Flank Pain and Renal Colic ConcernAPPROACH

RENAL AND URINARY · 19 SECTIONS

⚲

504 items

☷ Legend

⚲

Resuscitation and Universal Approaches9▾

Chest and Cardiovascular12▾

Respiratory11▾

Abdominal and Gastrointestinal24▾

Renal and Urinary7▾

Oliguria And Anuria Catheter Related Urinary Complaints Dialysis Patient Presentations Flank Pain And Renal Colic Concern Urinary Retention Hematuria Scrotal Pain

Neurologic11▾

Back and Neck8▾

Women's Health, Pregnancy, and GU11▾

Infectious Disease and Fever Syndromes11▾

Allergy and Dermatology7▾

Musculoskeletal and Extremities14▾

Trauma and Wounds14▾

ENT, Eye, Dental10▾

Endocrine, Metabolic, and Abnormal Labs9▾

Toxicology and Behavioral14▾

Pediatrics16▾

Environmental and Exposure4▾

01History/hx66

HPI core

›Flank pain history core

›Symptom start context

›Pain location pattern

›Prior similar episodes

›Baseline urinary function

›OPQRST

›Onset

›Sudden

›Gradual

›Provocation/Palliation

›Worse with movement

›No position relief

›Relief after analgesia

›Quality

›Colicky

›Constant

›Region/Radiation

›Groin

›Testicle

›Labia

›Lower abdomen

›Severity

›Peak intensity

›Current intensity

›Timing

›Intermittent waves

›Persistent

›Associated symptoms

›Nausea

›Vomiting

›Hematuria

›Dysuria

›Urinary frequency

›Urinary urgency

›Fever

›Chills

›Inability to void

Stone risk history

›Stone risk profile

›Prior nephrolithiasis

›Prior stone type known

›Prior urologic procedures

›Family history nephrolithiasis

›Low fluid intake pattern

›High sodium diet pattern

›High animal protein intake

›High oxalate foods exposure

›Bariatric surgery history

›Malabsorption history

Infection and obstruction context

›Infection and obstruction context

›Recent UTI symptoms

›Recent antibiotics

›Immunocompromised state

›Solitary kidney history

›Known CKD history

›Pregnancy status

›Indwelling ureteral stent history

Alternate diagnosis screen

›Nonrenal pain screen

›Chest pain

›Dyspnea

›Pleuritic pain

›Back pain focal midline

›Abdominal pain migratory

›Vaginal bleeding

›Vaginal discharge

›Testicular pain acute

›Trauma history

02Alarm Features/alarm38

Immediate threats

›Time critical red flags

›Obstructed infected system

›Fever or rigors

›Hypotension

›Tachycardia

›Toxic appearance

›Altered mental status

›Aortic catastrophe concern

›Age older

›Severe sudden back or flank pain

›Syncope

›Known AAA history

›Pulse deficit

›Focal neurologic deficit

›Renal infarction concern

›Sudden flank pain

›Atrial fibrillation

›Embolic risk

›Testicular torsion concern

›Acute scrotal pain

›High riding testis

Vital sign danger thresholds

›Danger thresholds

›Systolic BP less than 90 mmHg

›Persistent HR greater than 120

›SpO2 less than 92 percent

›Temperature 38.0 C or higher

High risk populations

›High risk context

›Pregnancy

›Solitary kidney

›Transplant kidney

›Immunocompromised

›Anticoagulated

›Older adult

Escalation triggers

›Escalation

›If sepsis concern, immediate IV antibiotics and source control pathway

›If obstructed infected stone suspected, urgent urology for decompression

›If shock, resuscitation bay

›If refractory pain or vomiting, IV analgesia and antiemetic escalation

03Medications/meds29

Medication reconciliation

›Current meds relevant to flank pain

›NSAIDs

›Acetaminophen

›Opioids

›Alpha blockers

›Diuretics

›Anticoagulants

›Antiplatelets

›SGLT2 inhibitors

›Lithium

Stone forming medications

›Stone promoting meds

›Topiramate

›Acetazolamide

›Indinavir and atazanavir

›Triamterene

›High dose vitamin C

Medication contraindication traps

›Contraindications and interactions

