August 2013 Case of the Month

A 36yo male presented with one day history of lower abdominal discomfort and decreased appetite.  He otherwise appeared well.  On physical exam he was noted to have tenderness in the right lower quadrant.   Bedside ultrasound demonstrated the following:

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The patient was diagnosed with acute appendicitis.  A high frequency linear transducer was used, placing the probe at the site of maximal tenderness as identified by the patient.  Landmarks to identify when looking for the appendix include the Psoas muscle and the Iliac vessels.  A normal appendix should have wall measurements less than 3mm and a maximal diameter less than 6mm and should be compressible.  The video clearly demonstrates a non-compressible appendix by the graded compression technique, and the wall measurements are > 6mm.  Applying color also clearly identifies hyperemia in the wall of the appendix!

If the appendix had ruptured you may see fluid or anechoic material surrounding the appendix.  You may also see shadowing from an appendicolith.

Keep in mind that nearly 60% of appendices are retrocecal, so inability to visualize the appendix does not exclude appendicitis!



July 2013 Case of the Month courtesy of Meghan Spyres

A 31yo male presented with right flank pain over the past two weeks.  He stated that he had a history of kidney stones over 10 years ago but stated that his current symptoms are much worse.  He also reported that he had some blood in his urine when his symptoms started that had since resolved.  On exam patient was noted to have right CVA tenderness.  His labs demonstrated leukocytosis and a UTI with large blood.

Bedside Ultrasound revealed the following:

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These ultrasound images demonstrate moderate to severe hydronephrosis with a visible stone (demonstrating shadowing).  The patient was started on antibiotics, given analgesia and admitted to Urology.  A CT that was obtained revealed a large intra-renal staghorn calculus measuring 2.1cm within the renal pelvis extending into the proximal ureter with associated moderate to severe left hydronephrosis.  He underwent emergent cystoscopy and bilateral stent placement with good results.

When obtaining ultrasound images of the kidneys, it is important to obtain both longitudinal and transverse views.  Often renal vasculature can be mistaken for hydronephrosis, so color doppler can be used to distinguish the two.  Hydronephrosis can be measured in three severities- mild, moderate and severe.

degrees hydro (image courtesy of


An official welcome to the new members of our Ultrasound team!!

We have two new members of our team- Kristin Carmody and our new fellow Adenike Folorunsho

KC  Kristin joins us from Boston Medical Center, where she was the Ultrasound Director.  She completed her residency at Kings County Hospital Center/SUNY Downstate and her Ultrasound fellowship at Yale University.     We are excited to have her!!

AdenikeF  Nike is our new Ultrasound fellow!  She attended medical school at the University of Southern California, San Francisco and completed her residency at New York Presbyterian at the University Hospital of Columbia and Cornell.  Nike is originally from Nigeria and has a special interest in International Emergency Medicine.