{"version":"1.0.0","segments":[{"startTime":1.18,"endTime":3.353,"body":"♪ (music) ♪"},{"startTime":3.353,"endTime":5.461,"body":"(Cathy) Hi, welcome to \u003ci\u003eHarrison's Podclass\u003c/i\u003e"},{"startTime":5.461,"endTime":8.612,"body":"where we discuss important concepts"},{"startTime":5.461,"endTime":8.612,"body":"in internal medicine."},{"startTime":8.612,"endTime":10.784,"body":"- I'm Cathy Handy."},{"startTime":8.612,"endTime":10.784,"body":"- (Charlie) And I'm Charlie Wiener,"},{"startTime":10.784,"endTime":14.054,"body":"and we're coming to you from"},{"startTime":10.784,"endTime":14.054,"body":"the Johns Hopkins School of Medicine."},{"startTime":14.054,"endTime":15.732,"body":"♪ (music) ♪"},{"speaker":"(Charlie) Welcome to Episode 35","startTime":15.732,"endTime":19.808,"body":"A 48-Year-Old with Flank Pain.\""},{"speaker":"(Charlie) Welcome to Episode 35","startTime":19.808,"endTime":21.383,"body":"I'll read you the question."},{"speaker":"(Charlie) Welcome to Episode 35","startTime":21.383,"endTime":26.221,"body":"A 48-year-old man with diabetes,"},{"speaker":"(Charlie) Welcome to Episode 35","startTime":21.383,"endTime":26.221,"body":"hyperlipidemia, and atrial fibrillation"},{"speaker":"(Charlie) Welcome to Episode 35","startTime":26.221,"endTime":29.451,"body":"presents to the emergency department"},{"speaker":"(Charlie) Welcome to Episode 35","startTime":26.221,"endTime":29.451,"body":"for evaluation of left flank pain,"},{"speaker":"(Charlie) Welcome to Episode 35","startTime":29.451,"endTime":31.496,"body":"that is radiating to his groin."},{"speaker":"(Charlie) Welcome to Episode 35","startTime":31.496,"endTime":35.175,"body":"It's been severe and present"},{"speaker":"(Charlie) Welcome to Episode 35","startTime":31.496,"endTime":35.175,"body":"for approximately three hours."},{"speaker":"(Charlie) Welcome to Episode 35","startTime":35.175,"endTime":39.759,"body":"His medications include metformin,"},{"speaker":"(Charlie) Welcome to Episode 35","startTime":35.175,"endTime":39.759,"body":"atorvastatin, and warfarin."},{"speaker":"(Charlie) Welcome to Episode 35","startTime":39.759,"endTime":42.088,"body":"On examination,"},{"speaker":"(Charlie) Welcome to Episode 35","startTime":39.759,"endTime":42.088,"body":"he is visibly uncomfortable"},{"speaker":"(Charlie) Welcome to Episode 35","startTime":42.088,"endTime":46.721,"body":"with a temperature of 37 °C,"},{"speaker":"(Charlie) Welcome to Episode 35","startTime":42.088,"endTime":46.721,"body":"a heart rate of 105 per minute,"},{"speaker":"(Charlie) Welcome to Episode 35","startTime":46.721,"endTime":51.881,"body":"a blood pressure of 145 over 95,"},{"speaker":"(Charlie) Welcome to Episode 35","startTime":46.721,"endTime":51.881,"body":"a respiratory rate of 25 per minute,"},{"speaker":"(Charlie) Welcome to Episode 35","startTime":51.881,"endTime":54.62,"body":"and a room air saturation of 98%."},{"speaker":"(Charlie) Welcome to Episode 35","startTime":54.62,"endTime":56.209,"body":"The rest of his physical examination"},{"speaker":"(Charlie) Welcome to Episode 35","startTime":56.209,"endTime":58.691,"body":"is notable for left flank pain"},{"speaker":"(Charlie) Welcome to Episode 35","startTime":56.209,"endTime":58.691,"body":"to palpation,"},{"speaker":"(Charlie) Welcome to Episode 35","startTime":58.691,"endTime":63.181,"body":"but no abdominal organomegaly"},{"speaker":"(Charlie) Welcome to Episode 35","startTime":58.691,"endTime":63.181,"body":"or focal abdominal tenderness."},{"speaker":"(Charlie) Welcome to Episode 35","startTime":63.185,"endTime":65.387,"body":"An electrocardiogram shows"},{"speaker":"(Charlie) Welcome to Episode 35","startTime":63.185,"endTime":65.387,"body":"sinus tachycardia"},{"speaker":"(Charlie) Welcome to Episode 35","startTime":65.387,"endTime":67.607,"body":"with nonspecific ST-T wave changes"},{"speaker":"(Charlie) Welcome to Episode 35","startTime":67.607,"endTime":70.698,"body":"and no suggestion"},{"speaker":"(Charlie) Welcome to Episode 35","startTime":67.607,"endTime":70.698,"body":"of acute myocardial infarction."},{"speaker":"(Charlie) Welcome to Episode 35","startTime":70.698,"endTime":73.016,"body":"His INR is 2.0."},{"speaker":"(Charlie) Welcome to Episode 35","startTime":73.016,"endTime":75.964,"body":"His laboratories demonstrate"},{"speaker":"(Charlie) Welcome to Episode 35","startTime":73.016,"endTime":75.964,"body":"that his renal function is normal,"},{"speaker":"(Charlie) Welcome to Episode 35","startTime":75.964,"endTime":79.397,"body":"and a urinalysis shows"},{"speaker":"(Charlie) Welcome to Episode 35","startTime":75.964,"endTime":79.397,"body":"that he has many red blood cells,"},{"speaker":"(Charlie) Welcome to Episode 35","startTime":79.397,"endTime":83.833,"body":"few white blood cells, no bacteria,"},{"speaker":"(Charlie) Welcome to Episode 35","startTime":79.397,"endTime":83.833,"body":"and no crystals."},{"speaker":"(Charlie) Welcome to Episode 35","startTime":83.833,"endTime":86.761,"body":"Cathy, what are your thoughts"},{"speaker":"(Charlie) Welcome to Episode 35","startTime":83.833,"endTime":86.761,"body":"based on what you've heard so far?"