Page 106 - Journal of Special Operations Medicine - Fall 2014

An Ongoing Series

Flank Pain

Tony Meriano, MD

CONCEPT AND OBJECTIVES
The series objective is to review various clinical con- On examination, his vital signs are as follow: tempera-
ditions/presentations, including the latest evidence on ture 36.8ºC, respirations 12/min, heart rate 100 beats/
management, and to dispel common myths. In the pro- min, blood pressure 150/80mmHg, and SpO greater
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cess, core knowledge and management principles are en- than 98%. He looks like he is in a lot of pain and is ten-
hanced. A clinical case will be presented. Cases will be der to right flank percussion; his abdomen displays no
drawn from real life but phrased in a context that is ap- evidence of peritonitis; and there is no pulsatile mass or
plicable to the Special Operations Forces (SOF) or tac- clinical evidence of an enlarged abdominal aorta. There
tical emergency medical support (TEMS) environment. is no inguinal hernia, and examination of the genital is
Details will be presented in such a way that the reader unremarkable. There has been no blunt or penetrating
can follow along and identify how they would manage trauma.
the case clinically depending on their experience and
environment situation. Commentary will be provided What is going on with this patient? What is your dif-
by currently serving military medical technicians. The ferential diagnosis?
medics and author will draw on their SOF experience Common differential diagnosis of acute nontraumatic
to communicate relevant clinical concepts pertinent to flank pain
different operational environments including SOF and
TEMS. Commentary and input from active special op- • Renal calculi
erations medical technicians will be part of the feature. • Pyelonephritis
• Ruptured abdominal aortic aneurysm
Keywords: flank pain, renal calculi, hydronephrosis • Pneumonia
• Rib pain
• Radicular pain from the spine
CASE PRESENTATION: FLANK PAIN
What are your next steps?

SITUATION Your first steps should be to ensure the stability of the
You are the lone clinician working with a deployed patient. He is in a lot of pain, his vital signs show tachy-
small unit in an arid austere setting. You are in a semi- cardia, but he is afebrile with a good oxygen saturation
permissive environment, but local medical resources and blood pressure. The abdominal exam is not con-
are extremely limited. Evacuation requires a 6-hour ve- cerning for a pulsatile mass or peritonitis. A urine dip is
hicle trip and then prolonged fixed-wing transport. A performed, which shows red blood cells but no leuko-
40-year-old Operator is brought into see you with acute cytes or nitrates. Treating his pain should be considered.
onset of right-sided flank pain.
This is a fairly classic presentation of renal calculi, which
The pain is constant and severe and radiates to the is a rather common condition. Approximately 11% of
groin. He is nauseated and has vomited but denies fever. men and 7% of women will develop a renal calculi in
He denies hematuria. His past history is significant only their lifetime. There seems to be a predilection of kid-
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for hypertension. There has been no preceding illness. ney stones in dry, warm climate. As such, it can be com-
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There is no cough or upper respiratory track illness. monly seen by deployed troops operating in these arid
There has been no trauma. settings, due in part to insufficient hydration.

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