Nama saw a 55yo female who presented with CP. She was treated with aspirin and GTN by MAS. Her obs were stable and she looked well. She had undergone a stress MIBI 2 years previously: NAD.
On examination, she had no murmurs, a clear chest and normal ECG.
However, she had RUQ tenderness and a positive Murphey's sign.
Does she have cardiac CP or biliary colic?
trop came back normal.
but so did WCC and CRP <2
But this is why we have US.
Nama did a beautiful GB US
Benign looking GB with hyper echoic stone and shadowing
Another view of the GB shows a stone in the GB neck and pericholecystic fluid.
The patient was fasted and admitted under EGS. She had a cholecystectomy for acute cholecystitis the next day.
The presence of gall stones and a positive sonographic Murphey's are two of the key features to look for with suspected acute cholecystitis in ED.
Other supportive features are
1. dilated GB >5cm (trans) >10cm (long)
2. thickened GB wall >4mm, fluid in GB wall, gas in GB wall
3. pericholecystic fluid
4. dilated CBD >6mm (with this need to consider ascending cholangitis).
Gordon had an elderly patient who presented via MAS sats 70%, diaphoretic, altered conscious state, HR 90. He had a hx of COPD, HT and CCF. No further hx.
Listening to his chest he had a few scattered crackles only.
CXR was not very helpful (see below)
Gordon did a lung US and echo which clarified the diagnosis of APO, R sided pleural effusion and cardiomyopathy.
Multiple coalescing B lines (vertical) seen anteriorly R and L.
Normal lung with horizontal A lines for comparison
R pleural effusion with collapsed lung.
dilated CM on PLAx
The patient had prompt and appropriate management for APO and responded well.
Bilateral multiple B lines anteriorly in a hypoxic patient is typically due to APO. However, other differentials could be:
1. bilateral pneumonia (would also have thickened pleural line)
2. pulmonary fibrosis (PHx and thickened pleural line)
3. ARDs (patchy, there will be skip areas, abnormal pleural line)
Cardiac US can also help with differentiation.