Answer radER Vol. 1.6

radER Winners:

Allison Loynd

Answer to Case 1.6

A 49-year old man fell off a ladder 4 days ago and continues to have pain in his right wrist. He denies pain in other parts of his body.  On examination, there is tenderness and swelling at the dorsal medial aspect of his wrist.  The patient receives a dose of oral analgesic medication.  The following radiograhs are obtained.

Questions

1.  What is the radiographic diagnosis?

2.  What is the most appropriate ED treatment and follow up?

Answers

1.  Acute triquetral dorsal chip fracture.
2.  Volar splint and follow up with an orthopedic or hand surgeon within 7-10 days

The above radiographs show a small dorsal chip on the lateral radiograph.  This is pathognomonic for a triquetral fracture.  The triquetrum is the second most commonly fractured carpal bone.  The mechanism of injury can either be forced hyperextension, hyperflexion or a direct blow.  Patients typically have pain and swelling on the dorsal medial aspect of the wrist.  Tenderness is often palpated just distal to the distal ulna and ulna styloid.  The triquetrum has a very rich vascular supply and non-union is usually not an issue.  All patients should be splinted and given orthopedic or hand surgeon follow-up.

Wrist radiographs can be difficult to interpret and missed injuries are common.  Radiograph interpretation is aided by knowing which injuries are common, which can be easily missed, and the findings on physical examination.  In the wrist, distal radius fractures are by far most common and, although usually obvious, the radiographic findings are occasionally subtle or the radiographs are normal (an occult fracture).

Among carpal injuries, scaphoid fractures account for 60%.  The radiographs may have subtle findings or be normal.  The second most commonly fractured carpal is the triquetrum – a dorsal chip fracture that is seen on the lateral view.  (The triquetrum is the most dorsally projecting carpal bone on the lateral view.)  When a patient with a wrist injury presents with pain and swelling on the dorsum of the wrist, a dorsal chip triquetrum fracture should be suspected and the lateral view examined for this injury.  In this patient, there is also soft tissue swelling over the dorsal surface of the wrist on the lateral view.  Dorsal chip fractures of the triquetrum account for 20% of carpal injuries.

Most of the remaining 20% of carpal injuries are “perilunate injuries,” a spectrum of ligmentous injuries, subluxations, dislocations and fractures in proximity to the lunate.  Injuries of other carpals are uncommon, but can also be difficult to detect radiographically.  Therefore, any patient with significant wrist pain following an injury should be splinted and referred to an orthopedist or hand surgeon for further evaluation.  This may entail repeat radiographs, a bone scan (no longer used), MRI or possibly MDCT.

trquetrum

References:

Schwartz DT: Emergency Radiology: Case Studies, McGraw-Hill, 2008, pp.249-256, 257-266.

radER is a weekly contest, hosted by Dr. Kerin Jones’ “Fracture”,  consisting of a radiograph selected from various areas of emergency medicine that are central to the education of medical students and residents in training.

Intern Report Case Discussion 2.2

intern-report

Presented by Sarah Albers, MD

CC: FeverHPI: A 23-month-old female presents to the ED with fever for the last 2-3 days.  Recently finished antibiotics for an ear infection.  Mom said she was doing well until 2-3 days ago, when she developed some nausea, non bloody, nonbilious vomiting, loose stools, and a fever as high as 104 at home.  She was seen at another hospital last night, diagnosed with a virus and told her to take Motrin and Tylenol, 10 cc of each alternating.

Apparently, there was some miscommunication between mom and the previous hospital.  She has been giving 10 cc of Tylenol and Motrin Infant Drops instead of the child formula and so there is a concern for overdose.  She has had 2 doses of each, last dose of Motrin was about an hour and a half ago, Tylenol was about three and half hours ago.  The patient is eating and drinking, awake, interactive, slightly decreased urine output.  Mom said the urine is very foul smelling and darker than normal.

PAST MEDICAL HISTORY: Reflux.

HOSPITALIZATIONS: None.

PAST SURGICAL HISTORY: None.

MEDICATIONS: Zantac.

ALLERGIES: None

IMMUNIZATIONS: Up to date.