},{"speaker":"(Charlie) Welcome to Episode 35","startTime":86.761,"endTime":89.661,"body":"(Cathy) So, what we've heard so far"},{"speaker":"(Charlie) Welcome to Episode 35","startTime":86.761,"endTime":89.661,"body":"is that we have a middle-aged man."},{"speaker":"(Charlie) Welcome to Episode 35","startTime":89.661,"endTime":91.844,"body":"He's at risk for vascular disease,"},{"speaker":"(Charlie) Welcome to Episode 35","startTime":91.844,"endTime":94.582,"body":"given his history of diabetes"},{"speaker":"(Charlie) Welcome to Episode 35","startTime":91.844,"endTime":94.582,"body":"and hyperlipidemia."},{"speaker":"(Charlie) Welcome to Episode 35","startTime":94.582,"endTime":97.678,"body":"But in addition, he is anticoagulated"},{"speaker":"(Charlie) Welcome to Episode 35","startTime":94.582,"endTime":97.678,"body":"for atrial fibrillation"},{"speaker":"(Charlie) Welcome to Episode 35","startTime":97.678,"endTime":99.443,"body":"and his INR is at goal."},{"speaker":"(Charlie) Welcome to Episode 35","startTime":99.443,"endTime":103.017,"body":"Heard that his EKG doesn't suggest"},{"speaker":"(Charlie) Welcome to Episode 35","startTime":99.443,"endTime":103.017,"body":"an acute cardiac process,"},{"speaker":"(Charlie) Welcome to Episode 35","startTime":103.017,"endTime":105.292,"body":"but given his acute severe flank pain,"},{"speaker":"(Charlie) Welcome to Episode 35","startTime":105.292,"endTime":108.799,"body":"I'm thinking that this may be"},{"speaker":"(Charlie) Welcome to Episode 35","startTime":105.292,"endTime":108.799,"body":"genitourinary, potentially infectious"},{"speaker":"(Charlie) Welcome to Episode 35","startTime":108.799,"endTime":110.172,"body":"or an obstruction."},{"speaker":"(Charlie) Welcome to Episode 35","startTime":110.172,"endTime":111.699,"body":"We're given a urinalysis,"},{"speaker":"(Charlie) Welcome to Episode 35","startTime":111.699,"endTime":114.73,"body":"so I'm also thinking that this is likely"},{"speaker":"(Charlie) Welcome to Episode 35","startTime":111.699,"endTime":114.73,"body":"going to be GU related,"},{"speaker":"(Charlie) Welcome to Episode 35","startTime":114.73,"endTime":118.396,"body":"but there're no white blood cells"},{"speaker":"(Charlie) Welcome to Episode 35","startTime":114.73,"endTime":118.396,"body":"or bacteria seen on the urinalysis,"},{"speaker":"(Charlie) Welcome to Episode 35","startTime":118.396,"endTime":120.516,"body":"so infection is less likely."},{"speaker":"(Charlie) Welcome to Episode 35","startTime":120.516,"endTime":122.154,"body":"He does have hematuria,"},{"speaker":"(Charlie) Welcome to Episode 35","startTime":122.154,"endTime":124.612,"body":"so nephrolithiasis"},{"speaker":"(Charlie) Welcome to Episode 35","startTime":122.154,"endTime":124.612,"body":"is definitely on the list."},{"speaker":"(Charlie) Welcome to Episode 35","startTime":124.612,"endTime":126.623,"body":"And then other things"},{"speaker":"(Charlie) Welcome to Episode 35","startTime":124.612,"endTime":126.623,"body":"that you have to think about,"},{"speaker":"(Charlie) Welcome to Episode 35","startTime":126.623,"endTime":129.525,"body":"like vascular or malignant causes"},{"speaker":"(Charlie) Welcome to Episode 35","startTime":126.623,"endTime":129.525,"body":"of flank pain,"},{"speaker":"(Charlie) Welcome to Episode 35","startTime":129.525,"endTime":132.932,"body":"that wouldn't usually cause"},{"speaker":"(Charlie) Welcome to Episode 35","startTime":129.525,"endTime":132.932,"body":"this acute onset of pain, generally."},{"speaker":"(Charlie) Welcome to Episode 35","startTime":132.932,"endTime":134.747,"body":"(Charlie) Okay, so"},{"speaker":"(Charlie) Welcome to Episode 35","startTime":132.932,"endTime":134.747,"body":"as you narrow things down,"},{"speaker":"(Charlie) Welcome to Episode 35","startTime":134.747,"endTime":137.612,"body":"what is the highest"},{"speaker":"(Charlie) Welcome to Episode 35","startTime":134.747,"endTime":137.612,"body":"on your differential diagnosis?"},{"speaker":"(Charlie) Welcome to Episode 35","startTime":137.612,"endTime":141.012,"body":"(Cathy) Most likely, given the location,"},{"speaker":"(Charlie) Welcome to Episode 35","startTime":137.612,"endTime":141.012,"body":"the timing, and the urinalysis,"},{"speaker":"(Charlie) Welcome to Episode 35","startTime":141.012,"endTime":143.923,"body":"would be nephrolithiasis"},{"speaker":"(Charlie) Welcome to Episode 35","startTime":141.012,"endTime":143.923,"body":"or pyelonephritis."},{"speaker":"(Charlie) Welcome to Episode 35","startTime":143.923,"endTime":147.447,"body":"Less likely, but given his comorbidities,"},{"speaker":"(Charlie) Welcome to Episode 35","startTime":143.923,"endTime":147.447,"body":"would be an abdominal process,"},{"speaker":"(Charlie) Welcome to Episode 35","startTime":147.447,"endTime":151.693,"body":"such as appendicitis, cholelithiasis,"},{"speaker":"(Charlie) Welcome to Episode 35","startTime":147.447,"endTime":151.693,"body":"a perforating duodenal ulcer,"},{"speaker":"(Charlie) Welcome to Episode 35","startTime":151.693,"endTime":153.708,"body":"pancreatitis or diverticulitis,"},{"speaker":"(Charlie) Welcome to Episode 35","startTime":153.708,"endTime":156.832,"body":"or even a vascular process"},{"speaker":"(Charlie) Welcome to Episode 35","startTime":153.708,"endTime":156.832,"body":"such as aortic dissection."