SonoCase: 45 yr male- flank pain & hematuria- not always a kidney stone – by Dr. Marzec et al. in @westjem #FOAMed

Western Journal of Emergency Medicine must be great proponents of bedside ultrasound! I love that journal! Of course, I am biased as I am one of the section editors, but these cases deserve mention. There have been quite a few in the March 2013 issue and this case in particular is a great review of renal ultrasound and what to lookout for in bedside ultrasound. Limited renal ultrasound typically involves an evaluation for hydronephrosis, but it is important to know what normal ultrasound anatomy looks like, as you may identify something else…. Dr. Marzec et al. at USC do a great job at discussing their case, describing their ultrasound, and giving a literature review on the finding. The case:

“A 45-year-old male with no previous medical history presented to the emergency department (ED) with 1 week of hematuria and left flank pain. The patient had noted that over the preceding 4 days his urine had progressed from a pink color to dark red. He had also experienced left flank pain that was sharp, non-radiating, and increasing in severity over the week prior to presentation. He denied a history of renal calculi, weight loss, fevers, fatigue, or abdominal masses. Upon physical examination, his vital signs included blood pressure of 157/89 mmHg, heart rate of 64 beats/min, temperature of 97.4 °F, respiratory rate of 18 breaths/min, and oxygen saturation of 99% on room air. The patient appeared comfortable. His abdomen was soft, non-tender and non-distended. The patient had left-sided costo-vertebral angle tenderness to palpation. There was frank hematuria in the urine sample at bedside. Subsequent microscopic analysis revealed > 50 red blood cells and 4–10 white blood cells. Bedside emergency ultrasound (EUS), initially performed to look for hydronephrosis, showed ….”

WJEM_RCC_Movie_1

►

To read on the case, what happened, and a great review of the literature of ultrasound’s utility with this finding compared to other imaging modalities, go here.

SonoCase: 72yo demented, abdominal distension -by Drs Teresa Wu/Brady Pregerson in @EPMonthly #FOAMed

Once again another great case by Drs. Teresa Wu and Brady Pregerson in EP Monthly. Whenever I read their cases, I can actually imagine myself going through the case too. This is especially true for this one, as it is a prime example of how ultrasound can get you the diagnosis immediately, and how ultrasound can be utilized in the elderly and demented nursing home patients who get sent to the emergency department for “she just doesn’t seem normal” or, in this case, “abdominal distension”. Trust me, both can actually end up with the same diagnosis. It’s also a great entry as it speaks of a procedure that all emergency physicians should know how to do – it is too easy!

The case: “72-year-old male brought in by his nursing home aide for abdominal distension. He has a history of dementia and is primarily bedridden at baseline. The patient cannot give any reliable history, but on physical exam, his otherwise thin abdomen shows obvious signs of suprapubic distension. Your intern recaps his vital signs, which include tachycardia at 120 bpm, a blood pressure of 190/86 mmHg, a respiratory rate of 20/min, and a normal temperature and O2 saturation.”…. So, the differential diagnosis? Well, you should always think of the most emergent first, like an abdominal aortic aneurysm, which can also be diagnosed by ultrasound immediately – as discussed in a prior post of another elderly patient with altered mental status. (To see more sonocase posts in evaluating the altered patient, go here). Other badness? perforated bowel, volvulus, mesenteric ischemia, hemorrhage…. Oh, the list keeps going on and on when you have an elderly patient, a demented patient, a nursing home patient – or, in this case, it was all of the above!

Whenever I am evaluating the elderly patient with abdominal complaints, I think bedside ultrasound immediately (of course, with a very low threshold for CT scan since they can have anything happen! – and let’s be honest, they aren’t the ones we think about when we talk of the radiation risks… But, healthcare bill/cost? That’s a whole other conversation…). After as best of a history and physical exam that I can get (it can be challenging when they are demented and no caregiver at the bedside! Calling the nursing home is always done but usually they are too sick or the person on the other end of the line gives limited information), I bring my ultrasound machine and explore their abdomen: FAST (which also gives you a good look at the kidneys for hydronephrosis), Aorta, Gallbladder, Bladder, Bowel, +/- Pelvic/Testicular (depending on exam). Doing that may give you the answer, as in the case highlighted above…. to find out what they found and what happened to that patient, read on here. Trust me, you’ll love it.

SonoCase: 35 yr old – acute urinary retention, penile pain – by Drs. Peabody, Mailhot, Perera

In the recent issue of WestJEM, a case report of another excellent application for bedside ultrasound is described by our very own Dr. Phil Perera (yup, he is more than just the RUSH exam). A video where he discusses the ultrasound application and case follows….

“A 35-year-old man presented to the emergency department (ED) for acute urinary retention and penile pain for 4 hours. The patient denied any significant medical history or history of trauma. Physical exam revealed testicles that were nontender, without masses. However, a tender mass was felt at the distal end of the penis, adjacent to the urethral meatus. Placement of a Foley catheter resulted in a return of 700 cc of clear yellow urine and immediate resolution of the patient’s suprapubic and penile pain.

During the ED course, the Foley catheter was removed with a subsequent trial of voiding. Initially, the patient was able to void 15 cc of urine until the normal stream was abruptly cut off. The patient then complained of extreme penile pain, near the urethral meatus. A small, circular and firm mass was again palpated in the distal penile shaft. Bedside emergency ultrasound (EUS), performed with a 10 MHz linear array probe placed along long axis of penis, revealed a hyperechoic, dense and round structure with characteristic acoustic shadowing at the distal end of the urethra, with obstruction of the urinary flow (Video). The object, a 9 mm stone, was removed with forceps. Following stone removal, the patient experienced immediate pain relief and was able to spontaneously void.

While urethral imaging has traditionally been performed with retrograde urethrography (RUG), more recently ultrasound has been used to minimize the pain associated with RUG and to provide clinicians more detailed information about urethral pathology.² As demonstrated in this case, EUS allowed a prompt diagnosis of the patient’s condition with appropriate rapid treatment and removal of the urethral stone.”

wjem-13-515-s001 (1)

►

SonoCase (and studies): Renal colic, do we really need to get another CT?

38 year old male with a history of kidney stones c/o severe right flank pain, radiating to the groin, “feels just like my kidney stones” with small amount of blood in his urine, begging for pain meds. Ok, I know this is not the most mysterious case, but when I looked over his chart he has a radiology list of 8 CT scans over the last 5 years to evaluate for kidney stones! Why? Do we really work in an era where we MUST know the diagnosis instead of just being able to screen for the emergent conditions, and treat by using our clinical judgement… and bedside ultrasound? I sure hope not, because that’s not how I practice. This is not the first-time flank pain patient, although some would argue that you dont need to get a CT for that either if labs and ultrasound are clear/negative. This is also not the elderly patient that could have belly-badness that will die soon –  but not from CT scan-radiation-induced cancer, that’s for sure.