Case 12

44 yo M with h/o kidney stones, recently passed a stone in October, but at that time was told he had a 1.7cm stone in L kidney, which may cause a problem trying to pass. Patient reports being awakened by pain at 3am similar to previous kidney stone pain in the past. He took 1 Vicodin he had at home with mild relief and went to work. While at work, pain worsened causing him to come to ED. He admits to mild nausea, denies vomiting, fever, chills, diarrhea. No CP or SOB. No difficulty urinating. 

ROS:

CONSTITUTIONAL: (-) fever, (-) chills, (-) malaise,
GASTROINTESTINAL: (+) pain, (-) gas, (-) abdominal distension LLQ, L flank Nausea: Patient has mild nausea. Vomiting Episodes: Negative.
CARDIOVASCULAR: (-) chest pain, (-) syncope,
RESPIRATORY: (-) cough, (-) SOB rest,
MUSCULOSKELETAL: (+) back pain, (-) stiffness,
INTEGUMENTARY: All Negative
NEURO: (-) lightheadedness, (-) dizziness,
ALLERGIC/IMMUN: All Negative.
HEME/LYMPH: All Negative. 

PHYSICAL:

Vitals: T: 97.2 HR: 80 RR: 18 BP: 155/88 Osat: 99% on RA Pain scale: 8/10

CONSTITUTIONAL: The patient is alert and in no apparent distress. Appears WDWN. Appears uncomfortable
GI/ABDOMEN: Mild tenderness LLQ. No rebound or guarding. No CVAT
CARDIOVASCULAR: Regular rate and rhythm, heart sounds normal, no gallops, rubs or murmurs, no edema present.
MUSCULOSKELETAL/EXTREMITES: Non-tender, normal ROM, no pedal edema or calf tenderness. NVT intact.
RESPIRATORY: Breath sounds clear, no distress present, no wheezing rales, rhonchi or tachypnea. Normal rate and effort.
HEME/LYMPH: No adenopathy, no palpable or tender nodes.

LABS: 

WBC 15.7 Hgb:15.8 Hct:44.9 Plt: 211
Na 136 K 4.0 Cl 104  CO2 26 BUN 19 Cr. 1.24 Gl: 99
UA: protein 30, + large blood, + small leukocytes

1. What positive finding is present in this image?

2. What ultrasound modality are we using to verify the pathology?

3. What additional abnormality is present?