The Quizzes about Ultrasound in the Emergency Department (22 test)

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Ultrasound in the Emergency Department

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Question 1

A 35-year-old woman presents to the ED via ambulance after being involved in an automobile EMS reports the patient was a restrained front seat passenger in a car struck on the front passenger door with significant cabin intrusion. The patient was nonambulatory on scene and required prolonged extraction from the vehicle. The vital signs on scene after extrication were blood pressure (BP) 105/80 mm Hg, heart rate (HR) 115 beats per minute, respiratory rate (RR) 22 breaths per minute, and oxygen saturation 100% on a non-rebreather mask. Two larger-bore IVs were established with 2 L of normal saline infused during extrication and transport. On arrival in the emergency department (ED), the patient does not remember what happened. She complains of pain in the right forearm and abdomen. In the ED her vital signs are BP 90/65 mm Hg, HR 140 beats per minute, temperature 98.9°F, RR 35 breaths per minute, and oxygen saturation 100% on a non-rebreather mask. Physical exami- nation reveals a diaphoretic patient who responds to painful stimuli. She answers questions but is confused. On examination, her abdomen is non- distended, soft, and tender along the right upper and lower quadrants on moderate palpation. Her dorsal forearm has a 4-cm laceration with active oozing of blood. She is neurovascularly intact in the right extremity, and no deformities are noted. There is no other evidence of trauma. A second liter of normal saline is started, type O–negative blood is ordered, and the type and cross match is sent to the laboratory. Chest and pelvis radiographs are negative for acute injury. You obtain a focused assessment by sonography for trauma (FAST) examination, shown in the following image. What is the next best step in the management of the patient?

A	Continue intravenous (IV) fluids and obtain a computed tomographic (CT) scan of her head.
B	Continue IV fluids and obtain a CT scan of her abdomen and pelvis.
C	Wait for the hemoglobin result and, if low, administer 2 units of packed red blood cells (RBCs).
D	Transport the patient to the operating room for emergent therapeutic laparotomy.
E	Place interlocking stitches to close the forearm laceration to control bleeding and prevent her BP from dropping even further.

Question 1 Explanation:

The pelvic view of this FAST examination shows an anechoic collection in the pouch of Douglas (rectouterine pouch) and vesicouterine pouch representing free fluid in the peritoneal cavity. In the setting of trauma, free peritoneal fluid is presumed to be blood. In the supine position the pelvis is the most dependent portion of the peritoneal cavity making it the most sensitive region to find free fluid. In female patients, fluid often collects between the anterior wall of the rectum and posterior wall of the uterus. In male patients the equivalent is the rectovesical pouch. This is anatomically significant because free fluid often collects between the anterior wall of the rectum and posterior wall of the bladder in males. Obtaining a CT of head (a) is a good consideration with the mechanism of injury and depressed mental status. However, the more likely cause of the depressed mental status in this patient is profound shock. Taking the patient for a CT scan will delay definitive management in the operating room. (b) Although CT scan of the abdomen and pelvis may provide diagnostic images, it is not recommended in the unstable patient because it delays definitive therapy. Abdominal exploration and hemorrhage control by the trauma surgeon is both diagnostic and therapeutic. (c) Following hemoglobin is misleading in the early stages of hemorrhage. Initial hemoglobin studies will be near normal because the concentration of hemoglobin remains the same despite low blood volume. This patient has lost a significant volume of blood and laboratory studies should not delay the initiation of a blood transfusion in an unstable patient. Hemorrhage control (e) is paramount; however, the primary source of bleeding for this patient is in the abdomen and nothing should delay transport to the operating room.

Question 2

A 16-year-old girl present to the ED complaining of severe sudden- onset sharp pain located in the right lower quadrant (RLQ). The pain started suddenly 1 hour before The pain is associated with a single epi- sode of nonbloody emesis; however, no diarrhea, vaginal bleeding, vaginal discharge, frequency, or burning with urination was reported. The patient denies any sexual activity in her past. She states she is G0P0 and her last normal menstrual period was 3 weeks ago. Her BP is 130/75 mm Hg, HR is 115 beats per minute, temperature is 99.3°F, RR is 18 breaths per minute, and oxygen saturation is 100% on room air. Physical examination shows a very uncomfortable appearing patient holding her RLQ. Her abdomen is tender in the RLQ with mild voluntary guarding but no rebound tender- ness, Rovsing sign, psoas, or obturator signs. Pelvic examination shows right adnexal tenderness, with no masses, cervical motion tenderness, or discharge. Laboratory results reveal a urinalysis with 1+ leukocyte esterase, negative qualitative b-human chorionic gonadotropin (b-hCG), white blood cell (WBC) count 8000/mL, hematocrit 46%, and platelets 270/mL. Which of the following ultrasound findings helps to rule out ovarian tor- sion as this patient’s diagnosis?

A	Unilateral enlarged ovary secondary to edema
B	Venous and arterial blood flow detected with Doppler sonography of the right ovary
C	Free fluid in the pouch of Douglas
D	Normal-sized ovary with no surrounding ovarian mass
E	Presence of right adnexal mass measuring 5 cm at largest diameter

Question 2 Explanation:

The diagnosis of ovarian torsion can be difficult to rule out468 Emergency Medicine despite all imaging modalities available to the clinician. The gold standard to ruling out ovarian torsion is laparoscopy; however, this is not practical and reserved for patients with high clinical suspicion for torsion. However, patients with no ovarian or adnexal masses measuring 3 to 4 cm in diameter and normal-sized ovaries are extremely unlikely to have ovarian torsion. Unilateral enlarged ovary secondary to edema (a) is the most common ultrasound finding in patients who do have torsion. Ovarian enlargement, in the case of torsion, results from venous and lymphatic congestion secondary to crimped vascular supply to and from the ovary. Venous and arterial flow detected with Doppler sonography of the right ovary (b) does not rule out ovarian torsion. The ovary is a dual-bloodsupply organ meaning that blood flow to one area of ovary does not mean that blood flow to other areas of the ovary is adequate. Free fluid in the pouch of Douglas (c) is a very nonspecific finding that can often be found in the case of ovarian torsion. Presence of a right adnexal mass measuring 5 cm in diameter (e) does not rule out ovarian torsion. In fact, masses greater than 3 to 4 cm are often required to tilt the ovary leading to vascular compromise.

Question 3

A 23-year-old woman presents to the ED with abdominal discomfort located in the left lower quadrant (LLQ) for the past 3 The pain is intermittent, nonradiating, with no alleviating or aggravating factors. She denies vomiting, diarrhea, dysuria, vaginal bleeding, or vaginal discharge. The patient states she is sexually active with one partner and her last menstrual period (LMP) was 2 weeks ago. Her BP is 115/70 mm Hg, HR is 75 beats per minute, temperature is 98.6°F, RR is 15 breaths per minute, and oxygen saturation is 100% on room air. Physical examination is unre- markable. Urinalysis shows no evidence of hematuria or infection. Qualita- tive b-hCG is positive. Bedside transvaginal pelvic ultrasound is obtained as seen below.

Which of the following is the earliest ultrasound finding confirming intra- uterine pregnancy (IUP)?

A	Gestational sac with visualized endometrial stripe
B	Gestational sac containing yolk sack and embryonic pole with visualized endo- metrial stripe
C	Blighted ovum with visualized endometrial stripe
D	Intradecidual sign with visualized endometrial stripe
E	Gestational sac containing yolk sac with visualized endometrial stripe

Question 3 Explanation:

The ultrasound (see figure below) reveals a gestational sac containing the yolk sac, characterized by a ringlike echogenic structure located at the periphery of the gestational sac. A gestational sac surrounding a yolk sac confirms gestational product. IUP can be confirmed if the endometrial stripe can be visualized with both the gestational and yolk sacs. The yolk sac can be detected by transvaginal ultrasound between 5 and 6 weeks and transabdominal ultrasound at 6 weeks. An intrauterine gestational sac (a) is suggestive of an IUP; however isolated fluid collections in the uterus are not uncommon with ectopic pregnancy. Isolated fluid collections in the uterus are called pseudogestational sacs and can be falsely reassuring of an IUP. An intrauterine gestational sac with yolk sac and embryonic pole (b) confirms an IUP, but it is not the earliest finding. An embryo can be detected on transvaginal ultrasound around 6 weeks and transabdominal ultrasound around 7 weeks. Blighted ovum (c) is a consistent with embryonic demise. It is characterized by a gestational sac with a gestational age greater than 7 weeks and absence of embryonic product development inside. Intradecidual sign (d) is an embryo completely embedded within the endometrial decidua but does not displace the endometrial stripe. This finding isUltrasound in the Emergency Department Answers 469 difficult to recognize and easily mimicked by small fluid collections in the uterus. Therefore, the intradecidual sign is not a reliable confirmation of IUP. The double decidual sign is another finding diagnostic of an IUP. It is characterized as a gestational sac surrounded by two layers: inner layer decidua capsularis and outer layer decidua vera. The decidua capsularis and decidua vera are separated by a thin hypoechoic layer forming the double decidual sign. Some authors list the double decidual sign as the earliest conformational finding of an IUP. However, like the decidual sign it is technically difficult to recognize and small uterine fluid collections can mimic the double decidual sign.

Question 4

Emergency medical service (EMS) was called to the scene of an unconscious 38-year-old man with labored EMS intubated the patient, placed two large-bore IVs, and began a normal saline infusion. On arrival in the ED, his BP is 70/30 mm Hg, HR is 140 beats per minute, temperature is 98.9°F, and oxygen saturation is 100% on a non-rebreather. Physical examination reveals a diaphoretic male, moving all four extremi- ties spontaneously, but he is not following commands. The neck exami- nation reveals elevated jugular venous pressure and a midline trachea. A single puncture wound is noted just below the xiphoid process; however, no abdominal distension is appreciated on abdominal examination. Your FAST examination is as shown in the following the ultrasound image. What is the next best step in the patient’s management?

A	ED resuscitative thoracotomy after placement of a chest tube.
B	Immediate transfer to the operating room for emergent laparotomy and pelvic binding.
C	Immediate transfer to operating room for emergent thoracotomy.
D	Stat CT scan of the abdomen and pelvis to evaluate for hollow viscus injury.
E	Perform a stat bedside pericardiocentesis.

Question 4 Explanation:

This patient has a partial anechoic and echogenic collection between the heart and pericardium consistent with hemopericardium. The patient’s clinical presentation of hypotension, elevated jugular venous pressure, and hemopericardium is consistent with pericardial tamponade, which is a life-threatening condition. Pericardiocentesis should be attempted, in addition to fluid Double decidual Yolk sac Fetal pole470 Emergency Medicine resuscitation, as a temporizing measure so the patient can be transferred to the operating room for definitive repair of his injuries. The classic presentation of pericardial tamponade is associated with Beck triad: low arterial BP, jugular venous distention, and muffled or distant heart sounds. However, when the classic presentation is not appreciated clinically, ultrasound provides valuable information that can rapidly guide management. There are multiple findings on ultrasound that suggest cardiac tamponade. The earliest finding is usually the collapse of the right atrium during atrial diastole, then collapse of the right ventricle during ventricular diastole. During end ventricular diastole both ventricles should be maximally dilated. The last finding, and the most difficult to appreciate on bedside ultrasound, is flattening or deviation of the interventricular septum toward the left ventricular cavity. Another ultrasonographic finding that supports the diagnosis of cardiac tamponade is a plethoric inferior vena cava. Normally, the inferior vena cava transiently narrows during inspiration when blood is pulled into the thoracic cavity during inspiration. This occurs secondary to negative pressure in the thoracic cavity that is generated by respiration and creates a gradient for blood to flow across the diaphragm between the abdomen and thorax. In cardiac tamponade, the inferior vena cava will appear plethoric and have no respiratory variation as blood flow into the heart is blocked by the tamponade. However, if the patient’s circulatory volume is low secondary to hemorrhage elsewhere, respiratory variation may still be present. ED resuscitative thoracotomy (a) is not indicated in this case. The most widely accepted indication for ED thoracotomy is in a penetrating trauma patient with a loss of vital signs in or near the ED. Taking the patient to the operating room for laparotomy (b) is not the best choice, because the patient has no evidence of hemoperitoneum. Transfer to the operating room for thoracotomy (c) should occur after a temporizing pericardiocentesis is performed. If the tamponade is not immediately addressed, the patient is at risk of deteriorating into pulseless electrical activity. A CT scan (d) is not indicated because a diagnosis of pericardial tamponade was made by ultrasound.