FAMILY HISTORY: None

SOCIAL HISTORY: Positive for sick contacts.

BIRTH HISTORY: Full term, no complications.

Physical Exam and Vitals

BP 97/52, P 148, RR 32, Temp 39.0 (temporal), repeat 40.2 axillary.

HEENT:

Head:  Normocephalic, atraumatic.

Eyes:  Extraocular movements intact.  Pupils are equal, round, and reactive.  No conjunctival pallor or scleral icterus.

Mouth:  Mucous membranes pink, moist.  No intraoral lesions.

NECK:  Supple.

CARDIOVASCULAR:  S1, S2 regular.  No murmurs, rubs, or gallops.

RESPIRATORY:  Clear bilaterally.  No wheezing, rales, or rhonchi.

ABDOMEN:  Soft, nontender, nondistended.

MUSCULOSKELETAL:  No gross deformity.

EXTREMITIES:  No cyanosis, clubbing, or edema.

SKIN:  Warm, dry, and intact.

NEUROLOGIC:  The patient is awake, alert, interactive, and has a normal gait

Labs:

WBC: 18

Hgb: 12.2

Hct: 36.5

Plts: 243

Fecal leukocytes: negative

Ova and parasites: negative

Stool culture: negative

C diff: negative

Blood culture: negative

UA:

pH 7.5

sp gr 1.009,

blood 1+

LE 3+

Nitrites neg

WBC’s 50-100

Bacteria 1+

UCx: >100,000 E Coli

Abd U/S Final Read:

1.  Unremarkable ultrasound examination of the kidneys.

2.  Two splenules in the left upper quadrant.

Side note:

This is a 23-month-old who had fever for 2 days.  She was seen previously at another hospital, and no urine was obtained.   Also, she had approximately 2 g of Tylenol over 2 hours.  Her 24 hour dose calculates to be approximately 80 mL/kg per dose which is below the toxic level.  The patient has also had approximately 400 mg of Motrin which calculates about 30 mg/kg which is below the toxic level as well.  Toxicology should be (and was) consulted (with no acute intervention).

Questions:

1)    What is the most common source of UTI in Pediatrics?

  1. E coli
  2. b. Fungi (Candida species)
  3. Staphylococcus saprophyticus
  4. Streptococcus group B
  5. Adenovirus

Answer Aa)    E coli is the most frequent pathogen, causing 75-90% of UTI’s.

b)    Fungi (Candida) occurs especially after instrumentation of the urinary tract.

c)    Staphylococcus saprophyticus, occurs especially among sexually active females

d)    Streptococcus group B occurs especially among neonates

e)    Adenovirus (rare)

2)    How should the urine analysis be obtained in this non toilet trained child?

  1. Sterile bag collection
  2. Bladder catheterization
  3. Suprapubic catheterization
  4. Wring out the diaper
  5. Wait for the child to urinate

Answer BA urine specimen for urinalysis and culture in a non-toilet trained child should be obtained by bladder catheterization or suprapubic aspiration, before treatment is started.  Sterile bag collection has a notoriously high false positive rate (up to 85%).

3)    What is the concentration/dosage of Children’s Tylenol?

  1. 80 mg / 0.8mL
  2. 160 mg  /5 mL
  3. 100 mg / 5mL
  4. 50 mg / 1.25 mL
  5. 150 mg / L

Answer: Ba) Tylenol – infant drops concentration with calibrated dropper, c) children’s Motrin, d) Motrin – infant drops with calibrated dropper,  e)  Toxic dose of tylenol at the 4 hour mark.  If the Tylenol level is at or above this level, it must be treated!

UTI Pathophysiology

Almost all urinary tract infections are ascending in origin. Disturbance of the normal periurethral flora, which is part of the host defense against colonization by pathogenic bacteria, predisposes a person to a urinary tract infection. Bacteria of the periurethral flora also inhabit the distal urethra. Urine in the proximal urethra, urinary bladder, and other proximal sites in the urinary tract is normally sterile. Uropathogens must gain access to the urinary bladder and proliferate for infection to occur. Uropathogens in the distal urethra may gain access to the bladder because of turbulent urine flow during normal voiding or because of dysfunctional voiding. Successful urinary bladder colonization is unlikely unless bladder defense mechanisms are impaired because normal voiding usually results in an essentially complete washout of contaminating bacteria.

