每日一题_2022.06.21

A 36-year-old man is evaluated in the emergency department for right flank pain. His only medical history is the donation of his left kidney to his brother eight years ago. He is in considerable distress and has difficulty sitting on the stretcher. The pain is associated with intense nausea and vomiting; he also reports a subjective low-grade fever. Vital signs are: heart rate 130 beats/min, blood pressure 130/70 mm Hg, temperature 38°C (100.4°F), respiratory rate 26 breaths/min, oxygen saturation 100% on room air. Physical examination is notable for a soft abdomen and pain localized to the right flank and back. Laboratory analysis shows white blood cells 20,000/μL, creatinine 4.0 mg/dL, lactate 4 mmol/L, urinalysis positive for nitrite, and leukocyte esterase 3+. Bedside ultrasound shows moderate right-sided hydronephrosis.

Which of the following is the most appropriate next step in management?

A. Abdominal CT and noncontrast pelvic CT

B. Blood and urine cultures, IV antibiotics and fluids, and pain medication

C. Blood and urine cultures, IV antibiotics, and nephrology consultation for dialysis 

D. IV fluids, pain control, and tamsulosin

答案解析：

该患者有急性肾功能衰竭的证据，很可能是肾结石引起的梗阻。 这是一个医疗紧急情况，因为他有一个孤立的肾脏，以及由于尿路阻塞引起的严重败血症的证据。 床边超声用于确定这一诊断，显示中度右侧肾积水。 泌尿科医生最终可能会要求 CT 来计划干预，但最关键的下一步是开始对严重脓毒症进行管理，同时咨询泌尿科以控制感染源和缓解梗阻。 鉴于严重脓毒症和孤立肾的发现，将该患者视为单纯性肾结石并单独进行疼痛管理是不合适的。 同样，患者最终可能需要透析和肾脏科会诊，但在急性期，优先治疗伴有严重败血症的阻塞性肾结石，希望可以避免透析。

正确答案：B