November Case #4

50 y/o WM presents from his ALF for suprapubic catheter replacement. He states that "it just fell out." He has brought the remains of the previous catheter and you notice that it appears to be missing the distal portion of the catheter. Before you replace the catheter, you quickly ultrasound his bladder.

What do these images tell you?





Thanks to A.J. Wheeles for submitting these images!

November Case #3: Discussion

The IVC is measured about 2 cm from the entrance into the right atrium of the heart. Using M-mode, both inspiratory and expiratory diameters are measured. This patient has almost complete collapse of his IVC with respiration. His expiratory diameter is 1.63cm and his inspiratory diameter is 0.67cm. With this information, we look at the caval index chart below:

His caval index is 59%, which correlates to a CVP of 5-10mmHg and he is therfore under volume rescitated. He will need more IVF.

Caval Index Evaluation in the Ventilated Patient

Just a reminder that the IVC diameter chart is for spontaneously breathing, non-vented patients. If you want to measure IVC diamter in ventilated patients, you must remember that due to the positive pressure ventilkation, the IVC will be the largest diameter with inhalation. Therefore, you should measure the IVC when the patient is sedated and not spontaneously breathing. Once you obtain the inspiratory and expiratory diameter, you must then plug it in to the following formula:

Inspiratory diameter- expiratory diameter/ expiratory diameter

If the answer is >18%, then the patient is still dry and needs IVF.

November Case #3

52 y/o AAM presents to the ED via EMS with respiratory distress. He has been increasingly short of breath over the past 3 days. He denies CP, N/V/D. Admits to subjective fevers and "feeling cold" + cough productive of brown sputum. He was recently admitted to the hospital MICU with respiratory distress.

PMHx: sarcoidosis, stage 4; anemia
PSHx: none
Family Hx: DM, HTN, cancer and anemia
Social Hx: denies ETOH, tobacco or drug use
Medications: prednisone plus "others"
Allergies: levaqin

PE: BP 135/88, P 165, R 36, POx 85% on NRBM, T UTO
GEN: ill appearing AAM, respiratory distress, diaphoretic, alert and oriented x 4
CHEST: fine crackles bilaterally with labored respirations, retractions, tachypnea
CV: tachycardic, RR, no M/R/G
ABD: soft, NTND, +BS
EXT: no C/C/E

Pt is started on nasal BIPAP and given 2 liters NS and a foley temperature is obtained, which is 102.9. CXR is obtained and looks unchanged from previous with chronic interstitial disease. EKG shows sinus tachycardia around 150bpm.

Labs return with a WBC of 16.6 with left shift and antibiotics are empirically started. 2 more liters of IVF are given and patient states he feels somewhat better. His HR has decreased to 120s and his Pox has increased to 98%, but he continues to have fine crackles bilaterally on physical exam. His temperature goes down to 101.1.

Bedside ultrasound is obtained to look at his IVC to determine his fluid status.
The m-mode tracing is below:


What does this say about his fluid status?
What is his likely CVP?

Thanks to David Imbt who subimitted this case!

November case #2: Discussion

This patient appears to have a complete Achilles Tendon Rupture.

Normal Achilles Tendon Evaluation

The patient should be placed in a prone position so that you can easily reach the area of interest. The high frequency linear probe is placed in a longitudinal plane along the posterior ankle with the probe indicator toward the patient's head. The Achilles tendon may be visualized as a hyperechoic straited area (below pic). Moving from the proximal calf to the heel, the tendon may be followed to its insertion at the calcaneus.

Achilles Tendon Rupture

The Achilles Tendon attaches the soleus and gastrocenemius muscles to the calcaneus. Rupture is due to forceful plantar flexion. If there is a full thickness tear, as in this case, there will be a complete disruption of the tendon fibers with resultant retraction of the tendon proximally. This usually occurs about 3-4 cm proximal to the attachment to the calcaneus where there is a decreased vascularity. The ends of the ruptured tendon usually appear tapered and may cause some acoustic shadowing posteriorly (refraction). The space between the two tendon stumps may be filled with heterogeneous fluid, anechoic fluid (blood) or some of the adjacent fatty tissue (from Kager's fat pad).

It is important to evaluate the tendon in motion. This can be done by calf squeeze or by passive motion of the foot. This will make a tendon tear more obvious as one of the tendon stumps will move but the other will not.

Lastly, watch for an avulsion fracture of the calcaneus in Diabetic patients, which can mimic an Achilles tendon tear. The tendon itself will remain intact, but the portion of the calcaneous where the tendon attaches will be fractured off. This will be evident as you follow the tendon distally to the calcaneus.

November Case # 2

36 y/o male presents to ED with c/o pain to back of right lower leg. Pain began the day prior while playing basketball. Pain was a sudden onset while running and pt now unable to plantar flex his foot.


PMHx: none
PSHx: none
FamHx: none
Meds: none
Allergies: none
SocialHx: denies tobacco, ETOH or drugs


PE: BP 98/60, P83, R16, T98.6, POx 92% RA
GEN: NAD
EXT: no discoloration or bruising, mild edema to R calf w/ TTP, decreased ROM R foot- unable to plantar flex, sensation intact, 2+ distal pulses bilaterally. Thompson test +


What is your differential diagnosis?


Bedside ultrasound is used to evaluate the injury, what does the following image indicate?

Special thanks to Ashley Doscher and Matt Hale who submitted this image!

November Case #1: Discussion

The initial images illustrate a multicystic kidney which is grossly enlarged. There appears to be flow through the ureter as demonstrated by color flow in the transverse bladder view.

The differential for this patient should include:
1. hydronephrosis
2. renal cysts
3. polycystic kidney disease
4. tuberous sclerosis

To aid us in this differentiation, we took a quick scan through his liver and found the following:


The above pictures illustrate multiple cysts on the liver. This, along with the findings of bilateral multicystic kidneys and bilateral urine flow demonstrated by bladder jets, supports the diagnosis of Polycystic Kidney Disease.

Polycystic Kidney Disease

• Autosomal dominant form found in adults.
• Kidneys appear enlarged bilaterally due to multiple cysts of varying sizes.
• In advanced stages, cysts may destroy renal tissue and cause renal failure and hypertension.
  
• Cysts may be visualized as early as the 2nd decade of life
• Associated with cysts in the liver, pancreas and spleen and arterial aneurysms, especially berry aneurysms in 20% of cases
  

November Case #1

A 62 y/o man presents to the ED with complaints of right flank pain which began several hours prior. The pain is localized, constant and non-radiating. He denies dysuria, hematuria or urinary frequency or urgency. He denies CP, SOB, F/C, N/V, or any other complaints.

PMHx: HTN, DM, "kidney problem"
PSHx: none
Family Hx: unknown
Social Hx: lives alone, denies alcohol, tobacco and drugs

PE:
Gen: WNWD, WM, NAD
Chest: CTA B, nonlabored
CV: RRR, no M/R/G/
Abd: soft, NTND, +BS, no CVAT
Ext: no C/C/E

What's your differential diagnosis?



Bedside ultrasound illustrates the following:





What is the differential for this ultrasound exam?

What other structures should you investigate based on this scan?