UCONN Emergency Medicine Interest Group

Posts Tagged ‘ultrasound’

Ultrasound Case #7

In RADIOLOGY on January 28, 2012 at 2:27 PM

Syndicated from the UCONN EM Residency website; credit to Dr. Russell and Dr. Kleinberg for cases and images.

Case

CC: Right flank pain

HPI: 54 yo male with PMH HTN and high cholesterol presents to the ED with acute onset of right sided flank pain beginning 18 hours prior to arrival.  Associated with nausea, vomiting and chills.  Pain is  intermittent, 10/10 and colicky.  He denies any diarrhea, constipation or urinary symptoms.

SH: Smokes 1.5 pack year history, denies other drugs or alcohol use.

FH: DM2, HTN, Hyperlipidemia

PE: Afebrile, VSS
Abdomen is obese, soft, non-distended, tender in RUQ, + Murphy’s sign, + bowel sounds

Labs: WBC’s16.2 with left shift.  Otherwise rest of CBC and chem7 within normal limits.

UA: 10 RBC’s, >25 WBC’s, no nitrites.

Urine culture: polymicrobial.

Bedside U/S:

What do you see?

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Ultrasound Case #6

In RADIOLOGY on November 29, 2011 at 7:00 AM

Syndicated from the UCONN EM Residency website; credit to Dr. Russell and Dr. Kleinberg for cases and images.

CC: left leg swelling

HPI: 81 yo male with PMH HTN, DM2, h/o colon cancer with recent colon resection one month prior presents to ED with left leg swelling, beginning 2-3 days ago.  Denies any chest pain, fevers, chills, h/o recent travel or urinary complaints.

SH: history of 20 pack years but quit 10 years ago.  No other drugs.

FH: denies.

PE: afebrile, VSS
Left lower extremity: calf edema, remarkably larger than the right. No tenderness to palpation, no erythema.  Distal pulses intact.

Labs: WBC slightly elevated at 11.8, otherwise rest of CBC and Chem7 grossly wnl.

Bedside U/S: see above images.

Where are the 2 points that should be compressed to look for a lower extremity DVT? What was the finding in this case?

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Ultrasound Case #5

In RADIOLOGY on October 23, 2011 at 7:00 AM

Syndicated from the UCONN EM Residency website; credit to Dr. Russell and Dr. Kleinberg for cases and images.

Gallbladder wall

Common bile duct

CC: Abdominal pain – RUQ

HPI: 25 yo female with no PMH presents to the ED with nausea, vomiting and abdominal pain beginning the previous evening ½ hour after eating dinner.  Pain located in RUQ, 10/10 intermittent colicky pain.  Denies any fevers, chills, diarrhea, constipation, urinary symptoms or anorexia.

SH: Smokes 1.5 pack year history, denies other drugs or alcohol.

FH: DM2, HTN, Hyperlipidemia, Colon Cancer

PE: Afebrile, VSS
Abdomen is obese, soft, non-distended, tender in RUQ, + murphy’s sign, + bowel sounds

Labs: WBC’s14.9 with left shift.  H/H, Platelets and Chem7, AST, ALT, lipase and bilirubin within normal limits.  Alk Phos 141.

Bedside U/S: see above images.

How would you describe the ultrasonographic findings?

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Ultrasound Case #4

In RADIOLOGY on September 25, 2011 at 11:19 AM

Syndicated from the UCONN EM Residency website; credit to Dr. Russell and Dr. Kleinberg for cases and images.

CC: shortness of breath

HPI: 62 yo female with no significant pmh presents with shortness of breath worsening over the last 3 days with associated lest sided chest pain, low grade fever and non productive cough.

SH: 40 pack year smoking history, occasional alcohol.  Denies drug use.

FH: Lung cancer

PE: T 100.8 BP 110/90 HR 99 RR 24 SAT 90% ra. GEN: Uncomfortable, speaking in fragmented sentences.  CV: Regular rate and rhythm, no MRG.  PULM: Moderate respiratory distress.  Absent breath sounds in the base and midway up the back on the left.  Dullness to percussion on the left compared to the right.

EKG: Normal sinus rhythm with occasional PVCs.

Labs: WBC 12.5 with left shift, remainder of CBC, Chem7, PT/INR and cardiac enzymes grossly within normal limits.

Bedside U/S: see beginning of post for 1st still image; click for video.