Question 5

A 42-year-old woman presents to the ED complaining of abdominal pain that is located in her right upper quadrant (RUQ). The pain started 5 hours before presentation after a She describes the pain as sharp, radiating around the right flank and into the back. The pain never com- pletely goes away but waxes and wanes in intensity. This pain is associated with nausea and vomiting, but no diarrhea or fever has been noted. Her review of systems reveals that she has been getting sharp pains in her RUQ after meals for the past year. Her BP is 145/75 mm Hg, HR is 110 beats per minute, temperature is 100.3°F, RR is 16 breaths per minute, and oxygen saturation is 100% on room air. The physical examination shows a non- distended abdomen with tenderness to palpation in the RUQ. There is no rebound or guarding. When the patient tries to inhale during deep palpation of the RUQ, she is forced to pause during inspiration because of extreme pain. Laboratory results reveal WBC 16,000/mL, hematocrit 48%, platelets 250/mL, aspartate aminotransferase (AST) 45 U/L, alanine aminotransferase (ALT) 40 U/L, alkaline phosphatase 75 U/L, amylase 50 U/L, lipase 40 U/L, sodium 140 mEq/L, potassium 3.5 mEq/L, chloride 110 mEq/L, bicarbon- ate 24 mEq/L, blood urea nitrogen (BUN) 9 mg/dL, creatinine 0.5 mg/dL, and glucose 85 mg/dL. You obtain a bedside ultrasound scan as seen below and find the following image showing a gallbladder wall thickness of 7 mm. Which of the following is a later finding of cholecystitis?

0.7cm

A	Cholelithiasis
B	Sonographic Murphy sign
C	Mucosal sloughing
D	Gallbladder wall thickening
E	Pericholecystic fluid

Question 5 Explanation:

his patient’s RUQ study reveals (figure below) a thickened gallbladder wall, pericholecystic fluid, cholelithiasis, and a sonographic Murphy sign. Considering the history, physical examination findings, and bedside ultrasound images, cholecystitis is the most likely diagnosis. MucosalUltrasound in the Emergency Department Answers 471 sloughing occurs as a result of prolonged ischemia to the mucosal surface of the gallbladder wall. Characterized by debris floating in the gallbladder lumen, mucosal sloughing is evidence of advanced disease. There are numerous ultrasound findings that suggest cholecystitis. However, no ultrasound finding alone is enough to make the diagnosis of cholecystitis and must be considered with the entire clinical picture. The presence of a sonographic Murphy sign and cholelithiasis (a and b) alone has a sensitivity of 91% and specificity of 66% for cholecystitis. The sonographic Murphy sign is considered more specific for cholecystitis than hand palpation because the gallbladder is compressed under direct visualization as the patient inhales. The presence of cholelithiasis does not mean cholecystitis, but their presence supports the diagnosis. At least 95% of patients found to have cholecystitis have gallstones present. Gallbladder wall thickening (d) is another finding suggestive of cholecystitis. Measurement of the anterior gallbladder wall should be less than 3 mm. A wall thickness of 3 to 5 mm is indeterminate particularly after a meal, as the postprandial gallbladder contracts giving a thickness up to 5 mm. A gallbladder Cholelithiasis Shadowing472 Emergency Medicine wall greater than 5 mm is abnormal. However, congestive heart failure (CHF) and chronic liver disease are known to cause thickened gallbladder walls without the presence of cholecystitis. Gallbladder distension is a sign of gallbladder obstruction. The normal gallbladder is often less than 10 cm in length and 5 cm in diameter. However, this is a very nonspecific finding. Pericholecystic fluid (e) is a later finding of cholecystitis characterized by a collection of fluid around the gallbladder wall. Of all the ultrasound findings, pericholecystic fluid is the most specific finding for cholecystitis. However, similar to gallbladder wall thickening, CHF and chronic liver disease can lead to pericholecystic fluid without the presence of cholecystitis.

Question 6

A 25-year-old man presents to the ED after being shot in the face with a shotgun at long The patient complains of pain generally across his face; however, the pain is greatest around his right eye. He is not sure if he can see out of the eye because the right eyelid is swollen shut. His BP is 140/80 mm Hg, HR is 105 beats per minute, temperature is 98.4°F, RR is 18 breaths per minute, and oxygen saturation is 100% on room air. Physi- cal examination shows multiple pellet marks across the face. The right eyelid has a grouping of pellet marks and is swollen shut with surround- ing ecchymosis and edema. The eyelid cannot be pried open secondary to pain limitation and further attempts at direct visualization of the eye where deferred for concern of manually increasing intraocular pressure. The rest of the physical examination was unremarkable. Bedside ocular ultrasound was obtained as seen below. Which of the following is the most likely diagnosis?

A	Intact globe
B	Retinal detachment
C	Lens dislocation
D	Globe rupture
E	Retrobulbar hematoma

Question 6 Explanation:

The globe is a fluidfilled structure that is easily evaluated by ultrasound. Serious ocular injury can be easily missed, as the patient may not be able to report vision loss secondary to lid edema or altered mental status. Lid edema also makes a complete evaluation of the eye difficult for the physician and repeated evaluations can be deleterious to the patient. The normal anterior and posterior chamber is typically anechoic as seen in the figure. The image provided in this case reveals a posterior chamber with echogenic matter occupying most of the volume of the vitreous chamber consistent with a vitreous hemorrhage. In the setting of penetrating trauma a vitreous hemorrhage is highly suggestive of globe perforation. Other ultrasound findings suggestive of globe perforation or rupture are decreased size of globe and buckling of the sclera posteriorly secondary to vitreous matter leaking. When evaluating the eye with ultrasound, particularly in the case of potential globe rupture, care must be taken to minimize pressure exerted on the eye by the ultrasound probe itself. Proper technique consists of liberal application of ultrasound gel over the closed eye lid with the sonographers hand rested on the patient’s forehead or nasal bridge. The ultrasound probe only requires contact with the gel to obtain adequate images of the globe and therefore does not need to rest on the closed eyelid itself. A completely anechoic anterior and posterior chamber (a) would be highly suggestive of a globe without major injury. However, the image provided shows obvious vitreous hemorrhage. Retinal detachment (b) is characterized by a highly echoic membrane that floats freely in the vitreous matter with eye movement. Retinal detachment is often associated with blunt trauma and typically does not lead to large vitreous hemorrhage. Significant lens dislocation (c) can be characterized as either partial or complete.Ultrasound in the Emergency Department Answers 473 A partial dislocation on ultrasound shows a lens positioned in its usual location just posterior to the iris; however, with ocular movements the lens appears to move independently of the surrounding structures. With complete lens, dislocation the lens is completely out of normal position relative to the iris. Vitreous hemorrhage is not associated with lens dislocation. A retrobulbar hematoma (e) is characterized by hypoechoic stripe posterior to the globe. The ultrasound in this case shows bleeding in the vitreous chamber. If the bleeding had been outside the eye between the orbital wall and globe, retrobulbar hematoma would be the correct answer.

Question 7

A 70-year-old man presents to the ED complaining of pain in his left back and He describes the pain as dull and aching. The pain started 1 day before presentation while watching TV. The pain is constant and does not radiate. He has no history of trauma or heavy lifting, and nothing seems to make the pain worse or better. His BP is 170/95 mm Hg, HR is 88 beats per minute, temperature is 97.6°F, RR is 17 breaths per minute, and oxygen saturation is 100% on room air. The physical examination and laboratory studies are unremarkable. A bedside ultrasound is obtained as seen below with the transverse and sagittal views of the aorta. Which of the following is the most accurate way to measure abdominal aortic aneurysm diameter?

A	While viewing the aorta in a sagittal plane, measure anterior to posterior diameter from inner wall to inner wall.
B	While viewing the aorta in a transverse plane, measure anterior to posterior diameter from inner wall to inner wall.
C	While viewing the aorta in a transverse plane, measure anterior to posterior diameter from outer wall to outer wall.
D	While viewing the aorta in a sagittal plane, measure the anterior posterior diameter from outer wall to outer wall.
E	While viewing the aorta in a transverse plane, measure anterior to posterior diameter from outer wall to inner wall.

Question 7 Explanation:

In the case of an unstable patient many clinicians may go directly to the distal aorta to evaluate for abdominal aortic aneurysm because it is the most common location for aneurysmal development. The distal aorta can usually be identified with the probe placed just superior to the umbilicus. In the stable patient, however, a systematic approach is used to evaluate the abdominal aorta for pathology. The abdominal aorta is broken into a proximal, middle, and distal segment. The proximal segment is defined by the aorta visualized just below the xiphoid process to the takeoff of the Lens Cornea Anterior chamber Vitreous chamber 474 Emergency Medicine superior mesenteric artery. The middle segment is the area just distal to the superior mesenteric artery. The anatomic significance of the middle segment is any aneurysm within 1 to 2 cm of the superior mesenteric artery that is highly likely to include the renal arteries. The distal segment of the aorta is just proximal to the aortic bifurcation into the common iliac arteries. While imaging, each segment in transverse orientation anterior to posterior diameter is taken measuring from outer wall to outer wall. This ensures accurate measurements by including any mural thrombus that would be excluded if the measurements were taken from (b) inner wall to inner wall. The aorta tapers from proximal to distal with the upper limit of normal 2.5 cm in the proximal segment and 1.8 cm in the distal segment. The diagnosis of abdominal aortic aneurysm can be made when a measurement greater than or equal to 3 cm is recorded in any one of the three segments. Sagittal sections of the aorta can also be obtained to further evaluate the contour of the aorta and assess for luminal irregularities, such as thrombus, or intimal flaps that would suggest aortic dissection. (a and d) However, caution should be used when measuring anterior to posterior diameter on sagittal sections because of cylinder tangent effect. A longitudinal beam slice through the center of the vessel will show an accurate maximal diameter. However, caution should be used as an off-center slice of the sidewall of the vessel will give a falsely reduced AP diameter. Measuring outer wall to inner wall (e) is not an accurate measurement because it could potentially miss mural thrombus.

Question 8

A 55-year-old woman is brought to ED after being struck by an auto- mobile. Per EMS, she was crossing an intersection when an automobile ran a stop sign striking her on the left The patient was found lying supine in the street alert and oriented to person, place, and time. Prehospital vital signs were BP 100/85 mm Hg, HR 120 beats per minute, RR 22 breaths per minute, and oxygen saturation 95% on room air. Intravenous access was established with normal saline being infused during transfer to your ED. On arrival in the ED, the patient complains of pain in the left hip and pelvic region. Vital signs in the ED are BP 95/60 mm Hg, HR 135 beats per minute, temperature 97.5°F, RR 28 breaths per minute, and oxygen saturation 100% on a non-rebreather. Physical examination reveals a pale diaphoretic patient. The breath sounds are clear bilaterally and her abdomen is soft and nondistended. Her pelvis appears stable, but exquisite pain is elicited with rocking of the pelvis. Her extremity examination reveals no leg length or temperature discrepancies, and she is neurovascularly intact throughout the lower extremities. The examination of her perineum reveals ecchymosis on the perineum and blood at the urethral meatus. You obtain a FAST examination as seen below and a pelvic radiograph that shows markedly widened view of the pubic symphysis. After pelvic binding is applied, what is the next best step in the management of this patient?

