Tag Archives: case

FAST five ways

The FAST exam is generally described as a trauma assessment (hence the acronym). But it is often used as a metanym to mean any assessment of the peritoneum for fluid. In fact when I was a resident folks would often say, “let’s FAST that gallbladder,” or “get the FAST machine so we can put that central line in.” And we didn’t have Twitter.

Anyway, here are a few cases where the “FAST” was used in a non-trauma patient to assess the peritoneum:

Cirrhotic with abdominal pain and tenderness:

who was found to have ascites, and spontaneous bacterial peritonitis

Lower abdominal pain in pregnancy:

who was found to have hemoperitoneum from a ruptured ectopic pregnancy

Diffuse abdominal tenderness in a healthy ten-year-old:

who was found to have idiopathic seromas of the peritoneum, pleura, and pericardium!

Shortness of breath and abdominal distension:

which turned out to be massive abdominal abscesses

Diffuse abdominal tenderness and distension after hysteroscopy:

which was complicated by a bowel perforation; hence fecal material throughout the peritoneum

Take home points:

  • Assessment of the peritoneum greatly aids medical and surgical diagnoses
  • Fluid appears black (anechoic) on ultrasound. Very difficult to tell what TYPE of fluid by appearance alone
  • Your clinical assessment must guide the differential diagnosis for your ultrasound findings

Case- vaginal bleeding

This young healthy woman presented in her first trimester of pregnancy with lower abdominal pain and vaginal bleeding. She had diffuse abdominal tenderness and was mildly tachycardic with a normal blood pressure. After IV access was established, labs and blood bank sample were sent, and the following ultrasound of the right upper quadrant was obtained:

So there’s a bit of free fluid in Morison’s pouch. Can we make it more evident for the kids in the back row? The next image was taken with the patient in Trendelenberg position:

That made a pretty big difference.

In this sagittal view of the uterus the bladder is visible to the screen right; there is free fluid in the pelvis just to the left of this, and it can be seen to move with probe pressure on the lower abdomen.

Thus a diagnosis of ruptured ectopic pregnancy was strongly suspected, and the patient underwent emergency laparoscopy with the obstetrics service.

Check out our pelvic ultrasound and FAST tutorials for more details on performing these assessments.

 

What The Heck 1

This patient presented with right upper quadrant abdominal pain. There was RUQ tenderness on exam, but no fever, rebound or Murphy sign. A point-of-care ultrasound was performed to assess for signs of cholecystitis and the following image was obtained. This prompted the operator to ask, “What the heck?”

GB1 500x376 What The Heck 1
What structures are visible here? How could you differentiate them? More after the break!

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XRS- Rib pain

32 year old female with no past medical history presents with cough for two weeks, no fever, no sputum. Multiple sick contacts with same symptoms at work. She acutely presents with left rib pain for several days.  She reports no trauma, and noted the sharp, positional pain during a fit of coughing. Her vital signs are all within normal limits. She is breathing comfortably, with good air movement, no wheezes, rales, or ronchi. She displays point tenderness over her anterior left 8th rib at the anterior axillary line.  A chest x-ray was ordered; images are below.

 

Sonopalpation of the tender area revealed the following:

Untitled from Sinai EM Ultrasound on Vimeo.

 

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XRS – 1

X-Ray Stinks #1: Finger Injury

In this new series we will highlight cases where ultrasound proved more useful than x-ray.

A seven year old boy presented with distal phalanx pain, tenderness after a fall.

The following x-ray was performed:

XRS1 x ray XRS   1What is your diagnosis? Can ultrasound help? How would you perform an ultrasound on such a superficial structure?

The following ultrasound of the distal finger was performed (probe marker towards fingertip):

XRS1 phalanx fx XRS   1What is your diagnosis now? Continue reading

Case 3

54M with h/o HTN, DM, Tobacco and Focal Segmental Glomerulosclerosis presents with neck mass.  He looks dyspneic and uncomfortable at triage and has an obvious mass above his left clavicle to the degree that his head is tilted a bit to the right.  Concerned, the triage RN defers the EKG and A-Side attending consult and rolls the patient into your formerly mellow cardiac room shift.  Although overall he looks gaunt, his face is swollen and dark colored (“facial plethora”).  You go through your IV/O2/Monitor/ABCDEFGHIJKLMNOPQRST and then grab the ultrasound machine.

After turning on the machine,  you obtain the following images of the left neck.

nocompression Case 3

Without Compression

compression Case 3

With Compression

What do you think the patient has and whatcha  going to do about it?

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Case 2

This 16 year old patient presents to the Emergency Department you have just started at in Menominee Michigan.   All of today’s patients have been on their way home this last day of hunting season.  You suspect this patient will be more interesting, as she is wearing a PETA shirt and not a shred of orange or leather.  Although her chief complaint was nausea and vomiting, her urine pregnancy test was positive, prompting the ultrasound evaluation which revealed this image:

case 2 Case 2

What is your diagnosis and what is the next step for this patient?

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