Archive | May, 2013

Cough, fevers, interesting Chest Xray…

May 27, 2013

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This patient came in with cough, chills, fevers.  The patient’s initial pulse oximetry was 46% on room air, came up into the 90s on a non-rebreather mask.  He has had several months of weight loss and night sweats.  His chest xray:

PJP PNA

What are the concerning features of this Chest Xray and what would be on your differential diagnosis?

Answer to follow.

Author:  Russell Jones, MD

Image Contributor:  James Chenoweth, MD

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WWWTP#7 Answer

May 24, 2013

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Apparently the patient had been admitted to another hospital with sepsis recently.  On the Chest Xray you can see a thin metallic wire extending from the superior vena cava to the left hemidiaphragm area.  This was initially missed on the Xray and found on further imaging.  The patient had an abdominal CT (she had right lower quadrant pain) and with mediastinal windows the metallic object can be seen:

Guidwire chest CT 1Guidewire chest CT 2

The patient had a retained guidewire from a previously placed right IJ catheter.  This was a very weird incidental finding!  She was eventually sent to interventional radiology where it was removed.  Unfortunately it had nothing to do with her abdominal pain.

Author:  Russell Jones, MD

Image Contributor:  Aaron Hougham, MD

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WWWTP #7 (What’s Wrong With This Picture)

May 22, 2013

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This patient came in with abdominal pain.  An upright chest Xray was ordered to eval for free air.  Can you see any abnormalities?

Guidewire chest

What’s wrong with this picture? (HINT: you may need to zoom in on the cardiac silhouette and mediastinum to see the abnormality)

Answer to follow.

Author:  Russell Jones, MD

Image Contributor:  Aaron Hougham MD

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Pancreatitis CT…

May 18, 2013

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A colleague pointed out an interesting CT on a patient with epigastric pain…

Pancreatitis CT2Pancreatitis CT1Pancreatitis CT 3

This CT shows stranding around the pancreas with fluid tracking in Gerota’s fascial plane.  What is Gerota’s fascia you say?

Gerota’s fascia (otherwise known as “Renal Fascia”) is the layer of connective tissue surrounding the kidneys and suprarenal glands.  Anterior to this fascial compartment is the prerenal space which contains the pancreas, ascending colon, descending colon, and the second-fourth portions of the duodenum.  Any inflammation with these organs can lead to fluid within Gerota’s fascia.  On the CT above this is demonstrated by the fluid stripe anterior to the left kidney on the middle image (sagittal plane)  and superior to the left kidney on the third image (coronal plane).  For an anatomic picture of Gerota’s fascia see the following Wikipedia reference:

Gerota’s Fascia

Author:  Russell Jones, MD

Image Contributor:  Tag Hopkins, MD

References

1.  Renal Fascia. http://en.wikipedia.org/wiki/Renal_fascia.  Accessed: 5/2013

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New Stroke Tutorial – Evolution from acute to chronic infarction…

May 15, 2013

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Its important for medical students and EM providers to know the radiologic progression and timing of acute ischemic stroke. I came across this blog post from Radiopaedia.org today. Great video review of Acute Ischemic Stroke temporal changes on CT!

Radiopaedia

New Stroke Tutorial – Evolution from acute to chronic infarction on CT and MRI. VIEW VIDEO: http://goo.gl/Q4PLF

via our Facebook page

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Another interesting medical device…

May 14, 2013

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This patient presented with chest pain, we obtained a chest xray:

Epicardial pacemaker 2Epicardial Pacemaker 1

Overlying the cardiac silhouette is a pair of wires for an epicardial pacemaker.  The patient had a coronary artery bypass graft procedure several years ago and required an epicardial pacemaker in the postoperative period.  The leads were left in and the pacemaker is now gone.  The wires are unique to this type of pacemaker as they have the button-like attachment to the epicardial surface.  They are typically used in the postoperative period and are indicated for temporary use; their function deteriorates in a matter of days to weeks (1).

