So a 72 year old man is brought to the ER after collapsing at home. His family had noted weight loss in the last months, and recently some fever and general weakness. His HR is 108, T 38.8, BP 80/40, GCS 14 – somnolent – he is in lactic acidosis (4.5) and renal failure (cr 180 – baseline 120), with some vague abdominal pain, a clear chest and warm extremities.
POCUS shows a normal IVC, normal RV/LV, A profile lungs, no ascites, and this on the left flank:
What is the main diagnosis?
Scroll below for the answer:
So the clip shows fairly severe hydronephrosis, the “bear paw” with very dilated calyces. The patient was suffering from obstructed pyelonephritis due to massive retroperitoneal adenopathy later found to be lymphoma. A couple of hours later he got a nephrostomy tube to take care of the septic source (double J could not pass) and his sepsis resolved within a few days, and he headed off to chemo for the NHL.
The advantage of POCUS here is. once again, the speed of diagnosis. He went straight from CT to the readied urologists and source control happened within a couple of hours. His relatively benign abdomen may not have prompted a rapid CT otherwise.
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