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Saving Brainspace with POCUS

February 8, 2018

Here is a cool case that Lloyd Gordon recently sent us…

“A 60 year-old woman had a fever of 39.6C and vomiting. The triage note mentioned abdominal pain but she didn’t have any pain when I saw her and she never asked for analgesics. Her abdomen was completely benign and she looked well. Not much to go on, especially with roughly another patients with influenza and gastroenteritis in the ED at the same time. I POCUS’ed all over, of course.

Here is her IVC:

Somewhat underfilled.

Here is her right kidney:

The right kidney showed a very prominent medulla, looking like nephrocalcinosis.

And her left kidney:

The left kidney had moderate hydronephrosis. [Ed. note: One wonders about a stone in the renal pelvis where there seems to be calcification (see circle). But there is no shadowing.]

Here is the CT scan:

A big stone at the UPJ.

So from an initial non-specific fever/vomiting/?abdomen pain, an immediate diagnosis of a urological emergency: renal colic with sepsis. Her lactate was 4.0. IV bolus/antibiotics and referral to urology.”

Ed. note: Think about what would have happened before POCUS in such a patient. 60 years old. Fever and vomiting. Abdo pain but non-tender. Flu season. Here’s your IV fluids and anti-emetics. Feeling better? Perfect! Because we don’t have any beds so you can go. If you are more concerned about her, maybe you do more tests and admit her, and you or the admitting MD falls upon the diagnosis…eventually. POCUS saves Brainspace on shift. The diagnosis is made up front. Treatment is started sooner. No diagnostic dilemma. Disposition from the get-go. The chart is off the EP’s clipboard and the case is off the brain of the EP, which is now clearer and ready to tackle the other patients, without the details of this case clouding their cortex.

Lloyd brings up nephrocalcinosis. Rather than blabbing on about it, here are some links regarding that entity from the good folks at Sonoworld and Radiopaedia.

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