},{"speaker":"(Charlie) Welcome to Episode 35","startTime":156.832,"endTime":161.081,"body":"And if this was a female patient,"},{"speaker":"(Charlie) Welcome to Episode 35","startTime":156.832,"endTime":161.081,"body":"I'd also include gynecologic pathologies."},{"speaker":"(Charlie) Welcome to Episode 35","startTime":161.081,"endTime":163.682,"body":"(Charlie). Okay, there's a lot of things"},{"speaker":"(Charlie) Welcome to Episode 35","startTime":161.081,"endTime":163.682,"body":"on the differential here."},{"speaker":"The question is now going to ask","startTime":165.729,"endTime":168.783,"body":"\"Which of the following"},{"speaker":"The question is now going to ask","startTime":165.729,"endTime":168.783,"body":"is the preferred diagnostic study?\""},{"speaker":"And the options are","startTime":169.895,"endTime":172.55,"body":"A. a 24-hour urine collection;"},{"speaker":"And the options are","startTime":172.55,"endTime":174.955,"body":"B. cystoscopy;"},{"speaker":"And the options are","startTime":174.955,"endTime":178.415,"body":"C. magnetic resonance imaging, or MRI;"},{"speaker":"And the options are","startTime":178.415,"endTime":181.539,"body":"D. is a non-contrast CT scan;"},{"speaker":"And the options are","startTime":181.539,"endTime":183.735,"body":"or E. is an ultrasound."},{"speaker":"And the options are","startTime":183.735,"endTime":184.949,"body":"(Cathy) Of the choices listed,"},{"speaker":"And the options are","startTime":184.949,"endTime":187.481,"body":"and because I'm thinking most"},{"speaker":"And the options are","startTime":184.949,"endTime":187.481,"body":"about nephrolithiasis,"},{"speaker":"And the options are","startTime":187.481,"endTime":191.977,"body":"the most sensitive imaging test"},{"speaker":"And the options are","startTime":187.481,"endTime":191.977,"body":"for that diagnosis is a non-contrast CT."},{"speaker":"And the options are","startTime":191.977,"endTime":194.135,"body":"Almost 90% of renal stones in adults"},{"speaker":"And the options are","startTime":194.135,"endTime":196.603,"body":"are either calcium oxalate"},{"speaker":"And the options are","startTime":194.135,"endTime":196.603,"body":"or calcium phosphate,"},{"speaker":"And the options are","startTime":196.603,"endTime":199.251,"body":"and another 6 to 8% are uric acid,"},{"speaker":"And the options are","startTime":199.251,"endTime":202.302,"body":"but both of which"},{"speaker":"And the options are","startTime":199.251,"endTime":202.302,"body":"are easily visualized by CT."},{"speaker":"And the options are","startTime":202.302,"endTime":205.913,"body":"So, the CT has an excellent chance"},{"speaker":"And the options are","startTime":202.302,"endTime":205.913,"body":"of visualizing a stone or other process,"},{"speaker":"And the options are","startTime":205.913,"endTime":209.143,"body":"and avoids the potential toxicity"},{"speaker":"And the options are","startTime":205.913,"endTime":209.143,"body":"of intravenous contrast,"},{"speaker":"And the options are","startTime":209.143,"endTime":212.653,"body":"because in CT scans for stones,"},{"speaker":"And the options are","startTime":209.143,"endTime":212.653,"body":"you should not use contrast."},{"speaker":"And the options are","startTime":212.653,"endTime":215.797,"body":"(Charlie) And we also know"},{"speaker":"And the options are","startTime":212.653,"endTime":215.797,"body":"that IV contrast has a greater potential"},{"speaker":"And the options are","startTime":215.797,"endTime":217.982,"body":"for toxicity in diabetic patients."},{"speaker":"And the options are","startTime":217.982,"endTime":220.926,"body":"What about the option of an"},{"speaker":"And the options are","startTime":217.982,"endTime":220.926,"body":"abdominal ultrasound in this patient?"},{"speaker":"And the options are","startTime":220.929,"endTime":224.289,"body":"(Cathy) Ultrasound offers the advantage"},{"speaker":"And the options are","startTime":220.929,"endTime":224.289,"body":"of avoiding radiation and contrast"},{"speaker":"And the options are","startTime":224.289,"endTime":226.769,"body":"and provides information"},{"speaker":"And the options are","startTime":224.289,"endTime":226.769,"body":"on hydronephrosis,"},{"speaker":"And the options are","startTime":226.769,"endTime":230.48,"body":"but it's not as sensitive as CT"},{"speaker":"And the options are","startTime":226.769,"endTime":230.48,"body":"for suspected nephrolithiasis."},{"speaker":"And the options are","startTime":230.48,"endTime":232.591,"body":"Ultrasound testing images only the kidney"},{"speaker":"And the options are","startTime":232.591,"endTime":234.941,"body":"and possibly the proximal segment"},{"speaker":"And the options are","startTime":232.591,"endTime":234.941,"body":"of the ureter."},{"speaker":"And the options are","startTime":234.941,"endTime":238.274,"body":"Thus most ureteral stones"},{"speaker":"And the options are","startTime":234.941,"endTime":238.274,"body":"are not detectable by ultrasound."