labs are there to document sepsis severity in ppl you are admitting. Not so useful in ppl going home.
 
Honestly I see about one to two people a year with rapidly increasing creatinine from unilateral stones.

I suppose, if you're finding kidney stone patients with unexplained "rapidly" increasing creatinines, something weird is going on that they need work up for, maybe not even related to the stone.

Or does the creatinine bump slightly until the unobstructed kidney kicks it up a notch, bringing the creatinine back to normal in a clinically irrelevant way? Are you actually getting consultants to bite on admitting kidney stones for a slightly and temporarily bumped creatinine?

That would be like getting ortho to admit all ankle fractures, "just in case the other ankle breaks."

I'm used to having to admit all patients through a 5-foot-thick concrete-wall of non-admitting obstinance.
 
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I only call or worry when it gets to the 2+ range really. No push back when they are in obvious acute failure. I get pushback more for infected stones when the WBC isn't huge because the urologists around here love that test for some reason more than obvious Pyuria.
 
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I only call or worry when it gets to the 2+ range really. No push back when they are in obvious acute failure. I get pushback more for infected stones when the WBC isn't huge because the urologists around here love that test for some reason more than obvious Pyuria.

That's because a positive UA does not indicate an infected stone. Obstructing stones with a positive UA can go home. Obstructing stones with fever or leukocytosis (>15,000) warrant admission and surgical intervention regardless of UA findings. Mild leukocytosis (<15,000) is typical in an acute stone episode, but higher numbers suggest systemic infection. You can have obstructed pyelonephritis with a completely normal UA if no urine is getting past that stone.

If you are considering a urology consult they are probably going to insist on labs: CBC, chemistry, and UA/UCx. The indications for admission/decompression include: bilateral obstructing stones, obstructing stone in a solitary or functional solitary kidney (ie. moderate-severe CKD), septic stone (ie. signs of pyelo: fever/chills, leukocytosis), acute renal failure, or uncontrolled pain/nausea/vomiting. Notice that none of those indications include size or location of the stone or degree of hydronephrosis on imaging. Laboratory values are important for the admission decision and the decision to intervene surgically and how rapidly.
 
Cpants, just for my own education, would you mind to post some references for that WBC15 cutoff? Thanks!
 
I usually will get a CBC and metabolic panel for the reasons listed above: lawyers, urology consultants, general public perception, etc… I realize that in the vast, vast majority of cases, bloodwork makes zero difference in a patient with a unilateral kidney stone, but I'm still forced to order it. The way I see it, the patient is already going to have to wait an hour to get a CT scan and radiology read. The bloodwork will be done by that time anyway. And as I usually put in an IV to give anti-emetics and pain relief, getting bloodwork does not require any additional needle sticks.
 
That's because a positive UA does not indicate an infected stone. Obstructing stones with a positive UA can go home. Obstructing stones with fever or leukocytosis (>15,000) warrant admission and surgical intervention regardless of UA findings. Mild leukocytosis (<15,000) is typical in an acute stone episode, but higher numbers suggest systemic infection. You can have obstructed pyelonephritis with a completely normal UA if no urine is getting past that stone.

If you are considering a urology consult they are probably going to insist on labs: CBC, chemistry, and UA/UCx. The indications for admission/decompression include: bilateral obstructing stones, obstructing stone in a solitary or functional solitary kidney (ie. moderate-severe CKD), septic stone (ie. signs of pyelo: fever/chills, leukocytosis), acute renal failure, or uncontrolled pain/nausea/vomiting. Notice that none of those indications include size or location of the stone or degree of hydronephrosis on imaging. Laboratory values are important for the admission decision and the decision to intervene surgically and how rapidly.
This pretty much nails it. Your exceptions that need admission are spot on, with the addition that it's likely only going to be, maybe 1 in 100 (maybe 1 in 50) kidney stones. Otherwise you're either abusing your urology service, they're unusually hungry for admissions or you're at a hospital where abuse of the urology service is encouraged, ie, in-house urology residency. The majority of what urologists do for kidney stones can be done more efficiently, faster and cheaper outpatient.
 
