What is the treatment plan for an 88-year-old female with severe pain, dyspnea (difficulty breathing), and microscopic hematuria with calcium oxalate crystals, following a normal chest computed tomography (CT) scan and emergency room (ER) evaluation?

From the Guidelines

For an 88-year-old female with severe pain, dyspnea, and microscopic hematuria with calcium oxalate crystals, I strongly recommend a comprehensive approach addressing both her urinary findings and pain symptoms, prioritizing increased fluid intake and pharmacologic management as outlined by the American College of Physicians guideline 1.

Key Recommendations

• Increase hydration to at least 2 liters of water daily to prevent recurrent nephrolithiasis, as recommended by the American College of Physicians guideline 1.
• Initiate a low-oxalate diet, avoiding foods such as spinach, rhubarb, nuts, and chocolate, to reduce the concentration of lithogenic factors in the urine.
• Consider pharmacologic monotherapy with a thiazide diuretic, citrate, or allopurinol to prevent recurrent nephrolithiasis, as recommended by the American College of Physicians guideline 1.

Pain Management

• Start with pain management using acetaminophen 500-1000mg every 6 hours, not exceeding 3000mg daily in elderly patients.
• Consider short-term tramadol 25-50mg every 6 hours as needed if pain is severe.

Monitoring and Follow-up

• Monitor renal function with follow-up labs within 1-2 weeks, including comprehensive metabolic panel, urinalysis, and urine calcium/oxalate levels.
• Schedule a follow-up appointment in 1 week to assess pain control and symptom improvement.
• If pain persists or worsens, consider urological consultation to evaluate for kidney stones that may not have been visible on the chest CT.

Additional Considerations

• The normal chest CT rules out pulmonary causes for her breathing pain, suggesting the pain may be musculoskeletal or related to kidney stone formation.
• Consider obtaining a stone analysis if a stone is available, as recommended by the American Urological Association guideline 1.
• Perform additional metabolic testing, including 24-hour urine collections, to identify metabolic and environmental risk factors and direct dietary and medical therapy, as recommended by the American Urological Association guideline 1.

From the Research

Treatment Plan for Severe Pain, Dyspnea, and Microscopic Hematuria

The patient's symptoms of severe pain, dyspnea, and microscopic hematuria with calcium oxalate crystals require a comprehensive treatment plan.

• The presence of calcium oxalate crystals suggests a possible kidney stone, which can cause severe pain and dyspnea 2.
• The treatment plan should focus on managing the patient's pain and addressing the underlying cause of the symptoms.

Pain Management

• Nonsteroidal anti-inflammatory drugs (NSAIDs) and morphine are effective for pain relief in patients with renal colic 2.
• Acetaminophen and NSAIDs are first-line treatment options for most patients with acute mild to moderate pain 3, 4.
• Topical NSAIDs are recommended for non-low back, musculoskeletal injuries 3.
• For severe or refractory acute pain, treatment can be briefly escalated with the use of medications that work on opioid and monoamine receptors (e.g., tramadol, tapentadol) or with the use of acetaminophen/opioid or NSAID/opioid combinations 3, 4.

Dyspnea Management

• The patient's dyspnea should be managed concurrently with the pain management plan.
• Oxygen therapy may be necessary to alleviate dyspnea, especially if the patient has a history of respiratory disease.

Microscopic Hematuria Management

• The presence of microscopic hematuria with calcium oxalate crystals suggests a possible kidney stone.
• The patient should be monitored for any changes in urine output, and imaging studies (e.g., CT scan) may be necessary to confirm the diagnosis.

Considerations for the 88-Year-Old Female Patient

• The patient's age and potential comorbidities should be considered when developing the treatment plan.
• NSAIDs should be used with caution in patients with a history of gastrointestinal bleeding, cardiovascular disease, or chronic renal disease 2, 3, 4.
• Acetaminophen is generally well-tolerated, but lower doses should be used in patients with advanced hepatic disease, malnutrition, or severe alcohol use disorder 3, 4.