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Dr. Tharun
Dr. Tharun, Urology Resident
Category: Urology
Satisfied Customers: 3585
Experience:  MBBS, DNB surgery and presently working as Urology resident towards the degree of Urologist.
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Hi, My husband who had progressive MS developed a kidney stone

Resolved Question:

Hi,
My husband who had progressive MS developed a kidney stone in Feb. 2013 with severe pain so we went to the ER. My husband was on 5mg. prednisone, Oxycontin, Vicodin and morphine pills for his MS. He is pretty tough but this was the worst pain he had ever had. The CAT scan showed a 6mm stone in the distal ureter and a 4mm stone above it. The scan showed mild hydronephrosis. His WBC was 13.39, Alk phosphate 38, Differential neut abs 8.44, lymph abs 3.94, had hazy urine with small amts. of blood, positive nitrite, large leukocyte esterase, 9 wbc, 29 rbc's, light bacteria, and light mucous. After 3 doses of morphine he seemed to have a bit of pain relief. We were discharged within 3 hours with pain medicine, cipro and phenergan and told to follow up with a urologist. The ED thought he would pass the stone. This happened at 5 am Sunday morning. He slept most of the day had no appetite, woke up at 3 am and took 2 pain pills. He said he would be alright and so I left for work at 6 am Monday morning. When I arrived at 4:30 pm Monday he was breathing irregularly, diaphoretic, looked to be the same place I left him, had attempted to use the rest room and had diarrhea and was mentally almost incoherant. He was rushed to the hospital, intubated, central line started, had a creatinine of 6.7 and was rushed to the OR to have stents placed. The urologist said there was pus behind the stones and was unable retrieve the stones due to his unstable condition. He was put on levophed drip and was in septic shock. He arrested 3 times, had developed DIC and died Thursday morning. He was 57 and was still up and about teaching golf until this. This was his first incidence of a stone. I cannot understand given his immonocompromised and immunosuppressed state, why he was discharged. In hind sight he was prime for sepsis. No one will answer much for fear of legal action. I would like your opinion, please.
Thank you,
Laura
Submitted: 1 year ago.
Category: Urology
Expert:  Dr. Tharun replied 1 year ago.
HI

Sorry to hear about your loss.

Given the history of steroids, creatinine test would have helped in emergency dept.Usually creatinine is done in normal patients too who are older than 50.

They would have detected the impending sepsis if they had requested creatinine levels in the blood sample.They already did blood counts and could have added this test too in the same sample.

I am not saying things would be entirely different had he been diagnosed of kidney failure earlier, but definitely the chances would have been much better .

Steroids mas most of signs of sepsis like fever, chills etc.So this mild increase in the WBC count should have caused some alert.

This is just an opinion based on the clinical picture you gave me.Things could be different in real time .

I hope you understand.Take care.

Regards

Dr.Tharun
Customer: replied 1 year ago.

Thank you Dr. Tharun,


His creatinine was 1.1 which is considered normal.


Is it reasonable to expect a 6mm stone to pass with no surgical intervention?


I fell like there was no real physical assessment performed. Due to the extreme pain they rushed him back. The ED touched his flank area and that was the extent. There were no questions regarding his history of MS; whether he had problems urinating which MS can affect.


The problem is that in the dictation by the ED doctor he did not mention the steroids or oxycontin and morphine he was on for pain almost daily for Multiple Sclerosis...the H&P was incomplete..are there instances in which a patient is admitted for stents for this? Doesn't the hydronephrosis indicate a potential problem?


Thank you for your help.


Laura

Expert:  Dr. Tharun replied 1 year ago.
HI Laura,

I was not aware that creatinine was done which was normal.

6 mm stones can pass without intervention,although the chances are not as great as 3 or 4 mm stones, but there is no harm in trying without intervention if the creatinine levels are normal.

Hydronephrosis is inevitable in any stone in the ureter and cannot be considered significant unless there is gross hydronephrosis.

Steroids are the only positive finding in the history, which could have prompted a better treatment plan than what happened.But with normal creatinine levels doctors may not find it too serious.Severity of the stone is decided by creatinine levels and presence of infection.Both these things seemed to be normal in his case, which could have made them discharge your husband.

Regards

Dr.Tharun
Customer: replied 1 year ago.


Thank you, XXXXX XXXXX


The presence of infection in and of itself with a stone would not necessitate further treatment in a patient with history of an immunocomprimised status?


You have helped clear my questions and thank you very much!


Laura

Expert:  Dr. Tharun replied 1 year ago.
Hi

Whether further intervention is required or not is decided by if there is block in the kidneys or not.

Just infection without block requires only antibiotics. But infection with block is an emergency and requires immediate intervention like stenting.

Infection without block is rarely stented if there is severe infection with rise in the creatinine levels.


Infection in immuno compromised state needs to be treated immediately, but there has to be documented evidence for it.

If urine , blood and scans don't show any evidence, rarely will any doctor intervene.

Regards,

Dr.Tharun
Customer: replied 1 year ago.


There was a block in the ureter; a 6mm stone and a 4mm stone plus the infection. If I am understanding your reply correctly, given the block and infection stents should have been placed? The urine showed infection plus increased WBC. The scan showed the stones and hydronephrosis. The doctor knew he had MS.


Do you think the fact that the creatinine was normal and he was afebrile was the reason he was discharged? I guess I feel you have to look at the whole picture and am trying to wrap my brain around the rationale for discharge so quickly.


Thank you!


Laura

Expert:  Dr. Tharun replied 1 year ago.
Hi,

There could be arguments on both sides. On one hand his creatinine was normal and he had no toxic symptoms. He had mild elevation of wbc in blood and 9 wbc in urine which is again borderline and in normal circumstances not considered as a sign of severe infection.

On the other hand he was immuno compromised due to steroids and even mild symptoms and raise in wbc could be due to heavy infection . Even if it was mild at that time , infections in such patients can rapidly deteriorate .So this forms the basis for immediate intervention.

Both the actions can be argued because there was a mixed picture at presentation which could have confused the judgment.


Regards

Dr.Tharun
Dr. Tharun, Urology Resident
Category: Urology
Satisfied Customers: 3585
Experience: MBBS, DNB surgery and presently working as Urology resident towards the degree of Urologist.
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Dr. Tharun
Urologist
3585 Satisfied Customers
MBBS, DNB surgery and presently working as Urology resident towards the degree of Urologist.