},{"speaker":"And the options are","startTime":238.274,"endTime":239.662,"body":"So it's not as good a choice"},{"speaker":"And the options are","startTime":239.662,"endTime":242.211,"body":"as non-contrast CT"},{"speaker":"And the options are","startTime":239.662,"endTime":242.211,"body":"for the initial study."},{"speaker":"And the options are","startTime":242.211,"endTime":244.383,"body":"(Charlie) What about the other"},{"speaker":"And the options are","startTime":242.211,"endTime":244.383,"body":"listed studies?"},{"speaker":"And the options are","startTime":244.383,"endTime":247.653,"body":"(Cathy) Urologic intervention,"},{"speaker":"And the options are","startTime":244.383,"endTime":247.653,"body":"such as cystoscopy, should be postponed,"},{"speaker":"And the options are","startTime":247.653,"endTime":249.995,"body":"unless there's evidence"},{"speaker":"And the options are","startTime":247.653,"endTime":249.995,"body":"of a urinary tract infection,"},{"speaker":"And the options are","startTime":249.995,"endTime":252.591,"body":"a low probability of spontaneous passing."},{"speaker":"And the options are","startTime":252.591,"endTime":256.759,"body":"For example, if there is a large stone"},{"speaker":"And the options are","startTime":252.591,"endTime":256.759,"body":"which typically is considered a stone"},{"speaker":"And the options are","startTime":256.759,"endTime":260.749,"body":"that's at least 6 mm,"},{"speaker":"And the options are","startTime":256.759,"endTime":260.749,"body":"or if there's some anatomic abnormality."},{"speaker":"And the options are","startTime":260.749,"endTime":265.629,"body":"Or the other reason to consider cystoscopy"},{"speaker":"And the options are","startTime":260.749,"endTime":265.629,"body":"is if there's intractable pain."},{"speaker":"And the options are","startTime":265.629,"endTime":268.245,"body":"A ureteral stent may be placed"},{"speaker":"And the options are","startTime":265.629,"endTime":268.245,"body":"by cystoscope,"},{"speaker":"And the options are","startTime":268.245,"endTime":271.2,"body":"but this procedure typically requires"},{"speaker":"And the options are","startTime":268.245,"endTime":271.2,"body":"general anesthesia."},{"speaker":"And the options are","startTime":271.2,"endTime":272.889,"body":"And a stent can be quite uncomfortable,"},{"speaker":"And the options are","startTime":272.889,"endTime":277.22,"body":"and it can also cause gross hematuria"},{"speaker":"And the options are","startTime":272.889,"endTime":277.22,"body":"and can increase the risk of a UTI."},{"speaker":"And the options are","startTime":277.22,"endTime":278.848,"body":"(Charlie) So, what about plain films?"},{"speaker":"And the options are","startTime":278.848,"endTime":280.979,"body":"In the old days,"},{"speaker":"And the options are","startTime":278.848,"endTime":280.979,"body":"that's what they would do for stones."},{"speaker":"And the options are","startTime":280.979,"endTime":283.7,"body":"(Cathy) Yeah, we didn't mention it here"},{"speaker":"And the options are","startTime":280.979,"endTime":283.7,"body":"in any of the answer choices,"},{"speaker":"And the options are","startTime":283.7,"endTime":285.434,"body":"but it's sometimes considered."},{"speaker":"And the options are","startTime":285.434,"endTime":288.24,"body":"While it can visualize"},{"speaker":"And the options are","startTime":285.434,"endTime":288.24,"body":"a calcium-containing stone,"},{"speaker":"And the options are","startTime":288.24,"endTime":290.231,"body":"it can miss a stone"},{"speaker":"And the options are","startTime":288.24,"endTime":290.231,"body":"in the ureter or kidney,"},{"speaker":"And the options are","startTime":290.231,"endTime":291.807,"body":"even if it is radiopaque,"},{"speaker":"And the options are","startTime":291.807,"endTime":294.402,"body":"and it doesn't provide"},{"speaker":"And the options are","startTime":291.807,"endTime":294.402,"body":"much information on obstruction."},{"speaker":"And the options are","startTime":294.402,"endTime":299.784,"body":"So, these are generally not typically used"},{"speaker":"And the options are","startTime":294.402,"endTime":299.784,"body":"as adequate testing for nephrolithiasis."},{"speaker":"And the options are","startTime":299.784,"endTime":301.59,"body":"(Charlie) So, this is a two-part question."},{"speaker":"The second part of the question asks","startTime":304.354,"endTime":308.942,"body":"\"A non-contrast abdominal CT"},{"speaker":"The second part of the question asks","startTime":304.354,"endTime":308.942,"body":"is performed and shown here."},{"speaker":"The second part of the question asks","startTime":308.942,"endTime":311.762,"body":"Which of the following"},{"speaker":"The second part of the question asks","startTime":308.942,"endTime":311.762,"body":"is the most likely diagnosis?\""},{"speaker":"The second part of the question asks","startTime":311.762,"endTime":314.788,"body":"Cathy, describe what we're seeing"},{"speaker":"The second part of the question asks","startTime":311.762,"endTime":314.788,"body":"on the CT scan."