That's because a positive UA does not indicate an infected stone. Obstructing stones with a positive UA can go home. Obstructing stones with fever or leukocytosis (>15,000) warrant admission and surgical intervention regardless of UA findings. Mild leukocytosis (<15,000) is typical in an acute stone episode, but higher numbers suggest systemic infection. You can have obstructed pyelonephritis with a completely normal UA if no urine is getting past that stone.

If you are considering a urology consult they are probably going to insist on labs: CBC, chemistry, and UA/UCx. The indications for admission/decompression include: bilateral obstructing stones, obstructing stone in a solitary or functional solitary kidney (ie. moderate-severe CKD), septic stone (ie. signs of pyelo: fever/chills, leukocytosis), acute renal failure, or uncontrolled pain/nausea/vomiting. Notice that none of those indications include size or location of the stone or degree of hydronephrosis on imaging. Laboratory values are important for the admission decision and the decision to intervene surgically and how rapidly.

Maybe I'm cavalier, but I don't get excited about leukocytosis. I've seen patients have 18k white counts from stress response from vomiting. Even trauma patients frequently have high white counts.

To say that a WBC of 15 requires admission is not the standard of care in any place where I have practiced. Even pyelo patients who are febrile, have a leukocytosis, and a nasty looking UA go home if they can tolerate PO antibiotics. The same is true of someone with a 4 mm stone and a WBC of 18.
 
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In flank/back pain/colicky patients, I generally only do blood testing if I'm ordering a CT.
 
It depends on the H&P, and sometimes you can't trust the H&P.

If you know it's just a stone, the only lab you need is the UA.

But if you don't yet know that it's a stone, and the patient's tach-ing away with an unreliable pulseOx and a bad case of the oh-Oh-OOHH's, maybe you need a troponin, blood cultures, and [gasp] a d-dimer...

This is the difference between an "expert's" recommendation (it's very reasonable for a Urologist to want to admit all obstructed stones with WBC's>15k) and a pragmatist's practice (I am not going to check a CBC on every flank pain, and I sure as heck am not going to admit someone for a WBC of 16... but sometimes I scan panic attacks from stem to stern).
 
Maybe I'm cavalier, but I don't get excited about leukocytosis. I've seen patients have 18k white counts from stress response from vomiting. Even trauma patients frequently have high white counts.

To say that a WBC of 15 requires admission is not the standard of care in any place where I have practiced. Even pyelo patients who are febrile, have a leukocytosis, and a nasty looking UA go home if they can tolerate PO antibiotics. The same is true of someone with a 4 mm stone and a WBC of 18.

I'd say that is a little bit cavalier. I don't know that there has been a study determining the WBC level which indicates systemic infection, but urologists are taught that a WBC count >15,000 should raise a concern for pyelonephritis. In the setting of an obstructing stone pyelonephritis is a surgical emergency. Now, will there be some patients with obstructed pyelo and a normal white count? Sure. And, do some patients with a WBC of 18,000 just have a severe reactive leukocytosis? Sure. But, I think this is similar to the idea that surgeons should be taking out a few normal appendixes to be on the safe side. The natural history of an obstructed pyelonephritis is worsening septic shock and then death, so the stakes are pretty high.

This is directly from the 2008 AUA Update, "Management of the Acute Stone Event":
The minimum laboratory evaluation in the patient with suspected renal colic due to a renal or ureteral calculus includes a complete blood count, metabolic panel (serum electrolytes, blood urea nitrogen, creatinine, liver function tests and calcium) and urinalysis. Although mild leukocytosis (10,000 to 15,000/mm2) is commonly seen in patients with acute renal colic due to demargination of white blood cells in response to stress, a white blood count exceeding 15,000/mm2 should raise suspicion of pyelonephritis with or without an obstructive etiology.

So I would say that it is certainly the standard care, at least among urologists, to do a laboratory evaluation and to consider intervention in a patient with obstructing calculus and leukocytosis. If you are going to send the patient home without me being involved, do whatever you want. If you are going to consult me or even curbside me over the phone, I am going to recommend labs.

