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It’s one of those average days in the ED where you work. It’s not too busy, but it’s not exactly what you would call slow either. Your shift has been a little bit on the boring side: lots of URIs, non-specific abdominal pain, low-risk chest pain, ankle sprains, and the occasional mild CHF or COPD flare. Also, too many people with the dreaded “multiple complaints” presentation.
You’re actually hoping for a trauma, a STEMI, appendicitis or something you can fix or at least treat. The next chart you pick up says “Right flank pain”. The differential diagnosis region of the right lobe of your brain immediately starts churning– pyelonephritis, nephrolithiasis, muscle strain – less likely, but not to be forgotten, are renal infarct, cancer, pulmonary embolism, shingles, pneumonia, gallstones, appendicitis – you stop there as you are about to enter the patient’s room.
Sitting in front of you is a Spanish-speaking female who states that she has been having pain on her right side for about 5 months. It is getting much worse, and tonight she thinks she saw blood in her urine. She’s been to a clinic doctor three times for this and each time they give her antibiotics for a “kidney infection”, but the pain is not going away. She denies any fever, nausea, vomiting, trouble breathing, radiation of the pain, change in appetite, or any other associated symptoms. She got scared when she saw the blood in her urine, so she got a friend to drive her in. Except for hypertension and asthma she is otherwise healthy. Her only prior surgical history is two C-sections. She’s never had a kidney stone or kidney infection and she has no family history of any significant diseases.
On physical exam, she appears to be fairly comfortable with normal vital signs except for her blood pressure, which is 180/122 mmHg. Her head and neck are normal to inspection. Her heart is regular and lungs are clear. She has symmetric pulses, bilaterally, throughout. Her abdominal exam shows mild diffuse right sided tenderness, both in the upper and lower quadrants, but more so at the level of the umbilicus. She does have right CVA tenderness as well, which seems to be more severe than her abdominal tenderness. Her urine is at the bedside and appears clear and yellow.
In terms of your initial differential diagnosis, you feel pretty confident that this is not pulmonary. If there is truly blood in the urine, it strongly suggests a renal process, but the “blood” could be a red herring. Perhaps she is menstruating or she ate beets or it was never really there. Although the differential is still broad, you doubt that she’s going to have appendicitis or gallstones. You decide to perform a quick bedside scan of her abdomen to determine how to proceed. If you see emergent pathology on her bedside renal and biliary scan, you can follow-up by ordering a comprehensive scan through radiology. If her kidneys and biliary system look pristine, you will proceed with a CT scan of her abdomen and pelvis to rule out the other etiologies you were considering.
Here are two of the images you obtain. What do you see? In addition to a UA, CBC and BMP, what type of imaging should you order? Conclusion on next page.