What is the cause of the patient’s dyspnea? (click below to see the answer below the fold)

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Journal Article Synopsis: β-hCG, Ultrasound, and Ectopic Pregnancies

In JOURNAL CLUB on August 8, 2011 at 3:32 PM

Summary of “Use of a β-hCG Discriminatory Zone With Bedside Pelvic Ultrasonography” By Ralph Wang et al, Annals of Emergency Medicine vol 58: pp. 12-20. 2011.

What is already known on this topic:
Currently, pregnant women presenting to the ED with abdominal pain, vaginal bleeding, or syncope are assessed with pelvic ultrasonography and quantitative serum β-human chorionic gonadotropin (β-hCG) to rule out the possibility of an ectopic pregnancy. In 10-30% of these cases pelvic ultrasound is unable to reveal either an intrauterine (IUP) or ectopic pregnancy- an “indeterminate result”. A level of β-hCG above the “discriminatory zone” of 1500-3000 mIU/mL, in combination with an indeterminate ultrasound, has been shown to be associated with ectopic pregnancy.

What question this study addressed:
What is the utility of the β-hCG discriminatory zone in differentiating between ectopic and intrauterine pregnancies after an indeterminate bedside pelvic ultrasonography in symptomatic pregnant patients presenting to the ED?

What was the study design:
Cross-sectional study of 256 first-trimester pregnant patients presenting to ED with symptoms of abdominal pain or vaginal bleeding. All pelvic ultrasonography was performed by emergency physicians who were blinded to the patient’s β-hCG levels. Research assistants (blinded to the ultrasound results) contacted and performed a standardized interview with all enrolled patients at 8 weeks.

What this study adds to our knowledge:
A β-hCG cutoff of 3000 mIU/mL is not acceptable for use in clinical practice when attempting to identify ectopic pregnancy in symptomatic patients with an indeterminate result on bedside pelvic ultrasonography (sensitivity of 35% and specificity of 58%). On follow up, it was found that 65% of patients with an ectopic pregnancy have a β-hCG < 3000 mIU/mL.

How this is relevant to clinical practice:
When pelvic ultrasound is indeterminate for intrauterine pregnancy, serum β-hCG level alone does not differentiate intrauterine and ectopic pregnancy. A β-hCG cutoff of 3,000 mIU/mL will not aid with the exclusion of ectopic pregnancy and will cause 65% of cases to be missed.

Other considerations:
In the future the discriminatory zone of β-hCG must be re-evaluated. The bedside pelvic ultrasound can reliably exclude ectopic pregnancy only when they demonstrate a clear intrauterine pregnancy in symptomatic pregnant ED patients. Practitioners should avoid an inappropriate interpretation of β-hCG levels in patients without a clear diagnostic result.

Ultrasound Case #3

In RADIOLOGY on June 16, 2011 at 8:43 AM

Syndicated from the UCONN EM Residency website; credit to Dr. Russell and Dr. Kleinberg for cases and images.

CC: RLQ abdominal pain.

HPI: 25 yo female presents to ED with severe right lower quadrant abdominal pain beginning yesterday.  LMP about 7 weeks ago.  Denies vaginal discharge or bleeding.  No history of abnormal pap smears, STI’s or previous pregnancies.  Sexually active without protection.

FH: denies alcohol, smoking or drug use.

PE: Afebrile. VSS.  Abdomen tender to palpation suprapubic, right and left lower quadrants.  Pelvic exam with bilateral adnexal tenderness.  Cervical os closed.

Labs: Urinalysis negative for infection.  Urine pregnancy positive. H/H stable.  Quantitative B-hCG: 83,000.

Bedside U/S: (see beginning of post for 1st still image): click for video.

What is the next step in management? (click below to see answer below the fold)

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Journal Article Synopsis: Bedside Ultrasound for Pediatric Long Bone Fractures

In JOURNAL CLUB on June 13, 2011 at 11:00 AM

Summary for “Bedside Ultrasound for Pediatric Long Bone Fractures ” by Keith Cross in Clinical Pediatric Emergency Medicine Vol 12 (1); pp 27-36

What is already known on this topic:
Almost all suspected fractures are currently evaluated by radiographs, with fractures requiring reduction often requiring multiple radiographs and/or fluoroscopy. Bedside ultrasound may provide an alternate imaging modality with advantages of decreased radiation exposure, identifying occult fractures in young children with poorly ossified bones, and use in austere conditions without ready access to X-rays.

What question this study addressed:
Can bedside ultrasound be used in pediatric patients with suspected long bone fracture to diagnose fracture accurately?

