Archive | October, 2013

CT Hemorrhagic stroke

October 30, 2013

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Young patient presented with altered mental status, concern for drug use per EMS.  The patient had some response to naloxone but didn’t return to normal orientation.  On exam there was a subtle left gaze preference with a blood pressure of 280/160 mmHg.  The patient’s head CT non-contrast:

CT ICH

This head CT shows a large hemorrhagic stroke with 8mm of midline shift.  It also showed left uncal herniation on other cuts. 

This is an unfortunate complication to stimulant drug use, most commonly implicated are cocaine and methamphetamines.  One of the many reasons not to do drugs!

Author:  Russell Jones, MD

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What is this device?

October 26, 2013

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What is this device?

LVAD 2 LVAD CXR 1

This patient has two devices on Chest Xray and KUB:

1.  The large, radiodense structure just below the cardiac silhouette is a Left Ventricular Assist Device (LVAD).  Specifically it is a Heartmate II®.  LVADs are implanted in patients with severe cardiac depression for augmented left ventricular output.  Often these are implanted in patients awaiting cardiac transplant, however we are seeing more patients with implanted LVADs for “Destination Therapy.”  This is a long-term treatment for severe CHF with no intention of eventual cardiac transplantation.   The goal of these devices is to improve quality-of-life in severe CHF.  Complications most-often include thrombotic (ischemic stroke) or hemorrhagic (patients require anticoagulation with these devices which predisposes them to GI, CNS, other hemorrhagic events). 

2.  He has an Automatic Implantable Cardiverter Defibrillator (AICD) in the left upper chest.  It also functions as a pacemaker. 

A word of warning:  some of these patients will not have pulses because these devices provide a continuous left ventricular output.  A good way to obtain a blood pressure is to manually inflate the blood pressure cuff with a doppler transducer on the radial artery, as you release the blood pressure cuff you will obtain a doppler signal at some point.  This is your blood pressure (a single number).  Often they will have pulsatile flow if the intrinsic function of the heart provides enough stroke volume on top of the LVAD. 

Author:  Russell Jones, MD

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Answer AIDS PNA…

October 22, 2013

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On a previous post I posed a question on the differential diagnosis of pneumonia in an AIDS patient with this chest Xray:

AIDS CXR PNA

This is a multilobar pneumonia vs. ARDS (Acute Respiratory Distress Syndrome).  AIDS patients can have the same bacterial causes of multilobar pneumonia that is present in other patient populations (Streptococcus pneumoniae, Staphylococcus aureus, Haemophilus Influenza, Moraxella catarrhalis, Mycoplasma pneumoniae, Chlamydophila pneumoniae, Legionella pneumoniae, etc.).  If they are healthcare associated or hospital-acquired further drug-resistant bugs such as Pseudomonas aeruginosa and MRSA could be implicated.  Infectious organisms specifically involved in immunocompromised hosts could include (among others):

  • Pneumocystis Jiroveci (PCP pneumonia)
  • Coccidioides species
  • Cytomegalovirus (CMV)
  • Tuberculosis (TB)
  • Histoplasma species
  • Aspergillus species
  • Mycobacterium avium complex (MAC)
  • Influenza
  • Herpes simplex virus (HSV)
  • Varicella-zoster virus (VZV)
  • Legionella species
  • Nocardia species
  • Cryptococcus neoformans
  • Mucoraceae species
  • Strongyloides species
  • Toxoplasma species
  • Capnocytophaga species

Non-infectious causes of multilobar infiltrates such as this could include diffuse alveolar hemorrhage, cardiogenic pulmonary edema, ARDS, among others. The multilobar involvement of the Xray above could implicate certain pathogens in favor of others (for example, Pneumocystis Jiroveci is usually multilobar as opposed to Streptococcus pneumonia which usually will cause a dense, lobar pneumonia).  The other interesting feature of the Xray is that it appears multi-nodular.  This can implicate entities such as CMV rather than a bat-wing ground-glass appearance of Pneumocystis Jiroveci.  For further discussion on pneumonia radiographic findings in AIDS, please see radiopaedia.org discussion below:

http://radiopaedia.org/articles/pulmonary-manifestations-of-hiv-aids

Incidentally, the endotracheal tube should be pulled back about 2 cm.

