CASE 590: INFECTIOUS THORACIC AORTIC ANEURYSM, Dr PHAN THANH HẢI, Dr CHÂU NGỌC MINH PHƯƠNG, MEDIC MEDICAL CENTER, HCMC, VIETNAM.

A 44 years-old male patient, complaint of substernal chest pain for one week, increased with cough and inspiration. He also had mild fever, dry cough, and dyspnea. He was first seen on July 4^th 2020, and was followed up at home with an initial diagnosis of Suspected Pericarditis – Urinary Infection. He was then readmitted 7 days later at ER department. 

ECG on July 4^th, 2020 showed ST changes associated with pericardial effusion.

Blood test on July 4^th, 2020 showed highly elevated white blood counts, marked increase of hsCRP, and urinary infection. The serum troponin was normal.

Echocardiography showed minimal pericardial effusion.

Chest X-ray was normal.

He was given oral antibiotics (Levofloxacin) and anti-inflammation for 7 days.

On July 10^th, 2020, he was admitted to ER due to severe chest pain, mild fever, and dyspnea. Physical examination at ER showed tachycardia, normal BP, and no heart murmur.

Repeated ECG on July 10^th, 2020 showed flattened T-wave on DIII.

Second blood test showed persistent elevated WBC, hsCRP and elevated D-dimers.

Chest CT-scan on July 10^th, 2020 showed suspected mediastinum abscess surrounding the ascending aorta, with saccular aneurysm at the beginning of the aortic arch, and mild pericardial effusion. The differential diagnosis was thoracic aortic aneurysm with surrounding hematoma.

The patient was then transferred to Binh Dan Hospital. He was operated on the very next day, and surgery report showed inflammation and necrosis of the aortic aneurysm’s wall. The necrotic tissues were removed, and the aortic arch was partially replaced with a Vascutek 16 graft.

During his hospital staying, pericardial fluid culture came back positive for Staphylococcus aureus. He was treated with a combination of Vancomycin and Imipenem.

He’s currently stable with minimal pain at the surgical site. His white blood count went down to almost the normal range.  

CONCLUSION=

Echocardiography and EKG detected pericardial effusion, CT revealed infected aneurysm and mediastinal abscess and patient remained well post-op ; that is a great success for saving patient life  came from an interesting combination of clinical and imaging of diagnosing and surgery.

CASE 589: TB OF TESTIS, Dr PHAN THANH HẢI-Dr LÊ THANH LIÊM, MEDIC MEDICAL CENTER, HCMC, VIETNAM

Male 28yo, with swelling and scrotal pain in thrombophlebitis management and spermatic vein thrombosis for 2 months but nothing change that a hospital in HCM city made decision to surgery because of not ruling out a sarcoma?

US and MRI cannot rule out a spermatic tumor.

At Medic Center utrasound detected edema of epidydimal head, hypervascular #36x24mm with some calcium nodules, scrotal skin edema and small amount of  fluid in scrotum while seldom revealed lymph nodes that are poor echoic  in necrosis and calcified  at left neck=10-31mm that made  thought about TB abscess of left epidydimis

Blood tests: WBC 10.900 / mL;  CRP 13.63 mg/L; AFP 1.94 ng/ml; BetaHCG blood < 0.2  mUI/ml.


Chest X-Rays detected fibrotic lesion in right subclavian area and suspected TB lesion of right lung.

FNAC for left neck lymph node thinks about TB node.

Pulmonary and TB PNT hospital suspected TB testis and peripheric nodular disorders.

For 4 months of TB treatment, on ultrasound in Medic Center, head of epidydimis decreases volume #24x16mm, hyperechoic pattern, non hypervascular irrigation with existing a small abscess of 16x11mm, and scrotal skin slightly thickend with small amount of fluid in scrotum.

Decreasing of volume of left neck lymph nodes =10-29mm.

Post TB therapy course 9 months

Small scare of epidydimis, normal testicular vein. Neck nodes reduce the sizes.

CASE 588:THIGH MUSCLE THICKENING [TMT] AFTER FEMUR BONE FRACTURE, Dr PHANTHANH HẢI, Dr LÊ THỊ THANH THẢO, Dr PHAN THANH HẢI PHƯỢNG, MEDIC MEDICAL CENTER, HCMC, VIETNAM

Female 86yo. Right femur neck fracture due to falling for 2 months.

X-Rays = Right neck femur bone fracture, Garden 4. Severe osteoporosis on Osteogram and calcaneus ultrasound.

MSK ULTRASOUND=

Old fracture of right femur neck with existing callus, non continuous rough surface and edema soft tissue around without hematoma.

Ultrasound for sarcopenia by mesurement of Thigh Muscle Thickening (TMT)=
 R= 12mm/ L=23mm.

Noted decreasing of  right thigh muscle [rectus and mediale femoris] volume.

CASE 587 : POCUS for A CASE of CHEST PAIN, Dr PHAN THANH HẢI , Dr LÊ THANH LIÊM, MEDIC MEDICAL CENTER, HCMC, VIETNAM

Female 92 yo, complaint of a right chest pain and subcostal pain for 5 days that gets more painful when coughing and moving. In emergency examination, she is in consciousness and well contact.

Pouls and blood tension are normal

EKG PoC at bed :Ischemic myocardial  regions in lateral anterior, lateral high  and diaphragmatic of heart.

Chest X-Rays PoC (in supine) results: Cardiopathy due to atherosclerosis, nothing abnormal detected of lungs, pleural and thoracic cage, elevated right diaphragm.

               

Lung Ultrasound PoCUS 
No pneumothorax proved by existing sliding sign (+).

                

No pleural effusion

               

Abdomen Ultrasound PoCUS = No free fluid, no findings of contusion of solid organs = liver, spleen, pancreas, kidneys.

               

Thoracic wal ultrasound PoCUS= Light fracture of 3rd rib anterior arcade without deplacement, and soft tissue around slight edema.

                

CONCLUSION:

 PoCUS at home helps ruling out dangerous conditions like pneumothorax, hemopleuresis, hemoperitoneum, solid organ contusions. PoCUS may evaluate painful points and decide on site (at home) appropriate managements. In face- to - face  contact, PoCUS  may help patient coming down and getting out of anxiety in emergency. 

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