Category: Visual Diagnosis
Posted: 9/12/2011 by Rob Rogers, MD
(Updated: 12/12/2024)
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A 50 year-old patient presents after a self-inflicted eye injury. The patient had taken some type of needle and inserted it into their eye.
What is the diagnosis and what complications might result?
The image shows air bubbles in the anterior chamber. Since air has been introduced into the eye, the patient is at risk for elevated intraocular pressures. In addition, you would need to consider endophthalmitis as a complication.
Category: Visual Diagnosis
Posted: 9/4/2011 by Haney Mallemat, MD
(Updated: 8/28/2014)
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26 year old male presents s/p basketball dunk. Diagnosis?
Answer: Talar dislocation
Below, a post-reduction Xray, as well as a link to a video demonstrating a few ankle reductions (the video's background music makes all the difference): http://www.youtube.com/watch?v=AzqCsLX1K1E
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Category: Visual Diagnosis
Posted: 8/29/2011 by Rob Rogers, MD
(Updated: 12/12/2024)
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Patient presents with right-sided chest and shoulder pain....
What's the diagnosis?
Herpes Zoster
Category: Visual Diagnosis
Posted: 8/22/2011 by Haney Mallemat, MD
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79 y.o. male lung cancer patient with tachypnea, tachycardia, and normal blood pressure. Click here: http://vimeo.com/27973006
Possible diagnosis?
Answer: Right ventricular (RV) dysfunction secondary to submassive pulmonary embolism (PE).
Ultrasound for suspected PE
Consider bedside echo with PE and elevated troponin or BNP.
Recall the classes of PE:
Ultrasound “clues” of submassive / massive PE:
Lodato JA, Parker Ward RP, Lang RM. Echocardiographic Predictors of Pulmonary Embolism in Patients Referred for Helical CT. Echocardiography 2008;25:584-590.
McConnell MV, Solomon SD, Rayan ME, et. al. Regional Right Ventricular Dysfunction Detected by Echocardiography in Acute Pulmonary Embolism. Am J Cardiol. 1996; 78: 469-473.
ACEP. Critical Issues in the Evaluation and Management of Adult Patients Presenting to the Emergency Department With Suspected Pulmonary Embolism. http://www.acep.org/content.aspx?id=30060. [July 24, 2011].
John Griffiths. Respiratory: Management of small, submassive and massive pulmonary embolism. http://www.frca.co.uk/article.aspx?articleid=100750. [July 24, 2011].
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Category: Visual Diagnosis
Posted: 8/7/2011 by Haney Mallemat, MD
(Updated: 8/8/2011)
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13 year-old right-hand dominant male following assault with blunt object. Diagnosis?
Answer: Monteggia fracture
Monteggia Fracture
Bruce H.E., Harvey J.P., Wilson J.C. Monteggia Fractures. J Bone Joint Surg Am. 1974;56:1563.
Reckling F.W. Unstable fracture-dislocation of the forearm (Monteggia and Galeazzi lesions). J Bone Joint Surg Am. 1982;64:857.
http://emedicine.medscape.com/article/1231438-overview
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Category: Visual Diagnosis
Posted: 7/25/2011 by Haney Mallemat, MD
(Updated: 8/28/2014)
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34 y.o. male with history of IVDA (intravenous drug abuse) complains of fever, chills and cough. Diagnosis?
Answer: Lung Abscess (from septic pulmonary emboli)
Lung Abscess
Necrosis of lung parenchyma with pus and debris-filled cavities
Caused by direct injury (e.g., aspiration pneumonia) or secondary causes (e.g., tricuspid endocarditis, bacteremia, etc.)
Suspect with:
Loss of airway reflexes (e.g., CVA, seizures, alcohol / narcotic abuse, etc)
Poor dentition
Immunosuppression
IVDA
Gram positives, negatives and anaerobic bacteria have all been implicated.
CXR may suggest diagnosis, but CT scan better identifies abscess, necrotic tissue, empyema, or other pathology (see image below).
After drawing blood cultures, broad-spectrum antibiotics should be started and narrowed once culture data is available; address underlying cause (e.g., valve replacement for endocarditis).
Prognosis is generally good with normal immune function and antibiotics, but mortality sharply increases with immunocompromise and treatment delay.
Mansharamani N, et al. Lung abscess in adults: clinical comparison of immunocompromised to non-immunocompromised patients. Respiratory Medicine. Mar 2002;96(3):178-85
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Category: Visual Diagnosis
Posted: 7/10/2011 by Haney Mallemat, MD
(Updated: 8/28/2014)
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48 year old male following 15 foot fall onto both feet. What is the diagnosis?