},{"speaker":"The second part of the question asks","startTime":314.788,"endTime":318.755,"body":"(Cathy) Right. So, this is a CT scan"},{"speaker":"The second part of the question asks","startTime":314.788,"endTime":318.755,"body":"with a coronal view of the abdomen."},{"speaker":"The second part of the question asks","startTime":318.755,"endTime":321.445,"body":"There is no contrast"},{"speaker":"The second part of the question asks","startTime":318.755,"endTime":321.445,"body":"that's seen on this imaging."},{"speaker":"The second part of the question asks","startTime":321.447,"endTime":324.454,"body":"The liver, bowel, and the major"},{"speaker":"The second part of the question asks","startTime":321.447,"endTime":324.454,"body":"blood vessels look okay."},{"speaker":"The second part of the question asks","startTime":324.454,"endTime":326.009,"body":"And we can see both kidneys,"},{"speaker":"The second part of the question asks","startTime":326.009,"endTime":329.527,"body":"and within the patient's left kidney,"},{"speaker":"The second part of the question asks","startTime":326.009,"endTime":329.527,"body":"you see a bright, white, round density"},{"speaker":"The second part of the question asks","startTime":329.527,"endTime":332.208,"body":"that's about the same density"},{"speaker":"The second part of the question asks","startTime":329.527,"endTime":332.208,"body":"as the pelvic bones."},{"speaker":"The second part of the question asks","startTime":332.208,"endTime":334.718,"body":"And you also see"},{"speaker":"The second part of the question asks","startTime":332.208,"endTime":334.718,"body":"some left-sided hydronephrosis"},{"speaker":"The second part of the question asks","startTime":334.718,"endTime":338.176,"body":"and some perinephric fat stranding"},{"speaker":"The second part of the question asks","startTime":334.718,"endTime":338.176,"body":"on the same side."},{"speaker":"(Charlie) So, the question asks","startTime":339.665,"endTime":342.223,"body":"\"Which of the following is the diagnosis?\""},{"speaker":"(Charlie) So, the question asks","startTime":342.223,"endTime":344.166,"body":"A. appendicitis;"},{"speaker":"(Charlie) So, the question asks","startTime":344.166,"endTime":346.239,"body":"B. nephrolithiasis;"},{"speaker":"(Charlie) So, the question asks","startTime":346.239,"endTime":348.308,"body":"C. renal cell carcinoma;"},{"speaker":"(Charlie) So, the question asks","startTime":348.308,"endTime":350.549,"body":"D. pyelonephritis;"},{"speaker":"(Charlie) So, the question asks","startTime":350.549,"endTime":353.577,"body":"and E. a retroperitoneal hematoma."},{"speaker":"(Charlie) So, the question asks","startTime":353.577,"endTime":355.896,"body":"(Cathy) So, in this imaging"},{"speaker":"(Charlie) So, the question asks","startTime":353.577,"endTime":355.896,"body":"you see nephrolithiasis,"},{"speaker":"(Charlie) So, the question asks","startTime":355.896,"endTime":357.687,"body":"and given the brightness on CT,"},{"speaker":"(Charlie) So, the question asks","startTime":357.687,"endTime":360.176,"body":"it's most likely"},{"speaker":"(Charlie) So, the question asks","startTime":357.687,"endTime":360.176,"body":"a calcium-containing stone."},{"speaker":"(Charlie) So, the question asks","startTime":360.176,"endTime":363.773,"body":"As I mentioned earlier,"},{"speaker":"(Charlie) So, the question asks","startTime":360.176,"endTime":363.773,"body":"almost 90% of renal stones are this type,"},{"speaker":"(Charlie) So, the question asks","startTime":363.773,"endTime":366.785,"body":"and they have a signal density"},{"speaker":"(Charlie) So, the question asks","startTime":363.773,"endTime":366.785,"body":"that's similar to bone."},{"speaker":"(Charlie) So, the question asks","startTime":366.785,"endTime":369.321,"body":"The stone is causing some obstruction"},{"speaker":"(Charlie) So, the question asks","startTime":366.785,"endTime":369.321,"body":"and early inflammation,"},{"speaker":"(Charlie) So, the question asks","startTime":369.321,"endTime":373.177,"body":"and that's why you also see"},{"speaker":"(Charlie) So, the question asks","startTime":369.321,"endTime":373.177,"body":"the hydronephrosis and the fat stranding."},{"speaker":"(Charlie) So, the question asks","startTime":373.177,"endTime":375.885,"body":"(Charlie) So, since we have"},{"speaker":"(Charlie) So, the question asks","startTime":373.177,"endTime":375.885,"body":"a diagnosis of nephrolithiasis,"},{"speaker":"(Charlie) So, the question asks","startTime":375.885,"endTime":379.096,"body":"let's quickly review the epidemiology"},{"speaker":"(Charlie) So, the question asks","startTime":375.885,"endTime":379.096,"body":"and pathophysiology."},{"speaker":"(Charlie) So, the question asks","startTime":379.096,"endTime":380.514,"body":"Who's at risk?"