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: 32yr old with right flank pain, fever, cough – by Dr. McKaigney in @westJEM

In the March 2013 issue of Western Journal of Emergency Medicine, Dr. McKaigney highlights a case that illustrates there is more to a thoracic and right upper quadrant bedside ultrasound study than just free fluid, renal and gallbladder evaluation. You must look everywhere and appreciate when something looks abnormal. I always say, know what NORMAL looks like, because when you see something abnormal, you’ll identify at least that, then want to find out what that abnormality is by further testing.

The case: “A 35-year old male presents to the emergency department (ED) with what he describes as right-sided upper back and flank pain, which he attributes to a “cupping” procedure the day prior. The cupping procedure is an alternative medicine practice that uses local suction to theoretically stimulate blood flow and promote healing. He had no previous issues with the procedure. On further history he reported having had approximately 6 weeks of intermittent fevers, cough, anorexia and general malaise. He had seen multiple naturopathic physicians for these complaints, before an urgent care visit one week earlier. At that time, he had been started on azithromycin and doxycycline for a presumptive diagnosis of pneumonia. In the interim week he reported an improvement in his febrile symptoms and overall well-being. He was an otherwise healthy heterosexual male, without drug use or travel outside the country. He had no known sick contacts.

On physical examination his vital signs included a blood pressure of 116/75 mmHg, a heart rate of 119 beats per minute, and a respiratory rate of 20 breaths per minute. His temperature in the ED was 36.2°C. Oxygen (O₂) saturation was 97% on room air. The patient was alert, and appropriate with no signs of respiratory distress. Pertinent physical findings revealed typical, non-tender cupping marks on his back. More concerning was an absence of breath sounds on the right side of the chest on auscultation. His abdomen was soft and non-tender. The remainder of the physical examination was non-contributory.

The initial diagnostic test ordered was a chest radiograph, which showed 80% opacification of the right hemithorax, consistent with pneumonia and associated parapneumonic effusion seen in Figure 1. A bedside ultrasound was subsequently performed in the ED, initially in order to examine the size of the pleural effusion in which a startling discovery was made…..”

So, “what is that?” – you may be asking…. and what happened to the patient, what can be done about it, and what is the evidence based review on the topic? Read on as Dr. McKaigney does an excellent job in discussing it all….here

SonoCase: “My back hurts, I just need a med refill.” Yeah, except….

This case scares me. Truly. We have all had patients with this chief complaint, maybe on a weekly, if not daily, basis. You know the one – guy comes in, says he has been diagnosed with …. lets see, its usually “herniated disk”, “muscle strain”, “sciatica”, or he may throw out a term that gets more of your attention like “stenosis”, but usually it’s just “I have a bad back” and now on narcotics (because there’s just no other way – ugh!) and just needs a refill. He may even have an empty bottle in hand. He just might ask for the medicine by name : “Norco 10s work really well, but my doctor put me on Oxycontin now. Can you give me enough for a month?” Response: “uh… No.” But I digress…..lets go to our crazy-scary case…

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.