A	CT scan of the abdomen and pelvis with intravenous contrast
B	Transport to operating room for emergent laparotomy
C	Transport to the interventional radiology suite for embolization
D	Foley catheter to evaluate for hematuria
E	CT thorax with intravenous contrast

Question 8 Explanation:

This patient has a negative FAST examination. This patient’s examination and radiograph reveals an open book pelvis fracture. Pelvic fractures have a high association with retroperitoneal hemorrhage. Ultrasound is not sensitive or specific for evaluating the retroperitoneal space. The optimal management choice is transport to interventional radiology for embolization of the bleeding retroperitoneal vessels from the pelvic fracture. A CT scan of the thorax, abdomen, and pelvis with intravenous contrast (a and e) would be ideal if the patient was stable. CT scan is very sensitive and specific for solid-organ injury, hollow viscous injury, and retroperitoneal injury. However, considering this patient’s injuries and instability, CT scan is not the best answer. Emergent exploratory laparotomy (b) is a reasonable answer for this patient as other peritoneal injuries can be evaluated and managed. In addition, the pelvis can be packed in an effort to limit hemorrhage. However, the patient may still need vascular embolizationUltrasound in the Emergency Department Answers 475 despite the surgeon’s effort. Therefore, laparotomy delays definitive management of the bleeding. Evaluating for hematuria (d) is not priority at this time as the patient is not stable. There is already high suspicion for urogenital injury given her pelvic fracture and finding of blood at the urethral meatus. Once stabilized, the patient should get a retrograde cystourethrogram to evaluate for severity of urogenital injury before Foley placement.

Question 9

A 30-year-old man presents to the ED complaining of severe pain in the left side and He states that the pain started suddenly 5 hours before presentation and describes the pain as stabbing. The patient has never experienced the pain previously and states the pain comes and goes in intensity but never completely goes away. The pain radiates to his left groin and denies any alleviating or aggravating factors. The patient denies any hematuria, burning with urination, fever, vomiting, changes in bowel habits, recent trauma, or heavy lifting. His BP is 155/80 mm Hg, HR is 105 beats per minute, temperature is 99.5°F, RR is 18 breaths per minute, and oxygen saturation is 100% on room air. Physical examination shows a patient in obvious pain who cannot seem to find a position of comfort. The only remarkable finding was costovertebral angel tenderness on the left side. Laboratory results reveal sodium 142 mEq/L, potassium 4.0 mEq/L, chloride 110 mEq/L, bicarbonate 24 mEq/L, BUN 12 mg/dL, creatinine

0.7 mg/dL, and glucose 100 mg/dL. Urinalysis shows 2+ blood and RBC 20

to 50/hpf. A bedside renal ultrasound is obtained. Which of the following findings on ultrasound is consistent with severe hydronephrosis?

A	Anechoic collections around the renal pelvis with dividing segments of renal cortex
B	Prominent anechoic renal calyces
C	Prominent anechoic renal pelvis and calyces
D	Prominent anechoic renal pelvis and calyces with cortical thinning
E	Prominent renal pelvis and calyces with echogenic structure at ureteropelvic junction casting clean shadowing in the background

Question 9 Explanation:

This patient’s presentation, examination, and laboratory studies are classic for nephrolithiasis. The gold standard for evaluation for nephrolithiasis is spiral CT scan of the abdomen and pelvis without intravenous contrast; however, this requires exposure to ionizing radiation. In young patients with classic presentation of nephrolithiasis and microscopic hematuria or young patients with repeat visits for similar to previous episodes of nephrolithiasis, ultrasound is a great alternative to CT scan. Identification of severe hydronephrosis on ultrasound is an indication of further imaging and admission for urology evaluation. Severe hydronephrosis is defined by the presence of dilation of both the renal pelvis and calyces leading to thinning of the renal cortex. Prominent anechoic renal calyces and prominent anechoic renal pelvis and calyces (b and c) are descriptive of minor and moderate hydronephrosis, respectively. Grading mild to moderate hydronephrosis is subjective and of little clinical significance; however, the key feature of no cortical thinning is absent in both cases. Comparing the affected kidney to the unaffected kidney is often required to fully appreciate mild hydronephrosis. Patients with mild to moderate unilateral hydronephrosis, no UTI, and are low risk for abdominal aortic aneurysm, ovarian tumors, and retroperitoneal masses can follow up with urology on an outpatient basis if their pain is controlled and are tolerating oral intake. Anechoic collections around the renal pelvis with dividing segments of renal cortex (a) are consistent with sonolucent renal pyramids. Sonolucent renal pyramids are normal variants. They can be differentiated from dilated renal calyces by the presence of renal cortex separating each sonolucent triangle. Prominent renal pelvis and calyces with echogenic structure at ureteropelvic junction are casting clean shadow in the background. (e) The dilated renal pelvis and calyces are consistent with moderate hydronephrosis. There is no mention of cortical thinning that goes against severe hydronephrosis. The echogenic structure with clean shadowing is consistent with476 Emergency Medicine a renal stone lodged at the ureteropelvic junction; in this case it is likely the source of obstruction. Detecting obstructing renal stones in between the ureteropelvic and ureterovesicular junction is uncommon secondary to shadowing from bowel gas. Stones located in the renal pelvis are nonobstructive and of little clinical significance.

Question 10

A 48-year-old man was reroofing the second story of his house when he slipped and fell to the ground, landing on his right EMS arrived at the scene, placed the patient in spinal precautions, and established an IV. On arrival to the ED, he complains of pain along the right costal margin going to his right lateral chest and in his RUQ. He states it hurts to breathe but has not other complaints. His BP is 130/80 mm Hg, HR is 110 beats per minute, temperature is 98.9°F, RR is 25 breaths per minute and shallow, and oxygen saturation is 100% on room air. Physical examination reveals the patient taking rapid shallow breaths and holding his right hemithorax. His neck examination shows no elevated jugular venous pressure and his trachea is midline. His chest wall is tender down the right lateral wall. You do not palpate crepitus. His breath sounds are equal to auscultation bilateral. His abdominal examination reveals a nondistended abdomen, but there is tenderness in the RUQ. A 2-L bolus of normal saline is started and you obtain a FAST examination, as shown in the following image. What is the next best step in the management of this patient?

A	Chest tube thoracostomy
B	Rapid sequence intubation
C	CT scan of the thorax with intravenous contrast
D	CT scan of the abdomen and pelvis with intravenous contrast
E	Transport to the operating room for emergent laparotomy

Question 10 Explanation:

This patient’s FAST examination shows an anechoic fluid collection above the right hemi-diaphragm as seen in figure below. In addition, there is loss of normal mirror artifact and continuation of the spinous shadow beyond the diaphragm. Mirror artifact around the diaphragm is a normal finding and, when absent, raises suspicion for underlying pathology. The liver is a highly reflective organ and therefore easily interrogated with ultrasound. The aerated lung tissue, on the other hand, reflects very little sound, and therefore lung is not easily evaluated by ultrasound. Physical properties beyond the scope of this text lead to near 100% reflection of sound waves at the tissueair interface of the diaphragm. The reflected sound waves then cross-back through the liver where they are again reflected in various angles before they either completely attenuate or make it back to the ultrasound probe. The ultrasound machine assumes the signal has traveled in a straight line and incorrectly interprets these signals as if they had originated far beyond the diaphragm. Therefore, a liver-like image is projected superior to the diaphragm almost as if the diaphragm is a mirror of the true liver. Because almost all of the sound waves are reflected at the diaphragm, the hyperechoic surface of the spine is not visible superior to the diaphragm. However, with hemothorax or pleural effusions the tissue-fluid interface is less reflective of sound. As more sound waves now pass through to the highly reflective thoracic vertebral bodies, an image of the spinal column can be scene superior to the diaphragm. In the setting of trauma, a fluid collection above the diaphragm is presumed to be a hemothorax. Chest tube thoracostomy is required to prevent further accumulation of blood from compromising respiratory status and monitor loss of blood. An immediate output of greater than 20 mL/kg of blood or continued bleeding of greater than 3 mL/kg/h is generally viewed as an indication for thoracotomy in the operating room. Rapid sequence intubation (b) is not indicated at this time. The patient is having difficulty breathing because of pain limitation; however, his saturation is acceptable and his normal mental status suggests he is ventilating well. Should the patient become hemodynamically unstable, develop hypercapnia fromUltrasound in the Emergency Department Answers 477 hypoventilation, or become hypoxic refractory noninvasive oxygen supplementation, intubation would be indicated. CT thorax, abdomen, and pelvis with intravenous contrast (c and d) should be done after the hemothorax is addressed. Emergent laparotomy (e) is not indicated in this case as the patient has no free fluid in the abdomen and the patient’s vital signs are acceptable.

Question 11

A 55-year-old man presents to the ED complaining of epigastric abdominal He describes the pain as gradual in onset, burning in nature, and radiates through to his back. It is associated with vomiting and diarrhea. His BP is 180/90 mm Hg, HR is 100 beats per minute, temperature is 98.9°F, RR is 20 breaths per minute, and oxygen saturation is 100% on room air. On physical examination, his abdomen is soft and nondis- tended, but there is marked tenderness in the epigastrium. The remainder of his examination is normal. Laboratory results reveal WBC 12,000/mL, hematocrit 48%, platelets 250/mL, AST 500 U/L, ALT 600 U/L, alkaline phosphatase 450 U/L, amylase 1500 U/L, lipase 2000 U/L, total bilirubin

3.0 mg/dL, sodium 150 mEq/L, potassium 4.4 mEq/L, chloride 90 mEq/L, bicarbonate 20 mEq/L, BUN 9 mg/dL, creatinine 0.5 mg/dL, and glucose 110 mg/dL. You obtain a bedside ultrasound scan that reveals as shown in the following image. Which of the following findings is consistent with extrahepatic biliary obstruction?

A	Mickey Mouse sign
B	Increased echogenicity with irregular texture of the liver
C	Playboy bunny sign
D	Double barrel shotgun sign or parallel channel sign
E	Antler signs

Question 11 Explanation:

This patient’s history and physical examination is nonspecific; however, the laboratory values suggest biliary tract obstruction with pancreatitis. On ultrasound the CBD is normally much smaller than the portal vein. When dilated, it becomes similar in size to the neighboring portal vein that gives the appearance of a “double barrel shotgun” or “parallel channel.” Suspicion of biliary obstruction requires an evaluation of the CBD to assess for dilation. The CBD is most easily seen at the portal triad consisting of the portal vein, CBD, and hepatic artery. The three come together to make the “Mickey Mouse sign” (a) with the head Kidney Diaphragm Liver Blood Spine478 Emergency Medicine being the portal vein, the right ear the CBD, and the left ear the hepatic artery. The Mickey Mouse sign is a normal anatomic finding. The main lobar fissure tracks to the gallbladder and excellent landmark for locating a contracted gallbladder. A CBD that appears similar in size to the portal vein highly suggests CBD obstruction. In most people a CBD width of less than 7 mm is considered normal. However, instances exist where a CBD diameter greater than 7 mm is normal. The CBD dilates with age and after cholecystectomy. Postcholecystectomy patients have a normal CBD diameter up to 1 cm. Age can be accounted for by adding 1 mm for every decade greater than age 40. For example, an 8-mm-diameter CBD in a patient aged 80 years is normal. Increased liver echogenicity with irregular texture (b) is a finding of liver cirrhosis. The playboy bunny sign (c) is another normal anatomic finding. When the hepatic veins converge on the inferior vena cava, they often give the appearance of the playboy bunny emblem. The hepatic veins can be important structures because they divide the liver into its anatomic lobes. The middle hepatic vein travels in the median longitudinal fissure (MLF). The anatomic significance of this is that the gallbladder often lies near the MLF. Thus, the middle hepatic vein is a good reference point to find the MLF and in turn the gallbladder. The antler sign (e) is a pathologic finding for intrahepatic biliary duct dilation. It is characterized as irregular dilated tubules radiating outward from the porta hepatis, giving the appearance of dear antlers. The antler sign is indicative of biliary obstruction; however, the sonographer cannot differentiate intrahepatic from extrahepatic obstruction with this finding alone. Common causes of intrahepatic obstruction are biliary duct cancer and hepatic masses.

