Issue 4:1

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

Suspicious Skin Lesion in an 11-Year-Old Male

Rachel E Bonczek, MSN^*, Kimberley M Farr, MD^{^} and Corrie E Chumpitazi, MD, MS^‡

DOI: https://doi.org/10.21980/J8JK9TIssue 4:1 No ratings yet.

The patient had a 5 cm ulcerative lesion with raised borders and a yellow, “fatty” center. There was no active drainage, site tenderness, or lymphadenopathy.

Visual EM Dermatology Infectious Disease

Guilty as Charged: Jailed Coronary Vessel Presenting as Wellens’ Syndrome Type B

Aderonke Susan Akapo, DO^*, Ryan Fashempour^*, Mohamad Moussa, MD^* and Patrick Bruss, MD^{^}

DOI: https://doi.org/10.21980/J8DS6H Issue 4:1 No ratings yet.

Evolving changes to electrocardiograph (ECG) were noted during serial ECG monitoring involving leads V2 and V3, along with some T-wave inversion in V4 and V5 that were concerning for a Wellens’ syndrome type B on second ECG. She was admitted and subsequently taken to cardiac catheterization suite where it was revealed that the previously placed stent in the left anterior descending (LAD) artery was patent. Unfortunately, the stent blocked off an adjacent side branch vessel off the LAD in proximal two-third region of the stent (as seen in the cartoon).

Visual EM Cardiology/Vascular

Ovarian Teratoma

Laura Rubi Cuevas, BS^* and Lauren Sylwanowicz, MD^*

DOI: https://doi.org/10.21980/J8934XIssue 4:1 No ratings yet.

The CT scan with oral contrast in the emergency department revealed a large heterogeneous abdominopelvic mass measuring 13.2 x 18.8 x 23.1 cm (see white lines), suggestive of an ovarian teratoma from the right ovary. This mass included fat, fluid, calcifications (see yellow arrows), and enhancing soft tissue components. The teratoma resulted in mass effect upon large and small bowel loops (see blue highlighted areas), inferior vena cava (IVC), distal aorta (see red highlighted area) and right common iliac artery. A small volume of ascites was also observed. There was no evidence of bowel obstruction, vascular occlusion or other significant emergent finding. Additionally, transabdominal and transvaginal ultrasound images were obtained. The transabdominal image visualized the abdominopelvic mass (see four yellow stars). The transvaginal image visualized a cross section of the teratoma (see four red stars) in relation to the bladder (see four blue stars).

Ob/Gyn Visual EM

Warm & Blue: A Case of Methemoglobinemia

Danielle Biggs, MD^* and David C Castillo, DO^*

DOI: https://doi.org/10.21980/J8591M Issue 4:1 No ratings yet.

The patient hadperioral cyanosis, blue coloration around her mouth, but the rest of the skin on her face appeared normal. She also had acrocyanosis to bilateral hands that can be seen in the image. The patient has a tan complexion up to the level of her wrists, but the palms of her hands are pale and cyanotic.

Hematology/Oncology Visual EM

Intramural Hematoma with Type B Aortic Dissection

Ronald Goubert, BS^*, Robert Rowe, MD^* and Alisa Wray, MD, MAEd^*

DOI: https://doi.org/10.21980/J81M03Issue 4:1 No ratings yet.

Computed tomography angiography of the chest and abdomen revealed a 9.5 cm thoracoabdominal aneurysm (red outline) with intramural hematoma (yellow shading) and large left pleural effusion versus hemothorax with old blood (blue shading).

Cardiology/Vascular Visual EM

Radiolucent Foreign Body Seen on Point-of-Care Ultrasound but not on X-ray

Julian Jakubowski, DO^*

DOI: https://doi.org/10.21980/J8WS77Issue 4:1 No ratings yet.

X-rays of the foot were obtained and no radiopaque foreign body was visualized. Due to high clinical suspicion for retained foreign body, a point-of-care ultrasound was performed by applying a high-frequency linear probe at the area of discomfort. In the long axis an ovoid focus of hypoechogenicity (orange outline) is visualized. Within this finding there is a linear focus (yellow line) of increased echogenicity measuring 1 mm in diameter and 1 cm in length. On short axis view, a rectangle focus (green dot) demonstrating shadowing (blue highlight) is seen.

Ultrasound Visual EM

Open Globe with Intraocular Foreign Body

Stephen Weiss, MD^*, Dustin Williams, MD^*, Yih Ying (Eva) Yuan, MD^* and Jo-Ann Nesiama, MD, MS^*

DOI: https://doi.org/10.21980/J8S348 Issue 4:1 No ratings yet.

On physical exam, his extraocular movements were intact. The right anterior chamber appeared cloudy, particularly nasal to the pupil. The conjunctiva of the right eye was injected. The right pupil was 3 mm and sluggishly reactive and appeared slightly irregular (see yellow arrow). Of note, the right eye also had a 1 mm hypopyon, indicating inflammation of the anterior chamber, which was visible on slit lamp examination (not pictured). There was no fluorescein uptake or Seidel sign. His visual acuity was 20/60 OD (right eye) and 20/20 OS (left eye).

Ophthalmology Visual EM

Hypopyon

Chandni Ravi, MD^* and Tiffany Murano, MD^*

DOI: https://doi.org/10.21980/J8N92BIssue 4:1 No ratings yet.

Physical examination of the left eye revealed a hypopyon (green arrow) – which is a layered white to yellow sediment in front of the inferior aspect of the iris associated with scleral injection and chemosis. Extraocular movements were intact bilaterally and pain did not worsen with extraocular movement. The pupil was poorly reactive to direct light and only hand movement could be perceived. The intraocular pressure was 14 mmHg. Slit lamp exam demonstrated a dense cataract. Bedside ocular ultrasound demonstrated vitreous opacities concerning for possible intraocular foreign bodies.

Ophthalmology Visual EM