You are about to start your shift after a somewhat lengthy department meeting where one of the main topics discussed was utilization review with a special emphasis on cutting down the number of unnecessary advanced imaging studies. The physician champion for cutting down on unnecessary imaging had a lot of valid points. He stated that though advanced diagnostic imaging has many benefits, including first and foremost, decreased medical risk and, in general, better patient satisfaction, there are many down-sides, as well. Among these he listed were longer ED throughput times, unnecessary cost and having to explain and deal with the all too common incidental findings. The most important considerations, he opined, were exposure to the risks of ionizing radiation and of IV contrast associated with CT scanning.

After the meeting, the first patient you encounter is a 69-year-old man with a history of hypertension who presents with abdominal pain radiating to the back. He’s going to need a CT scan to rule out a AAA. Your second patient is a 23-year-old male who was hit in the head last night with a bottle and now has a splitting headache and recurrent vomiting. He’s going to need a CT scan too. You wonder if your third patient will require a CT as well? Will it be “three strikes and you’re out” or “third time’s a charm?” Great! As you pick up the chart, you see the chief complaint is “severe flank pain”.

The patient is a 25-year old female with a 2-hour history of severe left flank pain radiating to the groin. She states the pain came on suddenly and made her vomit twice. She denies missed periods, fever, dysuria and hematuria. She is otherwise healthy, but states her mom thinks it is a kidney stone because there is a family history of stones. You think to yourself that pyelo would be more likely given the demographics, but kidney stone, diverticulitis and pelvic pathology are also on your differential diagnosis radar. You’re at least thankful that the pain is not in the right lower quadrant.

You consider your approach. You’ll definitely need a UA and a pregnancy test. Will you need to do a CT scan? How about the dreaded pelvic exam? You decide to take to heart one of the strategies recommended at the end of the morning’s department meeting. One of your colleagues recommended forgoing formal imaging in patients with classic renal colic and no significant risk factors for aortic aneurysm or other more serious conditions as long as the UA was positive for blood. If you wanted additional diagnostic certainty, a focused ED sonogram could be done by the EP to look for hydronephrosis. You decide that this patient is perfect to implement this strategy on. She is young, so a AAA is pretty unlikely, and radiation from CT has the highest risk for younger patients.

You take the following image (image 1) of her left kidney. You also take a shot of her aorta to be safe and to practice your skills (image 2). What do the images show?

Image 1

Image 2


Should you take any other pictures?  Do you need to do a formal imaging study?
Conclusion on next page

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