Question 12

A 25-year-old woman with a history of pelvic inflammatory disease presents to the ED with abdominal The pain is located in the RLQ and has been sharp, constant, and nonradiating for the last 2 days. The pain is associated with some vomiting and vaginal spotting. The patient denies fever, change in bowel habits, or vaginal discharge. Her LMP was 4 weeks ago and has been having unprotected sex with two partners. Her BP is 110/75 mm Hg, HR is 80 beats per minute, temperature is 99.1°F, RR is 16 breaths per minute, and oxygen saturation is 100% on room air. Physical examination reveals a tender abdomen in the RLQ with no rebound or guarding. Pelvic examination shows a closed cervical os with scant vaginal bleeding. There was right adnexal tenderness without fullness and no cervical motion tenderness. Urinalysis shows no evidence of hema- turia or infection. Qualitative b-hCG is positive. The following ultrasound images are obtained of the uterus and left ovary, respectively. Which of the following confirms an ectopic pregnancy?

A	Free fluid in the cul-de-sac posterior to the cervix
B	Gestational sac with yolk sac in the adnexa
C	Complex adnexal mass
D	Tubal ring
E	Ring of fire sign

Question 12 Explanation:

Figure below shows an endometrial stripe with a tiny psuedogestational sac showing there is no obvious IUP. Figure below shows gestational sack with yolk sack in the left adnexa confirming ectopic pregnancy. There is also a fetal pole present; however, this is not required to make the definitive diagnosis of ectopic pregnancy. The other options provided are suspicious for ectopic pregnancy and depending on the clinical scenario still require laparoscopy. However, (a, c, d, and e) are only suspicious for ectopic pregnancy and not definitive findings. Free fluid in the pelvis (a) of a pregnant patient is concerning for ectopic pregnancy, however, nonspecific. One-third of patients with an ectopic pregnancy have no free fluid in the pelvis. Small volumes of free fluid inUltrasound in the Emergency Department Answers 479 Pseudogestational sac Endometrial stripe Fetal pole Gestational sac Yolk sac480 Emergency Medicine the cul-de-sac from ruptured ovarian cyst are not uncommon. However, the larger the volume of free fluid, the more suspicion there is for ectopic pregnancy. A complex adnexal mass (c) is the most common sonographic finding in ectopic pregnancy. The mass typically represents a tubal hematoma, ectopic trophoblastic tissue, or distorted contents of an ectopic gestational sac. Pelvic ultrasound of the pregnant patient that finds an empty uterus with a complex adnexal mass is highly suspicious for ectopic pregnancy. However, the presence of an adnexal mass does not confirm that an ectopic pregnant as surrounding bowel, abscess, and ovarian tissue can be similar in appearance. ED detection of a complex adnexal mass in the pregnant patient always warrants obstetrical consultation for possible laparoscopy or further imaging. A tubal ring (d) is a concentric hyperechoic (white) structure found in the adnexa; it is effectively a gestational sac outside of the uterus. It sometimes takes the appearance of ovarian cyst but has thicker and more echogenic margins. The presence of a tubal ring is associated with a greater than 95% chance of ectopic pregnancy. The ring of fire sign (e) describes the appearance of trophoblastic blood flow around an adnexal mass when color Doppler is applied to the image. Sonographers use this finding to differentiate adnexal mass from surrounding tissue. However, like an adnexal mass or tubal ring, it does not make the definitive diagnosis of an ectopic pregnancy.

Question 13

A 30-year-old, 8 weeks’ pregnant woman presents to the ED with vomiting 10 to 20 times a day for the past 5 The patient also noticed some vaginal spotting over the last day, with no discharge, no urinary com- plaints, no abdominal pain, and no diarrhea. Her BP is 135/75 mm Hg, HR is 100 beats per minute, temperature is 97.9°F, RR is 18 breaths per minute, and oxygen saturation is 100% on room air. Physical examination shows dry mucous membranes and a nontender abdomen with a gravid uterus extending half way between the pubic symphysis and umbilicus. Pelvic examination shows scant blood in the vaginal vault with a closed cervical os. Laboratory results reveal serum sodium 143 mEq/L, potassium

3.9 mEq/L, chloride 95 mEq/L, bicarbonate 19 mEq/L, BUN 15 mg/dL, creatinine 1 mg/dL, and glucose 105 mg/dL; urinalysis shows a specific gravity greater than 1.030 g/mL and 3+ ketones; and quantitative b-hCG is 1,500,000 mIU/mL. Which of the following ultrasound findings confirms the diagnosis?

A	Thin-walled unilocular anechoic cystic structure measuring 4 cm in diameter on the ovary
B	Cluster of grapes in the uterine cavity
C	Hypoechoic stripe between the endometrium and chorionic membrane
D	Multiple thin-walled multilocular cystic masses on each ovary measuring approximately 6 cm in diameter
E	Hypoechoic solid spherical mass in the uterine wall

Question 13 Explanation:

This patient presents with vaginal bleeding, uterus to large for dates, and hyperemesis gravidarum. Her metabolic and urine analysis are consistent with vomiting and dehydration. The quantitative β-hCG is extremely high. The β-hCG in normal pregnancies usually levels off at 10 weeks around 100,000 mIU/mL. The most likely diagnosis in this case is a molar pregnancy. A molar pregnancy can be confirmed by direct visualization of the hydatidiform mole with pelvic ultrasound. The classic appearance of a hydatidiform is a cluster of grapes or snowstorm appearance in the intrauterine cavity. A thin-walled unilocular anechoic cystic structure 4 cm in diameter on the ovary (a) is consistent with a corpus luteum cyst. The corpus luteum cyst is a simple cyst greater than 3 cm in diameter and typically a benign finding in pregnancy. The corpus luteum cyst is usually unilateral. If the patient has multiple large multilocular anechoic cystic masses on each ovary (d), it is suggestive of theca lutein cyst. Theca lutein cysts are exacerbated corpus luteum and have an association with very high β-hCG levels. They areUltrasound in the Emergency Department Answers 481 commonly seen in patients with gestational trophoblastic disease and with ovarian hyperstimulation from fertility medications. Though this patient likely has theca lutein cyst, it is a result of the gestational trophoblastic disease and not the primary problem. Both corpus luteum cyst and theca lutein cyst usually resolve spontaneously. A hyperechoic stripe between the endometrium and chorionic membrane (c) is consistent with a subchorionic hemorrhage. This is common finding in patients who present with vaginal bleeding in the first trimester. Pregnant patients with subchorionic hemorrhage are believed to have a higher incidence of embryonic demise. This finding, however, does not explain a uterus to large for dates, hyperemesis, and elevated quantitative β-hCG. Hypoechoic solid spherical mass in the uterine wall (e) is consistent with uterine fibroids. Uterine fibroids can create problems with dysfunctional uterine bleeding and pelvic pain; however, they are generally considered a benign finding. They are often palpable and can mislead the examiner for a uterus to large for dates; however, they do not explain the hyperemesis and elevated β-hCG.

Question 14

A 60-year-old woman presents to the ED stating that she is turning Her husband first noticed her skin turning yellow 2 weeks ago. The patient has no other complaints and is otherwise healthy. Her BP is 130/70 mm Hg, HR is 80 beats per minute, temperature is 97.4°F, RR is 16 breaths per minute, and oxygen saturation is 100% on room air. On physical examination, her abdomen is soft without any tenderness, orga- nomegaly, or masses. Her skin examination reveals jaundice. Laboratory results reveal WBC 10,000/mL, hematocrit 48%, platelets 250/mL, AST 400 U/L, ALT 450 U/L, alkaline phosphatase 500 U/L, amylase 50 U/L, lipase 40 U/L, direct bilirubin 15.2 mg/dL, total bilirubin 16.5 mg/dL, sodium 140 mEq/L, potassium 3.5 mEq/L, chloride 110 mEq/L, bicarbonate 24 mEq/L, BUN 10 mg/dL, creatinine 0.6 mg/dL, and glucose 85 mg/dL. Which of the following is an abnormal common bile duct (CBD) diameter?

A	40-year-old man postcholecystectomy with 9-mm-diameter CBD
B	75-year-old woman with 7-mm-diameter CBD
C	50-year-old man with 4-mm-diameter CBD
D	40-year-old postcholecystectomy with 10-mm-diameter CBD
E	60-year-old man with 9-mm-diameter CBD

Question 14 Explanation:

In the jaundiced patient initial workup consists of determining obstructive from nonobstructive jaundice. Ultrasound images diagnostic of a dilated CBD confirm obstructive jaundice. Once the CBD is identified either in long axis or in short axis, the diameter from inside wall to inside wall is obtained. Normal CBD diameter is usually less than 7 mm. However, patients who have had a cholecystectomy may have a diameter greater than 7 mm. Once the gallbladder has been removed, the reservoir for bile storage, after ampulla of Vater closure, is no longer present. Upon closure of the ampulla of Vater, the bile backs up the CBD normally dilating it up to 1 cm. Age is also a normal contributor to CBD dilation. The rule of thumb for CBD assessment in the elderly is addition of 1 mm for each decade of age greater than 40. For example, an 80-year-old patient with a CBD diameter of 8 mm is normal.

Question 15

A 58-year-old-woman presents to the ED with the complaint of left- sided back pain, fever, vomiting, and The patient states all of her symptoms started 15 days ago with low abdominal pain associated with burning on urination that has progressively worsened with migration of pain up her right side. She said that the pain was consistent with her previ- ous urinary tract infections (UTIs), so she tried home remedies before com- ing to the hospital 4 days ago. Chart review shows the patient was started on ciprofloxacin for pyelonephritis. She has been compliant with her medica- tions since they were started, but she seems to be getting worse. Her history is significant for multiple UTIs and diabetes. Her BP is 150/85 mm Hg, HR is 110 beats per minute, temperature is 100.5°F, RR is 18 breaths per minute, and oxygen saturation is 100% on room air. Physical examination shows a nontoxic-appearing patient with mild left-sided costovertebral angel tender- ness and left upper quadrant (LUQ) tenderness. Her examination shows no peritoneal signs or masses. Laboratory results reveal WBC 15,000/mL, hematocrit 48%, platelets 250/mL, sodium 135 mEq/L, potassium 4.5 mEq/L, chloride 110 mEq/L, bicarbonate 23 mEq/L, BUN 20 mg/dL, crea- tinine 1.2 mg/dL, and glucose 250 mg/dL. Urinalysis shows 1+ leukocyte esterase, 1+ blood, 1+ bacteria, 5 to 10 RBC/hpf, and 5 to 10 WBC/hpf. A bedside left renal ultrasound is obtained as shown in the following image. Which of the following is most suggestive of renal abscess?

A	Solitary anechoic cystic structure with internal septations and areas of echogenic debris
B	Solitary anechoic smooth cystic structure with no internal echoes
C	Prominent echolucent renal pelvis and calyces
D	Multiple anechoic smooth cystic structures with no internal echoes
E	An irregular heterogeneous solid structure that is hyperechoic relative to sur- rounding parenchyma

Question 15 Explanation:

This patient’s history is concerning forUltrasound in the Emergency Department Answers 483 the development of a renal abscess. Ultrasound evaluation is excellent screening tool for renal or perinephric abscess development. The sonographic appearance of an abscess, regardless of the location, is variable in terms of the cavity shape and degree of internal echo. Classically an abscess cavity appears as a spherical cystic structure. The purulent matter in the cavity is represented by internal septations and echogenic debris, either floating or collecting in dependent portions of the cavity. A renal abscess is contained within the renal cortex, while a perinephric abscess extends beyond the renal cortex into the perinephric fat. Smooth cystic structures with no internal echoes are consistent with renal cyst. Simple renal cysts (b) are common and, when present in small numbers, they have little clinical significance. However, when the surface area of both kidneys is occupied by an abundance of renal cyst (d), the suspicion for polycystic kidney disease is high. Patients with polycystic kidney disease are prone to renal insufficiency and cerebral aneurysm. Prominent echolucent renal pelvis and calyces (c) are consistent with a mild to moderate hydronephrosis. Hydronephrosis indicates renal outflow obstruction, and with coexisting infection it requires admission for urgent urology evaluation to prevent abscess formation. However, the presence of hydronephrosis alone is not consistent with renal abscess. Irregular heterogeneous solid structure that is hyperechoic relative to surrounding parenchyma (e) is concerning for renal malignancy. The most common malignancy of the kidney is renal cell carcinoma, which carries a poor prognosis if not detected early. Any solid mass or cystic mass with internal septations requires further imaging with CT scan or MRI for further evaluation to help differentiate benign from malignant mass. Though a solid appearing mass could represent an abscess, it is more suggestive of renal malignancy

Question 16

A 35-year-old man presents to the ED complaining of pain and swell- ing in his left lower The patient states the pain started when he woke up this morning. With further questioning, the patient states he was aboard a transatlantic flight from England yesterday. There is no history of trauma, he has never experienced leg pain like this in the past, and cur- rently has no chest pain or shortness of breath. He has no history of medical problems. His BP is 130/75 mm Hg, HR is 75 beats per minute, temperature is 99.3°F, RR is 16 breaths per minute, and oxygen saturation is 98% on room air. Physical examination shows his left leg is larger in circumference compared to his right. The left leg is slightly red and warm to touch with soft compartments, symmetric pulses, and intact sensation. The left calf is tender with palpation and dorsiflexion of the ankle. Which of the following ultrasound findings is consistent with deep venous thrombosis (DVT)?

