Basics of abdominal ultrasound


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bis stha    on Feb 13, 2013 Says :

good work...appreciated
dr bayan    on Oct 11, 2012 Says :

really nice .thx alot dr Zahran
zozo zahora    on Jun 10, 2012 Says :

thank you very much it is very helpful explaination
nimubona desire    on May 24, 2012 Says :

its a really good PPt ,it helped me to understand about ultrasound.
Ahmed    on Apr 30, 2011 Says :

excllenet presentation with good effort thank you ahmed saad
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1 : Basics of abdominal Ultrasonography Dr . Rabie Fahmy Zahran. Tropical M . Consultant. Damietta Fever Hospital. Egypt. rabiezahran@Gawab.com
2 : Definition Ultrasonography is study of internal organs or blood vessel using high frequency sound waves, the actual test called ultrasound scan or sonogram.
3 : rabiezahran@Gawab.com Definition Ultrasound are sound waves of frequencies greater than audible to human ear i.e. greater than 20,000Hz.
4 : Historical Introduction 1876 Sir Francis Galton : 1st ultrasound instrument developed in dog 1880 Jacques & Pierre : discovery of piezoelectric effect (mechanical electric) 1881 Curies : reverse piezoelectric effect for Industrial applications 1940 Ultrasonic energy was 1st applied in human body for medical purpose. 1954 Medical application of ultrasound. rabiezahran@Gawab.com
5 : Indications 1) detecting abnormalities of heart, uterus, pancreas, urinary bladder, liver, stomach, kidney, eye & teeth. 2) confirm intrauterine & exclude ectopic pregnancy, fetal sex determination, viable fetus, missed abortion, retained products after termination, evaluate anomalies, 3) Guided amniocentesis, choroinic vilius biopsy, intrauterine fetal transfusion. 4) check tumor, cholecystitis, intussuception ,gall stone, bile duct obstruction, cirrhosis, splenomegaly, & pancreatic abscess. rabiezahran@Gawab.com
6 : 5) Detect renal abnormalities, tumor, urinary calculi of urinary bladder, morphology of kidney. 6) Diagnose the prostatic malignant diseases. 7) Useful in Echocardiography& congenital heart defect. 8) Ultrasound also used to clean teeth in dental hygiene. 9) Ocular sonography used evaluation of internal ocular structures. Also useful in cataract treatment, Retrobulbar abnormalities which may be difficult to detect radiographically but easily identified sonographically. Indications rabiezahran@Gawab.com
7 : rabiezahran@Gawab.com :Basic Ultrasound Physics Sound is a series of pressure waves(mechanical waves) propagating through a medium. One cycle of the acoustic wave is composed of a complete positive and negative pressure change.  The wavelength is the distance traveled during one cycle, the frequency of the wave is measured in cycles per second or Hertz (Cycles/s, Hz).
8 : rabiezahran@Gawab.com
9 : * A sound waves travels in a pulse & when it is reflected back it becomes an echo. The pulse-echo principle is used for ultrasound imaging. * A pulse generated by one or more piezo-electric crystals in an ultrasound probe or transducer. * Ultrasound probe crystal is shocked by single extremely short pulse of electricity to vibrate at a frequency determined by its thickness. Principle rabiezahran@Gawab.com
10 : rabiezahran@Gawab.com Principle * Once echo are converted into electrical signals, these are processed & transformed into a visual display of the measure of the amplitude of the echo this is echo quantification. * The transducer picks up the return echo & record any changes in the pitch or direction of the sound, the image is immediately visible on the screen.
11 : rabiezahran@Gawab.com sound waves travel faster in solids than liquids or gases. The major cause of attenuation in soft tissue is absorption,
12 : Principle
13 : Color Doppler Image CDI can see the structure in different colors. Two dimensional echo. CDI was introduced in the middle 1980. Geoff Stevenson given first demonstration of Color Doppler. Color Doppler application includes : echocardiography, peripheral vascular disease detection of arterial stenosis , venous thrombosis, venous blood flow pattern, & development of aneurysms. In evaluation of blood flow to critical organ It also shows flow characteristics in portal hepatic veins artery & renal artery stenosis.
