By Adam Blumenberg, MD
A 75 year old woman with a history of left femur ORIF, and hypertension was “clipped” on the left knee by a turning car as she was crossing the street. She is dressed in religious garb, has a head scarf and long sleeves. She has been unable to bear weight since, and has a slowly expanding knee effusion. Distal pulses are intact. A CT of her knee just superior to the patella is shown.
1. Please describe this image.
2. What is the significance of the radiographic findings? How does the patient’s history influence your interpretation of this image?
3. What similar radiographic finding is highly specific for fracture?
4. What is the next step in management?
5. What is the patient’s disposition?
A 12 yo F with no PMHx presents to the pediatric ED with acute onset crampy and sharp left sided pelvic pain, which started 3-4 hours earlier, associated with nausea but no vomiting or diarrhea.
VS on arrival: HR 102, BP 110/86, T: 99.4
On your exam, you note a non-toxic appearing 12 yo F in moderate distress due to pain, with mild left pelvic tenderness to palpation but without peritoneal signs.
The rest of the exam is unremarkable.
You obtain a pelvic US which reveals the following findings:
Right Adnexa for comparison.
- What is your differential diagnosis for acute abdominal pain in the pediatric female patient?
- Based on the history and physical exam for the pediatric female patient, what work up, if any, would you consider in terms of labs, imaging, and consultations?
- Given the history, physical exam, and Ultrasound findings in this patient, what is the most likely diagnosis?
- Given the most likely diagnosis, what is your ED management?
A 12 year old boy presents to the emergency department at 7:00AM Sunday morning with 2 hours of left sided abdominal pain, waxing & waning nausea with vomiting. Vital signs are within the normal range and abdomen is soft and non-tender. Genitourinary examination reveals high-riding and tender left testicle and diminished cremasteric reflex. The following ultrasound image is obtained:
- What is the diagnosis?
- What historical and physical examination findings are typical of this disease? What other diagnoses must be considered?
- What is the emergency department management of this condition? What if you do not have immediate access to a specialist?
- What is the patient’s disposition?
A 75 yo male is brought in by EMS with worsening level of consciousness/alertness for the past 30 minutes as reported by his wife after experiencing a gradually worsening headache the past few hours at home associated with nausea but no vomiting. Vitals in the field: BP 214/128, HR 68, he is being bag mask ventilated by EMS as they could not successfully intubate him. They report that the patient’s wife endorsed a history of him being on warfarin for an irregular heart rhythm. After immediately establishing a secure airway with endotracheal intubation and getting IV access, you accompany him for a stat non-contrast head CT which demonstrates the following:
What key issues must you address and what are your critical next steps?
A 78 year old man presents to the ED for pre-syncope and back pain. Physical exam is remarkable for systolic blood pressure in the 80s and a pulsatile abdominal mass. Computed tomography imaging of the abdomen reveals the following:
- What is the diagnosis?
- What is the workup for this patient in the ER?
- What are the potential pitfalls that may delay definitive diagnosis? How would you navigate these pitfalls?
- What is this patient’s disposition?
A 68 yo F presents to the ED with nausea and vomiting since earlier in the morning with severe abdominal pain. She has a h/o several abdominal surgeries and is not passing gas. Last bowel movement was 3 days prior and she normally moves her bowels almost daily. VS on triage: BP: 150/80, HR: 104, RR: 20, SAT: 100% on RA, T: 98.6, FSG: 124 mg/dl. The exam is notable for an elderly woman who is in moderate distress due to abdominal discomfort, actively retching, vomiting feculent material. She has dry mucous membranes, a distended and tympanic abdomen and a bulging mass in her right groin that is hard and mildly tender to palpation. The following imaging is obtained:
- What is the most likely underlying diagnosis?
- What is your ED management plan?
A 35 year old man with no PMH presents to the ED with left flank pain, radiating into his left groin, which started about 2 hours earlier. The pain is sharp, colicky in nature, 10/10 in severity. Denies hematuria, no dysuria, no bowel changes, no fevers/chills. VS in the ED: BP: 148/88, HR: 110, RR: 22, SAT: 100% on RA, T: 98.1. You obtain the following CT abd/pelvis without contrast.
1) What is the most likely diagnosis?
2) What is your ED management?
An 82 y/o man is sent from a rehab facility for crampy abdominal pain and nausea/vomiting. Pt recently fell and had to have hip surgery. He has been immobilized and taking pain meds. He reports constipation and intermittent abdominal pain for 2 weeks, which has become constant over the last 6 hours. He denies fever/chills or bloody bowel movements. Exam reveals an elderly man, mildly tachypneic with dry mm. His abdomen is distended and tympanic to percussion.
1. What is the diagnosis?
2. What are the common signs of this disease on plain radiograph?
3. What are the emergent indications for surgery?
4. How should you manage this patient in the emergency department?
A 47 year old male with no past medical history presents to the ED with shortness of breath and dizziness first noted while he was working and lifting heavy objects. He is a truck driver and recently returned from a long trip on the road. His symptoms started 12 hours ago. Denies chest pain, no syncope, no fevers, chills, or cough, no hemoptysis. VS on triage: BP 140/90, HR: 104, RR: 19, SAT: 98% on RA but desats down to 88% when ambulating, T: 98. Rest of the exam is unremarkable and the patient does not appear toxic or in any severe distress. ECG demonstrates sinus tachycardia with right bundle branch pattern (no prior for comparison), and bedside transthoracic echocardium demonstrates good LV systolic function but there is evidence of right heart strain with IV septal bowing into the LV (“D sign”) on short axis view, with no pericardial effusion. Labs are only notable for troponin level of 0.2. A CT pulmonary artery is performed…this is looking like just another day at the County.
- What is the most likely diagnosis (be as specific as possible thinking about risk stratification)?
- What are your critical next steps?
A 50 year old woman with a history of HIV/AIDs comes into your emergency department with acute shortness of breath. The patient is breathing shallowly at 40 breaths/minute and cannot give a history. As the nurses are hooking her up to the monitor you find a small chest tube with a Heimlich valve in place.
Vitals: HR 120 BP 90/40 O2 sat 91% on non-rebreather
You listen to her anterior lungs and here breath sounds bilaterally. While you’re setting up to intubate, the xray technician rolls in you get the XR shown here:
You look back through her chart and see that she was discharged last week after a long hospital stay for a MAC infection which was complicated by ARDS, intubation, pneumothorax and subsequent chest tube placement.
- What is the diagnosis?
- How is this different than a typical pneumothorax?
- How do you treat this?
- How does a Heimlich valve work?
- How do you troubleshoot a clogged Heimlich valve?