A	Noncompressible anechoic cystic structure in the popliteal fossa
B	Noncompressible superficial femoral vein
C	Noncompressible spherical echogenic structure superficial to femoral artery
D	Noncompressible middle section of the great saphenous vein
E	Semicompressible cystic structure with fluid dissecting into the soft tissue planes of the calf

Question 16 Explanation:

Emergency ultrasound evaluation of the lower extremity for DVT requires sequential compression of the major deep veins from the common femoral vein to trifurcation of the popliteal vein. The common femoral vein bifurcates into the superficial and deep femoral veins. The superficial vein travels through obturator canal to the popliteal fossa where it becomes the popliteal vein. The popliteal vein further divides into the peroneal, anterior, and posterior vein known as the trifurcation. Normal deep veins collapse under moderate pressure applied by the sonographer. A study is positive for DVT when the deep vein under interrogation does not collapse fully when pressure is applied to the skin with the ultrasound484 Emergency Medicine probe. An artery is differentiated from the vein by its thicker wall and pulsatile nature. An anechoic cystic structure in the popliteal fossa (a) is consistent with a Baker cyst. A Baker cyst develops from a communication between the synovium of the knee and semimembranosus bursa. Chronic inflammation of the knee leads to increased synovial fluid production that tracks into the cyst causing cyst enlargement. The Baker cyst can be differentiated from a DVT on ultrasound by noting that the cyst has a spherical structure as opposed to the tubular shape of a vein. The Baker cyst can enlarge and rupture leading to intense pain and swelling of the calf. The fluid of a ruptured Baker cyst tracks trough the tissue planes of the calf. The volume loss of the cyst makes it somewhat compressible when pressure is applied to the cyst. (e) A noncompressible spherical structure superficial to the femoral artery is consistent with a lymph node. Lymph nodes are differentiated from DVT by the spherical shape of the lymph node compared to the tubular structure of the vein. Lymph nodes also tend to lie superficial to the vasculature. The sonographer can also apply Doppler to the lymph node showing blood flow in and out of the node hilum as well as throughout the node itself. The great saphenous vein (d) is a superficial vein. Thrombosis of the saphenous vein is not associated with embolic disease. However, thrombosis of the proximal segment, when it enters the common femoral vein, is often treated as a DVT because of the high frequency of proximal extension into the common femoral.

Question 17

A 35-year-old woman presents to the ED complaining of a The patient states the headache has been coming and going for months. The headache is not maximal or sudden in onset and today it is not really different from previous episodes. The patient decided to come to the ED today because she was experiencing periods where her vision seemed dim. With further questioning, the patient states she gets periodic whooshing sound in her ears. Her BP is 145/75 mm Hg, HR is 93 beats per minute, temperature is 97.9°F, RR is 16 breaths per minute, and oxygen saturation is 100% on room air. Her physical examination is unremarkable; however, the fundi were not clearly visualized on funduscopic examination. Ultra- sound evaluation of the eye is obtained as shown in the following image. Which of the following further suggests the most likely diagnosis?

A	Ribbon-like echogenic structure in the vitreous chamber that is free floating with eye movement
B	Optic nerve sheath diameter of 6 mm
C	Loss of globe volume with echogenic matter in the vitreous chamber
D	Optic nerve sheath diameter of 4 mm
E	Color Doppler flow of the optic disk showing only blood flow exiting the globe

Question 17 Explanation:

The most likely diagnosis in this case is idiopathic intracranial hypertension (previously pseudotumor cerebri). If adequate funduscopic examination could be obtained, it would show bilateral papilledema. Ultrasound evaluation of the optic nerve sheath can be helpful in suggesting elevated intracranial pressure. The image provided shows a normal globe with the optic nerve and sheath in the plane of view posterior to the globe. The optic nerve exits the globe posteriorly and is characterized as a homogenous structure with low internal echogenicity surrounded by the echogenic nerve sheath. A measurement of the optic nerve sheath diameter is taken 3 mm posterior to the optic disk. Normal measurements vary by age from 5 mm or less in adults (d), 4.5 mm in children age 1 to 15 years, and 4 mm in children younger than 1 year. Optic nerve sheath diameters typically plateau at approximately 7.5 mm even in significantly increased intracranial pressures.Ultrasound in the Emergency Department Answers 485 Ribbon-like echogenic structure in the vitreous chamber that is free floating with eye movement (a) suggests retinal detachment. Retinal detachment is often associated with scotomas and floaters followed by unilateral vision loss classically in a curtain closing like manner. Loss of globe volume with echogenic matter in the vitreous chamber (c) suggests globe rupture with vitreous hemorrhage. Globe rupture would be extremely unlikely without a history of trauma and no physical examination findings. Color Doppler flow of the optic disk showing only blood flow exiting the globe (e) suggests central retinal artery occlusion. When using color Doppler, two colors are displayed: red indicating blood flow in the direction of the probe and blue indicating blood flow away from the probe. If color Doppler is applied to an image of the optic disk, a normal image will consist of red and blue flow correlating with arterial blood flowing toward the retina and ultrasound probe and blue flowing away from the retina and ultrasound probe. Loss of the red color flow suggests there is obstruction of the retinal artery. Central retinal artery occlusion is characterized by painless unilateral vision loss.

Question 18

A 27-year-old woman, G2P1, currently 20 weeks’ gestation, presents to the ED complaining of right-side and back The pain was sudden in onset 2 hours before presentation and described as stabbing in nature. The pain radiates to the right groin and is not associated with any alleviat- ing or aggravating factors. The patient does complain of some vomiting but no other associated symptoms. Her previous pregnancy was uncompli- cated. Her BP is 120/70 mm Hg, HR is 90 beats per minute, temperature is 97.9°F, RR is 16 breaths per minute, and oxygen saturation is 100% on room air. Physical examination shows her in pain, and she cannot seem to find a position of comfort. There was mild right-sided costovertebral angle tenderness. The abdominal examination shows a gravid uterus palpable at the level of the umbilicus but no tenderness or peritoneal signs. Labo- ratory results reveal sodium 138 mEq/L, potassium 4.0 mEq/L, chloride 110 mEq/L, bicarbonate 24 mEq/L, BUN 15 mg/dL, creatinine 0.6 mg/dL, and glucose 105 mg/dL. Urinalysis shows 2+ blood and RBC 20 to 50/hpf. Which of the following ultrasound findings is suggestive of pathologic obstructive hydronephrosis in this patient?

A	Bilateral prominence of the renal collecting system with full bladder
B	Prominence of the right renal collecting system in the supine pregnant patient
C	Bilateral anechoic collections around the renal pelvis with dividing segments of renal cortex
D	Unilateral prominent renal pelvis located outside the medial margin of the renal cortex and no calyceal dilation
E	Prominence of the right renal collecting system while in the left lateral decubitus position

Question 18 Explanation:

In the patient with renal outflow obstruction, bedside ultrasound is used to evaluate primarily for hydronephrosis. There are multiple instances where hydronephrosis may not be pathologic. The pregnant patient with a large gravid uterus can normally have mild to moderate hydronephrosis, secondary to ureter compression by the uterus. Classically the right kidney is involved over the left kidney (b); however, hydronephrosis associated with pregnancy may be bilateral. The presence of right-sided hydronephrosis in a pregnant patient can be better evaluated by having the patient void and lay in the left lateral decubitus position for reevaluation. If the hydronephrosis does not resolve within a short period of time, it is much more suspicious for pathologic hydronephrosis. Bilateral prominent renal collecting system with a full bladder (a) is a common benign finding. In the well-hydrated patient with a full bladder, mild bilateral hydronephrosis can develop. Rescanning the both kidneys after emptying the bladder should show resolution of the hydronephrosis. Conversely, the dehydrated patient with urinary obstruction can have normal appearing kidneys. If there is a high clinical suspicion for renal outflow obstruction, reevaluation with ultrasound should be performed after intravenous or oral hydration. Bilateral anechoic collections around the renal pelvis with dividing segments of renal cortex (c) are consistent with486 Emergency Medicine sonolucent renal pyramids. Sonolucent renal pyramids are normal variants and easily mistaken for dilated renal calyces consistent with hydronephrosis. They can be differentiated from dilated renal calyces by the presence of renal cortex separating each sonolucent triangle. Unilateral prominent renal pelvis located outside the medial margin of the renal cortex and no calycle dilation (d) describes an extrarenal pelvis. An extrarenal pelvis is a benign congenital variant that is easily mistaken for hydronephrosis. The key features of an extrarenal pelvis are no surrounding renal cortex and no dilated renal calyces.

Question 19

A 27-year-old man presents to your ED by ambulance after being involved in an automobile The patient was a restrained rear seat passenger in T-bone–style accident striking the patient’s rear passenger side door. EMS reports there was significant cabin intrusion of the car. The patient was able to climb out of the other side of the car and was ambula- tory on scene. Now, he complains of neck and right chest pain. The chest pain is sharp and worse with breathing. He has no other complaints. His BP is 135/70 mm Hg, HR is 110 beats per minute, temperature is 98.2°F, RR is 20 breaths per minute, and oxygen saturation is 100% on room air. Physical examination reveals clear breath sounds bilaterally and marked tenderness of the right lateral thorax with no crepitus or ecchymosis. The abdomen is soft, nondistended, and nontender. A supine AP chest radio- graph is normal. You place the ultrasound on the patient’s anterior chest wall and obtain the following images. Which of the following diagnoses does the ultrasound finding support?

A	Pulmonary contusion
B	Chest wall contusion
C	Rib fracture
D	Pneumothorax
E	Hemothorax

Question 19 Explanation:

This is an example of a stratosphere sign (see figure below) with a lung point diagnostic of a pneumothorax. The “B” in B mode stands for brightness. B mode is the mode of ultrasonography used with routine imaging. When a sound wave returns to the transducer, it is converted to a grayscale pixel that corresponds to the amplitude or “loudness” of that reflected sound wave. The different shades of gray pixels represent the amount of reflected sound based on the acoustic impedance of the tissues scanned. From these pixels an image is generated and displayed on the monitor for interpretation. The “M” in M mode stands for motion. When the machine is switched to M mode, a line will appear on the B-mode image that is simultaneously displayed. This line corresponds to a single piezoelectric channel that can be focused on an area of interest. In this case the line is focused through the lung-chest wall interface. Once the line is focused on an area of interest, the channel is plotted in a graph with time on the horizontal axis and depth on the vertical axis. By plotting this single channel of ultrasound waves over time, the movement of tissue relative to the ultrasound probe can be interpreted. When scanning a normal thorax in M mode, the soft tissues of the chest wall generate a series of horizontal lines, while the aerated lung sliding deep to the chest wall gives a grainy appearance. This is called the seashore sign (see figure below). If air gets between the visceral and parietal pleura, the movement of the visceral pleura is no longer appreciated. Instead of the grainy beach-like image, a series of horizontal lines in projected. These horizontal lines look like a continuation of the horizontal lines from the chest wall giving a stratosphere sign. Once the stratosphere sign is appreciated, the probe is positioned posterolaterally in an effort to find where the visceral and parietal pleuraUltrasound in the Emergency Department Answers 487 contact. The site where the pneumothorax ends and normal lung starts is called the lung point. At the lung point, the screen will show stratosphere sign with brief periods of seashore sign as the visceral pleura slides into view with respiratory cycles. Visualizing the lung point is 100% specific for the diagnosis of pneumothorax. Another finding suggestive of pneumothorax is a sliding lung sign. With real-time imaging the parietal and visceral pleura are visualized as an echogenic surface deep to the chest wall. During a normal respiratory cycle, the mobile visceral pleura slides over the fixed parietal pleura. The presence of a sliding lung sign virtually rules out a pneumothorax. The absence of a sliding lung sign is highly sensitive for pneumothorax. However, false positives can be caused by pulmonary contusions, bullous emphysema, or acute respiratory distress syndrome (ARDS). Pulmonary contusion (a) is less likely with a normal chest radiograph and the presence of a stratosphere sign with lung point. If real-time imaging showed the loss of a sliding lung sign and a lung point was not shown, pulmonary488 Emergency Medicine contusion would be more likely. The patient may have chest wall contusions (b) and rib fractures (c), but these are not responsible for the ultrasound findings seen in the question. A hemothorax (e) would be represented by an anechoic fluid collection in the dependent portions of the thorax.