…and why is it called the “Lover’s Fracture”?
Answer: Calcaneus fracture; historically called the “Lover’s Fracture” for “lovers” jumping out of bedroom windows to evade suspicious spouses and landing directly on their feet.
Calcaneus fractures
Rosen's Emergency Medicine: Online Edition
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Category: Visual Diagnosis
Posted: 6/27/2011 by Haney Mallemat, MD
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49 y.o. female on Trimethoprim/sulfamethoxazole presents with rash and oral mucus membrane lesions. Diagnosis?
Answer: Steven-Johnson Syndrome
French LE. Toxic epidermal necrolysis and Stevens Johnson syndrome: our current understanding. Allergol Int. Mar 2006;55(1):9-16
Schöpf E. Toxic epidermal necrolysis and Stevens-Johnson syndrome. An epidemiologic study from West Germany. Arch Dermatol. 1991;127(6):839.
Roujeau JC. Severe adverse cutaneous reactions to drugs. N Engl J Med. 1994;331(19):1272.
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Category: Visual Diagnosis
Posted: 6/12/2011 by Haney Mallemat, MD
(Updated: 6/13/2011)
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13 y.o. with shoulder trauma (during basketball game). Arm held in adduction and exquisite scapular tenderness. Diagnosis?
Answer: Scapular Fracture
Scapular Fracture
Uncommon (1% of all fractures)
Extensive force required; high probability of associated injuries (pneumothorax, shoulder dislocation).
5 types: body/spine, acromion, neck, glenoid, and coracoid
Arm held in adduction and pain with shoulder movement; may mimic rotator cuff tear.
Obtain X-rays (AP shoulder and lateral scapula) or CT (if displaced).
Conservative management for non-displaced fractures; Orthopedic reduction for displaced fractures.
Complications include post-traumatic arthritis or bursitis.
NSAIDs are first-line analgesics.
Rosen P, Barkin R. Emergency Medicine: Concepts and Clinical Practice. Mosby Year Book; 2010:573-574.
Zlowodzki M, Bhandari M, Zelle BA, Kregor PJ, Cole PA. Treatment of scapula fractures: systematic review of 520 fractures in 22 case series. J Orthop Trauma. Mar 2006;20(3):230-3.
Category: Visual Diagnosis
Posted: 6/6/2011 by Rob Rogers, MD
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A 20 year-old female presents with bilateral neck pain that occurred at rest. No other complaints. See if you can find the subtle clue on the x-ray...
The x-ray shows air in the soft tissue of the right neck and supraclavicular area. Close inspection of the mediastinum reveals subtle air along the heart border. Diagnosis: pneumomediastinum.
Often the first clue of pneumomediastinum is air in the neck and supraclavicular area on plain film. So, always look at the soft tissues on chest x-ray.
Category: Visual Diagnosis
Posted: 5/30/2011 by Haney Mallemat, MD
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13 y.o. female with ankle pain following fall down escalator. What's the diagnosis? (Hint: Look very closely)
Answer: Tri-plane ankle fracture
Tri-plane Fractures (Submitted and written by Dr. Michael Santiago)
Category: Visual Diagnosis
Posted: 5/23/2011 by Haney Mallemat, MD
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50 yo female s/p motor vehicle crash. Diagnosis?
Answer: Pneumomediastinum from pneumothorax
Pneumomediastinum
Mediastinal air has multiple causes:
Listen for Hamman's sign ("crunching" with cardiac auscultation) and feel for crepitus (distinct feeling on palpation).
Treat the precipitating cause.
Usually resolves without mediastinal decompression; air travels along tissue planes decompressing increased mediastinal pressure.
Category: Visual Diagnosis
Posted: 5/9/2011 by Haney Mallemat, MD
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70 yo female from nursing home with fever. RUQ ultrasound is shown below. Diagnosis?
Acalculous Cholecystitis
Acalculous cholecystitis is due to gallbladder (GB) wall ischemia and GB stasis (reduced GB contraction from reduced PO intake)
which all leads to “sludging” (Figure 1; A), thickened GB walls (B), and pericholecystic fluid (C).
Risk factors include critical illness (especially sepsis), acute cholecystitis, total parenteral nutrition, diabetes, and GB dysmotility.
Treatment includes antibiotics covering enteric / biliary pathogens and cholecystectomy (if a surgical candidate) or percutaneous
cholecystostomy if unsuitable for the OR.