This is the AUA recommended algorithm for assessment and management of the acute stone episode from the same paper if anyone is interested:
upload_2014-12-23_10-20-24.png
 
Urologists aren't Emergency docs. They live in a bubble far removed from the routine, repeated acute evaluation of flank pain and possible ureterolithiasis. These sorts of guidelines suffer from a spectrum bias, as most benign disease never involves a urologist.

Uncomplicated stone disease requires neither imaging nor blood work. The natural course of the vast majority of stones, even moderately-sized, obstructing stones, is spontaneous passage. The only reason bloodwork is necessary at any point is the endless dogmatic perpetuation of the necessity of non-specific labs. Would you like an amylase with your WBC count?
 
Uncomplicated stone disease requires neither imaging nor blood work. The natural course of the vast majority of stones, even moderately-sized, obstructing stones, is spontaneous passage. The only reason bloodwork is necessary at any point is the endless dogmatic perpetuation of the necessity of non-specific labs.
Absolutely true (with the specification that the patients are age <50 or otherwise known not to have a AAA.)
 
Urologists aren't Emergency docs. They live in a bubble far removed from the routine, repeated acute evaluation of flank pain and possible ureterolithiasis. These sorts of guidelines suffer from a spectrum bias, as most benign disease never involves a urologist.

Uncomplicated stone disease requires neither imaging nor blood work. The natural course of the vast majority of stones, even moderately-sized, obstructing stones, is spontaneous passage. The only reason bloodwork is necessary at any point is the endless dogmatic perpetuation of the necessity of non-specific labs. Would you like an amylase with your WBC count?

Completely agree that I'm no ED doc. Just giving you some perspective on how we approach stones. If the guy looks great and passes stones all the time, by all means, skip the diagnostics. I get called all the time by ED attendings and residents though to run these routine stone cases by me and arrange follow up. I'm always going to say sure send him out on Flomax....as long as his WBC and creatinine are ok. I've had pushback on this before, but again, if you don't want to follow our standard of care, don't call us about the case. I have seen patients come back in to the ER <24 hours later septic who didn't have labs on their first presentation. I've seen patients die from obstructed urosepsis, which should be avoidable with early diagnosis and intervention. So if you want my name in your chart as being aware of the case and the plan, you'll need some labs.
 
Uncomplicated stone disease requires neither imaging nor blood work.
Well, as a community doc that isn't in an academic bubble, would you define "uncomplicated stone disease"? A person comes in with flank pain, and you call it a day? No UA and no CT?

Teach it to me like you would teach it to a college student, who COULD understand, but doesn't know anything.

Edit: My reading comprehension fail. You wrote "blood work". You did not say "lab work".

Most of what I said, though, I still ask.
 
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if you don't want to follow our standard of care, don't call us about the case

Exactly. If you don't want to get an MRI, don't call a Neurologist. If you don't want to check a CBC, don't call a Surgeon. If you don't want to get X-rays, don't call an Orthopedist. If you do call a specialist, be prepared to do a specialist style work up. I only get bothered when specialists want me to hurt people unnecessarily (NG lavage on GI bleeds), when they start suggesting workups outside of their area of expertise (like the Cardiologist wanting a Neuro and a Trauma consult on the syncope patient who fell from standing, had no seizure symptoms and came into the ED in a fib with RVR) or when they delay admission for tests that can and should be done as an inpatient.
 
The idea of routinely sending out renal colic without a work-up is preposterous in my practice setting. It's probably what's best from a population standpoint but the urologists would be lining up at peer review to crucify the first doc unlucky enough to have a patient develop sepsis from a stone. Unless you have near universal buy-in from the urologists (ideally a written protocol), not working up stones is career suicide.
 
In my setting, a work-up would include a history, physical, and usually a UA.

Additional work-up which I do on selected patients may include components of the following: a bedside renal and aorta ultrasound, blood testing, possibly a CT, and occasionally a KUB XR.
 