The wires were somewhat confusing to our treatment team until we reviewed his chart and did a little internet searching!

Author:  Russell Jones, MD

References

1.  Batra AS, Seshadri B.  Postoperative temporary epicardial pacing:  When, how, and why?  Ann Ped Card 2008, 1(2): 120-125. 

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CXR with a bunch of hardware…

May 10, 2013

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I had a patient come in the other day with an interesting Chest Xray:

Aortic valve repair

This patient has a lot of hardware in his chest.

  1. He has a tracheostomy present
  2. Surgical clips can be seen on the aortic arch
  3. This is an artificial aortic valve
  4. Sternal wires for closure after his aortic valve replacement

Here is a link to an interesting image the New England Journal of Medicine published in 2005 that shows a person with replacements in all 4 valves:

Four Valver!

Author:  Russell Jones, MD

References

Bijl M, van den Brink R.  Images in Clinical Medicine:  Four Artificial Heart Valves.  N Engl J Med 2005; 353: 712

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Really bad GI bleeder…

May 7, 2013

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We’ve all had them…the really, really bad GI bleeder.  Thus man came in peri-code.  He was resuscitated with massive-transfusion to somewhat clinically stable.  After NG tube initially showed over a liter of blood return it stopped, couldn’t be lavaged or suctioned, and his abdomen started distending over the course of the next 1/2 hour.  We decided to get a CT scan to evaluate the distension and this is what was found: Gastric varices 2CT gastric varicies

The abdominal CT with contrast shows very large varicies extending into the stomach!  His stomach has several fluid densities consistent with hematoma, blood, and an area concerning for active exstravasation.  On the coronal image you can also see some dependent ascites around the liver.  The distal portion of the nasogastric tube is thought to have been obstructed by the large hematoma in his stomach.

The patient ended up improving with octreotide and correcting his INR of 3.5.  He had an esophagogastroduodenoscopy (EGD) which confirmed varicies and several were banded.

WARNING:  CT abdomen is not a usual imaging modality for GI bleeders.  We obtained imaging because the patient had increasing distension and abdominal pain.  We wanted to rule out aortic pathology, mesenteric ischemia, hemorrhagic malignancy, gastric perforation, and other pathology that sometimes can be associated with GI bleeding.  I don’t advocate CT imaging in most GI bleeders.

Author:  Russell Jones, MD

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Ruptured globe…

May 4, 2013

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Fight broke out at the local prison and this man was shot in the face with a rubber bullet…

Ruptured globe 5Ruptured globe 4Ruptured globe 3Ruptured globe 2Ruptured globe 1

The “brain” weighting CT (first figure) shows a ruptured globe with hemorrhage into the orbit.  The remainder of the figures are in “bone” weighting and show various fractures:

  1. Sagittal view of a comminuted fracture of the ethmoid sinus (medial orbital wall)
  2. Sagittal view of a comminuted fracture of the maxillary sinus (inferior orbital wall)
  3. Sagittal view of a posterior orbital fracture
  4. Coronal view re-demonstrating the ethmoid and maxillary sinus fractures

This poor fellow ended up losing his eye and going back to prison.

Author:  Russell Jones, MD

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Interesting Acute Abdominal Series…

May 1, 2013

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This patient presented with nausea, vomiting, diffuse abdominal pain, and no bowel movement for a couple days.

Ogilvie's syndrome

This patient has a history of Ogilvie syndrome and this abdominal xray helps support this diagnosis.  Ogilvie syndrome is an acute pseudo-obstruction of the GI tract without a mechanical obstruction.  Xray will often show massive (>10cm) dilitation of the colon, usually on the cecal side.  This patient’s cecum measures out to be 21 cm!

Brief summary of Ogilvie Syndrome courtesy of Wikipedia:

Ogilvie

Author:  Russell Jones, MD

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