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Suspected renal colic with severe renal impairment and dehydration — MSRA MCQ

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HardUrologySuspected renal colic with severe renal impairment and dehydrationMSRA

A 64-year-old man presents to an urgent GP service with 9 hours of severe left-sided loin pain radiating to the groin. He is restless and has vomited four times, so has been unable to retain oral fluids or medication. He has no fever, dysuria or rigors. Temperature is 36.9°C, heart rate 104 beats/min and blood pressure 132/78 mmHg. He has left costovertebral-angle tenderness. Urine dipstick is positive for blood but negative for nitrites and leucocytes. He has chronic kidney disease with a recent stable eGFR of 18 mL/min/1.73 m². Renal colic is suspected. What is the most appropriate immediate management plan?

Educational content. Not a substitute for clinical judgement or local policy.

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Correct answer: E — Arrange urgent hospital assessment for intravenous paracetamol and low-dose non-contrast CT within 24 hours

Explanation lettering: E = shown as B · D = shown as C · B = shown as D · C = shown as E

This is suspected renal colic in a non-pregnant adult: the characteristic colicky loin-to-groin pain, restlessness and dipstick haematuria support this, while absent fever, nitrites and leucocytes make infected obstruction less likely. NICE recommends low-dose non-contrast CT urgently, within 24 hours of presentation, for adults with suspected renal colic. An NSAID would usually be first-line analgesia, but this patient has severe renal impairment and clinically important volume depletion from repeated vomiting. Ibuprofen is contraindicated in severe renal failure and significant dehydration. NICE therefore recommends intravenous paracetamol where NSAIDs are contraindicated; opioids are reserved for when both NSAIDs and intravenous paracetamol are contraindicated or ineffective. A is wrong because diclofenac is an NSAID and ultrasound is not first-line imaging for a non-pregnant adult. B is attractive given severe pain and vomiting, but morphine is not the next analgesic step when intravenous paracetamol remains suitable; ultrasound is again incorrect first-line imaging. D uses both an inappropriate NSAID and an unsuitable outpatient plan in a patient unable to take oral treatment. E selects appropriate analgesia but wrongly delays mandatory urgent diagnostic imaging.

Reference: NICE NG118: Renal and ureteric stones: assessment and management — Recommendations (2019) — https://www.nice.org.uk/guidance/ng118/chapter/Recommendations Ibuprofen 200 mg film-coated tablets — Summary of Product Characteristics (2026) — https://www.medicines.org.uk/emc/product/11165/smpc