Clinical Images

Special Announcement

To our followers:

First of all, thank you guys and gals for following this site. We’ve had a lot of fun writing these posts every month! We are so thrilled to share with you a piece of Kings County ED. We will be moving our image post to a different site starting next month. The Kings County Emergency Medicine department has it’s own blog: The Original Kings of County. We will begin posting our images there from now own.

Love,
Karen, Ray, Adam, and Mark

Clinical Image for October 2016

2016_10

20 yo M w/ no PMH presents after skateboarding injury. He states he was skateboarding around a construction site when he felt a sharp object cut the back of his right leg. Vitals are within normal limits.

  1. What do you see?
  2. What structures are you concerned about?
  3. What physical exam finding may help you?
  4. What would be your initial work up in the ED?
  5. Treatment?
  6. Dispo?

Answers

Clinical Image for September 2016

IMG_0918

57 yo M w/ COPD, HIV (on HAART, unknown last cd4) presents for skin lesion w/ pain. Pt states he noticed a small bump on his arm about 2-3 months ago. It has has been growing and developed into the lesion pictured above. He states it’s been painful. It has not been pruritic. Denies any fevers, chills, weight loss, pus drainage, allergies, or other similar lesions.

  1. Describe the lesion.
  2. What is the cause of this lesion? How do you confirm the diagnosis?
  3. What labs or imaging is indicated in the ED?
  4. What is the mobility/mortality associated with this lesion?
  5. Dispo?

Answers

Clinical Image for July 2016

image

37 yo M w/ hx of dm, pancreatitis, and chronic pain presents to the ED with high FSG. FSG was 467 in triage, rest of vitals unremarkable. During your exam, patient states he needs his pain medication. He has chronic pain for which he takes 4mg Dilaudid every 6 hours. You ask about any  toxic habits (specifically opioids) and patient denies. As you help your pt change into a gown, you notice syringes filled with a brown substance. When you ask the patient what is it, he states it’s is insulin. On exam, you note multiple skin lesions as pictured above.

1. What do you suspect the lesions are from?

2. On labs, you suspect the patient may be in DKA- What key findings would see on labs?

3. How would you manage this patient? How would you manage his pain? Dispo?

Clinical Image for April 2016

2016_04

16 yo M w/ no PMH presents to the ED with left arm injury and pain. He states he tripped while walking down the stairs and grabbed the rail as he was falling. He heard a pop and has been in pain since. During your exam, you note that he cannot flex, extend, supinate or pronate at the elbow joint without pain. Radial pulses are +2 b/l and sensation is grossly intact b/l.

  1. What do you suspect happened?
  2. Describe the anatomy of the elbow
  3. What structures would  you be concerned about damaging with this injury?
  4. What images / labs would you order?
  5. How would you treat in the ED?
  6. Dispo?

Answers

 

Clinical Image for March 2016

2016_03

56yo homeless male with unknown PMH is bibEMS found unresponsive on a park bench. In the ED, pt opens eyes to commands, moves spontaneously, but does not produce any comprehensible speech. Pt has no complaints. On your physical exam you note his vitals are Temp 89.9F, HR99, RR20, O2 sat 96%, FSG 89. You also note that the patient’s left lower extremity looks as pictured above.

  1. What do you see? What is the most likely cause of this patient’s presentation?
  2. How severe is this patient’s symptoms?
  3. What may you expect to see on this patient’s labs? or EKG?
  4. Is imaging necessary?
  5. How would you initiate treatment in the ED?
  6. Dispo?

Answers

Clinical image for February 2016

2016_02

37 yo M w/ hx of HTN presents intoxicated with the injury seen above. According to EMS report, pt had tumbled down a flight of stairs.  As you’re doing your physical exam, you note his right DP is weak/diminished compared to the left.

  1. What do you see? How would you describe this?
  2. How would you approach this patient?
  3. What labs/ imaging would you order?
  4. How would you management this in the ED?
  5. How do you disposition?

Answers

Clinical Image for January 2016

2016_01

8mo male brought in by his mother hysterical for bloody bowel movements. Pt is up to date with vaccinations and was born at 35wks via vaginal delivery w/out any complications. Over the past 5 days, mother states child has not been feeding as well and has been tired with periods of fussiness and crying. Pt has had 4 episodes of NBNB vomiting over 2 days. Vitals on presentation 90/60BP, 100HR, 27RR@100%, 98.7F. During your exam, you take off the pt’s diaper to see this.

  1. What do you see? How would you describe this?
  2. What do you think this patient has?
  3. Describe the pathophysiology.
  4. What labs/ imaging would you order?
  5. What is the definitive treatment?

Answers