Complications include perforation, GB gangrene, and extrabiliary abscess.
Category: Visual Diagnosis
Posted: 4/25/2011 by Haney Mallemat, MD
(Updated: 12/12/2024)
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Patient presents with the following X ray after yawning. Diagnosis?
Diagnosis: Mandibular Dislocation
The link below demonstrates an interesting alternative to the traditional reduction method; prospective randomized trails are pending.
Thanks to Dr. George Kochman for the image and Dr. Christopher Doty (EM Program Director at SUNY Downstate / Kings County Hospital Center) for the video.
Category: Visual Diagnosis
Posted: 4/10/2011 by Haney Mallemat, MD
(Updated: 4/11/2011)
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60 y/o male transferred from local rehab facility c/o abdominal pain.
Ogilvie's syndrome / Acute colonic pseudo-obstruction (ACPO)
Syndrome of decreased GI motility believed to be an autonomic imbalance (specifically, parasympathetic suppression) predominantly in the cecum and right colon. ACPO is also commonly due to narcotic overuse / abuse.
Differential diagnosis:
Abdominal XR:
Treatment:
Fazel A, Verne GN. New solutions to an old problem: Acute colonic pseudo-obstruction. JClin Gastroenterol 2005; Vol 39(1): 17-20.
Ozkurt H, Yilmaz F, et al. Acute colonic pseudo-obstruction (Ogilvie's syndrome): radiologic diagnosis and medical treatment with neostigmine. Report of 4 cases. Am J of Emer Med 2009; Vol 27: 757.e1 - 757e4.
Category: Visual Diagnosis
Posted: 3/27/2011 by Haney Mallemat, MD
(Updated: 3/28/2011)
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25 year old male presents after falling from 10 feet and landing on right shoulder. Diagnosis?
Yes...the shoulder is dislocated, but did you notice anything else? (see figure 1)
Glenoid Fossa Fracture: (Image submitted by Dr. George Kochman)
Fractures of the glenoid fossa occur when the head of the humerus collides with the glenoid margin; classically, by a laterally directed force. Although less than 10% of glenoid fossa fractures result in significant displacement, surgical repair is indicated if:
Schmidt, J. Scapular Fracture. eMedicine. January 12, 2011.
http://emedicine.medscape.com/article/826084-overview
Category: Visual Diagnosis
Keywords: lung, ultrasound, pneumonia, hepatization, sonogram, air bronchograms (PubMed Search)
Posted: 3/13/2011 by Haney Mallemat, MD
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65 yo female with breast cancer presents with dyspnea and CXR shown below. Diagnosis? Can anything help clarify the diagnosis?
The CXR shows an opaque right hemithorax, consistent with a pleural effusion, a large consolidation, or both. Ultrasound of the lung can clarify this ambiguity.
Consolidation of lung parenchyma (e.g., pneumonia) appears isoechoic to liver tissue on ultrasound and air bronchograms appear as hyperechoic areas within the consolidated lung parenchyma (Image 1). Together these findings are termed "hepatization" of the lung as consolidated lung appears similar to liver parenchyma on ultrasound (Image 2).
Durant, A. Nagdev, A. Ultrasound detection of Lung Hepatization. West J Emerg Med. 2010 September; 11(4): 322-323.
Category: Visual Diagnosis
Keywords: ultrasound, ectopic, free fluid, hypotension, pregnancy (PubMed Search)
Posted: 2/27/2011 by Haney Mallemat, MD
(Updated: 8/28/2014)
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24 yo woman presents with syncope, abdominal pain, and normal menses 4 days prior. Urine HCG(+) and quantitative beta-HCG is 1300 with the transvaginal ultrasound seen below. Diagnosis?
Ectopic Pregnancy Pearls
Tintinalli, Judith, et al. Tintinalli’s Emergency Medicine: A Comprehensive Study Guide, 7th Edition. 2011, McGraw-Hill Companies, Inc, China
Category: Visual Diagnosis
Posted: 2/21/2011 by Rob Rogers, MD
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Luxatio Erecta-inferior glenohumeral dislocation
A rare shoulder dislocation caused by a hyperabduction injury to the arm.
Category: Visual Diagnosis
Keywords: boxer's, fracture, orthopedics, hand, brawler's, radiology, xray (PubMed Search)
Posted: 1/17/2011 by Haney Mallemat, MD
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Boxer's (or Brawler's) Fracture
Many thanks to Dr. George Kochman for submitting this case!