Maryam Bahreini, Robab Sadegh, Javad Seyedhosseini

AIM

Point-of-care ultrasonography can play an important role in critical diagnoses in the emergency department and can effectively investigate the differential diagnoses in atypical presentations.

CASE PRESENTATION 

A 49-years old man presented to our emergency department with severe low back pain radiating to the back with left lower limb numbness.

He had a history of hypertension and a documented lumbar disc herniation in the last previous months that partially relieved with non-steroidal anti-inflammatory drugs.

Vital signs were as following: blood pressure 165/90, pulse rate 100 and no fever. On physical exam, negative straight leg rising test, no focal neurologic deficit, no midline bony tenderness and soft abdomen without tenderness, mass or rebound tenderness were detected.

His left extremity showed slightly weaker distal pulses. The pain was not efficiently controlled despite adequate doses of analgesics and he developed copious sweating and agitation with low back pain. He reported left limb paresthesia that has been attributed to the disc herniation.

Because of the discrepancy between symptoms and inadequate response to pain killers, point-of-care abdominal ultrasonography was done.

RESULTS

Point-of-care-ultrasonography in 3 short and long axes views revealed an infra-renal abdominal aortic aneurism with maximum diameter of 6 centimeters and a mural thrombosis without free fluid in the abdomen.

The color Doppler ultrasonography of the left extremity showed monophasic pattern of dorsalis pedis and tibialis posterior pulses. Therefore, vascular surgery consultation was requested and he was admitted for further vascular intervention.

CONCLUSION

The critical diagnosis of abdominal aortic aneurism can be variously presented with abdominal, flank or back pain or shock state resulting in delayed and sometimes uneventful outcomes.

Point-of-care ultrasonography is highly sensitive and specific for the diagnosis of abdominal aortic pathologies and can helpfully guide the patient diagnosis and disposition.

Figure 1: Abdominal aortic aneurism with a diameter of 6 centimeter containing a mural thrombosis.