Visual EM

Saddle Pulmonary Embolus

Colin Therriault, MD^*, Daniel Natkiel, DO^* and Megan Stobart-Gallagher, DO^{^}

DOI: https://doi.org/10.21980/J8N63P Issue 4:2 No ratings yet.

An electrocardiogram (ECG) showed evidence of right heart strain with an incomplete right bundle branch block, S1Q3T3 (see red arrow [S1], blue arrow [Q3], and black arrow [T3]), and ST-segment elevation in the septal leads (green arrows). Bedside echocardiography showed a dilated right ventricle with ventricular wall akinesis (red arrow) sparing the apex (purple arrow), which is known as McConnell’s Sign. It also showed a mobile hyperechoic mass (yellow arrow). These ultrasound findings were concerning for pulmonary embolism (PE), so computed tomography (CT) angiogram of the chest was ordered and confirmed massive bilateral obstructive filling defects (red arrows) consistent with saddle pulmonary embolism. Additionally, noted is flattening of the interventricular septum (blue arrow) consistent with right heart strain. Laboratory studies were notable for a troponin-I of 0.29 ng/mL, a B-type natriuretic peptide of 792.3 pg/mL, lactic acid of 5.30 mmol/L, and a creatinine of 2.0 mg/dL, consistent with end organ dysfunction. All other lab work was within normal limits.

Visual EM Cardiology/Vascular Respiratory

Sigmoid Diverticulitis Complicated by Colovesical Fistula Presenting with Pneumaturia

Faraz Khan, BS^*, Justin Yanuck, MD^* and C Eric McCoy, MD, MPH^*

DOI: https://doi.org/10.21980/J80G9TIssue 4:2 No ratings yet.

A CT scan of his abdomen/pelvis shows acute sigmoid colonic diverticulitis with adjacent extraluminal collection containing gas (axial view, white arrow) consistent with perforation, along with abutment of the urinary bladder with intraluminal bladder gas (sagittal and coronal views, white arrowheads) suggesting colovesical fistula.

Abdominal/Gastroenterology Visual EM

A Woman with Arm Spasms

Anita Mudan, MD^* and Wilma Chan, MD, EdM^*

DOI: https://doi.org/10.21980/J8VP88Issue 4:2 No ratings yet.

The patient had a witnessed episode of isolated left upper extremity jerking, shown in the video, during which she was completely awake and conversant. Lab results were significant for serum glucose of 1167 mg/dL, no anion gap, and negative serum/urine ketones. She had a computed tomography (CT) of the head that did not show any acute pathology, and underwent a brain magnetic resonance imaging (MRI) without any signs of stroke or other pathology, shown below.

Renal/Electrolytes Neurology Visual EM

Idiopathic Intracranial Hypertension and Optic Nerve Sheath Diameter

Lauren Ann Selame, MD^*and Zachary Risler, MD, MPH^*

DOI: https://doi.org/10.21980/J84631Issue 4:2 No ratings yet.

Optic nerve sheath diameter (ONSD) was measured via ultrasound with diameter 5.7mm on left and 6.2mm on right. In order to measure ONSD via optic ultrasound the high-frequency linear array probe (7.5-10-MHz or higher) is utilized in B-mode. The patient is positioned supine and an occlusive dressing, such as Tegaderm, is placed over a closed eyelid with copious conductive gel on top of the dressing. Being careful not to put pressure on the globe, an axial cross-sectional image of the globe is obtained. As demonstrated in the image “annotated left eye ONSD pre-lumbar puncture,” there are two main anechoic areas of the globe, the anterior chamber and the vitreous humor. These anechoic structures are separated by the hyperechoic iris, which surfaces the hyper-echoic-lined lens. At the back of the vitreous humor is the retina, which leads posteriorly into the optic nerve. The optic nerve is the hypoechoic structure posterior to the retina and surrounded by the hyperechoic subarachnoid space, which is encased by the hypoechoic dura mater. The outer edge of the hypoechoic dura matter is where the ONSD is measured.1 The user applies calipers to measure 3mm perpendicularly behind the retina along the hypoechoic optic nerve, and at this level the transverse dimensions of the ONSD are measured using calipers as shown in the images.Computed tomography (CT) of the head was performed and showed no abnormalities. Lumbar puncture was performed in left lateral decubitus position revealing elevated opening pressure of 29cm H2O. Thirty-five mL of clear cerebral spinal fluid was drained and was negative for all infectious studies. Optic nerve sheath diameter was again measured post-lumbar puncture with diameters 5.4mm on left and 5.4mm on right.