14 : rabiezahran@Gawab.com Edge artifact
15 : rabiezahran@Gawab.com Reverberations artifacts ultrasound echoes being repeatedly reflected between two highly reflective interfaces
16 : Ultrasonography Advantages - No ionizing radiation - Safe in pregnancy - No known side effect - Cheap, portable machine - Minimum preparation of patient . - Painless, noninvasive - Direct vision for biopsy Disadvantages * Sonographer should be expert in diagnosis . * Performing & interpreting the examination can be extremely difficult.
17 : Portable Ultrasound machine
18 : Ultrasonography Machine
19 : Introduction rabiezahran@Gawab.com
20 : 1. Ultrasound waves They are waves of very high frequency ranging between 3.5 – 10 MHz and up to 20 MHz in endo-sonography. When the frequency the resolution and penetration . rabiezahran@Gawab.com
21 : In adults the frequency used =3.5 MHz. In children the frequency used=5 MHz. In small parts = 7 MHz. In endosonography= 7.5-20 MHz. rabiezahran@Gawab.com
22 : It means the reflection of waves , and this depends on the material which is penetrated by US.   2. Echo pattern rabiezahran@Gawab.com
23 : 2. Echo pattern Echofree : When ultrasound waves pass through fluids ( ascites- simple cyst- blood vessels) no reflection occurs and these areas appears as black areas with posterior enhancement . rabiezahran@Gawab.com
24 : rabiezahran@Gawab.com Posterior enhancement & mirrored side
25 : 2. Echo pattern Echogenic :   When ultrasound waves pass through solids (bones – stone) all waves are reflected and appears as white color with posterior shadow . rabiezahran@Gawab.com
26 : rabiezahran@Gawab.com Posterior shadow
27 : a. Shape Linear Sector Linear convex b. Frequency Single Dual Range 3. Transducers rabiezahran@Gawab.com
28 : rabiezahran@Gawab.com
29 : rabiezahran@Gawab.com Anatomical overview of upper abdomen
30 : rabiezahran@Gawab.com
31 : Liver rabiezahran@Gawab.com
32 : 1. Size . 2. Focal lesion . 3.Diffuse liver disease . 4.Hepatic vasculature . ( portal vein & hepatic veins ) 5. Intrahepatic biliary radicles . Liver rabiezahran@Gawab.com
33 : Size: Lt. Lobe span (5-10 cm). Rt. Lobe span (8-15 cm). Liver rabiezahran@Gawab.com
34 : 1. Size . 2. Focal lesion . 3.Diffuse liver disease . 4.Hepatic vasculature . ( portal vein & hepatic veins ) 5. Intrahepatic biliary radicles . Liver rabiezahran@Gawab.com
35 : Focal lesions 1. Single or Multiple. 2. Size 3. Site (segmental anatomy) Liver rabiezahran@Gawab.com
36 : lesion) focal) Liver 4 .Echopattern Echofree e.g. hepatic simple cyst, hydatid cyst. Hypoechoic e.g. amoebic liver abscess, lymphoma. Hyperechoic (echogenic) e.g.haemangioma . Heterogeneous e.g. cancer, secondary metastasis. 5.Differential diagnosis rabiezahran@Gawab.com
37 : rabiezahran@Gawab.com Hemangioma of liver (hepatic hemangioma): Images show a large (8 cms.) rounded, well defined, hyperechoic, non-calcific mass in the right lobe of liver. There is a moderate amount of acoustic enhancement posterior to the lesion.
