Case 46

84yo M hx CABG, AAA s/p repair, & HTN presenting with hematuria x9 days. Hematuria is intermittent, sometimes with gross clots. Denies f/c/n/v/d, CP, SOB, dysuria, all other sx.  

ROS negative aside from painless hematuria.

96.7 degreesF
P 77
R 20
151/69  
96% on RA

CONSTITUTIONAL: The patient is alert and in no apparent distress. Appears WDWN. 
EYES: Conjunctivae: Normal
CARDIOVASCULAR: Regular rate and rhythm, heart sounds normal, no gallops, rubs or murmurs, no edema present. 
RESPIRATORY: Breath sounds clear, no distress present, no wheezing rales, rhonchi or tachypnea. Normal rate and effort. 
GI/ABDOMEN: Palpation: Soft, non-tender, no guarding or rebound tenderness. Bowel Sounds: normal. 
MUSCULOSKELETAL/EXTREMITIES: no cva ttp
INTEGUMENTARY: Color normal for race, warm and dry, no rash. 
NEURO: Oriented x 3. 
PSYCH: Normal mood and affect. 

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QUESTIONS

  1. What exam is being performed and which probe should be used for this exam
  2. What findings do you see in these images?
  3. What is in the differential diagnosis?
  4. What is your next best step in management?
  5. Why is color doppler useful in this exam?

ANSWERS

  1. The exam being performed is a renal ultrasound. Ideally, a curvilinear probe should be used for this exam as it is low frequency and high penetration with a large footprintHowever, the phased array probe also has a low frequency and high penetration and can be used for this exam.  In particular, the smaller footprint of the phased array probe may be more ideal in pediatric renal ultrasound.
  2. In the RUQ, we see a normal kidney. In the LUQ, we see moderate hydronephrosis as shown by the dilated renal pelvis without cortical thinning which would be seen in severe hydronephrosis. (Images attached) The renal ultrasound exam is performed by looking at b/l kidneys in both transverse and sagittal views, and putting color flow as necessary for any concerning findings (i.e. masses to differentiate between cyst vs vascular lesion). In addition to looking at the kidneys for a full renal ultrasound evaluation, the bladder must also be visualized to determine if there is any abnormal distension, wall thickening, stones, or lack or presence of ureteral jets via color flow, etc. The bladder must also be visualized in both transverse and sagittal views and must be fanned through completely. 
  3. Differential ddx includes obstructive stone or uropathy, including stricture, masses (extrinsic or instrinsic), and infection.  
  4. Next best step in management now knowing that there is unilateral hydronephrosis should include CT for visualizing a cause of the obstruction.  
  5. Color doppler is useful in renal ultrasound because it can differentiate normal vasculature or even pathologic dilation of renal vasculature from hydronephrosis, cysts, and abscesses.


This patient was found to have moderate L sided hydronephrosis on our ultrasound exam, subsequently underwent CT AP and was found to have moderate L hydrouteronephrosis without obstructive radiopaque GU calculus increased from a prior CT. This patient was then admitted and underwent a nuclear medicine renal flow function test with Lasix where the L kidney was found to account for 25% of total renal function. The primary team is still looking for a cause of this hydronephrosis and the patient is still admitted.