›NSAIDs

›CKD moderate to severe

›Dehydration

›Heart failure

›Pregnancy third trimester

›Anticoagulation high bleeding risk

›Opioids

›Concurrent sedatives

›OSA risk

›Tamsulosin

›Orthostatic hypotension risk

›Concomitant PDE5 inhibitors

04Diet/diet9

Hydration and triggers

›Intake and hydration

›Poor oral intake

›Dehydration symptoms

›High sodium intake pattern

›High animal protein intake

Relevant exposures

›Exposures

›Heavy sweating

›Heat exposure

›Recent fasting

05Review of Systems/ros22

GU and abdominal

›GU and abdominal symptoms

›Dysuria

›Frequency

›Urgency

›Hematuria

›Suprapubic pain

›Inability to void

Infectious and systemic

›Systemic symptoms

›Fever

›Chills

›Malaise

›Myalgias

Cardiopulmonary and vascular

›Cardiopulmonary and vascular

›Chest pain

›Dyspnea

›Syncope

›Leg pain or swelling

Neuro and MSK

›Neuro and spine

›Weakness

›Numbness

›Saddle anesthesia

›Bowel or bladder incontinence

06Collateral History and Family History/chafh11

Collateral and reliability

›Collateral context

›Source reliability

›Ability to follow discharge plan

Family history

›Family history

›Nephrolithiasis

›Gout (M10.9)

›Hyperparathyroidism (E21.3)

›Cystinuria

Household exposures

›Exposure context

›Sick contacts

›STI exposure risk

07Risk Factors/rf22

Stone risk factors

›Nephrolithiasis risk factors

›Prior stone history

›Family history stone disease

›Low urine volume

›Obesity (E66.9)

›Gout (M10.9)

›Hyperparathyroidism (E21.3)

›Type 2 diabetes mellitus (E11.9)

›IBD (K52.9)

›Bariatric surgery

Infection risk factors

›UTI and pyelonephritis risks

›Prior multidrug resistant organism

›Recent hospitalization

›Recent antibiotics

›Indwelling catheter or stent

›Pregnancy

›Diabetes (E11.9)

Vascular and thromboembolic risks

›Vascular risks

›Atrial fibrillation (I48.91)

›Recent MI or endocarditis

›Known AAA (I71.4)

›Smoking history

08Differential Diagnosis/ddx66

Life threatening

›Life threatening causes

›Obstructed infected stone

›Fever

›Hypotension

›Leukocytosis

›Hydronephrosis

›Abdominal aortic aneurysm rupture or leak (I71.4)

›Older age

›Hypotension

›Pulsatile abdominal mass

›Aortic dissection with abdominal branch ischemia (I71.00)

›Sudden severe pain

›Neurologic deficits

›Pulse differential

›Renal infarction (N28.0)

›Atrial fibrillation

›Elevated LDH

›Ectopic pregnancy (O00.9)

›Positive pregnancy test

›Vaginal bleeding

›Testicular torsion (N44.0)

›Acute scrotal pain

›Absent cremasteric reflex

Common

›Common causes

›Ureterolithiasis and renal colic (N20.1)

›Colicky flank pain

›Hematuria

›Acute pyelonephritis (N10)

›Fever

›CVA tenderness

›Pyuria

›Musculoskeletal strain

›Reproducible tenderness

›Worse with movement

›Herpes zoster

›Dermatomal pain

›Rash delayed

Less common

›Less common causes

›Nephrolithiasis without obstruction (N20.0)

›Nonobstructing stone imaging

›Atypical pain

›Renal mass hemorrhage

›Anticoagulation

›Flank mass

›Papillary necrosis (N17.2)

›Sickle cell disease

›NSAID exposure

›Ovarian torsion (N83.5)

›Sudden pelvic pain

›Adnexal tenderness

›Appendicitis (K35.80)

›RLQ tenderness

›Anorexia

›Diverticulitis (K57.92)

›LLQ tenderness

›Fever

Mimics and pitfalls

›Mimics and pitfalls

›Hematuria absent in stones

›Early or intermittent bleeding

›Hydration effect

›Pyelonephritis without fever

›Older adult

›Immunocompromised

›Early zoster without rash

›Allodynia

›Dermatomal pattern

09Past Medical History/pmh16

Relevant conditions

›Relevant PMH

›Nephrolithiasis history

›CKD stage

›Solitary kidney

›Kidney transplant

›Recurrent UTIs

›Diabetes (E11.9)