Visual EM Ophthalmology

Pericardial Clot on Point-of-Care Ultrasound

Rame Bashir, BS^*, Esther Kim, BS^*, Shadi Lahham, MD, MS^* and John C Fox, MD^*

DOI: https://doi.org/10.21980/J8ZH1TIssue 4:2 No ratings yet.

Focused assessment with sonography in trauma (FAST) scan was positive for a clinically significant pericardial effusion as evidenced by the hypoechoic fluid around the myocardium, indicated by the blue arrow in image 2. Findings are also consistent with tamponade process as evidenced by restricted expansion and collapse of the right ventricle during diastole. The hyperechoic floating structure between the pericardium and myocardium, adjacent to the right ventricle, represents a pericardial clot, indicated by the white arrow.The density of the pericardial clot differs from that of the myocardium, thus serving as an additional variable to avoid confusing this as part of the myocardial structure.

Cardiology/Vascular Ultrasound Visual EM

Wellens’ Syndrome

Brittany Perry Hoffstatter, DO^* and Brian Walsh, MD^*

DOI: https://doi.org/10.21980/J8FS8KIssue 4:1 No ratings yet.

Initial electrocardiogram (ECG) revealed the classic biphasic T waves in V2 and V3 of Wellen’s syndrome (see red outlines). A second EKG demonstrated an evolving deeply inverted T wave (see blue outlines).

Visual EM Cardiology/Vascular

Arteriovenous Graft Pseudoaneurysm

Erik Madsen, MD^*, Lauren Sylwanowicz, MD^{^} and Alisa Wray, MD, MAEd^{^}

DOI: https://doi.org/10.21980/J8B06ZIssue 4:1 No ratings yet.

A bedside ultrasound of the mass demonstrated a large compressible hypoechoic structure (see purple outline) above the arteriovenous graft (see red outline). The contents demonstrated movement of fluid within the structure. This was confirmed with Doppler mode, which allowed for visualization of flow communicating between the structure and the underlying vessel, which is diagnostic for a pseudoaneurysm.

Visual EM Cardiology/Vascular

Bilateral Shoulder Dislocation after Ski Injury

Alaina Rajagopal, PhD, MD^*, Brian Knight, BS^* and Lance Orr, MD^{^}

DOI: https://doi.org/10.21980/J86929Issue 4:1 No ratings yet.

An anteroposterior chest X-ray demonstrates bilateral shoulder dislocations. Both the right and left humeral heads (blue lines) are displaced medially, anteriorly, and inferiorly from their normal positions in the glenoid fossae (red lines), thus signifying bilateral anterior dislocations. There is also a fracture of the left humeral head at the greater tubercle (green arrow).

Orthopedics Trauma Visual EM

Abdominal Pain with Black Tongue

David A Adler, MD^* and Isabel M Algaze Gonzalez, MD^{^}

DOI: https://doi.org/10.21980/J8XS7JIssue 4:1 No ratings yet.

Patient’s tongue had a black discoloration, without elongated filiform papillae. We could not appreciate lymphadenopathy. His abdomen was tender to palpation.

ENT Visual EM

Beware the Devastating Outcome of a Common Procedure

Ellsworth J Wright IV, MBS^*, James F Martin MD^{^} and Kevin Sirchio, DO^{^}

DOI: https://doi.org/10.21980/J8T336Issue 4:1 No ratings yet.

Non-contrast head computed tomography (CT) demonstrates multifocal bilateral hypodense lesions (white arrows) representing air emboli. Note the lesions are located in the intra-axial distribution which indicates an underlying vascular origin.

Neurology Procedures Visual EM