The Rule of the Ring
A young woman was transported by EMS with excruciating ankle pain after slipping on the ice. A quick glance at the x-ray clearly shows the reason, but this should raise an additional red flag for EPs.
Always remember the "rule of the ring." The tibia and the fibula are held together by an interosseous ligament to form a ring in the lower leg. Undertake a search for a second abnormality if there is a fracture in the tibia or fibula above the ankle syndesmosis. This x-ray should beget another if you remember the rule of the ring.
This external rotation injury is a Maisonneuve fracture, in which there i...
Source: Lions and Tigers and Bears - December 16, 2014 Category: Emergency Medicine Tags: Blog Posts Source Type: blogs
Plumbing Problem
A woman in her mid-30s returned in tears with excruciating pain in her chipmunk cheek. Earlier that day she was discharged on Tylenol and sour candy for cheek swelling. The initial recommendations seemed appropriate for the most likely diagnosis: a salivary stone. Now what?
Physicians have an algorithm for many situations, and different chief complaints have well-travelled paths. This isn't one of them. When faced with an unusual diagnosis, I decide which outcome would be best for the patient and work back from there.
Hospitalization might be the final emergency department disposition unless her pain is much bett...
Source: Lions and Tigers and Bears - December 3, 2014 Category: Emergency Medicine Tags: Blog Posts Source Type: blogs
Plumbing Problem
A woman in her mid-30s returned in tears with excruciating pain in her chipmunk cheek. Earlier that day she was discharged on Tylenol and sour candy for cheek swelling. The initial recommendations seemed appropriate for the most likely diagnosis: a salivary stone. Now what?
Physicians have an algorithm for many situations, and different chief complaints have well-travelled paths. This isn't one of them. When faced with an unusual diagnosis, I decide which outcome would be best for the patient and work back from there.
Hospitalization might be the final emergency department disposition unless her pain is much better c...
Source: Lions and Tigers and Bears - December 3, 2014 Category: Emergency Medicine Tags: Blog Posts Source Type: blogs
Imminently Croakable
Coming out of a patient's room, my eyes immediately fell on a hallway bed on which a sobbing linebacker-sized 26-year old man rocked back and forth in a fetal position. He looked sort of like “a kidney stone,” but the tech handed me an EKG chirping "chest pain." The EMR indicated he had a past medical history of asthma, hypertension, and congestive heart failure, but he didn't take any medications. He smoked but denied drug use.
The EKG was not normal. There was no worrisome ST segment elevation, but left ventricular hypertrophy with diffuse T wave repolarization abnormalities suggested longstanding poor...
Source: Lions and Tigers and Bears - November 12, 2014 Category: Emergency Medicine Tags: Blog Posts Source Type: blogs
Imminently Croakable
Coming out of a patient's room, my eyes immediately fell on a hallway bed on which a sobbing linebacker-sized 26-year old man rocked back and forth in a fetal position. He looked sort of like “a kidney stone,” but the tech handed me an EKG chirping "chest pain." The EMR indicated he had a past medical history of asthma, hypertension, and congestive heart failure, but he didn't take any medications. He smoked but denied drug use.
The EKG was not normal. There was no worrisome ST segment elevation, but left ventricular hypertrophy with diffuse T wave repolarization abnormalities suggested longstanding poorly...
Source: Lions and Tigers and Bears - November 12, 2014 Category: Emergency Medicine Tags: Blog Posts Source Type: blogs
Night Fight Aftermath
A patient in her early 20s came into the ED holding her right arm near her body with a complaint of right shoulder pain. She said she was punched in the shoulder during a fight the night before. Do you believe her story?
Checking the contour of the scapula reveals a cortical break in body. The undressed physical exam revealed ecchymosis and tenderness near the right scapula. The patient was told a fractured scapula requires more force than a punch, and she then added that she was thrown back against a metal pole during the fight. A CT scan confirmed the diagnosis.
Scapular fractures are uncommon, ...
Source: Lions and Tigers and Bears - November 3, 2014 Category: Emergency Medicine Tags: Blog Posts Source Type: blogs
Night Fight Aftermath
A patient in her early 20s came into the ED holding her right arm near her body with a complaint of right shoulder pain. She said she was punched in the shoulder during a fight the night before. Do you believe her story?
Checking the contour of the scapula reveals a cortical break in body. The undressed physical exam revealed ecchymosis and tenderness near the right scapula. The patient was told a fractured scapula requires more force than a punch, and she then added that she was thrown back against a metal pole during the fight. A CT scan confirmed the diagnosis.
Scapular fractures are uncommon, estimated ...
Source: Lions and Tigers and Bears - November 3, 2014 Category: Emergency Medicine Tags: Blog Posts Source Type: blogs
'Probably Drunk'
EMS ambles in with a "probably drunk" patient around 4 a.m. They report finding this 70ish homeless man with mental health issues sitting on the sidewalk. The patient complained of a group of men coming upon him and kicking him in the butt.
I went to check him after he was settled in a room. To my shock, the supine gentleman was trying to pee in a urinal without success. I've seen plenty of guys peeing in the ED. My concern was that he was lying down. Anyone who has been in the ED for a period of time knows that drunk guys who are barely able to speak will still try to stand up to go. Even male hemiparetic s...