›Hypertension (I10)

Prior procedures

›Prior urologic history

›Ureteral stent

›Lithotripsy

›Ureteroscopy

›Nephrostomy tube

Baseline function

›Baseline status

›Baseline creatinine known

›Baseline voiding pattern

10Physical Exam/exam23

General and vitals

›General and vitals

›Toxic appearance

›Hydration status

›Fever pattern

›Hemodynamic stability

Abdominal and flank

›Abdomen and flank

›CVA tenderness

›Abdominal tenderness focality

›Peritoneal signs

›Palpable mass

GU and pelvic

›GU and pelvic

›Testicular exam

›Cremasteric reflex

›Inguinal hernia exam

›Pelvic exam indications

Vascular and cardio

›Vascular and cardiac

›Peripheral pulses symmetry

›Abdominal bruit

›New murmur

Neuro and spine

›Neuro and spine

›Focal neurologic deficits

›Midline spine tenderness

›Saddle anesthesia

11Lab Studies/labs20

Urine testing

›Urinalysis

›Hematuria

›Pyuria

›Nitrites

›Protein

›pH pattern

›Urine culture

›Pyelonephritis concern

›Sepsis concern

Bloodwork

›Basic blood tests

›CBC

›Creatinine and electrolytes

›CRP local protocol dependent

›Pregnancy test

›All patients with pregnancy potential

›Imaging selection impact

Interpretation pearls

›Pitfalls and interpretation

›Hematuria absence does not exclude stones

›Leukocytosis may occur with renal colic

›Creatinine elevation suggests obstruction or dehydration

12Imaging/img34

Scoring Systems

›Risk and pathway tools

›STONE score for uncomplicated ureteral stone probability

›Male sex

›Short pain duration

›Nonblack race

›Nausea or vomiting

›Hematuria

›Higher score increases stone likelihood

›Sepsis screening local protocol dependent

›qSOFA

›SIRS

MRI

›MRI role

›Pregnancy with nondiagnostic ultrasound

›Alternate diagnosis evaluation without ionizing radiation

›Limited availability and time

›CT imaging choices

›Noncontrast CT abdomen pelvis for stones

›Stone size and location

›Hydronephrosis

›Alternative diagnoses

›CT angiography if aortic pathology concern

›AAA rupture concern

›Dissection concern

›CT cautions

›Radiation exposure

›Contrast nephropathy risk local protocol dependent

›Contrast allergy history

Ultrasound

›Ultrasound approach

›Renal ultrasound hydronephrosis

›POCUS hydronephrosis screening

›Limited ureteral stone visualization

›Ultrasound pitfalls

›Early obstruction may be false negative

›Hydronephrosis absent with small distal stone

13Special Tests/spec10

Bedside maneuvers and procedural diagnostics

›Bedside tests

›Bladder scan for retention

›POCUS kidneys for hydronephrosis

›POCUS aorta if AAA concern

›Procedural diagnostics

›Straight catheter urine sample if contaminated specimen

›Pelvic exam if gynecologic differential high

Stone analysis planning

›Stone evaluation adjuncts

›Strain urine for stone capture

›Stone analysis if captured

14ECG/ecg8

Indications and patterns

›ECG indications

›Older adult with flank pain and vascular risk

›Syncope

›Chest pain

›Significant electrolyte abnormality

›ECG findings relevant to mimics

›Atrial fibrillation

›Ischemic changes

15Assessment/ax21

Working diagnosis and severity

›Working diagnosis structure

›Ureterolithiasis (N20.1)

›Stone size category

›Location category

›Hydronephrosis present

›Pyelonephritis (N10)

›Systemic signs present

›Obstruction concern

›Complications to rule out

›Obstructed infected stone

›AKI (N17.9)

›Sepsis (A41.9)

