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Emergency ultrasound case of the month……2014 !!

6 Jan

From Vincent Rietveld, SEH-arts/ Emergency physician at the Westfriesgasthuis Hoorn, @vindoctwit:

Happy new year to all !! Hope you got through december without an ultrasound case of the month on EM Dutch ;-).

Here’s one to start of 2014 , I  picked this one up on one of my shifts at the Westfriesgasthuis in Hoorn. To me it illustrates beautifully why emergency ultrasound can be so helpful in providing better care for your patients and should be a core competency for all (dutch) emergency physicians!  Read for yourself and see what you think ..

A 23 year old female, with no relevant past medical history, came to the ED the day before I saw her, with sudden onset right sided flank pain radiating to the lower adbomen and groin.

It was noted that during physical exam she experienced colik-like pain, her right lower quadrant was mildly tender on palpation and pelvic exam was not painful. No fever and labs were normal.

Preliminary diagnosis stated in the chart: ureter stone  or maybe even an appendicitis. She was told to come in the next day to be re-evaluated.
The next day she first was seen by the surgical resident who, thinking ureterstone, asked us to do an ultrasound for hydronefrosis. The EM-resident ( @HoekAmber ), who did an elective ultrasound rotation with us,  eagerly jumped at the ultrasound- opportunity that was presented to her. ” Ok”  I said to her ” Go ahead set up the machine and get started I’ll see you in two minutes”. One minute later she called me: “Vincent.. you might want to take a look at this …!!”

When I saw the patient , despite plenty of opiates,  she was still in a lot of pain which was now continuous and non-coliky and mostly in the right lower quandrant.

Her abdomen was still mildy tender on palpation in the right lower quadrant. Still no fever. No labs or urine yet  (all normal later on, HCG also neg)

Heeeeeeerrrrre’s ………….. the ultrasound  !!:

Right kidney

Casus EM dutch jan 2014 re nier

Left kidney

Casus EM dutchjan 2014 li nier

Pelvic views

casus EMdutch jan 2014

casus EMdutch jan 2014 2

Still thinking ureter stone ??

For diagnosis and rest of the case … click here



22 Dec

Here’s an interesting 12-lead ECG and rhythm strip from a 66 yo male with dyspnea and a fever, with a yet undefined proces in the right lung.

Interpret en describe the ECG/rhythm strip.  More on this case will follow in two weeks.


ECG AFl 2 op 1 180 per minuut.1

ECG AFl 2 op 1 180 per minuut.2


Continue reading

Emergency Ultrasound Case of November 2013

1 Nov

We are back again with another ultrasound case of the month !!

Brought to you by Amber Hoek. Emergency Medicine Resident, HAGA Teaching Hospital, The Hague . 

She came across this case during her Emergency Ultrasound Rotation at the Emergency Department of the Westfriesgasthuis in Hoorn.

A unexpected finding during a routine EFAST….with a brilliant clip….Enjoy !!

a 27-year-old male visited the ED with chest pain and respiratory distress.

3 weeks ago he was involved in a high speed motor vehicle crash, and fell from a dyke into the water. He refused to go to the hospital, however the day after he went to the ED because of chest pain on the left side. The Emergency Physician did a full physical exam and made a chest X-ray and shoulder X-ray. Only a left clavicle fracture was found.

Chest X-ray 3 weeks ago:

CHEST x ray ultrasound case of the month

Today the patient comes back with progressive chest pain on the left side and dyspnea since one week. He also has a fever of 39.0 °C

Vital signs: blood pressure 134/95 mmHg, heart rate 112/min, Sat. 100%, temperature is 37.8 °C. Auscultation: decreased breath sounds on the left with rales.

-What is your most likely diagnosis?

-What would you do next?

While the patient gets some fluids and waits for the chest X-ray, we do an EFAST:

-What’s your diagnosis now and what would you do now?

To see the answer and the outcome of this case of the month , check out EMDutch in 2 weeks ….

U/S after patella luxation

18 Oct

An interesting ultrasound case;

Recently, 2 patients have visited our ED after a patella luxation, which was replaced by EMS personnel. Besides physical examination and plain radiography an ultrasound was performed with a lineair probe to determine and confirm a ligament rupture.

Picture 1: a normal patella ligament of a healthy well built emergency physician (myself).

controle patellapees

Picture 2: a 50 year old man with a knee injury during a field hockey match.


Picture 3: a 37 year old man with a knee injury on both sides during exercise after revalidation from his myocardial infarction. He denied use of steroids.


Both patients received surgical repair later on.

I really love my ultrasound machine!!!

Arthur Rosendaal
Emergency Physician
Sint Franciscus Gasthuis, Rotterdam

CO-intoxication in the ED

8 Aug

Case report of Wendy vd Berg, aios SEH RKZ.

Groet Laura

Case Report CO