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The idea of routinely sending out renal colic without a work-up is preposterous in my practice setting. It's probably what's best from a population standpoint but the urologists would be lining up at peer review to crucify the first doc unlucky enough to have a patient develop sepsis from a stone. Unless you have near universal buy-in from the urologists (ideally a written protocol), not working up stones is career suicide.
In all fairness, xaelia didn't say "no UA." I think his point was against blood tests being done routinely or mindlessly. Seriously though. Ya'll know how to work up kidney stones:

Rule in stone

Rule out infection

Rule out AAA (if over 50)

Treat the pain


Done


Skin that cat anyway you want, based on the individual patients story, but that's watcha gotta do. It's that simple. Don't make it rocket science.
 
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In my setting, a work-up would include a history, physical, and usually a UA.

Additional work-up which I do on selected patients may include components of the following: a bedside renal and aorta ultrasound, blood testing, possibly a CT, and occasionally a KUB XR.

So you are THAT confident that you would rely ONLY on the H&P? I mean, when you say "usually", that (to me) means more than a handful DON'T get it.

And, let me present a case: 35 y/o female, not pregnant, R flank pain that has moved down to her pelvis, afebrile, hx stones 5 years ago on the same side. Pain is described as "burning, and stabbing, and it comes and goes". I did check the urine, and, on a 1-10 scale, with >= 5 gets antibiotics, it was about a 2 (which I would normally just send for culture), and trace blood.

To quote Dennis Hopper in Speed, "what do you do?" (There are no tricks here - straightforward case.) Tell me what you would do, then I'll give you what I did.
 
I would do a pelvic exam if she complained of lower abdominal pain, treat the pain, and look at the UA & pregnancy results.

There are quite a few obviously MSK back pain cases in which I do not check a UA.
 
I'm surprised about all the back and forth banter about whether to run blood work. I get the CT / no CT discussion, but...labs? Most of my renal colic patients (hell, most of my patients in general) have labs drawn and sent to lab by nursing staff before I even get in to see them, which is perfectly fine by me. Your CBC and chemistry is not going to break the national health care bank, nor hurt the patient in any meaningful way, and unless you routinely get your renal colic patients out the door in under an hour it probably won't change your discharge times. But it might stop people from pointing fingers at you if things go south and they bounce back. And it will almost always prevent the "they just checked my pee and sent me home" complaints to your director.

Dunno, seems like no biggie to me.
 
This is exactly how I see it, point for point.

1. to assess hydration status, electrolytes, glucose, and cr/gfr... etc

2. if you don't do it and they come back everyone will think you're stupid even if you're practicing good medicine.

3. to tell the patient "we checked your kidney function and it's normal".

4. this is an ER, I am here to r/o emergencies, not save the healthcare system money. all while practicing appropriate medicine of course...

5. patients with true symptoms of pyelo/utero-obstruction often have other associated symptoms (severe ttp, n/v, hematuria) which make assessment of other abd pathology necessary. lfts/lipase

6. only thing JDs and the public care about is the number of tests you do.

7. patients expect it.

these are kind of bs reasons that could apply to anything.. but I think in most patients presenting for emergent evaluation of acute abd pain which you attribute to a GU disorder should have blood work.

sure I dc lots of uncomplicated pyelo (ie, UA positive w/ mild cva ttp) but anyone w/ sig VS abnormalities/comorbidities/riskfactors/bad clinical presentation (ie >90% of our population) is going to get a blood draw.
 
To quote Dennis Hopper in Speed, "what do you do?"

What did you find on the abdominal exam? Was there any tenderness, particularly rebound tenderness? I would perform a bedside ultrasound to look for hydronephrosis. I would also likely do a pelvic exam, although I realize that it would be little utility. In a case like this, if there was a normal urinalysis and bedside kidney ultrasound, I might end up having to perform a CT of the abdomen and pelvis with intravenous and PO contrast.
 