38 : rabiezahran@Gawab.com Multiple metastases in the liver Heterogeneous echogenicity
39 : rabiezahran@Gawab.com Liver metastases Heterogeneous echogenicity
40 : rabiezahran@Gawab.com
41 : rabiezahran@Gawab.com Hydatid cyst or echinococcosis of liver Echo-free
42 : rabiezahran@Gawab.com Hydatid cyst
43 : rabiezahran@Gawab.com Amebic liver abscess hypoechoic nature of the lesions suggesting further breakdown of the solid liver tissue ( liquifactive necrosis)
44 : 1. Size. 2. Focal lesion. 3.Diffuse liver disease. 4.Hepatic vasculature. (portal vein & hepatic veins) 5. Intrahepatic biliary radicles. Liver rabiezahran@Gawab.com
45 : Diffuse liver disease Schistosomal hepatic fibrosis: (Thickened portal tracts): Portal tracts appear in US as portal vein radicles . If the wall of these radicles are thickened, we measure the portal tracts (outer-outer diameter). If the diameter is more than 3 mm in more than 3 tracts ? “Periportal Thickening”. Liver rabiezahran@Gawab.com
46 : Liver rabiezahran@Gawab.com Pp thickening
47 : Liver rabiezahran@Gawab.com Pp thickening
48 : Diffuse liver disease Liver cirrhosis: coarse echopattern with: (Miliary =echogenic fine liver dots). * Irregular surface. * Large caudate lobe *Attenuated hepatic veins. Liver rabiezahran@Gawab.com
49 : Liver rabiezahran@Gawab.com
50 : Liver rabiezahran@Gawab.com
51 : Diffuse liver disease Bright liver: Increase brightness “less dark”. Normally, the echopattern of the liver is slightly brighter than the renal parenchyma. D.D of Bright liver . Fatty liver (DM – Hyperlipidemia-obese patients) Chronic hepatitis Liver cirrhosis Liver rabiezahran@Gawab.com
52 : Liver rabiezahran@Gawab.com Bright liver
53 : Liver rabiezahran@Gawab.com Bright liver
54 : 1.Size. 2. Focal lesion. 3.Diffuse liver disease. 4.Hepatic vasculature. (portal vein & hepatic veins) 5. Intrahepatic biliary radicles. Liver rabiezahran@Gawab.com
55 : Hepatic Vasculature A- Portal Vein: - The diameter is normally up to 12mm, in fasting adults. - From 13-17mm in suspected cases of portal hypertension. Liver rabiezahran@Gawab.com
56 : rabiezahran@Gawab.com Liver Hepatic Vasculature >17 it is sure portal hypertension. NB: - In some cases of portal hyper-tension the P.V diameter is within normal due to the presence of collaterals.
57 : Portal Vein Thrombosis  Occurs in association with: H.C.C. After sclerotherapy. After splenectomy Liver rabiezahran@Gawab.com
58 : Liver rabiezahran@Gawab.com Portal Vein Thrombosis
59 : Liver rabiezahran@Gawab.com Portal Vein Thrombosis
60 : Collaterals  The presence of any collaterals is a sure sign of Portal Hypertension 1- Para umbilical vein : seen in the falciform ligament. 2- Coronary vein : seen in the inferior surface of the left lobe. Normally less than 5 mm. It is related to oesophageal varices. Liver rabiezahran@Gawab.com
61 : 3- Splenic hilum collaterals: lieno-renal collaterals (benign) around splenic vein& directed to the kidney lienogastric : Directed to stomach. related to fundal varices.. Collaterals Liver rabiezahran@Gawab.com
62 : Liver rabiezahran@Gawab.com Para umbilical vein
63 : Liver rabiezahran@Gawab.com Splenic hilum collaterals
64 : Liver rabiezahran@Gawab.com Coronary vein
65 : Hepatic Veins Importance of hepatic veins: * Attenuated in Liver cirrhosis and veno-occlusive disease. * Dilated in congested hepatomegaly. * In segmented Anatomy. Liver rabiezahran@Gawab.com
66 : Liver rabiezahran@Gawab.com Dilated HVs.
67 : Liver rabiezahran@Gawab.com HVs Attenuated
68 : Liver rabiezahran@Gawab.com Normal HVs.
