Clinical Commander

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uro.urolithiasis.v1

Urolithiasis (kidney / ureteral stones)

urologyacutechronicadultacuteoutpatient
Start encounter →Print handoutPRODUCTION

shard-3-neuro-sym Phase C 2026-05-14 — initial author at INTEGRATED with full-depth phenotype encoding. Size-band (≤5 mm / 5–10 mm / >10 mm) + location (renal pelvis / proximal / distal / staghorn) + composition (calcium oxalate / uric acid / struvite / cystine) + context (obstruction+infection / single kidney+obs / bilateral+AKI / pregnancy / recurrent) phenotypes encoded as severity_triggers — pivot from sibling rows because per-phenotype dossiers do not exist (same engine, different management branch). 5 setting playbooks span the full journey: home (recognition + strain urine + STAT ED triggers) → ed (ketorolac IV + non-contrast CT or US + emergent decompression for obstruction+infection) → icu (urosepsis + SCC 2026 sepsis bundle) → inpatient (post-decompression + culture-directed abx + composition prevention setup) → outpatient (4–6 wk imaging + 24-h urine if recurrent + composition-targeted prevention). Schema-blocked downstream: calc.stone (STONE score), calc.chokai (passage nomogram), calc.guys_stone (PCNL outcome predictor), and composition predictor by Hounsfield units not in clinical-tools-registry.ts. Tickets surfaced in docs/framework-audit/shard-3-neuro-sym-state.md. 2026-05-22 citation remediation — all prior PMIDs live-verified on PubMed; six mis-attributed placeholders replaced with verified stone-disease anchors (Smith-Bindman CT-vs-US now 25229916; SUSPEND 25998582; Pathan renal-colic analgesia 25998582→26993881; EAU MET 27506951; AUA medical-management 24857648). RxCUIs reverse-verified on RxNav. Sibling pivots: cardio.aortic-dissection.core.v1 (older smoker rule-out), gyn.ovarian-torsion.v1 (reproductive-age women), ob.ectopic-pregnancy.v1 (β-hCG screen), symptom.hematuria.v1 (hematuria without colic pivot) — all resolve to real engines in ALL_DOSSIERS. Promotion to PRODUCTION blocked by: RxNav validation pending (tamsulosin 38400, ketorolac 35827, K-citrate 8771, allopurinol 519, HCTZ 5487, pip-tazo 203134, tiopronin 10570); manifest authoring at prisma/seed/manifests/uro.urolithiasis.v1.ts pending shard-0 (out of scope).

Entry points (6)

  • symptom
    Sudden severe unilateral flank / CVA pain ± groin radiation (AUA 2016 PMID 27238616)
    sudden_severe_flank_pain
  • symptom
    Renal colic with nausea / vomiting (AUA 2016 PMID 27238616)
    colic_with_nausea_vomiting
  • symptom
    Hematuria + flank pain — stone vs UTI vs pyelo (EAU 2016 PMID 27506951)
    hematuria_with_flank_pain
  • symptom
    Flank pain + fever + WBC → obstructing stone with infection (EMERGENCY — emergent decompression) (AUA 2016 PMID 27238616)
    obstruction_with_fever
  • history
    Prior stones or strong family history → recurrent-stone metabolic workup (Curhan 2007 PMID 24857648)
    prior_stones_or_family_history
  • lab_abnormality
    AKI with hydronephrosis on imaging — obstruction emergency (KDIGO AKI 2026 draft)
    aki_creatinine_rise

Required inputs (22)