Source: Lions and Tigers and Bears - October 14, 2014 Category: Emergency Medicine Tags: Blog Posts Source Type: blogs
'Probably Drunk'
EMS ambles in with a "probably drunk" patient around 4 a.m. They report finding this 70ish homeless man with mental health issues sitting on the sidewalk. The patient complained of a group of men coming upon him and kicking him in the butt.
I went to check him after he was settled in a room. To my shock, the supine gentleman was trying to pee in a urinal without success. I've seen plenty of guys peeing in the ED. My concern was that he was lying down. Anyone who has been in the ED for a period of time knows that drunk guys who are barely able to speak will still try to stand up to go. Even male hemiparetic str...
Source: Lions and Tigers and Bears - October 14, 2014 Category: Emergency Medicine Tags: Blog Posts Source Type: blogs
A Sneaky Diagnosis
A man in his late 30s with no medical problems presented to the emergency department with three weeks of right upper quadrant abdominal pain. He was started on an H2 blocker and tramadol at a local clinic. An outpatient right upper quadrant ultrasound was performed three days before he came to the ED, and was read as normal. He was told to go to the ED if any new symptoms developed. He came in after he developed vomiting.
The patient’s vital signs were normal, including a temp of 97.5°F, in the ED. He said his pain was 8/10. He also had mild mid-epigastric tenderness. The only significant abnormality on the labs wa...
Source: Lions and Tigers and Bears - October 2, 2014 Category: Emergency Medicine Tags: Blog Posts Source Type: blogs
A Sneaky Diagnosis
A man in his late 30s with no medical problems presented to the emergency department with three weeks of right upper quadrant abdominal pain. He was started on an H2 blocker and tramadol at a local clinic. An outpatient right upper quadrant ultrasound was performed three days before he came to the ED, and was read as normal. He was told to go to the ED if any new symptoms developed. He came in after he developed vomiting.
The patient’s vital signs were normal, including a temp of 97.5°F, in the ED. He said his pain was 8/10. He also had mild mid-epigastric tenderness. The only significant abnormality on the labs was ...
Source: Lions and Tigers and Bears - October 2, 2014 Category: Emergency Medicine Tags: Blog Posts Source Type: blogs
Spitting Out Blood
A middle-aged woman presented to the ED with right-sided neck pain that she had developed that day. She reported that she had spit out a lot of blood, but denied fevers, chills, chest pain, shortness of breath, nausea, and vomiting. She said she hadn't felt well for the past few days.
The CT gives the answer.
The patient had a thrombosed right internal jugular vein with a fistula extending into the peritonsillar abscess — Lemierre's syndrome. ENT took the patient to the OR.
n Lemierre’s syndrome was first described by Andre Lemierre in a 1936 article of 20 cases. This septic thrombophlebiti...
Source: Lions and Tigers and Bears - September 17, 2014 Category: Emergency Medicine Tags: Blog Posts Source Type: blogs
Spitting Out Blood
A middle-aged woman presented to the ED with right-sided neck pain that she had developed that day. She reported that she had spit out a lot of blood, but denied fevers, chills, chest pain, shortness of breath, nausea, and vomiting. She said she hadn't felt well for the past few days.
The CT gives the answer.
The patient had a thrombosed right internal jugular vein with a fistula extending into the peritonsillar abscess — Lemierre's syndrome. ENT took the patient to the OR.
n Lemierre’s syndrome was first described by Andre Lemierre in a 1936 article of 20 cases. This septic thrombophlebitis of the in...
Source: Lions and Tigers and Bears - September 17, 2014 Category: Emergency Medicine Tags: Blog Posts Source Type: blogs
Subtle Clues
A 21-year-old woman came in to the ED in the middle of the night after hitting her hand with a hammer. She had swelling and tenderness over the dorsal first metacarpal. Two linear hypodense lines disrupting the normal trabecular pattern were seen, but there was no cortical break noted. Fracture?
Here is another view that shows the same lines.
The radiology read: Two parallel curvilinear hypodensities in the distal and midshaft of the first metacarpal, which are new since the prior exam and most consistent with nondisplaced, possible trabecular microfractures, which do not appear to extend to the cor...
Source: Lions and Tigers and Bears - September 3, 2014 Category: Emergency Medicine Tags: Blog Posts Source Type: blogs
Subtle Clues
A 21-year-old woman came in to the ED in the middle of the night after hitting her hand with a hammer. She had swelling and tenderness over the dorsal first metacarpal. Two linear hypodense lines disrupting the normal trabecular pattern were seen, but there was no cortical break noted. Fracture?
Here is another view that shows the same lines.
The radiology read: Two parallel curvilinear hypodensities in the distal and midshaft of the first metacarpal, which are new since the prior exam and most consistent with nondisplaced, possible trabecular microfractures, which do not appear to extend to the cortex.
...
Source: Lions and Tigers and Bears - September 3, 2014 Category: Emergency Medicine Tags: Blog Posts Source Type: blogs