69 : Liver rabiezahran@Gawab.com HVs Attenuated
70 : Liver rabiezahran@Gawab.com HVs Attenuated
71 : 1. Size. 2. Focal lesion. 3.Diffuse liver disease. 4.Hepatic vasculature. (portal vein & hepatic veins) 5.Intrahepatic biliary radicles . Liver rabiezahran@Gawab.com
72 : Intra-hepatic Biliary Radicles * Normally they are not seen, when dilated as in Obstructive Jaundice ?“double barrel sign” (portal vein tributary and intra-hepatic bile radicle ). Liver rabiezahran@Gawab.com
73 : rabiezahran@Gawab.com Intra-hepatic Biliary Radicles *When the obstruction is intra-hepatic (e.g hilar cholangio-carcinoma) there is no dilatation of CBD. * when the obstruction is extra hepatic there is dilatation of CBD. more than 8 mm
74 : Liver rabiezahran@Gawab.com double barrel sign
75 : Liver rabiezahran@Gawab.com double barrel sign
76 : Liver rabiezahran@Gawab.com IHBD
77 : rabiezahran@Gawab.com IHBD Liver
78 : Causes of bile duct obstruction * Stones in the CBD, hepatic duct, or ampulla of vater * Cancer head of pancreas, ampulla of vater, cholangiocarcinoma. * Lesions in the porta hepatis as porta hepatis lymph node enlargement. * Fasciola or ascaris. Liver rabiezahran@Gawab.com
79 : Segmental anatomy of the liver seg 6,7 Caudate lobe seg 1 seg 2 Left H.V and hep. Margin Left H.V and falciform lig. seg 3 Quadrate lobe seg 4 G.B and right hep. V seg 5,8 Rt hep. V. and margin of the liver rabiezahran@Gawab.com
80 : rabiezahran@Gawab.com
81 : rabiezahran@Gawab.com
82 : Gall Bladder rabiezahran@Gawab.com
83 : rabiezahran@Gawab.com Normal Anatomy of Gall bladder
84 : Size Wall thickness. Contents Stone. Parasites. Mud. Masses polyp cancer Gall Bladder rabiezahran@Gawab.com
85 : Size Long axis 6-12 cm , short axis 3-5 cm - Contracted < 5 cm. - Distended > 12 cm when the patient is fasting. Gall Bladder rabiezahran@Gawab.com
86 : - Size - Wall thickness. - Contents Stone. Parasites. Mud. - Masses polyp cancer Gall Bladder rabiezahran@Gawab.com
87 : Wall thickness - Measured in the side in contact with the liver. - Normally it is up to 3 mm. - From 3-5 mm >>> suspect thick wall. Gall Bladder rabiezahran@Gawab.com
88 : Liver Wall thickness * > 5 mm It is a thick wall gall bladder which is seen in: Cholecystitis (acute-chronic). Ascites . Hepatitis ( viral). Schistosomiasis . rabiezahran@Gawab.com
89 : rabiezahran@Gawab.com
90 : Size Wall thickness. Contents Stone. Parasites. Mud. Masses polyp cancer Gall Bladder rabiezahran@Gawab.com
91 : Contents * Stones: seen inside the gall bladder in all positions, mobile except at the neck. they appear white with posterior shadow. * Mud (infected bile) * Thick bile. Change with changing position with or without presence of stones. The picture occurs in the presence of thick bile in patients on IV fluids for 3-4 days with inflamed GB. Gall Bladder rabiezahran@Gawab.com
92 : Gall Bladder Contents Parasite: Fasciola appears pearl shape. Move as a whole. Ascaris rare appears as thrill inside G B. Cancer & polyps: Polypoidal or heterogeneous mass. rabiezahran@Gawab.com
93 : Gall Bladder rabiezahran@Gawab.com
94 : rabiezahran@Gawab.com
95 : Gall Bladder rabiezahran@Gawab.com
96 : rabiezahran@Gawab.com Gall Bladder
97 : Gall Bladder rabiezahran@Gawab.com
98 : Gall Bladder rabiezahran@Gawab.com
99 : Gall Bladder rabiezahran@Gawab.com
100 : Gall Bladder rabiezahran@Gawab.com Mud
101 : Gall Bladder rabiezahran@Gawab.com
102 : rabiezahran@Gawab.com Phrygian cap of GB
103 : rabiezahran@Gawab.com Carcinoma of gall bladder
104 : rabiezahran@Gawab.com Ultrasound images of double gall bladder
105 : rabiezahran@Gawab.com Mirizzi syndrome This syndrome is caused by impacted calculus in the Gall bladder neck or cystic duct causing extrinsic compression of the common hepatic duct. A common predisposing factor for this is the low insertion of the cystic duct into the common hepatic duct. This makes the cystic duct almost parallel to the common hepatic duct.
106 : rabiezahran@Gawab.com Hartmann's pouch calculus: is an out-pouching of the wall of the gallbladder at the junction of the neck of the gallbladder and the cystic duct.
107 : rabiezahran@Gawab.com Biliary sand or lime bile or lime water bile in gall bladder: large distended gall bladder with markedly echogenic contents. The echogenicity appears similar to that of the liver
108 : rabiezahran@Gawab.com Gall bladder sludge thickened gall bladder wall (suggestive of cholecystitis) with the GB (gall bladder) lumen filled with echogenic debris which is typical of gall bladder sludge.
