The game changer

Images Bashir Antoine Chakar (Emergency Registrar), text Genevieve Carbonatto

A 63 year old lady presents overnight with lower abdominal pain and left renal angle pain. She has blood and WCC in her urine. She is known to have recurrent UTI’s. The patient is handed over to you as a having a recurrence of her UTI with possible pyelonephritis. Her back/renal angle pain has improved and she is to be sent home. You go and see the patient and she appears uncomfortable. You decide to do an ultrasound.

This is her left kidney longitudinal scan

Note the mild to moderate hydronephrosis

This is her left kidney transverse scan. Note that while scanning an echogenic focus in the pelvis of the kidney is visualised and casts a shadow. This is a stone in the PUJ which is causing PUJ obstruction and hydronephrosis

To confirm the presence of the stone you look for the twinkling artifact.

This is clearly a game changer. The patient may have an infection in her urine, but her pain is most likely due to this stone in the PUJ (pelvi ureteral junction) which is causing hydronephrosis. Her journey though the Emergency Department changes. She is referred to Urology and gets a CTKUB.

Teaching point: The ability to perform point of care ultrasound can be a game changer. It is worthwhile remembering that the diagnosis made in the Emergency Department will often “stick” to the patient even when the patient is admitted. Getting the diagnosis in a timely manner at the bedside using focussed point of care ultrasound can revolutionise patient care and patient outcomes 


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