Nephrolithiasis: Differential Diagnosis

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Urolithiasis (ICD10-N20.1)

Nephrolithiasis can be defined as the accumulation of stones in kidneys (Tseng & Preminger, 2013). In contrast, Urolithiasis is the condition that implies the accumulation of stones in the urinary tract (particularly in the calyces, pelvis, urethra, or bladder). As crystals are formed in the urine, stones (typically calcium oxalate and calcium phosphate) emerge (Qaseem, Dallas, Forciea, Starkey, & Denberg, 2014). The stones typically develop in male patients aged 20-40 and trigger immense pain in the area from lower ribs to pelvis, as well as diarrhea, nausea, vomiting, renal angle tenderness, and hematuria. However, in a range of cases, the pain spreads to groin and genitalia (Hollier, 2016). Nephrolithiasis manifests itself in flank pain that may subside once the position of the patient is changed.

Furthermore, symptoms such as nausea, vomiting, frequent urinating, weakness, hematuria, diaphoresis, and dysuria (Dunphy, Winland-Brown, & Porter, 2015). The patient (Patrick) suffers from flank pain radiating to his groins, as well as sweating and nausea. The ultrasound test showed that there was a 5mm smooth round calculus between his urethra and bladder.

Patient Education

The patient must follow an oxalate-free diet (i.e., refuse from consuming chocolate, cocoa, black tea, nuts, rhubarb, spinach, lamb, etc.). Purine-rich products are also to be avoided (Dunphy et al., 2015). Furthermore, it is recommended to maintain physical activity. The patient should also be instructed to use a strainer to catch the stones while urinating. Preventing the instances of infection is also a must; moreover, drugs containing phosphorus or calcium must be avoided (Hollier, 2016).

Referrals

It is strongly recommended that the patient should visit a nephrologist or a urologist so that the stones could be safely removed from the urethra. Also, in case the symptoms aggravate and the patient experiences significant discomfort, hospitalization may be necessary. If the symptoms are not managed within four days, a urology referral will be crucial.

Follow-up

A follow-up must be provided within four days after the symptoms are registered. A week later, Creatinine levels must be checked (Hollier, 2016).

What the NP Should Do if the Patient Continues to Come back for Pain Medication

In case the patient requires more drugs, his symptoms must be assessed once again. At present, Patrick takes two tablets every hour, which is considered enough. Therefore, unless the symptoms vanish within four days, a urology referral will be essential.

Possible Warning Signs of Prescription Drug Abuse

In case Patrick continues consuming increasingly large doses of medication despite their detrimental effect, drug abuse must be suspected (Cheatle, 2015). In other words, if the patient starts frequenting the facility and asking for more prescription opioids, there may be a drug abuse problem (Shapiro, Coffa, & McCance-Katz, 2013).

Three of the Twelve 2016 CDC Recommendations That Would Help the Provider in Handling This Case

Recommendation 1

Realistic treatment objectives must be defined before administering medication to the patients (Centers for Disease Control and Prevention, 2016).

Recommendation 2

The risks and threats to which the patient may be exposed must be discussed in a multidisciplinary setting before administering the drug to the patient (Centers for Disease Control and Prevention, 2016).

Recommendation 3

When prescribing opioids as a part of the pain therapy, clinicians must make sure that the lowest effective doses are used. Furthermore, long-term treatment based on opioids must be considered only in instances of acute pain (Centers for Disease Control and Prevention, 2016).

References

Centers for Disease Control and Prevention. (2016). CDC guideline for prescribing opioids for chronic pain – United States. Web.

Cheatle, M. D. (2015). Prescription opioid misuse, abuse, morbidity, and mortality: Balancing effective pain management and safety. Pain Medicine, Supplement, 1(16), S3-S8. Web.

Dunphy, L. M., Winland-Brown, J. E., Porter, B. O., & Thomas, D. J. (2015). Primary care the art and science of advanced practice nursing (4th ed.). Philadelphia, PA: F. A. Davis Company. Web.

Hollier, A. (2016). Clinical guidelines in primary care (2nd ed.). Scott, LA: Advanced Practice Education Associates, Inc. Web.

Qaseem, A., Dallas, P., Forciea, M. A., Starkey, M., & Denberg, T. D. (2014). Dietary and pharmacologic management to prevent recurrent nephrolithiasis in adults: A clinical practice guideline from the American College of Physicians. Annals of Internal Medicine, 161(9). 695-667. Web.

Shapiro, B., Coffa, D., & McCance-Katz, E. (2013). A primary care approach to substance misuse. American Family Physician. 88(2). 113-121. Web.

Tseng, T. Y., & Preminger, G. M. (2013). Kidney stones. American Family Physician. 87(6). 441-443. Web.

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