Visual EM

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Croup

Victor Cisneros, MD, MPH*, Joseph Zakaria, BS* and Wirachin Hoonpongsimanont, MD*

DOI: https://doi.org/10.21980/J8W05JIssue 3:4[mrp_rating_result]
The anteroposterior X-ray reveals the classic steeple sign (blue outline) indicative of subglottic edema leading to tracheal narrowing, consistent with croup. The lateral x-ray shows narrowing of the subglottic region (green outline and arrows).
PediatricsRespiratoryVisual EM
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Various Degrees of Thermal Burns

Hamid Ehsani-Nia, DO*, Mohammad I Ehsani-Nia, BS* and John Collins, MD*

DOI: https://doi.org/10.21980/J8R91WIssue 3:4[mrp_rating_result]
On exam,there is a large swath of skin with evidence of thermal injury involving the neck, shoulder, chest, and face, including damage to the ear, external nostril, and lips. Burns exhibit varying degrees of severity and total approximately 4.5% of the body surface area. Several areas are charred and insensate to pinprick. The left earlobe is partially burned off. Patient's airway is patent with no evidence of thermal injury or obstruction to the oropharynx or nasal vestibule.
TraumaVisual EM
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Pemphigoid Gestationis

Michael Niechayev, BS* and Lauren Sylwanowicz, MD*

DOI: https://doi.org/10.21980/J8MG9DIssue 3:4[mrp_rating_result]
Physical exam findings were significant for 1-3 cm diameter well-demarcated superficial ulcers on the patient’s abdomen and extremities, with mucosal sparing. Several small tense bullae were present on the bilateral inner thighs and numerous small reddish plaques were scattered over the patient’s back. Nikolsky’s sign was negative. No lymphadenopathy was noted.
DermatologyVisual EM
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Don’t Forget the Pacemaker – A Rare Complication

Amanda Esposito, MD*, Kenneth Rapp, MD* and Albert Ritter, MD*

DOI: https://doi.org/10.21980/J8GS7HIssue 3:4[mrp_rating_result]
The ECG demonstrated the presence of pacemaker spikes without appropriate capture (green arrows) and a ventricular escape rhythm which can be identified by an absence of P waves prior to the QRS complex (purple arrows). The portable chest X- demonstrated displaced pacemaker leads (red arrows) that were coiled around the pulse generator (blue arrow).   
Cardiology/VascularVisual EM
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Bedside Ultrasound of Retinal Detachment in a 19-year-old

Rami San Gabriel, BS*, Maili Alvarado, MD* and Vy Han, MD*

DOI: https://doi.org/10.21980/J80W6TIssue 3:3[mrp_rating_result]
The ocular point of care ultrasound (POCUS) utilizing a high frequency linear probe shows a retinal detachment (RD) with a thick, hyperechoic undulating membrane in the vitreous humor that is anchored at the ora serrata anteriorly and the optic disc posteriorly. Note that the retina is detached all the way to the optic disc making it "mac off." The macula, and more specifically the fovea, is located in the central retina and contains a high concentration of cone photoreceptors responsible for central, high resolution, color vision. In a "mac on" RD, the retina detaches in the periphery but remains intact centrally. This is an ophthalmologic emergency and timely diagnosis and intervention can be vision saving. This patient also has evidence of a posterior vitreous hemorrhage which has a characteristic swirling appearance with kinetic exam on real-time imaging. The detached vitreous body is not as well defined and is not anchored posteriorly to the optic disc.
OphthalmologyVisual EM
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Bullous Emphysema

Valerie Lew, MD*, John Costumbrado, MD, MPH^ and Steven Kim, MD^

DOI: https://doi.org/10.21980/J8W62GIssue 3:3[mrp_rating_result]
The upright chest X-ray shows a large lucent area in the left lower lung field without lung markings, with associated curvilinear opacities (yellow arrows) consistent with a large air-filled bulla. The bulla is large enough to compress adjacent lung tissue as shown by the visible pleural line (blue line). The discontinuity of the pleural line and presence of lung markings superiorly makes these findings more consistent with bulla than pneumothorax. The chest computed tomography (CT) confirmed a large left hemithorax bulla.
RespiratoryVisual EM
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The Role of Chest X-Ray and Bedside Ultrasound in Diagnosing Pulmonary Bleb versus Pneumothorax

Mohamad Moussa, MD* and Venkat Reddy Vaddamani, BS*

DOI: https://doi.org/10.21980/J8MP7QIssue 3:3[mrp_rating_result]
The patient was evaluated with bedside ultrasound for concern of possible pneumothorax. Imaging of the left lung with M-mode demonstrated a “sea shore” sign showing a wavy pattern below the pleural line caused by lung sliding as well as “comet tail” artifact caused by from the deep pleura. However, there was no lung sliding on the right shown by a lack of “comet tail” artifact and a “bar code” sign where M-mode shows straight lines throughout the image, this is caused by lack of motion below the pleura. This lack of lung sliding is consistent with possible pneumothorax or bleb.  A two-view chest X-ray (CXR) revealed absent lung parenchyma in the right lung similar to a large pneumothorax (see red outline). Electronic medical record chart review revealed previous CXRs with similar findings. This patient was determined to have an acute COPD exacerbation with chronic blebs, but no pneumothorax.
RespiratoryVisual EM
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Fight Bite with Tendon Laceration

Michelle Chang, MD*, Grant Wei, MD*, Christopher J Bryczkowski, MD*, Sha Yan, DO* and Chirag N Shah, MD*

DOI: https://doi.org/10.21980/J8MP7QIssue 3:3[mrp_rating_result]
The video shows a water bath ultrasound of the right 4th digit, demonstrating soft tissue swelling with a hypoechoic region along the tendon consistent with edema and tendon disruption (see video and annotated still image).
OrthopedicsTraumaVisual EM