Risk stratification

›High risk features

›Fever with obstruction

›Rising creatinine

›Solitary kidney

›Uncontrolled pain

›Uncontrolled vomiting

›Diagnostic uncertainty

›Alternate diagnosis on imaging

›Persistent pain despite analgesia

16Plan/plan46

First 5 minutes

›Immediate stabilization

›Monitoring

›Cardiac monitor if unstable or sepsis concern

›Pulse oximetry if unstable

›IV access

›If vomiting

›If severe pain

›Fluids

›If dehydration

›If sepsis concern

Analgesia and antiemetic

›Symptom control

›NSAID first line if no contraindication

›Ketorolac IV 15 mg

›Maximum single ED dose local protocol dependent

›Acetaminophen adjunct

›PO 1000 mg

›IV 1000 mg if unable PO

›Opioid rescue for refractory pain

›Hydromorphone IV 0.5 mg

›Repeat every 10 to 15 minutes to effect

›Antiemetic

›Ondansetron IV 4 mg

›Repeat dosing local protocol dependent

Medical expulsive therapy

›Expulsive therapy pathway

›Tamsulosin PO 0.4 mg daily

›Best fit

›Distal ureteral stone

›Larger stone size category

Antibiotics and source control

›Infection management

›If pyelonephritis without obstruction

›Antibiotics per local antibiogram

›Urine culture

›If obstructed infected system

›Immediate broad spectrum IV antibiotics

›Urgent decompression

Reassessment loop

›Reassessment

›Pain score response within 30 to 60 minutes

›Oral intake tolerance

›Vitals trend

›Urine output and retention screen

Consultation plan

›Urology consultation triggers

›Sepsis with obstruction

›Solitary kidney with obstruction

›AKI or rising creatinine

›Large stone size category

›Refractory symptoms

17Disposition/dispo24

Level of care criteria

›ICU criteria

›Septic shock

›Vasopressor requirement

›Persistent lactate elevation local protocol dependent

›Inpatient admission criteria

›Obstructed infected stone

›AKI or rising creatinine

›Uncontrolled pain requiring IV opioids

›Uncontrolled vomiting

›Pregnancy with significant symptoms

›Observation pathway criteria

›Symptom control requiring repeat IV meds

›Borderline oral tolerance

›Diagnostic uncertainty requiring serial reassessment

›Discharge criteria

›Pain controlled on oral regimen

›Oral hydration tolerated

›No fever

›No AKI

›Reliable follow up

Follow up timing

›Follow up plan

›Urology within 1 to 2 weeks if stone concern

›Earlier urology within 24 to 72 hours if larger stone size category

›Primary care for metabolic evaluation after stone passage

18Discharge Instructions/di33

Copy discharge instructions

›Diagnosis summary

›Kidney stone pain can come in waves and may move toward the groin as the stone travels

›Some stones pass on their own, others require urology follow up

›Medications

›Acetaminophen

›1000 mg by mouth every 6 to 8 hours as needed

›Maximum 3000 mg per day

›Ibuprofen

›400 mg by mouth every 6 to 8 hours as needed

›Avoid if kidney disease, stomach ulcers, blood thinners, or pregnancy third trimester

›Tamsulosin

›0.4 mg by mouth once daily

›Dizziness risk, rise slowly

›Antiemetic

›Ondansetron 4 mg by mouth every 8 hours as needed

›Hydration and urine

›Drink fluids to keep urine light yellow

›Use a urine strainer if provided

›Activity

›Normal activity as tolerated

›Avoid driving if taking opioids

›Follow up

›Urology follow up as arranged

›Bring any captured stone for analysis

›Return to ED now for

›Fever

›Chills

›Worsening pain not controlled with medicines

›Persistent vomiting

›Inability to urinate

›Fainting

›New chest pain

›New severe abdominal pain

19References/r6

Guidelines and key sources

›Core references

›American Urological Association guideline on surgical management of kidney stones, 2016 with updates

›European Association of Urology guidelines on urolithiasis, latest annual update

›ACEP clinical policy and evidence reviews on imaging for suspected renal colic, local protocol dependent

›IDSA guidance on acute pyelonephritis and complicated UTI, most recent update

›NICE guideline on renal and ureteric stones assessment and management, current version

Evidence & Review

Reviewed by SymptomDx Medical Team · Last reviewed February 24, 2026

SymptomDx is an educational tool for medical professionals. It does not replace clinical judgment. Verify all clinical data and drug dosages with authoritative sources.

