The ultrasound images reveal hepatomegaly and an increased echogenicity of the liver parenchyma that is diffuse. The increased echogenicity can be best appreciated by a comparison to surrounding structures. It is important to note that the increased echogenicity is non-focal and consistent throughout the entire liver in multiple views. These findings can be consistent with nonalcoholic steatohepatitis as well as glycogenic hepatopathy.
In the image, one can see significant tracheal deviation around the right side of the mass (black arrows). This degree of deviation would make ventilation in a paralyzed patient extremely difficult, if not impossible.
Initial EKG was concerning for type I Brugada pattern with an incomplete right bundle branch block in V1 & ST segment elevation terminating in an inverted T wave in V2. There are also signs of sodium channel toxicity with a widened QRS complex, tachycardia and a terminal R wave present in aVR where the R wave is bigger than the S wave or the R wave is over 3mm in aVR.
An ultrasound (US) of the abdomen was obtained to evaluate for possible pyloric stenosis (see US transverse/dopper imaging). While imaging showed a normal pyloric channel, it revealed an unexpected finding: a complex cystic mass arising from the right adrenal gland (yellow outline), measuring 5.8 by 4.0 by 6.4 cm with calcifications peripherally and mass effect on the kidney without evidence of vascular flow (blue arrow). Computed tomography (CT) of the abdomen/pelvis with IV contrast was subsequently obtained and measured the lesion as 2.8 by 4.6 by 4 cm without evidence of additional masses, lymphadenopathy or left adrenal gland abnormality (see CT axial, coronal, and sagittal imaging).
Facial ultrasound revealed local inflammatory changes such as increased echogenicity and heterogeneity in the soft tissues of the right cheek, suggestive of soft tissue edema. There was evidence of a prominent right parotid gland with increased heterogeneity suggestive of a traumatic injury. Additionally, facial ultrasound demonstrated a 6mm ill-defined anechoic collection within the right cheek without increased doppler flow (green arrow), thought to represent a focal area of edema instead of an abscess.
Case Report: Thoracic Aortic Dissection in a Previously Healthy Male with an Unusual Inciting FactorDOI: https://doi.org/10.21980/J8G92S
A non-contrast computed tomography (CT) scan was negative for a suspected ureteral stone. However, there were aortic calcifications visualized at the infrarenal level that were notable given the patient’s age (red arrow). Given this finding in conjunction with the patient’s symptoms, bedside transabdominal ultrasonography was performed which revealed an intraluminal echogenic flap within the aorta near the common iliac arteries. CT angiography (CTA) with delayed contrast protocol revealed an extensive Stanford type A aortic dissection with involvement of the aortic root (purple arrow), brachiocephalic trunk, ostia of the left subclavian artery, descending aorta (blue arrow), bilateral common iliac arteries, and left internal iliac artery.
Point of Care Ultrasound as a Diagnostic Tool to Detect Small Bowel Obstruction in the Emergency Department: A Case ReportDOI: https://doi.org/10.21980/J8XD1G
The ultrasound findings suggestive of small bowel obstruction (SBO) are typically visualized in video; however, certain still images can also demonstrate SBO including greater than three dilated loops of small bowel (>2.5 cm), thickened-walled bowel (>3 mm), visualization of plicae circulares, and extraluminal fluid caused by inflammatory changes along the bowel wall, which are all highly suggestive of SBO.3 In this patient’s case, we were able to visualize several dilated loops of small bowel (red arrow) with oscillating intraluminal contents known as “Whirl Sign.” Additionally, we were able to visualize extraluminal fluid, demonstrated as an anechoic triangular-shaped collection. The characteristic shape of this triangular shaped collection of fluid is known as a “Tanga Sign,” given its name due to way it looks similar to the lower half of a bikini (blue arrow). Tanga sign can occur when the loops of dilated bowel appear prominent in contrast to the inflammatory extraluminal fluid in an SBO. These ultrasound findings were highly concerning for SBO which was later confirmed on CT imaging of the abdomen, which demonstrated SBO with a transition point in the left lower quadrant.
On vitals, the patient was found to be consistently hypertensive to the 230s/160s. Point-of-care glucose was within normal limits. Noncontrast CT imaging of the head revealed no acute intracranial hemorrhage or evidence of ischemic stroke, but was remarkable for areas of biparietal subcortical low-attenuation (white arrows), concerning for PRES. Patient subsequently underwent CT angiogram imaging of the head with perfusion which revealed no large vessel occlusion.
The patient was in noticeable respiratory distress and had oxygen saturation of 94% on room air. Bilateral jugular venous distention with severe right supraclavicular lymphadenopathy and diffuse bilateral wheezing was present. Although muffled heart sounds and hypotension are part of Beck’s Triad, these were not present in this case. Electrocardiogram obtained on arrival showed a sinus tachycardia with low-voltage QRS complexes and electrical alternans. Low voltage QRS can be seen on the ECG provided and is demonstrated by the low amplitude of the QRS complexes seen on all the leads. Electrical alternans may have an alternating axis or amplitudes of the QRS complex. Alternating axis is best visualized in V4-V6 on this ECG while alternating amplitudes are seen throughout the rest of the ECG. Computed tomography angiogram (CTA) of the chest revealed a large pericardial effusion with bilateral pulmonary emboli and a right upper lobe mass. A bedside transthoracic echocardiogram (TTE) was then performed and confirmed the large effusion, but also showed right ventricular collapse during diastole, indicative of cardiac tamponade.
CT head without contrast demonstrated a minimally displaced fracture of the frontal sinuses at the midline underlying his known laceration that involved the anterior and posterior tables of the calvarium. This is seen on the sagittal view and indicated by the blue arrow. There was a small volume of underlying subarachnoid hemorrhage along the falx. There was also extensive pneumocephalus most pronounced along the bilateral anterior frontal convexity associated with the frontal sinus fracture, seen on the axial image and indicated by the red arrow. This pattern of air is commonly referred to as the “Mount Fuji” sign.6 Other intracranial air can also be seen on the sagittal image and is indicated by the white arrow.