Archive | November, 2013

Can you find all the abnormalities?

November 28, 2013

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This patient came in after a reported gunshot wound.  Can you find all the abnormalities in this xray?

GSW

 

Answer to follow.

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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Answer WWWTP #13…

November 20, 2013

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An elderly male with difficulty swallowing:

WWWTP #13

The differential diagonosis of an elderly person with dysphagia includes infectious sources, stroke, malignant sources, as well as foreign bodies.  On history the difficulty swallowing started hours after eating fish.  On the soft tissue lateral neck a thin, radiopaque foreign body can be seen just posterior to the larynx in the upper esophageal area (you may need to zoom to see it):

wwwtp-13 edit

This patient had nasopharyngoscopy which revealed a small fish bone.

How sensitive are radiographs at picking up fish bones?  Not very good.  There aren’t many studies out there assessing this question but based on my experience, CT is the diagnostic imaging-of-choice.  Alternatively you can perform nasopharyngoscopy at the bedside or esophagoscopy.  There was a study in 2000 by Lue and colleagues which explored this subject (1).  They took 10 cadavers and placed fishbones in various positions in the neck and found a very poor sensitivity of plain films (39%).  CT, on the other hand, performed well at identifying bones from most commonly-eaten species of fish.  It also correctly identified a bone lodged in the soft tissue that may not be correctly identified by nasopharyngoscopy.

They did have small numbers in the study but it does correlate with my experience that fish bones are difficult to detect on plain films.  Several other studies have found poor plain film performance in this area.  The conclusions in this article argue that plain films should not be used in looking for fish bones.

Author:  Russell Jones, MD

References

1.  Lue AJ, Fang WD, Manolidis S.  Use of plain radiography and computed tomography to identify fish bone foreign bodies. Otolarnygol Head Neck Surg. 2000 Oct; 123 (4): 435-8.

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WWWTP #13 (What’s Wrong With This Picture?)…

November 16, 2013

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Elderly patient came in with complaints of difficulty swallowing for 5 days:

WWWTP #13 WWWTP# 13.1

What’s wrong with this picture?

Answer to follow.

Author:  Russell Jones, MD

 

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Hip pain after a fall…

November 12, 2013

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Middle-aged male presents with hip pain after a fall:

Hip pain

This is a pathologic fracture.  CT showed a 12 inch tumor found infiltrating the right pelvic structures.  The pelvis xray shows that his distal femur has displaced through the acetabulum and you can see there is ill-defined destruction of the inferior pubic ramus.  He has contrast in the bladder from a prior CT at a transferring institution.  What is your differential diagnosis for this Xray?

Author:  Russell Jones, MD

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Supracondylar fracture…

November 8, 2013

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Child came in with elbow pain after a fall:

SC Fx II 2 SC Fx II

This child has a Gartland Type II supracondylar fracture of the distal humerus.  On the film of the normal, asymptomatic right elbow if you draw an anterior humeral line it goes directly through the capitellum.  This is not true for the left film and demonstrates posterior displacement of the capitellum with an intact posterior cortex of the distal humerus.  The injured elbow also demonstrates and anterior and posterior fat pad sign.

Gartland classification of supracondylar elbow fractures:

Type I:  Nondisplaced

Type II: Mild posterior displacement with intact posterior cortex

Type III: Completely displaced

Author:  Russell Jones, MD

Image Contributor:  Ali Naqvi, MD

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19 month old with pneumonia…

November 3, 2013

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Peds PNA

This is an interesting pediatric chest Xray.  Immediately you notice that the right lung is diffusely more dense than the left.  This is because the patient is supine and a pleural effusion is layering behind the right lung in a dependent fashion.  Also notice the hyperinflation of the left side compared to the right.  This patient ended up having a post-obstructive pneumonia due to aspiration!

Author:  Russell Jones, MD

Image Contributor:  Kendra Grether-Jones, MD

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