VizD Vol 1.3

Case 1.3

Name that Bodily Fluid

1. A 23-year-old man after performing 30 minutes straight of leg-squats

2. A 66-year-old woman with abdominal distension

3. A 42-year-old man with epigastric pain that radiates to his back

Questions for each image above:

1. What is the fluid?  What condition is it associated with?

2. What is the fluid?  What condition is it associated with?

3. What is the substance?  What condition is it associated with?

Please post your answer in the “reply box” or click on the “comments” link You will not see your answer post until next week when all of the submitted answers will be posted. Good luck!

VizD is a weekly contest of an interesting or pathognomonic image from emergency medicine. Its goal is to integrate learning into a fun and relaxed environment. All images are original and are posted with the consent of the patient.

Answer radER 1.2

radER Winners:

Dave Mishkin           Devon Moore

Chris Guyer              Rob Klever

Answer to Case 1.2

A 29-year-old man presents to your ED with left should pain that started immediately after he struck a volley ball during his serve. On exam, the left arm is held in slight abduction and external rotation. The patient is unable to touch his uninjured shoulder with the hand from his injured arm. His radiograph is seen below.

1. What two nerves are at greatest risk for injury?

2. How do you test the integrity of these potential nerve injuries?

3. What is a Hill-Sachs deformity?

Answers:

1. Axillary nerve and Muscultaneous nerve – injury may occur when the shoulder is dislocated or reduced

2. Axillary nerve

  • sensory loss over the lateral aspect of shoulder
  • weakness in shoulder abduction (deltoid)

Musculocutaneous nerve

  • weakness of forearm flexors and supinators
  • sensory loss over dorsum of forearm

3. Hill-Sachs deformity-compression fracture of the posterolateral aspect of the humeral head

  • results from impaction of humeral head on the anterior glenoid rim as it dislocates or reduces
  • occurs in up to 50% of anterior dislocations (more common in recurrent dislocators)

Thank you for everyone who submitted an answer. Please stay tuned for next week’s radER.

radER is a weekly contest consisting of a radiograph selected from various areas of emergency medicine that are central to the education of medical students and residents in training.

Answer quizzER Vol 1.2

quizzER Winners:

Chris Guyer            Allison Loynd             Rob Klever

Sam Lee                  Dr Kuhn                     Brian Kern

Marjan Siadat          Julie Nguyen

Devon Moore          Dave Mishkin

Last Week’s Question

The answer is D

Patients with chest pain in the setting of cocaine use should be evaluated for possible myocardial ischemia. Patients suspected of ACS should be managed accordingly with oxygen, nitrates, morphine, aspirin, and benzodiazepines; however, β-adrenergic antagonist therapy is absolutely contraindicated. If β-adrenergic receptors are antagonized, α-adrenergic receptors are left unopposed and available for increased stimulation by cocaine. This may worsen into coronary and peripheral vasoconstriction, hypertension, and possibly ischemia. Therefore, benzodiazepines, which decrease central sympathetic outflow, are the cornerstone in treatment to relieve cocaine-related chest pain.

Check out this articlefrom Annals of Emergency Medicine regarding the use of Beta Blockers and cocaine

_______
(b) Diltiazem, a calcium channel blocker, can be used in patients with cocaine related chest pain. It is used to lower heart rate. (c) Aspirin should be administered to all patients with chest pain, unless there is a contraindication. In patients with cocaine related chest pain who also seize, aspirin may be held until a CT scan is performed to rule out an intracranial bleed. (a) Phentolamine is a reversible non-selective alpha-adrenergic recceptor antagonist.  The primary application for phentolamine is for the control of hypertensive emergencies, most notably due to pheochromocytoma.  It is also used in cocaine-related hypertension; however, benzodiazepines are favored as it reduces the sympathetic drive leading to a reduction in blood pressure and heart rate. (e) Nitroglycerin should be administered to these patients if they have chest pain. Nitrates dilate the coronary arteries, increasing blood flow to the myocardium.

To learn more about the diagnosis and management of cocaine-related emergencies, click on the image

(from EB Medicine)

Thank you for everyone who submitted an answer.  Please stay tuned for next week’s quizzER.

quizzER is a weekly contest consisting of a question selected from various areas of emergency medicine that are central to the education of medical students and residents in training.