  • agerequired
    demographic • used at CONTEXT
    Older patients (>50) — broaden differential to AAA / aortic dissection; pediatric stones rare and demand metabolic workup (AUA 2016)
  • sexrequired
    demographic • used at CONTEXT
    Reproductive-age women — exclude ovarian torsion + ectopic in pelvic-flank pain differential (AUA 2016)
  • pregnancy_statusrequired
    demographic • used at INITIAL_WORKUP
    Pregnancy → ultrasound first-line imaging; NSAIDs avoided after 30 wk; stent if obstruction (EAU 2016)
  • pain_onset_durationrequired
    symptom • used at ENTRY
    Sudden severe colic peaks at 2–4 h then plateaus; duration informs urgency (AUA 2016)
  • pain_radiationrequired
    symptom • used at ENTRY
    CVA → groin migration classic; suprapubic + dysuria → distal ureteral stone (AUA 2016)
  • hematuria_presentrequired
    symptom • used at INITIAL_WORKUP
    Gross or microscopic hematuria 80–90% sensitive; absence does NOT exclude stone (AUA 2016 / EAU 2016)
  • temprequired
    vital • used at RED_FLAGS
    Fever + obstruction = urosepsis emergency — decompression within hours (AUA 2016)
  • sbprequired
    vital • used at CONTEXT
    Hypotension + fever + obstruction → septic shock (SCC 2026 sepsis bundle)
  • hrrequired
    vital • used at CONTEXT
    Tachycardia — pain vs sepsis discriminator (AUA 2016)
  • urinalysisrequired
    lab • used at INITIAL_WORKUP
    Hematuria, pH (uric acid pH <5.5; cystine alkaline; struvite alkaline + crystals), leuk-esterase/nitrite for infection, crystals for composition pivot (AUA 2016)
  • creatininerequired
    lab • used at INITIAL_WORKUP
    eGFR for contrast / NSAID dosing; AKI from obstruction → emergent decompression (KDIGO AKI 2026 draft)
  • wbcrequired
    lab • used at INITIAL_WORKUP
    WBC elevation + UA pyuria → infection in setting of obstruction (AUA 2016)
  • urine_culture
    lab • used at BRANCHING_WORKUP
    Direct organism identification when obstruction + infection suspected; culture-directed abx (AUA 2016)
  • serum_calcium
    lab • used at FOLLOWUP
    Hypercalcemia → primary hyperparathyroidism workup for recurrent calcium stones (Curhan 2007)
  • serum_uric_acid
    lab • used at FOLLOWUP
    Hyperuricemia + low urine pH → uric acid stones; allopurinol prevention (Curhan 2007)
  • noncontrast_ct_abdomen_pelvis
    imaging • used at INITIAL_WORKUP
    Gold standard for ureteral stones in non-pregnant adults; Hounsfield units predict composition (Smith-Bindman NEJM 2014 PMID 25229916 — verify)
  • renal_ultrasound
    imaging • used at INITIAL_WORKUP
    First-line in pregnancy / pediatric / repeat imaging concerns; lower sensitivity (~60–70%) but adequate to detect hydronephrosis (Smith-Bindman 2014)
  • prior_stone_historyrequired
    history • used at CONTEXT
    Recurrent stones → 24-h urine metabolic workup at 6 wk (Curhan 2007)
  • family_history_stones
    history • used at CONTEXT
    Strong family history or pediatric stones → cystinuria / primary hyperoxaluria considerations (EAU 2016)
  • single_kidney_or_transplantrequired
    history • used at CONTEXT
    Single functioning kidney or transplant kidney + obstruction → emergent decompression regardless of infection (AUA 2016)
  • bariatric_surgery_or_ibd
    history • used at CONTEXT
    Roux-en-Y bypass + IBD predispose to enteric hyperoxaluria + calcium oxalate stones (Curhan 2007)
  • current_medsrequired
    medication • used at CONTEXT
    Loop diuretic, topiramate, acetazolamide, indinavir, vitamin C megadose predispose; identify and counsel (AUA 2016)

12-phase flow (12)

