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Point-Of-Care Ultrasound Use for Detection of Multiple Metallic Foreign Body Ingestion in the Pediatric Emergency Department: A Case ReportDOI: https://doi.org/10.21980/J83D2D
Bedside POCUS was performed on the patient’s abdomen using the curvilinear probe. The left upper quadrant POCUS image demonstrates multiple hyperechoic spherical objects with shadowing and reverberation artifacts concerning multiple foreign body ingestions. Though the patient and mother initially denied knowledge of foreign body ingestion, on repeated questioning after POCUS findings, the patient admitted to his mother that he ate the spherical magnets he received for his birthday about one week ago. The patient swallowed these over the course of two days. The presence of multiple radiopaque foreign bodies was confirmed with an abdominal X-ray.
The bedside ocular ultrasound (B-scan) was significant for small, hyperechoic signal (white arrow) in the distal aspect of the optic nerve, concerning for embolus in the central retinal artery. Subsequent direct fundoscopic exam was significant for a pale macula with cherry red spot (black arrow), consistent with central retinal artery occlusion (CRAO).
Upon arrival at the trauma center, a FAST revealed a large, well-circumscribed abnormality (red outline) deep to the liver (blue outline and star) and gallbladder (green outline and star). The right kidney and hepatorenal space were not clearly visualized. The remainder of the FAST showed no free fluid in the splenorenal space, pelvis, and no pericardial effusion. He had lung sliding bilaterally.
On physical exam, when the patient was asked to try and look to her right, the right eye failed to move laterally/abduct (blue arrow). Additionally, when asked to look straight ahead, the eye was slightly adducted (red arrow). There was a lack of motion of the right eye in abduction when the patient was asked to look to her right (yellow arrow).
The CT of the abdomen and pelvis showed evidence of a large subcapsular rim-enhancing fluid collection with multiple gas and air-fluid levels along the right kidney measuring 8 x 4 cm axially and 11 cm craniocaudally (blue outline) with mass effect on the right renal parenchyma (yellow outline). Another suspected fluid collection adjacent to the upper pole of the right kidney measuring 4 x 3.4 cm was noted (red outline). Bilateral pyelonephritis was suggested without hydronephrosis or nephrolithiasis. The findings suggested complicated pyelonephritis with emphysematous abscess and hematoma formation.
A Case Report of Subtle EKG Abnormalities in Acute Coronary Syndromes Indicative of Type One Myocardial InfarctionDOI: https://doi.org/10.21980/J8W06X
The ECG does show multiple subtle abnormalities that in conjunction with his symptoms and risk factors are concerning for ischemia and/or occlusion of the coronary artery vessel. 1) ST depression in aVL. Although slight, the ST segment is below the TP segment or isoelectric point (blue circles). 2) Focal hyper QT waves. The T-waves in II, III, AVF V2, V3, and V4 are hyper acute, namely peaked and tall in relationship to the QRS. These are best displayed in leads II, III, and AVF where the T-waves are taller than the QRS amplitude (vertical blue lines). 3) Straightening off the ST segment. Multiple leads display a straight ST segment namely aVL, III, AVF, and V2 (red lines). Of note, the length of the straight ST segment is greater than 1/4 the amplitude of the QRS (purple lines). 4) Although subtle, these abnormalities are focal in nature.
The presence of soft tissue stranding about the parotid gland suggested an underlying inflammatory or infectious process of the parotid gland. Cellulitis was considered as a possible diagnosis as well, given the presence of soft tissue stranding in the dermis that is adjacent to the parotid gland. Fortunately, no enhancement was seen in local muscles, fascia, or bones to suggest a myositis, fasciitis, or osteomyelitis. By using the anatomy of the patient and understanding the changes that occur on CT when inflammation is present, the appropriate depth and location of infection can be made, allowing for appropriate treatment regimens.
Video laryngoscopy of the upper airway was performed two days after initial burn injury. The images obtained demonstrated laryngeal edema and inflammation near the epiglottis. The dot identifies the epiglottis and the asterix identifies the area of moderate thermal burns. Imaging also demonstrated adequate patency of airway and ruled out the need for intubation at that time.
Images taken of the bilateral palmar skin lesions at our institution showed multi-centimeter, well-demarcated, friable, verrucous, crusted plaques with overlying fine yellow crust. Lesions such as these are suspicious for syphilitic gummas seen with cutaneous tertiary syphilis.
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Bedside ultrasound was performed and showed thickened bowel wall (orange marker), fat enhancement (green marker), and phlegmonous structure with central echogenicity (yellow marker). Imaging of the abdomen and pelvis with CT showed marked wall thickening and inflammatory change involving a 7.0cm segment of the distal/terminal ileum suspicious for severe ileitis with phlegmon and microabscess on the coronal image (yellow arrow). Additonally, the transverse images show a small rim-enhancing focus within this region of inflammation measuring up to 1.4cm which could represent microabscess (yellow arrow). Diagnosis of diverticulitis by ultrasound is made by identifying the following findings: colon wall thicker than 5mm, fat enhancement, evidence of abscess, visualized diverticuli, air artifacts suggesting diverticuli, and tenderness with compression of the probe.6 Diagnosis of diverticulitis by CT is made by identifying the following findings: colonic wall thickening, pericolic fat stranding, abscess formation and enhancement of the colonic wall. Often, these signs are associated with an identifiable inflamed diverticulum.7