},{"speaker":"(Charlie) So, the question asks","startTime":380.514,"endTime":383.066,"body":"(Cathy) Several conditions"},{"speaker":"(Charlie) So, the question asks","startTime":380.514,"endTime":383.066,"body":"predispose to stone formation,"},{"speaker":"(Charlie) So, the question asks","startTime":383.066,"endTime":386.674,"body":"including gastrointestinal malabsorption,"},{"speaker":"(Charlie) So, the question asks","startTime":383.066,"endTime":386.674,"body":"like Crohn's disease,"},{"speaker":"(Charlie) So, the question asks","startTime":386.674,"endTime":388.493,"body":"or gastric bypass surgery,"},{"speaker":"(Charlie) So, the question asks","startTime":388.493,"endTime":392.065,"body":"primary hyperparathyroidism,"},{"speaker":"(Charlie) So, the question asks","startTime":388.493,"endTime":392.065,"body":"obesity, type 2 diabetes,"},{"speaker":"(Charlie) So, the question asks","startTime":392.065,"endTime":394.564,"body":"and distal renal tubular acidosis."},{"speaker":"(Charlie) So, the question asks","startTime":394.564,"endTime":397.674,"body":"A number of other medical conditions"},{"speaker":"(Charlie) So, the question asks","startTime":394.564,"endTime":397.674,"body":"are more likely to be present"},{"speaker":"(Charlie) So, the question asks","startTime":397.674,"endTime":399.953,"body":"in individuals with a history"},{"speaker":"(Charlie) So, the question asks","startTime":397.674,"endTime":399.953,"body":"of nephrolithiasis."},{"speaker":"(Charlie) So, the question asks","startTime":399.953,"endTime":404.873,"body":"So, that would include hypertension, gout,"},{"speaker":"(Charlie) So, the question asks","startTime":399.953,"endTime":404.873,"body":"cardiovascular disease, cholelithiasis ,"},{"speaker":"(Charlie) So, the question asks","startTime":404.873,"endTime":407.954,"body":"reduced bone mineral density,"},{"speaker":"(Charlie) So, the question asks","startTime":404.873,"endTime":407.954,"body":"and chronic kidney disease."},{"speaker":"(Charlie) So, the question asks","startTime":407.954,"endTime":411.211,"body":"And if you recall, this patient"},{"speaker":"(Charlie) So, the question asks","startTime":407.954,"endTime":411.211,"body":"has diabetes and hypercholesterolemia,"},{"speaker":"(Charlie) So, the question asks","startTime":411.211,"endTime":413.503,"body":"so he is a typical at-risk patient."},{"speaker":"(Charlie) So, the question asks","startTime":413.503,"endTime":416.967,"body":"(Charlie) What is the pathophysiology"},{"speaker":"(Charlie) So, the question asks","startTime":413.503,"endTime":416.967,"body":"of nephrolithiasis?"},{"speaker":"(Charlie) So, the question asks","startTime":416.967,"endTime":418.97,"body":"(Cathy) So, recent studies"},{"speaker":"(Charlie) So, the question asks","startTime":416.967,"endTime":418.97,"body":"have changed the paradigm"},{"speaker":"(Charlie) So, the question asks","startTime":418.97,"endTime":421.33,"body":"for the site of initiation"},{"speaker":"(Charlie) So, the question asks","startTime":418.97,"endTime":421.33,"body":"of stone formation."},{"speaker":"(Charlie) So, the question asks","startTime":421.33,"endTime":424.581,"body":"So, we no longer think"},{"speaker":"(Charlie) So, the question asks","startTime":421.33,"endTime":424.581,"body":"that they initiate in the renal pelvis."},{"speaker":"(Charlie) So, the question asks","startTime":424.581,"endTime":428.398,"body":"Renal biopsies of stone formers"},{"speaker":"(Charlie) So, the question asks","startTime":424.581,"endTime":428.398,"body":"have revealed that calcium phosphate"},{"speaker":"(Charlie) So, the question asks","startTime":428.398,"endTime":430.43,"body":"is in the renal interstitium."},{"speaker":"(Charlie) So, the question asks","startTime":430.43,"endTime":432.756,"body":"It's hypothesized that"},{"speaker":"(Charlie) So, the question asks","startTime":430.43,"endTime":432.756,"body":"this calcium phosphate"},{"speaker":"(Charlie) So, the question asks","startTime":432.756,"endTime":435.184,"body":"deposits at the thin limb"},{"speaker":"(Charlie) So, the question asks","startTime":432.756,"endTime":435.184,"body":"of the loop of Henle,"},{"speaker":"(Charlie) So, the question asks","startTime":435.184,"endTime":436.966,"body":"and then extends down to the papilla"},{"speaker":"(Charlie) So, the question asks","startTime":436.966,"endTime":439.266,"body":"and erodes"},{"speaker":"(Charlie) So, the question asks","startTime":436.966,"endTime":439.266,"body":"through the papillary epithelium"},{"speaker":"(Charlie) So, the question asks","startTime":439.266,"endTime":441.086,"body":"where it provides a site for deposition"},{"speaker":"(Charlie) So, the question asks","startTime":441.086,"endTime":444.146,"body":"of calcium oxalate"},{"speaker":"(Charlie) So, the question asks","startTime":441.086,"endTime":444.146,"body":"and calcium phosphate crystals."},{"speaker":"(Charlie) So, the question asks","startTime":444.146,"endTime":446.13,"body":"Now, the majority"},{"speaker":"(Charlie) So, the question asks","startTime":444.146,"endTime":446.13,"body":"of calcium oxalate stones"},{"speaker":"(Charlie) So, the question asks","startTime":446.13,"endTime":449.138,"body":"grow on calcium phosphate"},{"speaker":"(Charlie) So, the question asks","startTime":446.13,"endTime":449.138,"body":"at the tip of the renal papilla,"},{"speaker":"(Charlie) So, the question asks","startTime":449.138,"endTime":451.989,"body":"which is also sometimes"},{"speaker":"(Charlie) So, the question asks","startTime":449.138,"endTime":451.989,"body":"called Randall's plaque."