109 : Spleen rabiezahran@Gawab.com
110 : Size Measure the diagonal axis: Normally it covers the upper 1/3 of the left kidney. - Longest axis (diagnostic) < 12 cm. - Relation to kidney. - Relation to costal margin. Spleen rabiezahran@Gawab.com
111 : Focal Lesions * Causes: Lymphoma. Cyst (simple-hydatid ). Infarction of a part (triangular area & base toward the edge). Sarcoma.  Spleen rabiezahran@Gawab.com
112 : Spleen Diffuse disease Hemosidrosis: White dots in spleen Means Portal Hypertension rabiezahran@Gawab.com
113 : Spleen rabiezahran@Gawab.com Longest axis
114 : Spleen rabiezahran@Gawab.com
115 : Spleen rabiezahran@Gawab.com
116 : rabiezahran@Gawab.com Normal kidney
117 : Anatomy Kidneys are retroperitoneal, T12 - L4 Right kidney is lower than the left kidney Right kidney is posterio-inferior to liver & gallbladder Left kidney is inferior-medial to the spleen Adrenal glands are superior, anterior, medial to each kidney
118 : IVC AORTA Celiac axis SMA Renal artery Renal vein Hepatic Veins Right kidney Left kidney Liver Spleen Anatomy
119 : Anatomy 9-12 cm long, 4-5 cm wide, 3-4 cm thick Gerota’s fascia encloses kidney, capsule, perinephric fat Sinus Hilum: vessels, nerves, lymphatics, ureter Pelvis: major and minor calyces Parenchyma surrounds the sinus Cortex: site of urine formation, contains nephrons Medulla: contains pyramids that pass urine to minor calyces. Columns of Bertin separate pyramids
120 : Renal artery Renal vein Ureter Renal capsule Cortex Medullary pyramids Minor Calyx Kidney Anatomy Medulla Sinus Major Calyx
121 : Sonographic Appearance Ureters are normally not seen Renal pelvis is black when visible Renal sinus is echogenic due to fat Medullary pyramids are hypoechoic Cortex is mid-gray, less echogenic than liver or spleen. Capsule is smooth and echogenic
122 : Liver Diaphragm Sinus Cortex Anterior Posterior Superior Inferior Right Kidney Long Axis
123 : Right Kidney Short Axis Vertebral Body R Kidney Aorta Renal a. GB IVC Liver Anterior Posterior Right Left
124 : Left Kidney Long Axis Anterior Posterior Superior Inferior Spleen Kidney Rib Shadow
125 : Left Kidney Short Axis Anterior Posterior Right Left Liver Spleen L Kidney
126 : Common Pitfalls in Renal Scanning Failure to scan both kidneys Mistaking prominent renal pyramids for hydronephrosis Mistaking prominent pyramids for cysts Confusing normal renal arteries for the ureter
127 : rabiezahran@Gawab.com Right Kidney ( normal) Left Kidney ( normal) Rt. lobe Spleen
128 : rabiezahran@Gawab.com Longitudinal image of normal Rt. kidney
129 : Degree of Hydronephrosis Normal Mild Moderate Severe
130 : rabiezahran@Gawab.com
131 : rabiezahran@Gawab.com
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134 : rabiezahran@Gawab.com
135 : rabiezahran@Gawab.com
136 : rabiezahran@Gawab.com
137 : rabiezahran@Gawab.com
138 : rabiezahran@Gawab.com
139 : rabiezahran@Gawab.com Fungating bladder mass
140 : rabiezahran@Gawab.com Hydronephrosis of the right kidney. Mega-ureter.
141 : rabiezahran@Gawab.com Tumour of the right kidney
142 : rabiezahran@Gawab.com Cortical cysts or simple renal cyst:
143 : rabiezahran@Gawab.com Chronic renal failure (Medical renal disease):
144 : rabiezahran@Gawab.com Kidney Stone:
145 : rabiezahran@Gawab.com Sonography of very large renal calculi: This huge calculus was discovered on ultrasound imaging of the left kidney. The calculus measuring almost 7 cms. is seen occupying the lower half of the left renal pelvis and the adjacent calyces. There is also mild dilatation of the renal pelvis due to urinary tract obstruction
146 : rabiezahran@Gawab.com Multiple renal calculi:     
147 : rabiezahran@Gawab.com Nephrocalcinosis markedly echogenic (hyperechoic) renal pyramids with the central parts also affected. Ultrasound images also reveal renal calculus formation. These images suggest presence of medullary nephrocalcinosis.
