Bezoar

A 23 year old mentally retarded man presented with chronic cough. A CXR was done. His lungs are unremarkable but opaque foreign bodies are seen in the stomach region.

Upon questioning, he admitted to having a peculiar habit of chewing every bit of chicken, including the bones. This is consistent with bezoar.

A bezoar is a mass found trapped in the gastrointestinal system (usually the stomach)^]though it can occur in other locations. There are several varieties of bezoar, some of which have inorganic constituents and others organic. Most of the time, it collects in the stomach and fails to pass through the intestines. Surgery may be needed.

Breast Cyst

50 year old lady presented with right breast discomfort. On physical examination, both breasts were lumpy. Ultrasound examination showed multiple and bilateral simple breast cysts. The largest measures 3cm in diameter located in the sub-areolar region of the right breast.
Breast cysts are fluid-filled sacs within the breast. They may be single or multiple. Breast cysts are common in women in their 30s and 40s. Most usually disappear after menopause, unless the patients are taking hormonal therapy.
Breast cysts don't require treatment unless a cyst is large and painful or otherwise uncomfortable. In that case, draining the fluid from a breast cyst can ease the symptoms.
The cause of breast cysts remains unknown. Some evidence suggests that excess estrogen in the body may play a role in breast cyst development.
Plans are being made to do fine-needle aspiration on the largest cyst in the right breast.

Achilles Tendon Bursitis (aka Retrocalcaneal Bursitis)

49 year old man with chronic pain just above the calcaneal bone in the vicinity of the insertion of Achilles tendon. Ultrasound showed a fluid filled thick walled bursa dorsal of the achilles tendon.
Achilles tendon bursitis is a common foot pain in athletes, particularly runners. It can often be mistaken for Achilles tendinitis or can also occur in conjunction with Achilles tendinitis.
The retrocalcaneal bursa in situated in the feet between the Achilles tendon and the calcaneum (heel bone). With repeated trauma or ill-fitting shoes, the bursa can become inflamed.

Uterine Fibroid

39 year old lady was referred for ultrasound because of severe period pain and pelvic pain after sexual intercourse. Ultrasound showed a large 11cm subserosal uterine fibroid. No associated necrosis or calcification.
Uterine fibroid is the most common benign tumour of the uterus. It is typically found in the age range of 20-40 years. This is because oestrogen receptors on the fibroids cause them to respond to estrogen stimulation during the reproductive years. Thus, during menopause, they are expected to shrink. Most are asymptomatic but some may present with heavy menses, pelvic pain and urinary urgency. It may be single or multiple. Location may be intramural (within the wall of the uterus), subserosal (just underneath the outer surface of the uterus), submucosal (beneath the endometrium) and cervical (in the wall of the cervix).
The role of ultrasound will be to confirm the diagnosis, measure the size and characterise the lesion. Ultrasound may be repeated after treatment to assess progress.

MRI-guided focused ultrasound surgery (FUS) is the latest in the treatment of fibroid. It is a non-invasive treatment option that preserves the uterus. Focused high-frequency, high-energy sound waves are used to target and destroy the fibroids while being guided by MRI.

Renal Tubular Acidosis

30 year old lady referred by a local GP for renal ultrasound. She is a known case of renal tubular acidosis (distal type) since 6 year ago. Her initial presentation was hypokalemia and she has been on potassium supplement since then. Her potassium level has normalised and her blood urea is within normal limit.
Ultrasound showed two 6mm calculi in the left kidney. Otherwise, both kidneys are of normal size and echotexture.
Renal tubular acidosis (RTA) is a disease that occurs when the kidneys fail to excrete acids into the urine. This makes the patient’s blood acidic. Without proper treatment, chronic acidity of the blood will lead to growth retardation in children, kidney stones, bone disease, chronic kidney disease, and possibly total kidney failure in adult.
The major aim of treatment is to correct the acidosis with sodium bicarbonate or sodium citrate. This will help to reduce the development of kidney stones.

Gallbladder Polyps

58 year old Chinese man with history of constipation walks in for an abdominal ultrasound scan. A recent colonoscopy was normal.

2 small gallbladder polyps were found. Both measure 2mm in diameter. Otherwise, the gallbladder is normal. No signs of acute or chronic cholecystitis. The rest of the abdomen is normal.