},{"speaker":"(Charlie) So, the question asks","startTime":451.989,"endTime":455.154,"body":"Tubular plugs of calcium phosphate"},{"speaker":"(Charlie) So, the question asks","startTime":451.989,"endTime":455.154,"body":"may be the initiating event"},{"speaker":"(Charlie) So, the question asks","startTime":455.154,"endTime":457.195,"body":"in calcium phosphate stone development."},{"speaker":"(Charlie) So, the question asks","startTime":457.195,"endTime":459.992,"body":"So, the process of stone formation"},{"speaker":"(Charlie) So, the question asks","startTime":457.195,"endTime":459.992,"body":"may begin years before"},{"speaker":"(Charlie) So, the question asks","startTime":459.992,"endTime":462.524,"body":"a clinically detectable stone"},{"speaker":"(Charlie) So, the question asks","startTime":459.992,"endTime":462.524,"body":"is identified."},{"speaker":"(Charlie) So, the question asks","startTime":462.524,"endTime":465.391,"body":"And the processes involved"},{"speaker":"(Charlie) So, the question asks","startTime":462.524,"endTime":465.391,"body":"in interstitial deposition"},{"speaker":"(Charlie) So, the question asks","startTime":465.391,"endTime":467.628,"body":"are under active investigation."},{"speaker":"(Charlie) So, the question asks","startTime":467.628,"endTime":470.031,"body":"(Charlie) So, the common theme there"},{"speaker":"(Charlie) So, the question asks","startTime":467.628,"endTime":470.031,"body":"is that these stones form"},{"speaker":"(Charlie) So, the question asks","startTime":470.031,"endTime":473.02,"body":"on a calcium crystal"},{"speaker":"(Charlie) So, the question asks","startTime":470.031,"endTime":473.02,"body":"to start things off."},{"speaker":"(Charlie) So, the question asks","startTime":473.02,"endTime":475.127,"body":"What about the other types of stones?"},{"speaker":"(Charlie) So, the question asks","startTime":475.127,"endTime":477.526,"body":"(Cathy) Uric acid stones"},{"speaker":"(Charlie) So, the question asks","startTime":475.127,"endTime":477.526,"body":"are the next most common --"},{"speaker":"(Charlie) So, the question asks","startTime":477.526,"endTime":482.176,"body":"at about 8% of stones that are found"},{"speaker":"(Charlie) So, the question asks","startTime":477.526,"endTime":482.176,"body":"in patients with hyperuricemia, mostly."},{"speaker":"(Charlie) So, the question asks","startTime":482.176,"endTime":485.12,"body":"Struvite stones are about 1%"},{"speaker":"(Charlie) So, the question asks","startTime":482.176,"endTime":485.12,"body":"of stones that we see,"},{"speaker":"(Charlie) So, the question asks","startTime":485.12,"endTime":487.67,"body":"and cystine stones are less than 1%."},{"speaker":"(Charlie) So, the question asks","startTime":487.67,"endTime":489.767,"body":"So, both of those are pretty uncommon."},{"speaker":"(Charlie) So, the question asks","startTime":489.767,"endTime":491.757,"body":"Remember that struvite stones are the ones"},{"speaker":"(Charlie) So, the question asks","startTime":491.757,"endTime":494.991,"body":"precipitated by bacterial infection"},{"speaker":"(Charlie) So, the question asks","startTime":491.757,"endTime":494.991,"body":"such as Proteus,"},{"speaker":"(Charlie) So, the question asks","startTime":494.991,"endTime":499.714,"body":"and that's because they promote conversion"},{"speaker":"(Charlie) So, the question asks","startTime":494.991,"endTime":499.714,"body":"of urea to ammonium and raise urinary pH."},{"speaker":"(Charlie) So, the question asks","startTime":499.714,"endTime":502.245,"body":"There're also some medications"},{"speaker":"(Charlie) So, the question asks","startTime":499.714,"endTime":502.245,"body":"that can cause stones,"},{"speaker":"(Charlie) So, the question asks","startTime":502.245,"endTime":506.21,"body":"such as acyclovir, atazanavir,"},{"speaker":"(Charlie) So, the question asks","startTime":502.245,"endTime":506.21,"body":"and triamterene."},{"speaker":"(Charlie) So, the question asks","startTime":506.21,"endTime":509.638,"body":"(Charlie) Okay, so that's a lot of stuff,"},{"speaker":"(Charlie) So, the question asks","startTime":506.21,"endTime":509.638,"body":"but any final comments on management?"},{"speaker":"(Charlie) So, the question asks","startTime":509.638,"endTime":512.504,"body":"(Cathy) In the acute setting,"},{"speaker":"(Charlie) So, the question asks","startTime":509.638,"endTime":512.504,"body":"you want to do pain management"},{"speaker":"(Charlie) So, the question asks","startTime":512.504,"endTime":515.098,"body":"and just make sure"},{"speaker":"(Charlie) So, the question asks","startTime":512.504,"endTime":515.098,"body":"that there's adequate hydration."