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Question: nephrolithiasis

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You are seeing a 15yo girl with a strong family history of nephrolithiasis who presents with colicky right flank pain, non-bloody non-bilious vomiting twice, and microscopic hematuria. Her UA results do not support a diagnosis of UTI or pyelonephritis. She is not sexually active. She was seen in the ED 6 months prior for RLQ abdominal pain and underwent a CT scan which was negative for appendicitis or any other pathology. She describes the current pain as different from the pain she had 6 months ago. After IV fluids, ketorolac, and morphine therapy her pain is improved.

What is the most appropriate imaging approach for this patient?
7 votes

pemsou5_wp • May 11, 2021

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  1. Kelly May 12, 2021 - 7:58 pm Reply

    D) Ultrasound of the kidneys and bladder +/- plain radiography KUB
    This patient presents with symptoms concerning for nephrolithiasis. Abdominal/pelvic CT without contrast is the most sensitive imaging study for work-up of nephrolithiasis. However, in this pediatric patient, especially with a prior CT radiation exposure, ultrasound of the kidneys and bladder +/- KUB will provide adequate information for initial management, namely whether there is evidence of obstruction (hydronephrosis). A randomized trial in adults found no difference in high-risk diagnoses with complications, serious adverse events, pain scores, return ED visits, or hospitalizations between those randomized to POCUS, radiology department ultrasound, or CT (Smith-Bindman et al NEJM 2014;371:1100-10

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