Flank Pain and Renal Colic ConcernAPPROACH

RENAL AND URINARY · 19 SECTIONS

⚲

504 items

☷ Legend

⚲

Resuscitation and Universal Approaches9▾

Chest and Cardiovascular12▾

Respiratory11▾

Abdominal and Gastrointestinal24▾

Renal and Urinary7▾

Oliguria And Anuria Catheter Related Urinary Complaints Dialysis Patient Presentations Flank Pain And Renal Colic Concern Urinary Retention Hematuria Scrotal Pain

Neurologic11▾

Back and Neck8▾

Women's Health, Pregnancy, and GU11▾

Infectious Disease and Fever Syndromes11▾

Allergy and Dermatology7▾

Musculoskeletal and Extremities14▾

Trauma and Wounds14▾

ENT, Eye, Dental10▾

Endocrine, Metabolic, and Abnormal Labs9▾

Toxicology and Behavioral14▾

Pediatrics16▾

Environmental and Exposure4▾

01History/hx66

HPI core

›Flank pain history core

›Symptom start context

›Pain location pattern

›Prior similar episodes

›Baseline urinary function

›OPQRST

›Onset

›Sudden

›Gradual

›Provocation/Palliation

›Worse with movement

›No position relief

›Relief after analgesia

›Quality

›Colicky

›Constant

›Region/Radiation

›Groin

›Testicle

›Labia

›Lower abdomen

›Severity

›Peak intensity

›Current intensity

›Timing

›Intermittent waves

›Persistent

›Associated symptoms

›Nausea

›Vomiting

›Hematuria

›Dysuria

›Urinary frequency

›Urinary urgency

›Fever

›Chills

›Inability to void

Stone risk history

›Stone risk profile

›Prior nephrolithiasis

›Prior stone type known

›Prior urologic procedures

›Family history nephrolithiasis

›Low fluid intake pattern

›High sodium diet pattern

›High animal protein intake

›High oxalate foods exposure

›Bariatric surgery history

›Malabsorption history

Infection and obstruction context

›Infection and obstruction context

›Recent UTI symptoms

›Recent antibiotics

›Immunocompromised state

›Solitary kidney history

›Known CKD history

›Pregnancy status

›Indwelling ureteral stent history

Alternate diagnosis screen

›Nonrenal pain screen

›Chest pain

›Dyspnea

›Pleuritic pain

›Back pain focal midline

›Abdominal pain migratory

›Vaginal bleeding

›Vaginal discharge

›Testicular pain acute

›Trauma history

02Alarm Features/alarm38

Immediate threats

›Time critical red flags

›Obstructed infected system

›Fever or rigors

›Hypotension

›Tachycardia

›Toxic appearance

›Altered mental status

›Aortic catastrophe concern

›Age older

›Severe sudden back or flank pain

›Syncope

›Known AAA history

›Pulse deficit

›Focal neurologic deficit

›Renal infarction concern

›Sudden flank pain

›Atrial fibrillation

›Embolic risk

›Testicular torsion concern

›Acute scrotal pain

›High riding testis

Vital sign danger thresholds

›Danger thresholds

›Systolic BP less than 90 mmHg

›Persistent HR greater than 120

›SpO2 less than 92 percent

›Temperature 38.0 C or higher

High risk populations

›High risk context

›Pregnancy

›Solitary kidney

›Transplant kidney

›Immunocompromised

›Anticoagulated

›Older adult

Escalation triggers

›Escalation

›If sepsis concern, immediate IV antibiotics and source control pathway

›If obstructed infected stone suspected, urgent urology for decompression

›If shock, resuscitation bay

›If refractory pain or vomiting, IV analgesia and antiemetic escalation

03Medications/meds29

Medication reconciliation

›Current meds relevant to flank pain

›NSAIDs

›Acetaminophen

›Opioids

›Alpha blockers

›Diuretics

›Anticoagulants

›Antiplatelets

›SGLT2 inhibitors

›Lithium

Stone forming medications

›Stone promoting meds

›Topiramate

›Acetazolamide

›Indinavir and atazanavir

›Triamterene

›High dose vitamin C

Medication contraindication traps

›Contraindications and interactions