What did you find on the abdominal exam? Was there any tenderness, particularly rebound tenderness? I would perform a bedside ultrasound to look for hydronephrosis. I would also likely do a pelvic exam, although I realize that it would be little utility. In a case like this, if there was a normal urinalysis and bedside kidney ultrasound, I might end up having to perform a CT of the abdomen and pelvis with intravenous and PO contrast.

Don't have US in my shop. Abdomen was nontender, apart from mild in the Right flank. The UA was very mildly dirty, and did have trace blood.

I haven't used PO contrast in YEARS.
 
I would do a pelvic exam if she complained of lower abdominal pain, treat the pain, and look at the UA & pregnancy results.

There are quite a few obviously MSK back pain cases in which I do not check a UA.

That doesn't answer the question of renal colic or not. You are skirting around the issue.
 
Don't have US in my shop. Abdomen was nontender, apart from mild in the Right flank. The UA was very mildly dirty, and did have trace blood.

I haven't used PO contrast in YEARS.

If the UA is dirty, even mildly, I scan.
 
If the UA is dirty, even mildly, I scan.

So, this "slam dunk" renal colic was clean on the CT. Pyridium, Bactrim, and clear instructions.

I just can't get my head around people that are so confident in their skills or the patients giving an accurate history. Have some humility, folks. Or, otherwise, look at post #31.
 
I just don't understand this. All sorts of subspecialties want to dictate emergency care when they have little if any experience in emergency care. Urologists don't see the vast majority of kidney stones; cardiologists don't see the vast majority of chest pain; ortho doesn't see fractures; etc. The fact that a subspecialists could testify against an ER doc should be criminal.

Further, flomax in kidney stones makes me crazy. The preponderance of evidence shows no benefit and there is potential for harm. Why not just throw everyone on a drug that causes orthostatic hypotension and doesn't help? What happened to "First, do no harm?" That's bad medicine.


I'd say that is a little bit cavalier. I don't know that there has been a study determining the WBC level which indicates systemic infection, but urologists are taught that a WBC count >15,000 should raise a concern for pyelonephritis. In the setting of an obstructing stone pyelonephritis is a surgical emergency. Now, will there be some patients with obstructed pyelo and a normal white count? Sure. And, do some patients with a WBC of 18,000 just have a severe reactive leukocytosis? Sure. But, I think this is similar to the idea that surgeons should be taking out a few normal appendixes to be on the safe side. The natural history of an obstructed pyelonephritis is worsening septic shock and then death, so the stakes are pretty high.

This is directly from the 2008 AUA Update, "Management of the Acute Stone Event":


So I would say that it is certainly the standard care, at least among urologists, to do a laboratory evaluation and to consider intervention in a patient with obstructing calculus and leukocytosis. If you are going to send the patient home without me being involved, do whatever you want. If you are going to consult me or even curbside me over the phone, I am going to recommend labs.

This is the AUA recommended algorithm for assessment and management of the acute stone episode from the same paper if anyone is interested:
View attachment 187962
 
ortho doesn't see fractures

Are you referring to emergently or overall? I sure hope that all of your fractures are being referred to an orthopedist (at least as an outpatient) if nothing else, so that he can say, "Everything looks well aligned. Keep the cast on for another five weeks."
 
Are you referring to emergently or overall? I sure hope that all of your fractures are being referred to an orthopedist (at least as an outpatient) if nothing else, so that he can say, "Everything looks well aligned. Keep the cast on for another five weeks."

Emergently.
 
That doesn't answer the question of renal colic or not. You are skirting around the issue.

I'm not skirting the issue at all – you asked me how I would approach a given case and I told you. If a person with a history of uncomplicated renal stone comes into the ED with another presentation and UA consistent with a renal stone, I would presumptively treat them as a kidney stone and might do no testing other than a UA.

I generally opt to do some type of imaging for first time renal stones, as well as patients with history of complicated stones. UA's can be quite difficult to interpret, and it is established that the presence of a kidney stone can cause leukocytes to be present in the urine, which do not equal an infection. Sometimes additional testing (blood testing, imaging, cultures, etc.) is necessary to determine whether an infection is present. Stable patients with small stones and a UTI would typically be discussed with our urologist on call, who may arrange follow-up, and they would be given a trial of outpatient therapy with return precautions for the ED.

