Case 24

46 y/o M with PMH of HTN presents with right flank pain that began suddenly last night, it is radiating to the front of his abdomen, it is 10/10 pain, not relieved by tylenol and is continuing today. Never had anything like this before, + frequency, no fevers, no chills, no urgency, no h/o STDs. Denies any history of trauma.

ROS:

  • GI: no n/v
  • pulm: no cough or respiratory distress
  • cards: no chest pain, no edema

EXAM:

  • Vitals: T 98.6F, P 80, BP 130/70, RR 14, O2Sat 100% on RA
  • Constitutional: NAD
  • Card: s1s2 regular, no MGR
  • Resp: CTAB
  • ABD: soft, nt/nd, + right CVAT
  • EXT: no edema

Here is video of the RUQ by bedside ultrasound.

Questions:

You decide to do an ultrasound of the right kidney

  1. What does it show?
  2. What are your differential diagnoses?
  3. What would confirmatory study should be performed?

Answers:

  1. perinephric stranding - Perinephric standing may be differentiated from free fluid by absence of trauma, an anechoic area contained within the renal capsule, and an non-compressible anechoic layer.
  2. hydronephrosis, nephrolithiasis, pyelonephritis
  3. CT abdomen & pelvis with contrast can distinguish pyelonephritis from hydronephrosis or nephrolithiasis.

Case Conclusion:

The patient had an uncomplicated 3  x  2  x  2  mm obstructing ureteral calculus at the right ureterovesical  junction. UA was negative, no fevers and no chills.  The patient was discharged home with pain medicine, Flomax, and instructions for ample hydration and urology follow up.