Answer VizD 1.2

VizD Winners:

Brian Kern                Marjan Siadat         Dave Mishkin

Scott Ottolini            Rob Klever

Devon Moore            Hong Chong

Richard Gordon        Allison Loynd

Answer to Case 1:2

A 35-year-old man presents to your ED after cutting his finger on the back of a refrigerator that he was moving for a friend.  He washed the finger and placed a bandage over it.  However, upon waking up this morning, he noticed increased redness and swelling as seen in the image below.

Questions:

1. What is the diagnosis?

2. What are Kanavel’s 4 cardinal signs?

3. What is the ED disposition?

Answers:

1. Pyogenic Flexor Tenosynovitis – inflammation of the tendon and the surrounding synovial sheath, typically results from a puncture wound

2. Kanavel’s Four Cardinal Signs of Flexor Tenosynovitis

  • finger held in slight flexion
  • symmetric swelling of the finger (sausage digit)
  • tenderness along the flexor tenon sheath
  • pain with passive extension of the finger

3. I.V. antibiotics, immoblization, elevation.  Hand surgeon consultation within 24-hours for incision and drainage

**if there is no history of trauma in a sexually active adult, consider disseminated GC and treat empirically with ceftriaxone until culture results are available**

_____________________________________________

“Morrison’s Pouch”

Please welcome our newest contributor to Receiving…Dr. Daniel Morrison, Director of Emergency Medicine Ultrasound for Detroit Medical Center.  Dr. Morrison is going to be leading the Ultrasound Section of Receiving.

If Dr Morrison cared for the patient in the clinical scenario above, an ultrasound of the finger would have been obtained to confirm the diagnosis of flexor tenosynovitis.  Included in the differential diagnosis is cellulitis and abscess of the digit without tendon involvement. (click on images to enlarge)

Normal Tendon

Finger Abscess Without Involvement of Tendon

Flexor Tenosynovitis (Fluid around tendon sheath)

Thank you to everyone who submitted their answer.  Stay tuned for next week’s VizD

VizD is a weekly contest of an interesting or pathognomonic image from emergency medicine. Its goal is to integrate learning into a fun and relaxed environment. All images are original and are posted with the consent of the patient.

radER Vol 1.2

Case 1.2

A 29-year-old man presents to your ED with left should pain that started immediately after he struck a volley ball during his serve.  On exam, the left arm is held in slight abduction and external rotation.  The patient is unable to touch his uninjured shoulder with the hand from his injured arm.  His radiograph is seen below.

1. What two nerves are at risk for injury?

2. How do you test the integrity of these potential nerve injuries?

3. What is a Hill-Sachs deformity?

Please post your answer in the “reply box” or click on the “comments” link  You will not see your answer post until next week when all of the submitted answers will be posted.  Good luck!

radER is a weekly contest consisting of a radiograph selected from various areas of emergency medicine that are central to the education of medical students and residents in training.

quizzER Vol 1.2

Chest Pain

A 47-year-old man with a history of hypertension presents to the ED complaining of continuous left-sided chest pain that began while snorting cocaine 1 hour ago. The patient states he never experienced chest pain in the past when using cocaine. His blood pressure is 170/90 mm Hg, heart rate is 101 beats per minute, respiratory rate is 18 breaths per minute, and oxygen saturation is 98% on room air. The patient states that the only medication he takes is alprazolam to “calm his nerves.” Which of the following medications is contraindicated in this patient?
a. Phentolamine
b. Diltiazem
c. Aspirin
d. Metoprolol
e. Nitroglycerin

Please post your answer in the “reply box” or click on the “comments” link  You will not see your answer post until next week when all of the submitted answers will be posted.  Good luck!

quizzER is a weekly contest consisting of a question selected from various areas of emergency medicine that are central to the education of medical students and residents in training.

VizD Vol 1.2

Case 1.2

A 35-year-old man presents to your ED after cutting his finger on the back of a refrigerator that he was moving for a friend.  He washed the finger and placed a bandage over it.  However, upon waking up this morning, he noticed increased redness and swelling as seen in the image below.

Questions:

1. What is the diagnosis?

2. What are Kanavel’s 4 cardinal signs?

3. What is the ED disposition?

Please post your answer in the “reply box” or click on the “comments” link  You will not see your answer post until next week when all of the submitted answers will be posted.  Good luck!

VizD is a weekly contest of an interesting or pathognomonic image from emergency medicine. Its goal is to integrate learning into a fun and relaxed environment. All images are original and are posted with the consent of the patient.