Question 20

A 28-year-old woman presents to the ED with vaginal The patient found out she was pregnant 7 weeks ago but was never able to follow up in the OB clinic for prenatal care. She is G3P2. The patient says the bleeding started 1 hour before presentation and was not associated with any trauma, abdominal pain, abdominal cramping, or a gush of clear fluid from the vagina. The patient is a smoker but denies using any drugs of abuse. Her BP is 120/70 mm Hg, HR is 85 beats per minute, tempera- ture is 98.2°F, RR is 16 breaths per minute, and oxygen saturation is 100% on room air. Physical examination is only remarkable for a gravid uterus extending approximately 30 cm above the pelvic brim and blood dripping from the introitus. Bedside transabdominal pelvic ultrasound is performed. Which of the following ultrasound findings would make a digital examina- tion of the cervix contraindicated?

A	Placenta implanted in the lower portion of the uterus
B	A cervix 4 cm in length
C	Hyperechoic fluid collection between the placenta and uterine wall
D	Placenta implanted high and posterior on the uterine wall
E	Breach fetus with foot as presenting part

Question 20 Explanation:

Placenta previa is a contraindication to digital examination of the cervix as placental trauma from the examination itself can lead to profuse vaginal bleeding. Any patient presenting to ED in the second or third trimester of pregnancy with bleeding should have ultrasound performed before pelvic examination to rule out placenta previa. Late in pregnancy, presenting fetal parts obscure the cervix from transabdominal ultrasonography making it difficult to determine the exact proximity of the placental edge to the internal cervical os. Thus, if the placenta is implanted in the lower uterine segment, the pelvic examination should be deferred until translabial or transvaginal ultrasound can be obtained to pinpoint the placental location in relation to the cervix. A cervical length of 4 cm (b) can be reassuring indicating the bleeding is not secondary to changes in labor. The normal cervical length is 3 toUltrasound in the Emergency Department Answers 489 5 cm. As the cervix shortens with effacement and dilation, a cervical length less than 3 cm is concerning for labor or risk of preterm labor. In this case the exact gestation age is not obvious; however, based on physical examination it is clearly a third-trimester pregnancy. Various fetal ultrasound measurements can be conducted to determine an estimated fetal weight, which would offer some correlation to appropriate gestational age such as biparietal diameter, femur length, and abdominal circumference. A hyperechoic fluid collection between the placenta and uterine wall (c) is suggestive of placental abruption. Ultrasound will show evidence of placental hemorrhage in only 50% of cases; thus it is not a reliable test to rule out abruption. Abruption is difficult to detect because the normal architecture of the placenta often mimics abruption on ultrasound. In addition depending on the age of the hemorrhage, abruption can be hyperechoic (early), hypoechoic, or anechoic (late). Whether evidence of abruption is detected or not cardiotocographic monitoring is required to determine next step in management. Placental abruption is not a contraindication to pelvic examination in pregnancy. A placenta implanted high and posterior in the uterus (d) is normal and rules out placenta previa; thus digital examination of the cervix is not contraindicated in this instance. Ultrasound is an excellent way to detect a breech fetus. (e) When a breech fetus is detected and the patient is in labor, digital examination is warranted.

Question 21

A 58-year-old woman presents to the ED with abdominal She reports that the pain is in the RUQ and has been getting progressively worse over the last month. The pain is now a sharp, constant, and non- radiating. The pain is worse when she lays on her right side. She denies any urinary complaints. Her BP is 125/75 mm Hg, HR is 75 beats per minute, temperature is 96.9°F, RR is 18 breaths per minute, and oxygen saturation is 98% on room air. On physical examination, her abdomen is nondis- tended and soft. She does have pinpoint tenderness to palpation under the right costal margin. Laboratory tests are within normal limits. You obtain a bedside ultrasound of the RUQ that revealed the following. Which of the following findings is suggestive of malignancy?

A	Heterogeneous mass with irregular boarders
B	Phrygian cap present in the mass
C	Well-defined smooth mass margins with no internal echoes
D	Homogenous echogenicity throughout the mass
E	Riedel lobe present in the mass

Question 21 Explanation:

Hepatic masses are a common incidental finding. Distinguishing benign from serious lesions by ultrasound can be difficult given the overlap in the sonographic appearance. Thus, most incidental lesions in the liver require further imaging. Normal liver tissue on ultrasound has a salt and pepper heterogeneous appearance. Solid heterogeneous or cystic lesions with soft internal echoes that contain irregular boarders are concerning for neoplastic or infectious lesions. When numerous heterogeneous lesions are present, the suspicion for metastatic disease is very high. Phrygian cap (b) is an incidental finding on the gallbladder. A mucosal fold in the fundus of the gallbladder giving a tortuous fundus characterizes it. This finding is not pathologic; however, it should be carefully evaluated as gallstones in the phrygian cap are often missed. Well-defined masses with smooth margins that are anechoic or homogenous internally (c and d) are usually associated with benign masses. Riedel lobe (e) is an accessory lobe off the right lobe extending inferiorly toward the pelvis. It is490 Emergency Medicine normal hepatic tissue and will have the same salt and pepper echogenicity as the rest of the liver. The clinical significance of this is that it can be mistaken for hepatomegaly.

Question 22

A 45-year-old man presents to your ED after a fall from standing The patient states he was not watching where he was going when he tripped on a rug and fell into the coffee table. The patient hit his left side on the edge of the table. He denies loss of consciousness. He complains of pain in the left flank and pain in his left shoulder when he takes a deep breath. On examination his vital signs include a BP of 140/75 mm Hg, HR of 95 beats per minute, temperature of 98.9°F, RR of 16 breaths per minute, and oxygen saturation of 100% on room air. The lungs are clear to auscultation bilaterally and the abdomen is tender in the LUQ. There is no rebound, guarding, or organomegaly. There is no ecchymosis noted in the left flank. You obtain a bedside FAST examination, shown in the following image. What is the next best step in the management of this patient?

A	Transfuse 2 units of type O-negative blood and start cross-matched blood once available.
B	Perform CT scan of the abdomen and pelvis with intravenous contrast.
C	Perform emergent laparotomy.
D	Upright chest radiograph to rule out free air under the diaphragm.
E	If his pain resolves, prescribe ibuprofen for pain control and have him follow up with his primary care physician in 5 days for a repeat abdominal examination.

Question 22 Explanation:

The perisplenic view of this FAST examination shows an anechoic stripe in the subphrenic space representing free fluid in the peritoneal cavity. In the setting of trauma free peritoneal fluid is presumed to be blood. Blood in the perisplenic region most commonly collects in the subphrenic space. In this case the patient gives a classic Kehr sign for splenic rupture. Blood in the left subphrenic space irritates the diaphragm giving referred pain to the left shoulder. Many low to moderate grade liver and spleen injuries can be managed nonoperatively or with interventional radiology by embolizing bleeding vessels. Because this patient is clinically stable, further imaging with a CT scan is the next best step in management. If the patient had been hemodynamically unstable, it would be appropriate to begin a blood transfusion and (a) bring the patient to the operating room (c) for definitive management. Solid organ injury does not lead to pneumoperitoneum (d); thus upright chest radiography would not be helpful. Further imaging and observation is required to ensure that the patient does not deteriorate. Discharging the patient home directly from the ED (e) is inappropriate in the setting of an intraperitoneal bleed.

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1.A 35-year-old woman presents to the ED via ambulance after being involved in an automobile EMS reports the patient was a restrained front seat passenger in a car struck on the front passenger door with significant cabin intrusion. The patient was nonambulatory on scene and required prolonged extraction from the vehicle. The vital signs on scene after extrication were blood pressure (BP) 105/80 mm Hg, heart rate (HR) 115 beats per minute, respiratory rate (RR) 22 breaths per minute, and oxygen saturation 100% on a non-rebreather mask. Two larger-bore IVs were established with 2 L of normal saline infused during extrication and transport. On arrival in the emergency department (ED), the patient does not remember what happened. She complains of pain in the right forearm and abdomen. In the ED her vital signs are BP 90/65 mm Hg, HR 140 beats per minute, temperature 98.9°F, RR 35 breaths per minute, and oxygen saturation 100% on a non-rebreather mask. Physical exami- nation reveals a diaphoretic patient who responds to painful stimuli. She answers questions but is confused. On examination, her abdomen is non- distended, soft, and tender along the right upper and lower quadrants on moderate palpation. Her dorsal forearm has a 4-cm laceration with active oozing of blood. She is neurovascularly intact in the right extremity, and no deformities are noted. There is no other evidence of trauma. A second liter of normal saline is started, type O–negative blood is ordered, and the type and cross match is sent to the laboratory. Chest and pelvis radiographs are negative for acute injury. You obtain a focused assessment by sonography for trauma (FAST) examination, shown in the following image. What is the next best step in the management of the patient?

Continue intravenous (IV) fluids and obtain a computed tomographic (CT) scan of her head.
Continue IV fluids and obtain a CT scan of her abdomen and pelvis.
Wait for the hemoglobin result and, if low, administer 2 units of packed red blood cells (RBCs).
Transport the patient to the operating room for emergent therapeutic laparotomy.
Place interlocking stitches to close the forearm laceration to control bleeding and prevent her BP from dropping even further.

2. A 16-year-old girl present to the ED complaining of severe sudden- onset sharp pain located in the right lower quadrant (RLQ). The pain started suddenly 1 hour before The pain is associated with a single epi- sode of nonbloody emesis; however, no diarrhea, vaginal bleeding, vaginal discharge, frequency, or burning with urination was reported. The patient denies any sexual activity in her past. She states she is G0P0 and her last normal menstrual period was 3 weeks ago. Her BP is 130/75 mm Hg, HR is 115 beats per minute, temperature is 99.3°F, RR is 18 breaths per minute, and oxygen saturation is 100% on room air. Physical examination shows a very uncomfortable appearing patient holding her RLQ. Her abdomen is tender in the RLQ with mild voluntary guarding but no rebound tender- ness, Rovsing sign, psoas, or obturator signs. Pelvic examination shows right adnexal tenderness, with no masses, cervical motion tenderness, or discharge. Laboratory results reveal a urinalysis with 1+ leukocyte esterase, negative qualitative b-human chorionic gonadotropin (b-hCG), white blood cell (WBC) count 8000/mL, hematocrit 46%, and platelets 270/mL. Which of the following ultrasound findings helps to rule out ovarian tor- sion as this patient’s diagnosis?

Unilateral enlarged ovary secondary to edema
Venous and arterial blood flow detected with Doppler sonography of the right ovary
Free fluid in the pouch of Douglas
Normal-sized ovary with no surrounding ovarian mass
Presence of right adnexal mass measuring 5 cm at largest diameter

3. A 23-year-old woman presents to the ED with abdominal discomfort located in the left lower quadrant (LLQ) for the past 3 The pain is intermittent, nonradiating, with no alleviating or aggravating factors. She denies vomiting, diarrhea, dysuria, vaginal bleeding, or vaginal discharge. The patient states she is sexually active with one partner and her last menstrual period (LMP) was 2 weeks ago. Her BP is 115/70 mm Hg, HR is 75 beats per minute, temperature is 98.6°F, RR is 15 breaths per minute, and oxygen saturation is 100% on room air. Physical examination is unre- markable. Urinalysis shows no evidence of hematuria or infection. Qualita- tive b-hCG is positive. Bedside transvaginal pelvic ultrasound is obtained as seen below.