148 : rabiezahran@Gawab.com Autosomal Dominant Polycystic Kidney Disease (ADPCK):
149 : rabiezahran@Gawab.com Normal pancreas.
150 : rabiezahran@Gawab.com Normal pancreas.
151 : rabiezahran@Gawab.com Tumour of the pancreatic head
152 : rabiezahran@Gawab.com an oval, echo-negative formation with well-defined, even outline visualised within the pancreatic body projection Pancreatic cyst
153 : rabiezahran@Gawab.com Benign prostatic hyperplasia
154 : rabiezahran@Gawab.com Large urinary bladder calculus
155 : rabiezahran@Gawab.com Urinary bladder wall trabeculation in a case of Lower urinary tract obstruction
156 : rabiezahran@Gawab.com Pleural effusion: large, clear, hypoechoic fluid collection in the left pleural space. The left lung has collapsed into a small mass of tissue compressed by the effusion. A small fibrotic band is seen traversing the fluid.
157 : rabiezahran@Gawab.com
158 : rabiezahran@Gawab.com
159 : rabiezahran@Gawab.com Measuring the uterine dimensions
160 : rabiezahran@Gawab.com Normal ovaries at the beginning of the cycle.
161 : rabiezahran@Gawab.com Uterine fibromyoma .
162 : rabiezahran@Gawab.com Normal uterine pregnancy. Duration of gestation: 4 weeks
163 : Case study rabiezahran@Gawab.com
164 : rabiezahran@Gawab.com Case 1 A 38-year-old man comes to the emergency department after falling 15 feet off scaffolding at work.  His systolic BP is 90; his heart rate is 125 bpm.  He is on a backboard and in a C-spine collar and complains of severe pain in his back and abdomen. You perform the FAST ultrasound scan as part of your trauma evaluation and find the following
165 : rabiezahran@Gawab.com Image case 1 Your diagnosis: Significant amount of intra-abdominal free fluid.  Shown here is the peri-hepatic area, also called “Morrison’s pouch”. ED management: Immediate transfer to the operating room for exploratory laparotomy.  The patient is clinically unstable and has a presumed intra-abdominal bleed, most likely from a solid organ injury or vascular injury.
166 : rabiezahran@Gawab.com Case 2 A 42-year-old female patient complains of sudden severe right flank pain.  During your interview she is restless and seems unable to find a position of comfort.  On exam she is afebrile, her vital signs are stable and she has tenderness over her right flank.  You perform a bedside ultrasound and find the following:
167 : rabiezahran@Gawab.com Your diagnosis:  Mild hydronephrosis right. ED management:  On extended bedside ultrasound her left kidney appears normal, also her aorta and FAST exam show no abnormalities. Symptomatic treatment with IV fluids and pain control resolve all symptoms.  Patient will need urgent outpatient follow-up with urology for renal colic with hydronephrosis without signs of infection and normal renal function.
168 : rabiezahran@Gawab.com Case 3 A 23-year-old woman presents to the ED with nausea and vomiting for the past few days.  Her last period was regular but very light and she can’t remember the exact date.  She does not take birth control or fertility drugs.  Her abdominal exam is unremarkable, on pelvic exam the cervical os is closed.  You perform a bedside pelvic ultrasound:
169 : rabiezahran@Gawab.com Your diagnosis:  Early intra-uterine pregnancy. (Image courtesy of W. Hosek, M.D.) ED management: Nausea and vomiting resolve with IV hydration and medication.  The patient is discharged with outpatient follow-up with OB and started on pre-natal vitamins.
170 : rabiezahran@Gawab.com Case 4 A 45-year-old patient presents with upper abdominal pain.  Her symptoms began after eating a burger.  On exam she is tender over the right upper abdomen. She mentions that she had two similar episodes recently, but they were less painful.  You start symptomatic treatment, order blood work and perform a bedside ultrasound:
171 : rabiezahran@Gawab.com Your diagnosis: Acute biliary colic with multiple gallstones. On ultrasound exam you find multiple gallstones but the gallbladder wall and common bile duct appear normal.  ED management: Blood work shows no infection or elevation of liver or pancreatic enzymes.  The patient improves with symptomatic management and her pain resolves.  She is discharged from the ED after surgical consultation and planned outpatient follow-up.
172 : Thank You rabiezahran@Gawab.com

 

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