Author:  Russell Jones, MD

References

1.  Jones J, Stanislavski A, et al.  Pulmonary Manifestations of HIV/AIDS.  http://radiopaedia.org/articles/pulmonary-manifestations-of-hiv-aids.  Accessed 10/2013.

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COPD and dyspnea…

October 18, 2013

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This patient has a history of COPD (Chronic Obstructive Pulmonary Disease) and presented with acute shortness of breath:

COPD and PTXCOPD and PTX 2

One of the complications of COPD are pulmonary bullae.  Bullae are thin-walled, air-filled spaces that enlarge over months to years.  Sometimes they can burst, causing pneumothoracies.  This Xray demonstrates a pneumothorax on the left side in which a chest tube was placed for reexpansion.  On the right side the patient has multiple large apical bullae which are also at risk of rupture.  The chest tube is in good position with the side-port visualized inside the thoracic cavity and reexpansion of the lung is demonstrated.

Author:  Russell Jones, MD

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Pneumonia in AIDS patient…

October 14, 2013

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This patient has a history of AIDS with very low CD4 count and came in with respiratory distress:

AIDS CXR PNA

This Xray shows a diffuse pulmonary infiltrates, bilateral pleural effusions.  There is an endotracheal tube near the carina, it could come back a couple centimeters.  He also has a nasogastric tube coursing below the diaphragm. 

What is the differential diagnosis of a multilobar pneumonia such as this in an AIDS patient?  Comments appreciated!

Author:  Russell Jones, M.D.

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WWWTP #11 Answer…

October 10, 2013

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Middle-aged diabetic woman with bilateral foot swelling:

WWWTP 11.1 WWWTP 11 WWWTP 11.3 WWWTP 11.2

This patient has extensive destruction, debris, dislocation, disorganization, and increased density of both midfeet, consistent with neuropathic foot.  Likely from years of poorly controlled diabetes.  Clinically this made sense because she did not have pain or sensation in a stocking-distribution below the knees.  She had good pulses and no overt signs of infection (on the differential is osteomyelitis causing significant bony destruction). 

For more info on neuropathic foot:

Charcot Changes in the Midfoot

Author:  Russell Jones, MD

References

1.  Charcot Changes in the Diabetic Foot and Ankle.  Wheeless’ Textbook of Orthopaedics.  http://www.wheelessonline.com/ortho/charcot_changes_in_the_diabetic_foot_and_ankle Accessed 10/2013.

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WWWTP #11 (What’s Wrong With This Picture?)

October 6, 2013

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Middle-aged female with diabetes comes into the ED with bilateral foot swelling for 2 months, no fevers, redness.  Her ankles are visibly swollen and deformed bilaterally.  Here are her ankle Xrays:

WWWTP 11.1 WWWTP 11.2 WWWTP 11.3 WWWTP 11

What’s wrong with these pictures?

Answer to follow.

Author:  Russell Jones, MD

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Distal Radius…

October 2, 2013

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Distal Radius 1 Distal Radius 2

This is an example of a distal radius fracture that needs closed reduction.  This fracture shows dorsal and radial angulation with translational displacement of the fracture fragment roughly 50% of the bone width.  The classic eponym for this type of fracture is a Colles’ Fracture. 

Acceptable angulation on reduction is a controversial topic.  It is obviously best to get these fractures as close as anatomic as possible with less than 10-15 degrees of angulation.  Remember to get a post-reduction X-ray so that when it falls off prior to the follow up ortho visit then you can’t be blamed!

Author:  Russell Jones, MD

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