Which of the following is the earliest ultrasound finding confirming intra- uterine pregnancy (IUP)?

Gestational sac with visualized endometrial stripe
Gestational sac containing yolk sack and embryonic pole with visualized endo- metrial stripe
Blighted ovum with visualized endometrial stripe
Intradecidual sign with visualized endometrial stripe
Gestational sac containing yolk sac with visualized endometrial stripe

4. Emergency medical service (EMS) was called to the scene of an unconscious 38-year-old man with labored EMS intubated the patient, placed two large-bore IVs, and began a normal saline infusion. On arrival in the ED, his BP is 70/30 mm Hg, HR is 140 beats per minute, temperature is 98.9°F, and oxygen saturation is 100% on a non-rebreather. Physical examination reveals a diaphoretic male, moving all four extremi- ties spontaneously, but he is not following commands. The neck exami- nation reveals elevated jugular venous pressure and a midline trachea. A single puncture wound is noted just below the xiphoid process; however, no abdominal distension is appreciated on abdominal examination. Your FAST examination is as shown in the following the ultrasound image. What is the next best step in the patient’s management?

ED resuscitative thoracotomy after placement of a chest tube.
Immediate transfer to the operating room for emergent laparotomy and pelvic binding.
Immediate transfer to operating room for emergent thoracotomy.
Stat CT scan of the abdomen and pelvis to evaluate for hollow viscus injury.
Perform a stat bedside pericardiocentesis.

5. A 42-year-old woman presents to the ED complaining of abdominal pain that is located in her right upper quadrant (RUQ). The pain started 5 hours before presentation after a She describes the pain as sharp, radiating around the right flank and into the back. The pain never com- pletely goes away but waxes and wanes in intensity. This pain is associated with nausea and vomiting, but no diarrhea or fever has been noted. Her review of systems reveals that she has been getting sharp pains in her RUQ after meals for the past year. Her BP is 145/75 mm Hg, HR is 110 beats per minute, temperature is 100.3°F, RR is 16 breaths per minute, and oxygen saturation is 100% on room air. The physical examination shows a non- distended abdomen with tenderness to palpation in the RUQ. There is no rebound or guarding. When the patient tries to inhale during deep palpation of the RUQ, she is forced to pause during inspiration because of extreme pain. Laboratory results reveal WBC 16,000/mL, hematocrit 48%, platelets 250/mL, aspartate aminotransferase (AST) 45 U/L, alanine aminotransferase (ALT) 40 U/L, alkaline phosphatase 75 U/L, amylase 50 U/L, lipase 40 U/L, sodium 140 mEq/L, potassium 3.5 mEq/L, chloride 110 mEq/L, bicarbon- ate 24 mEq/L, blood urea nitrogen (BUN) 9 mg/dL, creatinine 0.5 mg/dL, and glucose 85 mg/dL. You obtain a bedside ultrasound scan as seen below and find the following image showing a gallbladder wall thickness of 7 mm. Which of the following is a later finding of cholecystitis?

Cholelithiasis
Sonographic Murphy sign
Mucosal sloughing
Gallbladder wall thickening
Pericholecystic fluid

6. A 25-year-old man presents to the ED after being shot in the face with a shotgun at long The patient complains of pain generally across his face; however, the pain is greatest around his right eye. He is not sure if he can see out of the eye because the right eyelid is swollen shut. His BP is 140/80 mm Hg, HR is 105 beats per minute, temperature is 98.4°F, RR is 18 breaths per minute, and oxygen saturation is 100% on room air. Physi- cal examination shows multiple pellet marks across the face. The right eyelid has a grouping of pellet marks and is swollen shut with surround- ing ecchymosis and edema. The eyelid cannot be pried open secondary to pain limitation and further attempts at direct visualization of the eye where deferred for concern of manually increasing intraocular pressure. The rest of the physical examination was unremarkable. Bedside ocular ultrasound was obtained as seen below. Which of the following is the most likely diagnosis?

Intact globe
Retinal detachment
Lens dislocation
Globe rupture
Retrobulbar hematoma

7. A 70-year-old man presents to the ED complaining of pain in his left back and He describes the pain as dull and aching. The pain started 1 day before presentation while watching TV. The pain is constant and does not radiate. He has no history of trauma or heavy lifting, and nothing seems to make the pain worse or better. His BP is 170/95 mm Hg, HR is 88 beats per minute, temperature is 97.6°F, RR is 17 breaths per minute, and oxygen saturation is 100% on room air. The physical examination and laboratory studies are unremarkable. A bedside ultrasound is obtained as seen below with the transverse and sagittal views of the aorta. Which of the following is the most accurate way to measure abdominal aortic aneurysm diameter?

While viewing the aorta in a sagittal plane, measure anterior to posterior diameter from inner wall to inner wall.
While viewing the aorta in a transverse plane, measure anterior to posterior diameter from inner wall to inner wall.
While viewing the aorta in a transverse plane, measure anterior to posterior diameter from outer wall to outer wall.
While viewing the aorta in a sagittal plane, measure the anterior posterior diameter from outer wall to outer wall.
While viewing the aorta in a transverse plane, measure anterior to posterior diameter from outer wall to inner wall.

8. A 55-year-old woman is brought to ED after being struck by an auto- mobile. Per EMS, she was crossing an intersection when an automobile ran a stop sign striking her on the left The patient was found lying supine in the street alert and oriented to person, place, and time. Prehospital vital signs were BP 100/85 mm Hg, HR 120 beats per minute, RR 22 breaths per minute, and oxygen saturation 95% on room air. Intravenous access was established with normal saline being infused during transfer to your ED. On arrival in the ED, the patient complains of pain in the left hip and pelvic region. Vital signs in the ED are BP 95/60 mm Hg, HR 135 beats per minute, temperature 97.5°F, RR 28 breaths per minute, and oxygen saturation 100% on a non-rebreather. Physical examination reveals a pale diaphoretic patient. The breath sounds are clear bilaterally and her abdomen is soft and nondistended. Her pelvis appears stable, but exquisite pain is elicited with rocking of the pelvis. Her extremity examination reveals no leg length or temperature discrepancies, and she is neurovascularly intact throughout the lower extremities. The examination of her perineum reveals ecchymosis on the perineum and blood at the urethral meatus. You obtain a FAST examination as seen below and a pelvic radiograph that shows markedly widened view of the pubic symphysis. After pelvic binding is applied, what is the next best step in the management of this patient?

CT scan of the abdomen and pelvis with intravenous contrast
Transport to operating room for emergent laparotomy
Transport to the interventional radiology suite for embolization
Foley catheter to evaluate for hematuria
CT thorax with intravenous contrast

9. A 30-year-old man presents to the ED complaining of severe pain in the left side and He states that the pain started suddenly 5 hours before presentation and describes the pain as stabbing. The patient has never experienced the pain previously and states the pain comes and goes in intensity but never completely goes away. The pain radiates to his left groin and denies any alleviating or aggravating factors. The patient denies any hematuria, burning with urination, fever, vomiting, changes in bowel habits, recent trauma, or heavy lifting. His BP is 155/80 mm Hg, HR is 105 beats per minute, temperature is 99.5°F, RR is 18 breaths per minute, and oxygen saturation is 100% on room air. Physical examination shows a patient in obvious pain who cannot seem to find a position of comfort. The only remarkable finding was costovertebral angel tenderness on the left side. Laboratory results reveal sodium 142 mEq/L, potassium 4.0 mEq/L, chloride 110 mEq/L, bicarbonate 24 mEq/L, BUN 12 mg/dL, creatinine 0.7 mg/dL, and glucose 100 mg/dL. Urinalysis shows 2+ blood and RBC 20 to 50/hpf. A bedside renal ultrasound is obtained. Which of the following findings on ultrasound is consistent with severe hydronephrosis?

Anechoic collections around the renal pelvis with dividing segments of renal cortex
Prominent anechoic renal calyces
Prominent anechoic renal pelvis and calyces
Prominent anechoic renal pelvis and calyces with cortical thinning
Prominent renal pelvis and calyces with echogenic structure at ureteropelvic junction casting clean shadowing in the background

10. A 48-year-old man was reroofing the second story of his house when he slipped and fell to the ground, landing on his right EMS arrived at the scene, placed the patient in spinal precautions, and established an IV. On arrival to the ED, he complains of pain along the right costal margin going to his right lateral chest and in his RUQ. He states it hurts to breathe but has not other complaints. His BP is 130/80 mm Hg, HR is 110 beats per minute, temperature is 98.9°F, RR is 25 breaths per minute and shallow, and oxygen saturation is 100% on room air. Physical examination reveals the patient taking rapid shallow breaths and holding his right hemithorax. His neck examination shows no elevated jugular venous pressure and his trachea is midline. His chest wall is tender down the right lateral wall. You do not palpate crepitus. His breath sounds are equal to auscultation bilateral. His abdominal examination reveals a nondistended abdomen, but there is tenderness in the RUQ. A 2-L bolus of normal saline is started and you obtain a FAST examination, as shown in the following image. What is the next best step in the management of this patient?

Chest tube thoracostomy
Rapid sequence intubation
CT scan of the thorax with intravenous contrast
CT scan of the abdomen and pelvis with intravenous contrast
Transport to the operating room for emergent laparotomy

11. A 55-year-old man presents to the ED complaining of epigastric abdominal He describes the pain as gradual in onset, burning in nature, and radiates through to his back. It is associated with vomiting and diarrhea. His BP is 180/90 mm Hg, HR is 100 beats per minute, temperature is 98.9°F, RR is 20 breaths per minute, and oxygen saturation is 100% on room air. On physical examination, his abdomen is soft and nondis- tended, but there is marked tenderness in the epigastrium. The remainder of his examination is normal. Laboratory results reveal WBC 12,000/mL, hematocrit 48%, platelets 250/mL, AST 500 U/L, ALT 600 U/L, alkaline phosphatase 450 U/L, amylase 1500 U/L, lipase 2000 U/L, total bilirubin 3.0 mg/dL, sodium 150 mEq/L, potassium 4.4 mEq/L, chloride 90 mEq/L, bicarbonate 20 mEq/L, BUN 9 mg/dL, creatinine 0.5 mg/dL, and glucose 110 mg/dL. You obtain a bedside ultrasound scan that reveals as shown in the following image. Which of the following findings is consistent with extrahepatic biliary obstruction?

Mickey Mouse sign
Increased echogenicity with irregular texture of the liver
Playboy bunny sign
Double barrel shotgun sign or parallel channel sign
Antler signs

12. A 25-year-old woman with a history of pelvic inflammatory disease presents to the ED with abdominal The pain is located in the RLQ and has been sharp, constant, and nonradiating for the last 2 days. The pain is associated with some vomiting and vaginal spotting. The patient denies fever, change in bowel habits, or vaginal discharge. Her LMP was 4 weeks ago and has been having unprotected sex with two partners. Her BP is 110/75 mm Hg, HR is 80 beats per minute, temperature is 99.1°F, RR is 16 breaths per minute, and oxygen saturation is 100% on room air. Physical examination reveals a tender abdomen in the RLQ with no rebound or guarding. Pelvic examination shows a closed cervical os with scant vaginal bleeding. There was right adnexal tenderness without fullness and no cervical motion tenderness. Urinalysis shows no evidence of hema- turia or infection. Qualitative b-hCG is positive. The following ultrasound images are obtained of the uterus and left ovary, respectively. Which of the following confirms an ectopic pregnancy?