›NSAIDs

›CKD moderate to severe

›Dehydration

›Heart failure

›Pregnancy third trimester

›Anticoagulation high bleeding risk

›Opioids

›Concurrent sedatives

›OSA risk

›Tamsulosin

›Orthostatic hypotension risk

›Concomitant PDE5 inhibitors

04Diet/diet9

Hydration and triggers

›Intake and hydration

›Poor oral intake

›Dehydration symptoms

›High sodium intake pattern

›High animal protein intake

Relevant exposures

›Exposures

›Heavy sweating

›Heat exposure

›Recent fasting

05Review of Systems/ros22

GU and abdominal

›GU and abdominal symptoms

›Dysuria

›Frequency

›Urgency

›Hematuria

›Suprapubic pain

›Inability to void

Infectious and systemic

›Systemic symptoms

›Fever

›Chills

›Malaise

›Myalgias

Cardiopulmonary and vascular

›Cardiopulmonary and vascular

›Chest pain

›Dyspnea

›Syncope

›Leg pain or swelling

Neuro and MSK

›Neuro and spine

›Weakness

›Numbness

›Saddle anesthesia

›Bowel or bladder incontinence

06Collateral History and Family History/chafh11

Collateral and reliability

›Collateral context

›Source reliability

›Ability to follow discharge plan

Family history

›Family history

›Nephrolithiasis

›Gout (M10.9)

›Hyperparathyroidism (E21.3)

›Cystinuria

Household exposures

›Exposure context

›Sick contacts

›STI exposure risk

07Risk Factors/rf22

Stone risk factors

›Nephrolithiasis risk factors

›Prior stone history

›Family history stone disease

›Low urine volume

›Obesity (E66.9)

›Gout (M10.9)

›Hyperparathyroidism (E21.3)

›Type 2 diabetes mellitus (E11.9)

›IBD (K52.9)

›Bariatric surgery

Infection risk factors

›UTI and pyelonephritis risks

›Prior multidrug resistant organism

›Recent hospitalization

›Recent antibiotics

›Indwelling catheter or stent

›Pregnancy

›Diabetes (E11.9)

Vascular and thromboembolic risks

›Vascular risks

›Atrial fibrillation (I48.91)

›Recent MI or endocarditis

›Known AAA (I71.4)

›Smoking history

08Differential Diagnosis/ddx66

Life threatening

›Life threatening causes

›Obstructed infected stone

›Fever

›Hypotension

›Leukocytosis

›Hydronephrosis

›Abdominal aortic aneurysm rupture or leak (I71.4)

›Older age

›Hypotension

›Pulsatile abdominal mass

›Aortic dissection with abdominal branch ischemia (I71.00)

›Sudden severe pain

›Neurologic deficits

›Pulse differential

›Renal infarction (N28.0)

›Atrial fibrillation

›Elevated LDH

›Ectopic pregnancy (O00.9)

›Positive pregnancy test

›Vaginal bleeding

›Testicular torsion (N44.0)

›Acute scrotal pain

›Absent cremasteric reflex

Common

›Common causes

›Ureterolithiasis and renal colic (N20.1)

›Colicky flank pain

›Hematuria

›Acute pyelonephritis (N10)

›Fever

›CVA tenderness

›Pyuria

›Musculoskeletal strain

›Reproducible tenderness

›Worse with movement

›Herpes zoster

›Dermatomal pain

›Rash delayed

Less common

›Less common causes

›Nephrolithiasis without obstruction (N20.0)

›Nonobstructing stone imaging

›Atypical pain

›Renal mass hemorrhage

›Anticoagulation

›Flank mass

›Papillary necrosis (N17.2)

›Sickle cell disease

›NSAID exposure

›Ovarian torsion (N83.5)

›Sudden pelvic pain

›Adnexal tenderness

›Appendicitis (K35.80)

›RLQ tenderness

›Anorexia

›Diverticulitis (K57.92)

›LLQ tenderness

›Fever

Mimics and pitfalls

›Mimics and pitfalls

›Hematuria absent in stones

›Early or intermittent bleeding

›Hydration effect

›Pyelonephritis without fever

›Older adult

›Immunocompromised

›Early zoster without rash

›Allodynia

›Dermatomal pattern

09Past Medical History/pmh16

Relevant conditions

›Relevant PMH

›Nephrolithiasis history

›CKD stage

›Solitary kidney

›Kidney transplant

›Recurrent UTIs

›Diabetes (E11.9)