Which long bone fractures have the best evidence for ultrasound diagnosis?

What was the study design:
Brief reviews of several studies for diagnosis of radius/ulna injuries and fractures, reduction of forearm fractures, humerus injuries, clavicle injuries, femur injuries, tibia/fibula injuries. The technique for identifying long bone fractures by ultrasound is described with recommendations on transducer choice and imaging settings.

What this study adds to our knowledge:
Sensitivity and specificity for diagnosing pediatric long bone fractures was high for a wide variety of suspected fractures. One study demonstrated highest accuracy for simple fractures of the femur, humerus, and forearm bones, and lowest accuracy for compound fractures, small bone fractures, and Salter-Harris type I injuries. Several studies showed ultrasound-guided forearm fracture reduction was very frequently successful on first attempt. Diagnosis of proximal and midshaft humerus fractures has good evidence; diagnosis of supracondylar fractures has less evidence and may be more challenging. Diagnosis of clavicle fractures has excellent evidence and may be suitable as a primary imaging modality, and offers the advantages of avoiding radiation to thyroid tissue. Femur fracture diagnosis currently has limited evidence, but some case reports and case series suggest it may be feasible for midshaft fractures. Tibia and fibula fracture diagnosis also has limited evidence, and the largest study thus performed shows a lower sensitivity for identification of these fractures.

The author recommends using a 10 to 15 Mhz linear transducer with the vascular preset setting. Fractures may be identified as a disruption of the echogenic line of cortical bone, a hematoma over the bone at the point of fracture, an avulsed bone fragment, or callus formation appearing as a hypoechoic mass around the bone.

How this is relevant to clinical practice:
Ultrasound diagnosis may be a more rapid and less painful way to diagnose some pediatric fractures with less radiation exposure and potentially less time required and decreased pain to the patient, particularly for forearm and clavicle fractures.

Other considerations:
Many of the studies were performed by radiologists or orthopedists as the sonographers; it would be helpful to see more studies using emergency physicians as the primary sonographers.

Ultrasound Case #2

In RADIOLOGY on May 29, 2011 at 9:21 AM

Syndicated from the UCONN EM Residency website; credit to Dr. Russell and Dr. Kleinberg for cases and images.

CC: Vision loss in right eye

HPI: 59 yo male with PMH poorly controlled diabetes presents with painless vision loss in the right eye.  Patient initially noticed blurry vision in the periphery of his right eye for the past week and an increase in the number of floaters in the eye.  Today it was almost like a black curtain was coming down in the eye so he came to the ED for an evaluation.  He denies any history of trauma, redness or foreign body sensation.

SH: Smokes 1ppd for the past 40 years, no IVDU or alcohol use.

FH: Diabetes.

PE: Afebrile, VSS.  Eyes: EOMI, PERRLA, no evidence of globe trauma.  Fundoscopic exam: no obvious abnormality.  Visual acuity: patient not able to see light or moving objects in right eye, left 20/50.  Intraocular pressure, 15 bilaterally.  Visual fields: not able to see out of right eye, normal in left eye. SLE: anterior chamber appears normal, no foreign bodies or corneal ulcerations appreciated.

Bedside U/S (see beginning of post for 1st still image): click for video.

What is the diagnosis? (click below to see the answer below the fold)

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Ultrasound Case #1

In RADIOLOGY on May 1, 2011 at 5:51 AM

Syndicated from the UCONN EM Residency website; credit to Dr. Russell and Dr. Kleinberg for cases and images.

CC: Back pain

HPI: 68 yo male with PMH hyperlipidemia and HTN presents to the ED with sudden onset of back pain beginning about 3 hours ago.  Pain is severe and sharp.  Associated lightheadedness, nausea and vomiting.  Denies chest pain, urinary symptoms, constipation, diarrhea, fever, chills or problems breathing.

SH: + smoking 50 pack year history, denies alcohol or other drug use

FH: HTN

PE: afebrile.  BP 100/80 HR 105 remainder of vital signs within normal limits. ABD: soft, diffusely tender, pulsatile mass,  +bruit.  No evidence of scrotal hematoma or Cullen sign.  Back: No CVA tenderness.  No ecchymosis.  Rectal: heme negative.

Labs: CBC, Chem7, LFTs, PT/INR/PTT and lactate within normal limits.  Urinalysis > 25 RBC’s, no evidence of infection.

Bedside U/S (see beginning of post for 1st still image):

 

Click for doppler video.

What is the diagnosis? (click below to see the answer below the fold)

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