Free fluid in the cul-de-sac posterior to the cervix
Gestational sac with yolk sac in the adnexa
Complex adnexal mass
Tubal ring
Ring of fire sign

13. A 30-year-old, 8 weeks’ pregnant woman presents to the ED with vomiting 10 to 20 times a day for the past 5 The patient also noticed some vaginal spotting over the last day, with no discharge, no urinary com- plaints, no abdominal pain, and no diarrhea. Her BP is 135/75 mm Hg, HR is 100 beats per minute, temperature is 97.9°F, RR is 18 breaths per minute, and oxygen saturation is 100% on room air. Physical examination shows dry mucous membranes and a nontender abdomen with a gravid uterus extending half way between the pubic symphysis and umbilicus. Pelvic examination shows scant blood in the vaginal vault with a closed cervical os. Laboratory results reveal serum sodium 143 mEq/L, potassium 3.9 mEq/L, chloride 95 mEq/L, bicarbonate 19 mEq/L, BUN 15 mg/dL, creatinine 1 mg/dL, and glucose 105 mg/dL; urinalysis shows a specific gravity greater than 1.030 g/mL and 3+ ketones; and quantitative b-hCG is 1,500,000 mIU/mL. Which of the following ultrasound findings confirms the diagnosis?

Thin-walled unilocular anechoic cystic structure measuring 4 cm in diameter on the ovary
Cluster of grapes in the uterine cavity
Hypoechoic stripe between the endometrium and chorionic membrane
Multiple thin-walled multilocular cystic masses on each ovary measuring approximately 6 cm in diameter
Hypoechoic solid spherical mass in the uterine wall

14. A 60-year-old woman presents to the ED stating that she is turning Her husband first noticed her skin turning yellow 2 weeks ago. The patient has no other complaints and is otherwise healthy. Her BP is 130/70 mm Hg, HR is 80 beats per minute, temperature is 97.4°F, RR is 16 breaths per minute, and oxygen saturation is 100% on room air. On physical examination, her abdomen is soft without any tenderness, orga- nomegaly, or masses. Her skin examination reveals jaundice. Laboratory results reveal WBC 10,000/mL, hematocrit 48%, platelets 250/mL, AST 400 U/L, ALT 450 U/L, alkaline phosphatase 500 U/L, amylase 50 U/L, lipase 40 U/L, direct bilirubin 15.2 mg/dL, total bilirubin 16.5 mg/dL, sodium 140 mEq/L, potassium 3.5 mEq/L, chloride 110 mEq/L, bicarbonate 24 mEq/L, BUN 10 mg/dL, creatinine 0.6 mg/dL, and glucose 85 mg/dL. Which of the following is an abnormal common bile duct (CBD) diameter?

40-year-old man postcholecystectomy with 9-mm-diameter CBD
75-year-old woman with 7-mm-diameter CBD
50-year-old man with 4-mm-diameter CBD
40-year-old postcholecystectomy with 10-mm-diameter CBD
60-year-old man with 9-mm-diameter CBD

15. A 58-year-old-woman presents to the ED with the complaint of left- sided back pain, fever, vomiting, and The patient states all of her symptoms started 15 days ago with low abdominal pain associated with burning on urination that has progressively worsened with migration of pain up her right side. She said that the pain was consistent with her previ- ous urinary tract infections (UTIs), so she tried home remedies before com- ing to the hospital 4 days ago. Chart review shows the patient was started on ciprofloxacin for pyelonephritis. She has been compliant with her medica- tions since they were started, but she seems to be getting worse. Her history is significant for multiple UTIs and diabetes. Her BP is 150/85 mm Hg, HR is 110 beats per minute, temperature is 100.5°F, RR is 18 breaths per minute, and oxygen saturation is 100% on room air. Physical examination shows a nontoxic-appearing patient with mild left-sided costovertebral angel tender- ness and left upper quadrant (LUQ) tenderness. Her examination shows no peritoneal signs or masses. Laboratory results reveal WBC 15,000/mL, hematocrit 48%, platelets 250/mL, sodium 135 mEq/L, potassium 4.5 mEq/L, chloride 110 mEq/L, bicarbonate 23 mEq/L, BUN 20 mg/dL, crea- tinine 1.2 mg/dL, and glucose 250 mg/dL. Urinalysis shows 1+ leukocyte esterase, 1+ blood, 1+ bacteria, 5 to 10 RBC/hpf, and 5 to 10 WBC/hpf. A bedside left renal ultrasound is obtained as shown in the following image. Which of the following is most suggestive of renal abscess?

Solitary anechoic cystic structure with internal septations and areas of echogenic debris
Solitary anechoic smooth cystic structure with no internal echoes
Prominent echolucent renal pelvis and calyces
Multiple anechoic smooth cystic structures with no internal echoes
An irregular heterogeneous solid structure that is hyperechoic relative to sur- rounding parenchyma

16. A 35-year-old man presents to the ED complaining of pain and swell- ing in his left lower The patient states the pain started when he woke up this morning. With further questioning, the patient states he was aboard a transatlantic flight from England yesterday. There is no history of trauma, he has never experienced leg pain like this in the past, and cur- rently has no chest pain or shortness of breath. He has no history of medical problems. His BP is 130/75 mm Hg, HR is 75 beats per minute, temperature is 99.3°F, RR is 16 breaths per minute, and oxygen saturation is 98% on room air. Physical examination shows his left leg is larger in circumference compared to his right. The left leg is slightly red and warm to touch with soft compartments, symmetric pulses, and intact sensation. The left calf is tender with palpation and dorsiflexion of the ankle. Which of the following ultrasound findings is consistent with deep venous thrombosis (DVT)?

Noncompressible anechoic cystic structure in the popliteal fossa
Noncompressible superficial femoral vein
Noncompressible spherical echogenic structure superficial to femoral artery
Noncompressible middle section of the great saphenous vein
Semicompressible cystic structure with fluid dissecting into the soft tissue planes of the calf

17. A 35-year-old woman presents to the ED complaining of a The patient states the headache has been coming and going for months. The headache is not maximal or sudden in onset and today it is not really different from previous episodes. The patient decided to come to the ED today because she was experiencing periods where her vision seemed dim. With further questioning, the patient states she gets periodic whooshing sound in her ears. Her BP is 145/75 mm Hg, HR is 93 beats per minute, temperature is 97.9°F, RR is 16 breaths per minute, and oxygen saturation is 100% on room air. Her physical examination is unremarkable; however, the fundi were not clearly visualized on funduscopic examination. Ultra- sound evaluation of the eye is obtained as shown in the following image. Which of the following further suggests the most likely diagnosis?

Ribbon-like echogenic structure in the vitreous chamber that is free floating with eye movement
Optic nerve sheath diameter of 6 mm
Loss of globe volume with echogenic matter in the vitreous chamber
Optic nerve sheath diameter of 4 mm
Color Doppler flow of the optic disk showing only blood flow exiting the globe

18. A 27-year-old woman, G2P1, currently 20 weeks’ gestation, presents to the ED complaining of right-side and back The pain was sudden in onset 2 hours before presentation and described as stabbing in nature. The pain radiates to the right groin and is not associated with any alleviat- ing or aggravating factors. The patient does complain of some vomiting but no other associated symptoms. Her previous pregnancy was uncompli- cated. Her BP is 120/70 mm Hg, HR is 90 beats per minute, temperature is 97.9°F, RR is 16 breaths per minute, and oxygen saturation is 100% on room air. Physical examination shows her in pain, and she cannot seem to find a position of comfort. There was mild right-sided costovertebral angle tenderness. The abdominal examination shows a gravid uterus palpable at the level of the umbilicus but no tenderness or peritoneal signs. Labo- ratory results reveal sodium 138 mEq/L, potassium 4.0 mEq/L, chloride 110 mEq/L, bicarbonate 24 mEq/L, BUN 15 mg/dL, creatinine 0.6 mg/dL, and glucose 105 mg/dL. Urinalysis shows 2+ blood and RBC 20 to 50/hpf. Which of the following ultrasound findings is suggestive of pathologic obstructive hydronephrosis in this patient?

Bilateral prominence of the renal collecting system with full bladder
Prominence of the right renal collecting system in the supine pregnant patient
Bilateral anechoic collections around the renal pelvis with dividing segments of renal cortex
Unilateral prominent renal pelvis located outside the medial margin of the renal cortex and no calyceal dilation
Prominence of the right renal collecting system while in the left lateral decubitus position

19. A 27-year-old man presents to your ED by ambulance after being involved in an automobile The patient was a restrained rear seat passenger in T-bone–style accident striking the patient’s rear passenger side door. EMS reports there was significant cabin intrusion of the car. The patient was able to climb out of the other side of the car and was ambula- tory on scene. Now, he complains of neck and right chest pain. The chest pain is sharp and worse with breathing. He has no other complaints. His BP is 135/70 mm Hg, HR is 110 beats per minute, temperature is 98.2°F, RR is 20 breaths per minute, and oxygen saturation is 100% on room air. Physical examination reveals clear breath sounds bilaterally and marked tenderness of the right lateral thorax with no crepitus or ecchymosis. The abdomen is soft, nondistended, and nontender. A supine AP chest radio- graph is normal. You place the ultrasound on the patient’s anterior chest wall and obtain the following images. Which of the following diagnoses does the ultrasound finding support?

Pulmonary contusion
Chest wall contusion
Rib fracture
Pneumothorax
Hemothorax

20. A 28-year-old woman presents to the ED with vaginal The patient found out she was pregnant 7 weeks ago but was never able to follow up in the OB clinic for prenatal care. She is G3P2. The patient says the bleeding started 1 hour before presentation and was not associated with any trauma, abdominal pain, abdominal cramping, or a gush of clear fluid from the vagina. The patient is a smoker but denies using any drugs of abuse. Her BP is 120/70 mm Hg, HR is 85 beats per minute, tempera- ture is 98.2°F, RR is 16 breaths per minute, and oxygen saturation is 100% on room air. Physical examination is only remarkable for a gravid uterus extending approximately 30 cm above the pelvic brim and blood dripping from the introitus. Bedside transabdominal pelvic ultrasound is performed. Which of the following ultrasound findings would make a digital examina- tion of the cervix contraindicated?

Placenta implanted in the lower portion of the uterus
A cervix 4 cm in length
Hyperechoic fluid collection between the placenta and uterine wall
Placenta implanted high and posterior on the uterine wall
Breach fetus with foot as presenting part

21. A 58-year-old woman presents to the ED with abdominal She reports that the pain is in the RUQ and has been getting progressively worse over the last month. The pain is now a sharp, constant, and non- radiating. The pain is worse when she lays on her right side. She denies any urinary complaints. Her BP is 125/75 mm Hg, HR is 75 beats per minute, temperature is 96.9°F, RR is 18 breaths per minute, and oxygen saturation is 98% on room air. On physical examination, her abdomen is nondis- tended and soft. She does have pinpoint tenderness to palpation under the right costal margin. Laboratory tests are within normal limits. You obtain a bedside ultrasound of the RUQ that revealed the following. Which of the following findings is suggestive of malignancy?

Heterogeneous mass with irregular boarders
Phrygian cap present in the mass
Well-defined smooth mass margins with no internal echoes
Homogenous echogenicity throughout the mass
Riedel lobe present in the mass

22. A 45-year-old man presents to your ED after a fall from standing The patient states he was not watching where he was going when he tripped on a rug and fell into the coffee table. The patient hit his left side on the edge of the table. He denies loss of consciousness. He complains of pain in the left flank and pain in his left shoulder when he takes a deep breath. On examination his vital signs include a BP of 140/75 mm Hg, HR of 95 beats per minute, temperature of 98.9°F, RR of 16 breaths per minute, and oxygen saturation of 100% on room air. The lungs are clear to auscultation bilaterally and the abdomen is tender in the LUQ. There is no rebound, guarding, or organomegaly. There is no ecchymosis noted in the left flank. You obtain a bedside FAST examination, shown in the following image. What is the next best step in the management of this patient?

Transfuse 2 units of type O-negative blood and start cross-matched blood once available.
Perform CT scan of the abdomen and pelvis with intravenous contrast.
Perform emergent laparotomy.
Upright chest radiograph to rule out free air under the diaphragm.
If his pain resolves, prescribe ibuprofen for pain control and have him follow up with his primary care physician in 5 days for a repeat abdominal examination.

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