This case scares me. Truly. We have all had patients with this chief complaint, maybe on a weekly, if not daily, basis. You know the one – guy comes in, says he has been diagnosed with …. lets see, its usually “herniated disk”, “muscle strain”, “sciatica”, or he may throw out a term that gets more of your attention like “stenosis”, but usually it’s just “I have a bad back” and now on narcotics (because there’s just no other way – ugh!) and just needs a refill. He may even have an empty bottle in hand. He just might ask for the medicine by name : “Norco 10s work really well, but my doctor put me on Oxycontin now. Can you give me enough for a month?” Response: “uh… No.” But I digress…..lets go to our crazy-scary case…
57 year old overweight male with a history of hypertension and high cholesterol on medicine for management ….c/o back pain. Lower back pain. “I threw my back out a few months ago when I was moving and ever since then it’s bothered me. I ran out of my Norcos and need more.” It was a gradual onset a few days after he moved into his house. No other signs or symptoms. The vitals are stable and at his baseline: T 36.8 HR 80 RR 16 BP 148/86 O2sat100%RA. The abdomen is …well…protuberant… and nontender. Back is mildly tender in the upper bilateral lumbar paraspinal musculature but absent when you distract the patient by talking about the SF Giants (oh yeah!). No neuro deficits and has great strength and distal DP pulses bilaterally. You look at the empty bottle and wonder whether you should refill for the week or look him up on the CURES database to see if he has drug-seeking behavior. You decide to look him up, but the medical student on the Ultrasound Elective wants to practice and I ask that she perform a Renal, Bladder, and Aorta Study. Starting with the Renal study, she uses the low frequency probe and places it on the right and left midaxillary lines (indicator toward the head) and fans through the longitudinal view of the kidney to look for pathology, namely hydronephrosis.
Ok, so no hydronephrosis on these longitudinal views (which was confirmed on the transverse views as well – not shown).
Wow – full bladder!! And after asking him, yes, he has to pee. Its so full and all that anechoic urine is causing the deeper region to be poorly evaluated due to the posterior acoustic enhancement (brightness posteriorly) – Fluid truly is the lover of US! Makes everything bright beyond it…
Now she looks at his transverse Aorta by using the phased array low frequency probe with the indicator toward his right, starting in the subxiphoid view, keeping the probe perpendicular to the skin, pushing down to attempt to get the bowel gas out of the way (as air is the enemy of US!) and sliding/travelling down toward his umbilicus:
And following it down to the bifurcation:
What she thinks: “Holy S***!”
What she says: “Ok sir, Im all done. I’ll need to talk with my supervisor about your ultrasound and we will both be right back.”
What I said: “Holy S***!”
Called Vascular surgery, he got admitted, had a repair of his infrarenal 5cm abdominal aortic aneurysm prior to it rupturing…..Like I said, scary case. And, in case you were wondering, there was no pulsating mass…there usually never is in the obese.