I CT a lot of kidney stones, but I will add this article to the discussion:
http://www.nejm.org/doi/full/10.1056/NEJMoa1404446
 
I'm surprised about all the back and forth banter about whether to run blood work. I get the CT / no CT discussion, but...labs? Most of my renal colic patients (hell, most of my patients in general) have labs drawn and sent to lab by nursing staff before I even get in to see them, which is perfectly fine by me. Your CBC and chemistry is not going to break the national health care bank, nor hurt the patient in any meaningful way, and unless you routinely get your renal colic patients out the door in under an hour it probably won't change your discharge times. But it might stop people from pointing fingers at you if things go south and they bounce back. And it will almost always prevent the "they just checked my pee and sent me home" complaints to your director.

My experience is that both nurses and patients are typically NOT skilled in choosing appropriate diagnostic testing.

Patients would generally always like more testing and choosing diagnostic testing is something that nurses have literally zero training in other than osmosis.

I think it can be useful to have established nursing protocols for selected presentations or complaints which allow nurses to initiate appropriate testing or interventions that are agreed upon in advance by the ED administration. But willy-nilly nurse-chooses-your-adventure diagnostic workup – I would rather that the nurse not initiate that.
 
I still don't get the controversy. You're just running a couple of labs. You're not performing advanced imaging, this is not an invasive procedure -- just a couple of simple blood tests. I don't get why people are objecting in any way to a CBC and a BMP. In the spectrum of diagnostic possibilities, a CBC and chemistry are practically imperceptible. I can't count the number of times I've had the finger retrospectively pointed at me, or seen it pointed at a colleague, for not ordering basic tests that (at the time) could legitimately be justified as "not indicated". And yet, never once has anyone commended me on my laudable withholding of resources for the sake of medical efficiency.

Typically, if the nurses think labs should be sent, I let them send them off with few exceptions. Keep yourselves out of trouble, you're not saving the world by withholding a CBC or a BMP. As e30ftw pointed out earlier, people come to us to rule out badness, not to save the world from inefficiency one basic lab test at a time.

My experience is that both nurses and patients are typically NOT skilled in choosing appropriate diagnostic testing.

Patients would generally always like more testing and choosing diagnostic testing is something that nurses have literally zero training in other than osmosis.

I think it can be useful to have established nursing protocols for selected presentations or complaints which allow nurses to initiate appropriate testing or interventions that are agreed upon in advance by the ED administration. But willy-nilly nurse-chooses-your-adventure diagnostic workup – I would rather that the nurse not initiate that.
 
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I CT a lot of kidney stones, but I will add this article to the discussion:
http://www.nejm.org/doi/full/10.1056/NEJMoa1404446

For what it's worth, I'm writing the Annals of EM Journal Club discussion on this article as we [type].

I don't think folks in this thread are truly representing the extremes of practice their debate partners make them out to be. Uncomplicated stone disease is the guy who is 35 years old, says "ungh, it's another stone", his testicles are non-tender, has >182 RBCs on his micro with a only a couple of WBCs, is afebrile, and a chart biopsy shows a couple prior CTs with stone. A female with pelvic pain – stone is absolutely in the differential, but there are many confounders. These folks are candidates for a shared decision-making conversation about CT and stone disease and the low probability of serious outcomes, making sure they know their yearly insurance deductible and are OK with getting a couple $1000 bills from the hospital, the ED group, the radiologist, etc. Then you get to put in the chart: "offered CT, declined", which will always be more defensible in the retrospectoscope than the WBC or a Cr.

There's a spectrum of disease and presentations, nothing is "never", nothing is "always". I fall heavily on the save money/time/radiation side of the equation, and it takes a little extra work in communication to do that. Also it doesn't hurt to work in Texas.

p.s. leaving pure academia in a couple months – although, for a similarly distorted reality. Ha!
 
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