A 44-Year-Old Woman With Kidney Stones

Abstract

DR BURNS: Ms P is a 44-year-old woman with a history of morbid obesity and superficial thrombophlebitis who was diagnosed with kidney stones 1 month ago. She recently lost her medical insurance and is applying for free care. She is currently unemployed and lives with her daughter. While on vacation in Jamaica, Ms P developed severe diarrhea without nausea, vomiting, or fever. After returning to the United States her diarrhea resolved, but she developed brown urine that lasted for several days. She subsequently developed bilateral intermittent low back pain that she treated with acetaminophen and ibuprofen with good relief. She denied any radiation of the pain or any associated weakness or numbness. She had no fever, dysuria, or urinary frequency. She never had similar symptoms in the past. She does not smoke and denies alcohol use. Ms P contacted her primary care physician who suggested that she be evaluated. At her visit, physical examination was noteworthy for a morbidly obese woman, 370 lb, with right and left upper quadrant tenderness without rebound or costovertebral angle (CVA) tenderness. A urinalysis showed “large blood.” Ms P was thought to have a kidney stone causing her hematuria and back pain. She was instructed to continue with acetaminophen and ibuprofen for pain. A subsequent computed tomography (CT) scan revealed a 1.2 1.6-cm calculus within the right renal pelvis. The patient was referred to a urologist. At the time of her visit, she had no further discoloration of her urine. She continued to note episodes of colicky low back pain for which she took acetaminophen and ibuprofen as needed. She denied having fever, chills, or dysuria. She had no CVA tenderness on examination. Plain film of the abdomen revealed an 18 17-mm calcific density overlying the region of the pelvis of the right kidney, consistent with a calculus. At the time of her visit, treatment options were discussed, including extracorporeal shock wave lithotripsy (ESWL) vs ureteroscopy. The plan was to proceed with ESWL when her free care application was approved. In the interim, the plan was to alkalinize her urine to try to shrink the stone and minimize the number of potential future invasive procedures if ESWL failed. Ms P wonders whether she was being treated differently because of her size and lack of insurance and what is the best way to proceed.