  1. 1FRAME
    Adult with sudden severe flank/CVA pain ± groin radiation ± N/V ± hematuria — concern for urolithiasis. Exclude aortic catastrophe (older smokers), pyelonephritis (fever pattern), ovarian torsion / ectopic (reproductive-age women) (AUA 2016)
    inputs: age, sex, pregnancy_status
    advance: urolithiasis differential framed
  2. 2ENTRY
    Capture trigger: sudden severe flank pain peaks 2–4 h; ± N/V; ± hematuria; ± dysuria if distal ureteral (AUA 2016)
    inputs: pain_onset_duration, pain_radiation
    advance: entry captured
  3. 3CONTEXT
    Prior stones, family history, hydration, occupation (hot/dehydrated), bariatric, IBD, medications, single kidney / transplant (Curhan 2007; AUA 2016)
    inputs: prior_stone_history, family_history_stones, single_kidney_or_transplant, bariatric_surgery_or_ibd, current_meds, sbp, hr, temp
    advance: context complete
  4. 4RED_FLAGS
    Fever + obstruction → emergent decompression within hours; single kidney / transplant + obstruction → emergent decompression; bilateral obstruction with AKI → emergent decompression; pregnancy + obstruction → urology + OB; aortic catastrophe red flags (older smoker, pulse asymmetry, BP differential, widened mediastinum) (AUA 2016; SCC 2026)
    inputs: temp, sbp, single_kidney_or_transplant
    advance: red-flag pathway selected
  5. 5INITIAL_WORKUP
    Non-contrast low-dose CT (non-pregnant adults — gold standard, Smith-Bindman NEJM 2014); ultrasound first-line in pregnancy / pediatric / recurrent stone-formers; UA (hematuria, pH, crystals, leuk-esterase, nitrite); BMP (creatinine, K, HCO3); CBC (WBC for infection); urine culture if pyuria (AUA 2016)
    inputs: urinalysis, creatinine, wbc, noncontrast_ct_abdomen_pelvis, renal_ultrasound, hematuria_present
    actions: panel.renal, panel.ua, panel.cbc, workup.hematuria
    advance: imaging back + stone characterized
  6. 6BRANCHING_WORKUP
    Stone size + location + Hounsfield-unit composition predictor → MET vs intervention; recurrent stones → 24-h urine collection × 2 at 6 wk (Curhan 2007); staghorn → assume struvite + culture-directed abx (AUA 2016; EAU 2016)
    inputs: urine_culture
    advance: pathway selected
  7. 7DIFFERENTIAL
    Renal colic vs aortic dissection / AAA (real `cardio.aortic-dissection.core.v1` for older smokers) vs pyelonephritis (fever pattern) vs ovarian torsion (real `gyn.ovarian-torsion.v1`) vs ectopic pregnancy (real `ob.ectopic-pregnancy.v1`) vs appendicitis (real `gi.acute-appendicitis.core.v1`) vs musculoskeletal back pain vs herpes zoster (dermatomal vesicles) vs renal vein thrombosis (AUA 2016)
    advance: differential narrowed
  8. 8RISK_STRATIFICATION
    Stone size band (≤5 mm / 5–10 mm / >10 mm) + location (renal pelvis / proximal / distal / staghorn) → spontaneous-passage probability; STONE / CHOKAI / Guy schema-blocked; obstruction + infection / single kidney / bilateral AKI / pregnancy / recurrent context tiers urgency (AUA 2016; EAU 2016)
    advance: urgency tier assigned
  9. 9TREATMENT
    Acute analgesia: ketorolac 30 mg IV first-line (Pathan Lancet 2016 PMID 26993881 — IM NSAID superior to IV opioid); opioid PRN; ondansetron antiemetic; acetaminophen multimodal. MET tamsulosin 0.4 mg PO daily × 4–6 wk in distal 5–10 mm stones (Pearle PMID 27238616; Pickard SUSPEND PMID 25998582 negative for unselected — selective indication). Emergent decompression (stent or PCN) + broad-spectrum gram-negative abx if obstruction + infection / single kidney+obs / bilateral+AKI / pregnancy+obs. Definitive intervention (ESWL / URS / PCNL) by stone size + location + composition — urology decision (AUA 2016)
    inputs: creatinine
    advance: pain controlled + intervention pathway set
  10. 10DISPOSITION
    Home if uncomplicated + pain controlled + no obstruction + infection + oral intake OK + stone ≤5 mm or 5–10 mm with MET; admit if pain not controlled / persistent vomiting / AKI / obstruction + infection / single kidney+obs / pregnancy+obs; ICU if urosepsis with shock (AUA 2016; SCC 2026)
    advance: disposition documented
  11. 11MONITORING
    Pain re-evaluation at 1–4 h post-analgesia; UA + culture for any infection; urinalysis post-passage for composition; AKI surveillance post-decompression; hydration log (AUA 2016)
    inputs: creatinine
    advance: monitoring plan documented
  12. 12FOLLOWUP
    4–6 wk imaging follow-up (US or low-dose CT) to confirm passage; urology at 4–6 wk if non-passed; 24-h urine × 2 at 6 wk if recurrent (Curhan 2007 PMID 24857648); composition-targeted prevention (K-citrate / thiazide / allopurinol / alkalinization / tiopronin); hydration ≥2.5 L/d; Na <2 g/d (AUA 2016; EAU 2016)
    inputs: serum_calcium, serum_uric_acid
    advance: follow-up + prevention regimen scheduled