A transabdominal point-of-care ultrasound (POCUS) was initiated to determine whether an abnormality to the pregnancy could be identified. Curvilinear probe was used. Our transabdominal POCUS, in the transverse plane, showed a heterogenous mass with multiple anechoic areas in the uterus. The white arrow on the ultrasound identifies these findings. The classic “snowstorm” appearance was concerning for molar pregnancy.
Physical exam revealed a comfortable-appearing male patient with tachycardia and a regular cardiac rhythm. The genitourinary exam indicated significant erythema and fluctuance of the bilateral lower buttocks with extension to the perineum. Black eschar and ecchymosis were also noted at the perineum. There was significant tenderness to palpation that extended beyond the borders of erythema. There was no palpable crepitus on initial examination. Physical exam was otherwise unremarkable.
A Case Report of the Rapid Evaluation of a High-Pressure Injection Injury of a Finger Leading to Positive OutcomesDOI: https://doi.org/10.21980/J8TD2X
On exam the patient was noted to have a punctate wound to the ulnar aspect of his right index finger, just proximal to the distal interphalangeal joint. The finger appeared pale and taut, with absent capillary refill. The patient displayed diminished range of motion with both extension and flexion of the joints of the finger. Sensation was absent and no doppler flow was appreciated to the distal aspects of the finger. X-ray of the hand was obtained and showed many small foreign bodies in the soft tissue and extensive radiolucent material consistent with gas or oil-based material to the palmar aspect of the index finger tracking up to the level of the metacarpal heads.
A CT scan of the abdomen and pelvis with intravenous contrast for evaluation of new onset abdominal pain and distension was obtained in the emergency department. The axial view (CT Image A) shows the coil pack from the prior coil-assisted retrograde transvenous obliteration procedure, seen in the left renal vein and gastric varix (red arrow). The path of the coil (yellow arrow) is continuous into the inferior vena cava (CT Image B). It is then seen (CT Image C) situated in the right ventricle (green arrow). Finally, the coil pack is seen in a coronal section, demonstrating its upward path (blue arrow) in the inferior vena cava. (CT Image D). Additional findings included ascites with advanced cirrhosis. As noted in the CT images, a vascular embolization coil was seen within a varix near the junction of the left renal vein. This appeared to have unraveled and extended superiorly into the inferior vena cava and ultimately into the right atrium and right ventricle.
The neurology service was consulted in the ED and multisequence MRI and MR angiography (MRA) of the brain were obtained without and with IV contrast. Diffusion-weighted imaging (DWI) and T2-weighted-Fluid-Attentuated Inversion Recovery (FLAIR) sequences showed multifocal small areas of diffusion signal abnormality in the brainstem and basal ganglia (red asterisks) suggestive of ischemia. Additional multifocal bilateral supra- and infratentorial foci of signal abnormality including subcortical white matter and deep grey matter were highly concerning for encephalitis or demyelinating disease. MRI was repeated on day 3 and day 7 during evolution of disease.
Case Report of a Pelvic Kidney with Ureteral Obstruction from Inguinal Hernia Entrapment and Concurrent Cryptorchid TestisDOI: https://doi.org/10.21980/J8F345
The patient was afebrile with normal lactate and white blood cell count. Initial CT imaging showed an ectopic right pelvic kidney with entrapment of his right ureter within an indirect right inguinal hernia causing severe hydronephrosis (coronal: white arrow). Also discovered was an ovoid hypodensity in the right anterior pelvis consistent with right undescended testis (axial: orange arrow; coronal: green arrow) that was previously unknown to the patient, with a normal left scrotal testis (axial: red arrowhead; coronal: blue arrowhead). Other potential etiologies of the patient’s symptoms could include appendicitis or incarcerated inguinal hernia, though the imaging results and absence of systemic inflammatory response syndrome made these causes less likely.
Computerized tomography with angiography (CTA) of the entire aorta demonstrated an occluded distal infrarenal aorta with extension into the bilateral common femoral arteries (red outline), lack of flow through femoral arteries (yellow outline) and trickle flow reconstituted distally consistent with aortoiliac occlusive disease (blue outline). Some small segments of the proximal celiac axis showed signs of occlusion (purple outline). A short segment of non-specific bowel wall thickening, which may have been related to ischemic changes, was also seen (not seen on images). The included coronal slice shows the extent of the bilateral occlusive burden, with three-dimensional reconstruction emphasizing the same findings.
The CT imaging of the abdomen and pelvis demonstrated multiple loops of dilated small bowel with a whirl sign (red arrow) within the mid abdomen and a transition point (green arrow), suspicious for closed loop bowel obstruction and internal hernia.
A focused assessment with sonography in trauma (FAST) exam was performed initially to evaluate for intra-abdominal injury given the clinical picture. A phased-array ultrasound transducer was placed in sagittal orientation along the patient’s right and left flank, demonstrating extensive heterogenous fluid collections in Morrison’s pouch (red arrow), subphrenic space (solid green arrow), and splenorenal recess (dashed green arrow). To further evaluate, a phased-array transducer was placed over her pelvic area in transverse orientation, demonstrating, a large, heterogeneous mass (outlined in yellow arrows). The surgical team was promptly consulted and blood products were ordered. Although there was concern for impending hemorrhagic shock due to patient’s presenting tachycardia, the patient was hemodynamically stable enough for a CT scan of her chest, abdomen, and pelvis. The CT scan showed large-volume ascites, which exerted mass effect on all abdominal organs with centralization of bowel loops. Additionally, there was a large, 6.4 x 6.8 x 10.9-centimeter, midline pelvic mass (outlined in blue arrows).
A Case Report of Aortic Dissection Involving the Aortic Root, Left Common Carotid Artery, and Iliac ArteriesDOI: https://doi.org/10.21980/J8V93K
Computed tomography angiography (CTA) of the thoracic and abdominal aorta revealed an aortic dissection of the ascending aorta, with a dissection flap starting from the aortic root/aortic annulus (yellow arrows), extending into the aortic arch (light blue arrowhead) and involving the left common carotid artery (purple arrow), left subclavian artery (pink arrow), extending to the descending aorta (red arrows), and into the bilateral iliacs (green arrows). The true lumen (red star) and false lumen (blue star) created by the dissection flap can best be seen in the axial views.