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Practice Cases

Quick Image Reference

Case 1: 38 year old male falling 15 feet.

Case 2:  Acute vision loss.

Case 3:  Two months of chest pain and shortness of breath.

Case 4:  Right flank pain.

Case 5: Acute abdominal pain in an 88 year old smoker.

Case 6:  Young female with nausea and vomiting.

Case 7:  35 year old female with vaginal bleeding and abdominal pain.

Case 8: 45 year old with RUQ pain.

Case 9: Kicked in the groin.

Case 10: Assault with a gun.

Beatrice Hoffmann, M.D., Ph.D., RDMS

Note: The authors intend to expand this section significantly in the future including a CME quiz. The cases below represent a sampling of the included material.

Case 1
A 38-year-old man comes to the emergency department after falling 15 feet off scaffolding at work.  His systolic BP is 90; his heart rate is 125 bpm.  He is on a backboard and in a C-spine collar and complains of severe pain in his back and abdomen.
You perform the FAST ultrasound scan as part of your trauma evaluation and find the following:

Image case 1
Your diagnosis:
Significant amount of intra-abdominal free fluid.  Shown here is the peri-hepatic area, also called “Morrison’s pouch”. (Image courtesy of R. Reardon, M.D.)

ED management:
Immediate transfer to the operating room for exploratory laparotomy.  The patient is clinically unstable and has a presumed intra-abdominal bleed, most likely from a solid organ injury or vascular injury.

 

Case 2
A 57-year-old male comes to your emergency department complaining of vision loss in his right eye.  He says he has seen “floating dark spots” for a few days. After seeing a “flash of light”, he can’t really see much with his right eye.
Upon physical examination the patient is able to distinguish between light and dark but unable to count fingers with his affected eye.  His visual field is also significantly diminished. You perform a bedside ultrasound and find the following:

Image case 2
Your diagnosis:
Acute retinal detachment after retinal tear (rhegmatogenous retinal detachment = RRD), most likely affecting the macula. (Image courtesy of M. Blaivas, M.D.)

ED management:
This patient presents with an acute onset rhegmatogenous detachment that involves or threatens the macula.  An immediate retinal specialist consultation is indicated for surgical repair.

 

Case 3
You walk through the ED and notice a patient leaning over a chair in his exam room.  He is a 55-year-old male waiting to be seen. He informs you he came to the hospital because of shortness of breath, chest pain and dizziness.  He tells you this started a few weeks ago.  In the beginning, sitting up alleviated his symptoms.  Now he really has to lean over a chair or lie on his stomach to get any relief.  The patient denies any trauma.  He is a smoker but otherwise in good health.  He came in today because he feels like he is going to pass out. His triage blood pressure is 90/60 mmHg. You perform a bedside ultrasound with the following result:

Image case 3
Your diagnosis:
Large pericardial effusion with cardiac tamponade.

ED management:
This finding requires immediate intervention.  The pericardial effusion most likely developed over a few weeks but is now causing tamponade.  Emergent drainage is indicated in the emergency department before admission to the hospital.

 

Case 4
A 42-year-old female patient complains of sudden severe right flank pain.  During your interview she is restless and seems unable to find a position of comfort.  On exam she is afebrile, her vital signs are stable and she has tenderness over her right flank.  You perform a bedside ultrasound and find the following:

Image case 4
Your diagnosis: 
Mild hydronephrosis right.

ED management: 
On extended bedside ultrasound her left kidney appears normal, also her aorta and FAST exam show no abnormalities.
Symptomatic treatment with IV fluids and pain control resolve all symptoms.  Patient will need urgent outpatient follow-up with urology for renal colic with hydronephrosis without signs of infection and normal renal function.

 

Case 5
88-year-old man comes to emergency department for worsening abdominal pain over the last 1 week.  He used to smoke and has hypertension.  His vital signs are stable.  Your bedside ultrasound shows this finding:

Image case 5
Your diagnosis: 
Acute abdominal aneurysm, symptomatic; size over 5 cm. (Image courtesy of B. Ku, M.D.)

ED management: 
FAST exam to evaluate for free intra-abdominal fluid is negative.  Monitor vital signs closely, IV access with minimum of two large-bore IV’s, blood work including type & screen, emergent vascular surgery consult.

 

Case 6
A 23-year-old woman presents to the ED with nausea and vomiting for the past few days.  Her last period was regular but very light and she can’t remember the exact date.  She does not take birth control or fertility drugs.  Her abdominal exam is unremarkable, on pelvic exam the cervical os is closed.  You perform a bedside pelvic ultrasound:

Image case 6
Your diagnosis: 
Early intra-uterine pregnancy. (Image courtesy of W. Hosek, M.D.)

ED management:
Nausea and vomiting resolve with IV hydration and medication.  The patient is discharged with outpatient follow-up with OB and started on pre-natal vitamins.

 

Case 7
A 35-year-old female arrives in your ED with significant abdominal pain.  She had a positive pregnancy test about 3 weeks ago and denies vaginal bleeding or trauma.  She tells you she took Clomid before getting pregnant. On exam her abdomen appears very tender.  You perform a transabdominal ultrasound and discover an intrauterine pregnancy. You continue your exam with a pelvic ultrasound study because her pain and tenderness are disproportionate. Your exam and find the following:

Image case 7
Your diagnosis: 
Heterotopic pregnancy (coexistence of intrauterine and ectopic pregnancies). (Image courtesy of D. Mandavia, M.D.)

ED management:  Heterotopic pregnancy, once thought to be an extremely rare phenomenon, is becoming more common.  Risk factors include pelvic inflammatory disease and fertility treatments.  This patient has an ectopic pregnancy and an acute abdomen. Emergent OB evaluation is indicated with surgical removal of the ectopic gestation by salpingectomy or salpingostomy.

 

Case 8
A 45-year-old patient presents with upper abdominal pain.  Her symptoms began after eating a burger.  On exam she is tender over the right upper abdomen. She mentions that she had two similar episodes recently, but they were less painful.  You start symptomatic treatment, order blood work and perform a bedside ultrasound:

Image case 8
Your diagnosis:
Acute biliary colic with multiple gallstones. On ultrasound exam you find multiple gallstones but the gallbladder wall and common bile duct appear normal. 

ED management:
Blood work shows no infection or elevation of liver or pancreatic enzymes.  The patient improves with symptomatic management and her pain resolves.  She is discharged from the ED after surgical consultation and planned outpatient follow-up.

 

Case 9
A 23-year-old man comes to the ED after being assaulted.  He describes being kicked in the groin and has significant pain.  On exam he is tender over his right testicular area with scrotal swelling and ecchymosis.  Your bedside ultrasound shows the following:

Image case 9
Your diagnosis:
Intratesticular hematoma.  Testicular fracture (Image courtesy of M. Blaivas, M.D.).

ED management: 
Emergent urology consultation.  Early surgical exploration of a fractured testicle is associated with higher rates of testicular salvage.

 

Case 10
A 33-year-old man was robbed at a gas station and punched in the face.  He is brought to the ED for evaluation and says he thinks he heard a gun shot and felt a sharp pain in his neck.  On exam his neck has a small abrasion and is tender.  You perform a bedside ultrasound and find the following:

Image case 10
Your diagnosis: 
Foreign body in neck soft tissue; BB gun bullet.

ED management:
The foreign body is removed without problems.  The remainder of the trauma evaluation is negative and after an observation period the patient is discharged home.  Tetanus is updated before discharge.

 

 

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