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Multiple masses chest..

April 3, 2014

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Late 20s male presents with shortness of breath…

Chest masses Chest masses CT

This Xray and CT show a phenomena called “Cannonball Metastases.”  This refers to innumerable descreet masses in the chest.  Two tumors are highly suspected in this case: renal cell carcinoma and choriocarcinoma.   Others that have a higher prediliction to multiple lung mets are prostate, endometrial, and synovial sarcoma (1). 

This patient ended up having a choriocarcinoma of the testes. 

Image Contributors:  Kevin Murphy, MD and Mary Bing, MD

Author:  Russell Jones, MD

References:

1.  Knipe H, Bickle I, et al.  Cannonball Metastases. www.radiopaedia.org

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Abdominal pain…

March 24, 2014

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Patient had RLQ abdominal pain, we obtained a CT looking for appendicitis:

Pill frags 1

The patient has multiple, radiodense objects throught the small bowel.  Upon further history this patient was taking multiple calcium and iron supplement pills a day. 

Author:  Russell Jones, MD

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Device for spasticity…

March 11, 2014

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Here is a CT (with scout film) showing a not-to-uncommon device placed in the abdominal wall:

Baclofen 1 Baclofen 2 Baclofen 3

This is an example of an intrathecal pump, commonly used to deliver baclofen.  The first image shows the pump tubing coursing on the abdominal wall, into the thecal space (inserting just lateral to the spinous process of the lumbar vertebrae).  The second image shows a crossection where the pump is located in the abdominal musculature.  The scout film gives you a good idea how big these pumps are.  They have a reservoir port for percutaneous refilling of the baclofen and they can be interrogated for functioning and changing settings. 

Complications of these can include pump failure, baclofen running empty, tubing kink or breakage, and infection/hematoma, and a cerebrospinal fluid leak at the site of insertion.

Author:  Russell Jones, MD

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Should’ve worn eye protection…

February 8, 2014

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This patient was working on cutting copper wire without eye protection:

Ocular FB

 

On exam the patient had a small laceration just medial to the limbus in the scleral portion of the eye, no anterior chamber or corneal involvement.  He had a positive Seidel test (fluorcein stains vitreous green under blue light.  As the vitreous leaks out you can see green tinged fluid leaking from the area of concern). 

On CT there is a metallic fragment found in the posterior chamber indicative of a penetrating copper foreign body.  This is an ocular emergency and should prompt immediate evaluation by an ophthalmologist!

Author:  Russell Jones, MD

 

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Interesting finding on “Pan Scan”…

January 24, 2014

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The trauma “Pan Scan” has been a controversial topic for a while now.  “Pan Scan” has multiple meanings but is usually some combination of head, c-spine, chest and abdomen CT imaging to identify serious traumatic related injuries.  Downsides include cost, radiation, and contrast.  Upsides include early identification of serious trauma including solid organ injuries.  Here is an interesting case that presents an original argument for the “Pan Scan:”

Pills in skin folds 2 Pills in skin folds

This person came in with altered mental status and trauma (single car MVC).  CT identified a large number of hidden pills later identified as an opioid pain medication.  They were hidden in an abdominal fold just above the pubis!

(Disclaimer:  Please don’t misinterpret this as an argument to identify pills with a pan scan.  It would have been much more cost effective to find them on physical exam)

Image Contributor:  Julie Phan, MD

Author:  Russell Jones, MD

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I think I got stabbed in the eye…

January 18, 2014

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Patient presented after an altercation.  He thinks he got stabbed in the eye with a “razor blade or a pencil.”  Eye was swollen shut and unable to be opened due to significant edema:

Pencil orbit 1 Pencil Orbit 2

This patient has a radioopaque foreign body just lateral to the globe.  It is penetrating into the posterior orbital fossa but doesn’t appear to be causing proptosis or retrobulbar hematoma.  It does indeed look like a pencil!

Author:  Russell Jones, MD

Image Contributor:  Ken Kelley, MD

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Elderly male with syncope…

December 18, 2013

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One of my colleagues had an interesting case the other day.  An elderly patient came in after a syncopal event.  The only complaint was mild lower back discomfort.  Bedside ultrasound revealed the etiology (later visualized on this CT):
AAA 2

AAA 3

This CT shows a large infrarenal abdominal aortic aneurysm (AAA) that extended down into the iliac arteries bilaterally.   The aneurysm had intraluminal clot and concern for impending complete rupture near the iliac bifurcation.  The patient was expeditiously taken to the OR for operative repair.

This is a good case that demonstrates the utility of bedside ultrasound in the ED.  Syncope is an event that can be caused by a large variety of pathophysiology, AAA being one of the most feared.  It is very important in this situation to have a high index of suspicion and make the diagnosis quickly, accurately, and disposition the patient to the appropriate care.

For a brief tutorial on bedside aortic ultrasonography I refer you to a great blog from Mount Sinai:

Sinai EM Ultrasound

Image Contributor:  Rupi Chima, MD

Author:  Russell Jones, MD

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LeFort would cringe…

December 14, 2013

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Motorcycle accident:

CT face 2 CT face 3 CT face...

CT face 3D

This patient has severe facial trauma, comminuted fractures of most (if not all) of his facial bones, a ruptured right globe. 

A review of facial fractures including the LeForte classification, courtesy of the University of Washington:

Facial Fractures

Image Contributor:  Julie Phan, MD

Author:  Russell Jones, MD

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Answer: Can you find the abnormalities?

December 2, 2013

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I gave you this xray a couple days ago, can you find all the abnormalities?

GSW

1.  Intubated into the right mainstem bronchus

2.  Metallic foreign bodies coursing up the left chest to the neck

3.  Completely opacified left lung:  differential diagnosis of pulmonary contusion, hemothorax, or complete atelectasis from right mainstem intubation

4.  There is a chest tube in the right chest cavity, it looks to be in good position but could be coursing into the fissure between the left lobes

5.  Deep sulcus sign on the left side indicates possible pneumothorax vs. hemothorax

6.  Orogastric tube courses below the diaphragm in good position

7.  Subcutaneous emphysema in upper neck

8.  Two radiodense objects in the midline cardiac silhouette near the mid-portion of the coursing orogastric tube

Interestingly, this patient was shot in the chest coursing to the upper neck and the bullet was found in his posterior pharnyx.  He had a tooth found on chest CT (calcified opacity seen below) among other injuries.   Later EGD intraoperatively showed two tooth fragments in the stomach.  The radiodensities seen #8 above were presumed to be these teeth in the esophagus.

Tooth

Image Contributor:  Julie Phan, MD

Author:  Russell Jones, MD

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Heterotopic pregnancy CT….

November 24, 2013

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22-year old female came in with RLQ pain and a reported ultrasound positive intrauterine pregnancy a week ago, a visit two days ago consistent with spontaneous incomplete Ab on ultrasound.  On exam her RLQ was very tender, US showed minimal blood products in uterine cavity no IUP.  Serum beta-Hcg >5000. 

CT abdomen/pelvis:

Ectopic 1 Ectopic 2

CT shows fluid in pelvis with consistent with blood and has a right adenexal hemorrhagic mass consistent with ruptured ectopic pregnancy.

This patient, by history, had a documented intrauterine pregnancy that resulted in a spontaneous abortion.  She had the feared Heterotopic pregnancy.  Heterotopic pregnancy is when a dual gestation occurs, one in the uterus and one in the fallopian tube in an ectopic location.  It is very rare although seen in increasing prevalence with the advent of ovulation induction drugs (she was not taking these drugs!). 

Author:  Russell Jones, MD

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