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Mr. Sanchez likely has acute renal calculi. His complaints match the typical clinical presentation of the renal calculi. He has severe low back pain suggesting pain receptors involved due to distention of pelvis, calices, renal capsule, and upper ureter. Nausea and vomiting occur in at least 50% of patients with acute renal colic. Nausea is caused by the common innervation pathway of the renal pelvis, stomach, and intestines through the celiac axis and vagal nerve afferents. Urinary frequency is explained by stones irritating intramural ureter. Hematuria (visible blood in the urine) is the sign for mechanical damage to the urinary tract.

Most stones with mild symptoms may be treated with pain killers. Analgetics, like acetaminophen can be used for mild-to-moderate pain, however narcotics are sometimes unavoidable. Dehydration must be treated aggressively especially in cases of concomitant pyelonephritis, or diabetes; antiemetics will reduce morbidity. The size of the stone itself is a strong predictor of natural course, because sometimes spontaneous passage occurs. A stone less than 4 mm in diameter has an 80% chance of spontaneous passage. Active use of antibiotics is encouraged to prevent secondary urosepsis. The antibiotic must cover gram-negative bacteria concerning the most common etiology of the disorder (E.coli or Enterobacteriaceae). This may be a fluoroquinolone, a cephalosporin, a penicillin or an aminoglycoside. Active medical expulsive therapy has been shown to increasing the frequency of stone passage, and reducing the need for surgery: corticosteroids, calcium channel blockers, alfa-blockers, and non-steroid anti-inflammatory drugs.

Generally, surgery may be avoided and it is contraindicated in cases of untreated pyelonephritis, bleeding diathesis, and pregnancy. Should absolute contraindications be absent, surgery may be applied in other cases. Today, mini-invasive techniques, such as stent placement, extracorporeal shockwave lithotripsy or percutaneous nephrostomy are widely used. Open nephrostomy is applied in less than 1% of interventions.

 A regular diet to increase fluid intake and to avoid extremes in salt, protein is recommended. The goal is a total urine volume in 24 hours in excess of 2 liters. An empiric restriction of dietary calcium may also adversely affect bone mineralization and may have osteoporosis implications, especially in women.

Code: Sample20

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