SonoCase: Renal Ultrasound for Renal Colic: a cost/benefit analysis? by @EPMonthly #FOAMed

Once again, Drs. Teresa Wu and Brady Pregerson do an excellent job in highlighting a case in EP Monthly (and a topic that I am so incredibly passionate about – not only because of the benefit to the patient, the minimizing of CT scans/radiation, and the time spent in its work up – but also in health care cost and expediting diagnosis and management.) What am I talking about? Well, RENAL ULTRASOUND for RENAL COLIC. Yeah, I know, it sounds obvious. But, I heard of a patient the other day (again!) who had a known history of kidney stones, who had the same pain as her prior kidney stone flank pain, who begged to not have yet another CT scan done since it would have been her 13th for this at the age of 40. I highlighted this topic and other studies on it in a prior post, and AIUM posted a sound judgment series written by Drs. Chris Moore and Leslie Scoutt on this topic too.

So, let’s talk about TWu and Brady’s addition to the mix. Of course, they always start off their case with humor, yet reality, by saying : “I have to do a cost-benefit analysis of the situation,” your eager intern replies. It’s the end of the academic year and you are forcing your soon-to-be R2s to become more autonomous and confident in their management plans. You are amazed at the various answers you now get when you ask the simple question, “What do you want to do?” You ask your intern to summarize the case for you. He just finished evaluating a 21-year-old male who presented to your ED with back pain. The patient states that his “back is killing him” and he thinks he strained his muscles working out too hard at the gym last week. He just started doing CrossFit and he’s worried that he overdid it. The patient notes that the pain is 10/10 and that he has had minimal relief with his friend’s Vicodin. He’s tried icing his back and even sat in the hot tub all weekend per his friend’s recommendation. Nothing is working so his friend told him to come into the ED to get a prescription for something “stronger.”……

“Your question about whether or not this young 21 year old needs any imaging is giving him pause. “I think the cost of the imaging and the risk of radiation are too high. I don’t think there’s much benefit to keeping the patient here any longer. Plus I don’t know what we’d be looking for,” he replies. You are happy with your intern’s logic and pop into the room to see the patient. Within seconds, you realize that Vicodin and a hot tub probably won’t fix this patient’s pain. The patient is sitting hunched over on the stretcher rocking back and forth in pain. He has no appreciable tenderness to palpation over any of his back muscles, and there is no asymmetry or tightness on your exam. You are unable to reproduce or worsen his symptoms with testing his range of motion, but he is definitely rubbing his right lower back to try to ease his pain. You walk out of the patient’s room and grab your intern and the ultrasound machine. As you head back towards the patient’s room, you pimp your intern on the other more serious causes of low back pain. Acknowledging that you have the ultrasound machine in tow, your clever intern starts rattling off the diagnoses that can be easily made with bedside ultrasound. AAA, atypical appendicitis, cholecystitis, nephrolithiasis, abscess, etc. Since the patient is sitting upright and hunched over in pain, your intern decides to start his scan with a view of the right flank….”

BAM! oh yeah – do you see it? Weren’t expecting that? Funny what happens when you look, right? You must read about their findings and the pearls and pitfalls of renal ultrasound – go here for the true meat of the article.

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 ….”

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.”

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.