Polyps in the gallbladder are common. In the Western world, the prevalence is about 4 pc but in the Chinese, it can be as high as 9.5%*.

Gallbladder polyps do not necessarily imply that one is at increased risk of cancer. Majority are cholesterol, muscle tissue or inflammatory tissue. The minority are adenomatous polyps, which like the typical colon polyps can progress to cancer.

The size of a gallbladder polyp can be a useful predictor of whether it's malignant or benign. Generally, gallbladder polyps that are smaller than 1 centimeter are usually noncancerous and require no treatment.

This patient was given assurance and a repeat ultrasound is scheduled after a year.

* Journal of Gastroenterol Hepatology 23 (6): 965–9

Pulmonary granuloma

Granulomas make up about 40% of all SPN (solitary pulmonary nodules). They are seen as round or oval nodules ranging in size from 2mm - 10mm on chest -rays. They may or may not be calcified. The most common cause in the Asian population is tuberculosis while in the western world, histoplasmosis (fungal infection) may be more common.

Granulomas are basically scar tissue from previous inflammation. They do not cause any symptoms and are usually found incidentally on chest radiographs done for some other reason. However, tubercle bacilli may be present and dormant within these granulomas. This may lead to future re-activation.

Pulmonary fibrosis

Chest x-ray showing thick linear bands in the right apex and right mid zone.

Coarse linear shadows in both apices with elevated hila consistent with bilateral apical fibrosis.

Small left lung with gross mediastinal deeviation. This indicates that the left lung is completely collapse.

Small right lung with linear shadows in the right mid zone and blunting of right costo-phrenic angle. Right hemi-diaphragm is elevated. This is consistent with right pulmonary and pleural fibrosis.

Knee Osteoarthritis

67 year old lady with significant right knee pain and reduced mobility.
Her knee x-ray showed medial osteophytes, reduction in medial joint space and sclerosis of medial articular margin. The tibial spines are also sharp. These are signs of moderate osteoarthritis.
Osteoarthritis (OA) of the knee is a chronic, inflammatory, degenerative arthritic condition in which the cartilage in the knee joint gradually wears away. Osteoarthritis affects the knees more than any other joint. The average age at diagnosis of OA of the knee is 50. The incidence of OA increases with age, and is the leading cause of disability among the elderly.
The pain in OA of the knee is a major issue for most patients and is typically related to physical activity such as climbing stairs, getting out of a chair, or jumping. In mild cases, walking may not cause pain since there is minimal bending of the knee involved. The patient may feel stiffness in the knee upon getting up in the morning that usually lasts less than 30 minutes. Many people with severe OA of the knee experience a feeling as if their knee is "giving way" or "buckling under". There also may be swelling of the knee. At rest, pain is usually not present unless OA is severe.
Most of the time, the pain is mechanical and not inflammatory. A major mistake by doctors will be to treat the pain with anti-inflammatory drugs.

Ref: http://www.kneeosteoarthritis-info.com/

Pleural thickening

45 year old man with previous history of tuberculosis presented with shortness of breath. Chest x-ray showed thickened right lower pleural wall with blunting of right costo-phrenic angle.
Tuberculosis is the most common cause in the Asian context. However, pleural thickening may follow any form of inflammatory process of the pleura such as effusion, empyema, haemothorax, asbestosis, rheumatoid lung, radiation therapy and drugs.
It may also be due to infiltration of the pleural by malignant tumours such as mesothelioma and metastatic adenocarcinoma.
Ultrasound will be useful to differentiate thickening from loculated pleural effusion or empyema.

Chronic pneumothorax

21 year old male who presented with 3 months history of dyspnoea on exertion. He gave a history of previous 2 episodes of spontaneous pneumothorax that resolved after chest tube insertion.
Chest x-ray showed a small pneumothorax in the left upper chest. The lung margin is thick and lobulated indicating chronic status. The underlying lung is normal. No signs to suggest bullae or mediastinal shift.
Chronic pneumothorax is a rare complication of spontaneous pneumothorax. It may be due to thick pleurovisceral membrane and the patient may benefit from decortication.

Torus fracture

This young boy had a fall on his right hand while playing with some friends. He has no complained but the parents noticed his refusal to use his right hand for eating. A radiograph was taken.
Note buckling of the lateral margin of distal radius. This is consistent with Torus or buckled fracture, a fairly common fracture in children.