›Hypertension (I10)

Prior procedures

›Prior urologic history

›Ureteral stent

›Lithotripsy

›Ureteroscopy

›Nephrostomy tube

Baseline function

›Baseline status

›Baseline creatinine known

›Baseline voiding pattern

10Physical Exam/exam23

General and vitals

›General and vitals

›Toxic appearance

›Hydration status

›Fever pattern

›Hemodynamic stability

Abdominal and flank

›Abdomen and flank

›CVA tenderness

›Abdominal tenderness focality

›Peritoneal signs

›Palpable mass

GU and pelvic

›GU and pelvic

›Testicular exam

›Cremasteric reflex

›Inguinal hernia exam

›Pelvic exam indications

Vascular and cardio

›Vascular and cardiac

›Peripheral pulses symmetry

›Abdominal bruit

›New murmur

Neuro and spine

›Neuro and spine

›Focal neurologic deficits

›Midline spine tenderness

›Saddle anesthesia

11Lab Studies/labs20

Urine testing

›Urinalysis

›Hematuria

›Pyuria

›Nitrites

›Protein

›pH pattern

›Urine culture

›Pyelonephritis concern

›Sepsis concern

Bloodwork

›Basic blood tests

›CBC

›Creatinine and electrolytes

›CRP local protocol dependent

›Pregnancy test

›All patients with pregnancy potential

›Imaging selection impact

Interpretation pearls

›Pitfalls and interpretation

›Hematuria absence does not exclude stones

›Leukocytosis may occur with renal colic

›Creatinine elevation suggests obstruction or dehydration

12Imaging/img34

Scoring Systems

›Risk and pathway tools

›STONE score for uncomplicated ureteral stone probability

›Male sex

›Short pain duration

›Nonblack race

›Nausea or vomiting

›Hematuria

›Higher score increases stone likelihood

›Sepsis screening local protocol dependent

›qSOFA

›SIRS

MRI

›MRI role

›Pregnancy with nondiagnostic ultrasound

›Alternate diagnosis evaluation without ionizing radiation

›Limited availability and time

›CT imaging choices

›Noncontrast CT abdomen pelvis for stones

›Stone size and location

›Hydronephrosis

›Alternative diagnoses

›CT angiography if aortic pathology concern

›AAA rupture concern

›Dissection concern

›CT cautions

›Radiation exposure

›Contrast nephropathy risk local protocol dependent

›Contrast allergy history

Ultrasound

›Ultrasound approach

›Renal ultrasound hydronephrosis

›POCUS hydronephrosis screening

›Limited ureteral stone visualization

›Ultrasound pitfalls

›Early obstruction may be false negative

›Hydronephrosis absent with small distal stone

13Special Tests/spec10

Bedside maneuvers and procedural diagnostics

›Bedside tests

›Bladder scan for retention

›POCUS kidneys for hydronephrosis

›POCUS aorta if AAA concern

›Procedural diagnostics

›Straight catheter urine sample if contaminated specimen

›Pelvic exam if gynecologic differential high

Stone analysis planning

›Stone evaluation adjuncts

›Strain urine for stone capture

›Stone analysis if captured

14ECG/ecg8

Indications and patterns

›ECG indications

›Older adult with flank pain and vascular risk

›Syncope

›Chest pain

›Significant electrolyte abnormality

›ECG findings relevant to mimics

›Atrial fibrillation

›Ischemic changes

15Assessment/ax21

Working diagnosis and severity

›Working diagnosis structure

›Ureterolithiasis (N20.1)

›Stone size category

›Location category

›Hydronephrosis present

›Pyelonephritis (N10)

›Systemic signs present

›Obstruction concern

›Complications to rule out

›Obstructed infected stone

›AKI (N17.9)

›Sepsis (A41.9)

