Visual EM

Right Atrial Thrombus

Michael Berkenbush, MD, NRP^*, Mei-Yung Chan, MD^* and Amanda Esposito, MD^*

DOI: https://doi.org/10.21980/J8F93V Issue 4:3 No ratings yet.

History of present illness: A 77-year-old male presented to the emergency department with shortness of breath. Symptoms progressively worsened over the last 4-5 days, and on arrival was associated with chest tightness. He denied any medical conditions, smoking, or pertinent family history. He has not seen a primary care physician in “many years.” Upon arrival he was in mild

Cardiology/Vascular Visual EM

Posterior Vitreous Detachment

Hamid Ehsani-Nia, DO^* and Christopher Bryczkowski, MD^*

DOI: https://doi.org/10.21980/J89K9N Issue 4:3 No ratings yet.

Ocular ultrasound was performed and demonstrated a thin, slightly echogenic strand (blue arrow) extending from the posterior eye into the vitreous humor (yellow arrow) which was hyperkinetic with extraocular motion. These findings are consistent with a posterior vitreous detachment (PVD).

Ophthalmology Visual EM

Macula-Off Retinal Detachment Identified on Bedside Ultrasound

Colin Prather, MD^* and Bryson Hicks, MD^*

DOI: https://doi.org/10.21980/J8WP8KIssue 4:2 No ratings yet.

Point-of-care ultrasound was performed, demonstratinga free-floating, serpiginous, hyperechoic membrane (R) tethered at the optic nerve (ON) and ora serrata (OS), but detached at the macula (M) lateral to the optic nerve. This is diagnostic for macula-off retinal detachment. It can be differentiated from macula-on retinal detachment, in which the hyperechoic retina would appear attached posteriorly at the location of the macula just lateral to the optic nerve. Ophthalmology was consulted, agreed with the diagnosis of macula-off retinal detachment, and took the patient to the OR for laser photocoagulation.

Ophthalmology Visual EM

Point-of-Care Ultrasound for the Diagnosis of Systolic Heart Failure

Amal Shafi, BS^*, Maili Alexandria Drachman, MD^{^}, Michelle Bui, BS^* and Tushank Chadha, BS^*

DOI: https://doi.org/10.21980/J8HD1R Issue 4:2 No ratings yet.

Bedside ultrasound with the phased array probe was used to obtain a parasternal long axis view which demonstrated poor contractility and a severely decreased ejection fraction (EF). M-mode was placed over the anterior leaflet of the mitral valve to create a tracing depicting both the E-wave of early diastole (green arrow) and the A-wave from the atrial kick (blue arrow). The shortest distance between the septum and the mitral valve on the M-mode tracing gives the patient’s E-Point Septal Separation (EPSS) (pink arrow). EF can be estimated using the formula EF=75.5-2.5 x EPSS (in mm). This patient’s EPSS was measured to be 20mm which estimates that she had an EF of 25.5%.

Visual EM Cardiology/Vascular

Bedside Ultrasound for the Rapid Diagnosis of Fournier’s Gangrene

Patrick Penalosa, BS^*, Maili Alexandria Drachman, MD^{^} and Vy Han, MD^*

DOI: https://doi.org/10.21980/J8CP99Issue 4:2 No ratings yet.

Point of care ultrasound (POCUS) utilizing a high-frequency linear probe revealed heterogeneous debris with subcutaneous air within the scrotal wall extending into the perineum consistent with necrotizing fasciitis of the perineum or Fournier’s gangrene (FG). The video shows multiple foci of gas that appear as echogenic dots with “dirty shadows” posteriorly from reverberation artifact arising from gas within the soft tissue.

Infectious Disease Genitourinary Visual EM

Pneumocystis jirovecii (carinii) Pneumonia

Brian Knight, BS^*, Jonathan Patane, MD^* and Robert Katzer, MD, MBA^*

DOI: https://doi.org/10.21980/J8RW6NIssue 4:2 No ratings yet.

Chest X-ray showed diffuse, patchy interstitial and alveolar infiltrates bilaterally concerning for Pneumocystis jirovecii(previously Pneumocystis carinii) pneumonia (PJP). The AP radiograph (top left figure) showed the classic “bat-wing” distribution on the left side. Repeat radiograph (bottom figure) one day after admission showed worsening of the infiltrates.

Infectious Disease Respiratory Visual EM

Acute Pancreatitis

Ronald Goubert, BS^*, Jonathan Peña, MD^*, Alisa Wray, MD, MAEd^* and Eleanor Chu, MD^{^}

DOI: https://doi.org/10.21980/J88W5XIssue 4:2 No ratings yet.

Computed tomography of the abdomen and pelvis with contrast show edema of the pancreas (red outline) and duodenum (yellow arrow) with peripancreatic inflammation, fluid and fat stranding (blue highlight). The distal pancreatic tail was noted to appear normal (green arrow). There was no organized drainable fluid collection, and no parenchymal hypo-enhancement. These findings are consistent with moderate severity acute interstitial pancreatitis.

Abdominal/Gastroenterology Visual EM

Renal and Splenic Infarcts

Niketu Patel, MPH^* and Loice Swisher, MD^*

DOI: https://doi.org/10.21980/J8804KIssue 4:2 No ratings yet.

On the coronal sections of computed tomography (CT), bilateral renal infarctions (blue arrows) and several splenic infarctions (green arrows) are noted. Of particular interest, part of the clot totally occluding the left renal artery visibly extends into the aorta (red arrow). The vascular reconstruction image is remarkable for the absent left kidney, the unusual contour of the right kidney and the abnormal splenic blush.

Visual EM Abdominal/Gastroenterology

Erectile Dysfunction as a Presenting Symptom for Renal Cell Carcinoma

Frank Mayer III, MBA^*, Jonathan Wooden, MD^* and Megan Stobart-Gallagher, DO^*

DOI: https://doi.org/10.21980/J8563BIssue 4:2 No ratings yet.

The MRI showed extensive spondylotic changes suggestive of malignancy (red arrows) with severe spinal canal stenosis at the lumbar spine L3-L4 (purple arrows) level contributing to clumping of cauda equina nerve roots and severe bilateral neuroforaminal narrowing with diffuse disc bulges abutting the exiting nerve roots at multiple levels. Findings also showed a hypo-attenuated tumor (blue arrow) and hyper-attenuated loculated tumor (green arrow) consistent with renal cell carcinoma (RCC).

Visual EM Renal/Electrolytes

Pectoralis Muscle Tendon Rupture

Wyatt Verplaetse, MD^* and Gregory Podolej, MD^*

DOI: https://doi.org/10.21980/J81D01Issue 4:2 No ratings yet.

There is a noticeable difference in appearance and location of maximal prominence of the right pectoral muscle with arms outstretched (image 1). This is accentuated by having the patient perform an isometric arm press. (image 2).There is absence of the anterior axillary fold with adduction against resistance. The stump of the pectoralis muscle was palpated along his armpit. He otherwise has full range of motion in the shoulder with minimal pain.

Visual EM Orthopedics