altThings often come in threes, but not usually all in a row. You just had an elderly patient with neck pain from an odontoid fracture sustained from a fall, followed by a 28-year-old with neck and throat pain that was due to a retropharyngeal abscess. Your next patient also has neck pain and since your hospital is full and your ED is boarding 14 inpatients currently, you are seriously hoping that this is going to be torticollis or a cervical strain that you can eventually send home.    

Your high hopes start to drift downward almost immediately. She is a 50-year-old female who is on extended home IV antibiotics for tarsal osteomyelitis via a recently placed PICC line. She states that she has had gradually worsening pain in the left side of her neck. She denies any trauma, weakness, numbness, fever or sore throat. She has not had this pain before. Her past medical history is notable for diabetes, hypertension, heroin abuse and the recent hospitalization for osteomyelitis.

On exam she is afebrile with a pulse of 98 and a blood pressure of 174/93 and in no obvious distress. Her HEENT exam is notable for poor dentition, but is otherwise unremarkable. The neck has no posterior tenderness, or lymphadenopathy, but there is some pain with rotation and the sternocleidomastoid is somewhat tender on that side, and maybe even a tad swollen. The rest of the exam is essentially normal except for an ulcer on the bottom of her left foot and the PICC line in her left arm.

Suspecting that this in neither an odontoid or other cervical spine fracture, nor a retropharyngeal abscess, you decide to pull over the ED ultrasound machine to search for another possible cause of her ailment. You obtain these two images.


You obtain the two images above. What do they show? What is the difference between the two?  Conclusion on NEXT page


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