},{"speaker":"(Charlie) So, the question asks","startTime":515.098,"endTime":518.684,"body":"So, for pain management-- because stones"},{"speaker":"(Charlie) So, the question asks","startTime":515.098,"endTime":518.684,"body":"can be very painful for patients--"},{"speaker":"(Charlie) So, the question asks","startTime":518.684,"endTime":520.318,"body":"NSAIDs are a good place to start,"},{"speaker":"(Charlie) So, the question asks","startTime":520.318,"endTime":522.892,"body":"and are often sufficient"},{"speaker":"(Charlie) So, the question asks","startTime":520.318,"endTime":522.892,"body":"for controlling symptoms,"},{"speaker":"(Charlie) So, the question asks","startTime":522.892,"endTime":525.858,"body":"and have fewer side effects"},{"speaker":"(Charlie) So, the question asks","startTime":522.892,"endTime":525.858,"body":"when compared to opioids."},{"speaker":"(Charlie) So, the question asks","startTime":525.858,"endTime":528.165,"body":"There're also data"},{"speaker":"(Charlie) So, the question asks","startTime":525.858,"endTime":528.165,"body":"to support alpha-blockers,"},{"speaker":"(Charlie) So, the question asks","startTime":528.165,"endTime":532.387,"body":"for example, tamsulosin to increase"},{"speaker":"(Charlie) So, the question asks","startTime":528.165,"endTime":532.387,"body":"the rate of spontaneous stone passage,"},{"speaker":"(Charlie) So, the question asks","startTime":532.387,"endTime":535.029,"body":"and most stones will pass spontaneously."},{"speaker":"(Charlie) So, the question asks","startTime":535.031,"endTime":537.447,"body":"More invasive things"},{"speaker":"(Charlie) So, the question asks","startTime":535.031,"endTime":537.447,"body":"like surgical interventions"},{"speaker":"(Charlie) So, the question asks","startTime":537.447,"endTime":539.399,"body":"are reserved really for larger stones"},{"speaker":"(Charlie) So, the question asks","startTime":539.399,"endTime":543.185,"body":"or if there's significant obstruction"},{"speaker":"(Charlie) So, the question asks","startTime":539.399,"endTime":543.185,"body":"or an ascending infection."},{"speaker":"(Charlie) So, the question asks","startTime":543.185,"endTime":545.906,"body":"(Charlie) Okay, so the teaching point"},{"speaker":"(Charlie) So, the question asks","startTime":543.185,"endTime":545.906,"body":"of this case is that"},{"speaker":"(Charlie) So, the question asks","startTime":545.906,"endTime":548.644,"body":"in a patient with"},{"speaker":"(Charlie) So, the question asks","startTime":545.906,"endTime":548.644,"body":"suspected nephrolithiasis,"},{"speaker":"(Charlie) So, the question asks","startTime":548.644,"endTime":553.876,"body":"helical CT without contrast"},{"speaker":"(Charlie) So, the question asks","startTime":548.644,"endTime":553.876,"body":"is the initial diagnostic test of choice."},{"speaker":"(Charlie) So, the question asks","startTime":553.876,"endTime":556.631,"body":"The most common stones are"},{"speaker":"(Charlie) So, the question asks","startTime":553.876,"endTime":556.631,"body":"calcium-containing,"},{"speaker":"(Charlie) So, the question asks","startTime":556.631,"endTime":559.739,"body":"and that comprises, approximately,"},{"speaker":"(Charlie) So, the question asks","startTime":556.631,"endTime":559.739,"body":"90% of cases."},{"speaker":"(Charlie) So, the question asks","startTime":559.739,"endTime":563.132,"body":"And even in the smaller number"},{"speaker":"(Charlie) So, the question asks","startTime":559.739,"endTime":563.132,"body":"of patients with uric acid stones,"},{"speaker":"(Charlie) So, the question asks","startTime":563.132,"endTime":566.871,"body":"those can also be typically seen"},{"speaker":"(Charlie) So, the question asks","startTime":563.132,"endTime":566.871,"body":"on a non-contrast CT."},{"speaker":"(Charlie) So, the question asks","startTime":566.871,"endTime":568.61,"body":"The management is pain control"},{"speaker":"(Charlie) So, the question asks","startTime":568.61,"endTime":572.536,"body":"and ensuring adequate urinary flow"},{"speaker":"(Charlie) So, the question asks","startTime":568.61,"endTime":572.536,"body":"through hydration."},{"speaker":"(Charlie) So, the question asks","startTime":572.536,"endTime":576.295,"body":"You want to make sure that you're"},{"speaker":"(Charlie) So, the question asks","startTime":572.536,"endTime":576.295,"body":"maintaining euvolemia in the patients."},{"speaker":"(Charlie) So, the question asks","startTime":576.295,"endTime":579.792,"body":"Alfa-blockers can also be used"},{"speaker":"(Charlie) So, the question asks","startTime":576.295,"endTime":579.792,"body":"to help pass along the stones."},{"speaker":"(Charlie) So, the question asks","startTime":579.792,"endTime":582.015,"body":"(Cathy) And to read more"},{"speaker":"(Charlie) So, the question asks","startTime":579.792,"endTime":582.015,"body":"about this, you can go"},{"speaker":"(Charlie) So, the question asks","startTime":582.015,"endTime":584.265,"body":"to \u003ci\u003eHarrison's\u003c/i\u003e chapter on Nephrolithiasis"},{"speaker":"(Charlie) So, the question asks","startTime":584.265,"endTime":587.155,"body":"within the Disorders of the Kidney"},{"speaker":"(Charlie) So, the question asks","startTime":584.265,"endTime":587.155,"body":"and Urinary Tract."},{"speaker":"(Charlie) So, the question asks","startTime":587.167,"endTime":588.692,"body":"♪ (music) ♪"}]}