Risk stratification

›High risk features

›Fever with obstruction

›Rising creatinine

›Solitary kidney

›Uncontrolled pain

›Uncontrolled vomiting

›Diagnostic uncertainty

›Alternate diagnosis on imaging

›Persistent pain despite analgesia

16Plan/plan46

First 5 minutes

›Immediate stabilization

›Monitoring

›Cardiac monitor if unstable or sepsis concern

›Pulse oximetry if unstable

›IV access

›If vomiting

›If severe pain

›Fluids

›If dehydration

›If sepsis concern

Analgesia and antiemetic

›Symptom control

›NSAID first line if no contraindication

›Ketorolac IV 15 mg

›Maximum single ED dose local protocol dependent

›Acetaminophen adjunct

›PO 1000 mg

›IV 1000 mg if unable PO

›Opioid rescue for refractory pain

›Hydromorphone IV 0.5 mg

›Repeat every 10 to 15 minutes to effect

›Antiemetic

›Ondansetron IV 4 mg

›Repeat dosing local protocol dependent

Medical expulsive therapy

›Expulsive therapy pathway

›Tamsulosin PO 0.4 mg daily

›Best fit

›Distal ureteral stone

›Larger stone size category

Antibiotics and source control

›Infection management

›If pyelonephritis without obstruction

›Antibiotics per local antibiogram

›Urine culture

›If obstructed infected system

›Immediate broad spectrum IV antibiotics

›Urgent decompression

Reassessment loop

›Reassessment

›Pain score response within 30 to 60 minutes

›Oral intake tolerance

›Vitals trend

›Urine output and retention screen

Consultation plan

›Urology consultation triggers

›Sepsis with obstruction

›Solitary kidney with obstruction

›AKI or rising creatinine

›Large stone size category

›Refractory symptoms

17Disposition/dispo24

Level of care criteria

›ICU criteria

›Septic shock

›Vasopressor requirement

›Persistent lactate elevation local protocol dependent

›Inpatient admission criteria

›Obstructed infected stone

›AKI or rising creatinine

›Uncontrolled pain requiring IV opioids

›Uncontrolled vomiting

›Pregnancy with significant symptoms

›Observation pathway criteria

›Symptom control requiring repeat IV meds

›Borderline oral tolerance

›Diagnostic uncertainty requiring serial reassessment

›Discharge criteria

›Pain controlled on oral regimen

›Oral hydration tolerated

›No fever

›No AKI

›Reliable follow up

Follow up timing

›Follow up plan

›Urology within 1 to 2 weeks if stone concern

›Earlier urology within 24 to 72 hours if larger stone size category

›Primary care for metabolic evaluation after stone passage

18Discharge Instructions/di33

Copy discharge instructions

›Diagnosis summary

›Kidney stone pain can come in waves and may move toward the groin as the stone travels

›Some stones pass on their own, others require urology follow up

›Medications

›Acetaminophen

›1000 mg by mouth every 6 to 8 hours as needed

›Maximum 3000 mg per day

›Ibuprofen

›400 mg by mouth every 6 to 8 hours as needed

›Avoid if kidney disease, stomach ulcers, blood thinners, or pregnancy third trimester

›Tamsulosin

›0.4 mg by mouth once daily

›Dizziness risk, rise slowly

›Antiemetic

›Ondansetron 4 mg by mouth every 8 hours as needed

›Hydration and urine

›Drink fluids to keep urine light yellow

›Use a urine strainer if provided

›Activity

›Normal activity as tolerated

›Avoid driving if taking opioids

›Follow up

›Urology follow up as arranged

›Bring any captured stone for analysis

›Return to ED now for

›Fever

›Chills

›Worsening pain not controlled with medicines

›Persistent vomiting

›Inability to urinate

›Fainting

›New chest pain

›New severe abdominal pain

19References/r6

Guidelines and key sources

›Core references

›American Urological Association guideline on surgical management of kidney stones, 2016 with updates

›European Association of Urology guidelines on urolithiasis, latest annual update

›ACEP clinical policy and evidence reviews on imaging for suspected renal colic, local protocol dependent

›IDSA guidance on acute pyelonephritis and complicated UTI, most recent update

›NICE guideline on renal and ureteric stones assessment and management, current version

Evidence & Review

Reviewed by SymptomDx Medical Team · Last reviewed February 24, 2026

SymptomDx is an educational tool for medical professionals. It does not replace clinical judgment. Verify all clinical data and drug dosages with authoritative sources.