After birth, the periurethral area, including the distal urethra, becomes colonized with aerobic and anaerobic microorganisms that appear to function as a defense barrier against colonization by uropathogens. In early childhood, enterobacteria and enterococci are part of the normal periurethral flora. Escherichia coli is the dominant gram-negative species in young girls, whereas E coli and Proteus species predominate in boys. Children as old as about 5 years are predisposed to have urinary tract infections, partly because of periurethral colonization by E coli, enterococci, and Proteus species. These potential uropathogens usually diminish in the first year of life and are rarely found in children older than 5 years. Studies of girls and women prone to urinary tract infection showed that periurethral colonization occurs with the specific bacterium that causes the next infection.

Causes

Proliferation of bacteria in the urinary tract is the cause of urinary tract infection.

  • Infections are almost always ascending in origin and caused by bacteria in the periurethral flora and the distal urethra. These bacteria inhabit the distal GI tract and colonize the perineal area. E coli usually causes a child’s first infection, but other gram-negative bacilli and enterococci may also cause infection.
  • Staphylococcal infections, especially those due to Staphylococcus saprophyticus, are common causes of urinary tract infection among female adolescents.
  • Entry of bacteria into the urinary bladder may be the result of turbulent flow during normal voiding, voiding dysfunction, or catheterization. In addition, sexual intercourse or genital manipulation may foster the entry of bacteria into the urinary bladder. More rarely, the urinary tract may be colonized during systemic bacteremia (sepsis); this usually happens in infancy.
  • Risk factors for urinary tract infection include the following:
    • Children who receive broad-spectrum antibiotics (eg, amoxicillin, cephalexin) that are likely to alter GI and periurethral flora are at increased risk for urinary tract infection because these drugs disturb the natural defense against colonization by pathogenic bacteria.
    • Prolonged incubation of bacteria in bladder urine due to incomplete bladder emptying or infrequent voiding compromises an important bladder defense against infection. Symptoms of voiding dysfunction, such as urgency, frequency, hesitancy, dribbling, or incontinence may occur in the absence of infection or local irritation because of uninhibited detrusor contractions. When the child attempts to prevent incontinence during a detrusor contraction by posturing (eg, obstructing the urethra), bacteria-laden urine in the distal urethra may be milked back into the urinary bladder (urethrovesical reflux). This mode of bacterial access is a common risk factor for urinary tract infection among pediatric patients who use posturing or pelvic withholding procedures to prevent incontinence.
    • Voiding dysfunction is not usually encountered in a child without neurogenic or anatomic abnormality of the bladder until the child is in the process of achieving daytime urinary control. Children with voiding dysfunction may attempt to prevent incontinence during an uninhibited detrusor contraction by voluntarily increasing outlet resistance. This may be achieved by using various posturing maneuvers, such as tightening of the pelvic-floor muscles, applying direct pressure to the urethra with the hands, or performing the Vincent curtsy, which consists squatting on the floor and pressing the heel of one foot against the urethra.
    • Constipation, with the rectum chronically dilated by feces, is an important cause of voiding dysfunction. Neurogenic or anatomic abnormalities of the urinary bladder may also cause voiding dysfunction.
    • Neonatal circumcision decreases the risk of urinary tract infection by about 90% in male infants during the first year of life. The risk of urinary tract infection in a circumcised infant is about 1 in 1000 during the first year, whereas an uncircumcised male infant has a 1 in 100 risk of developing a urinary tract infection. Given this risk, 111 healthy male infants must be circumcised to prevent 1 urinary tract infection. The risk and long-term effect of scarring due to 1 preventable urinary tract infection in a male infant are not known.

This case discussion presented by Dr Sarah Albers

Intern Case Report 2.1

intern-report

Presented by Sarah Albers, MD

CC: FeverHPI: A 23-month-old female presents to the ED with fever for the last 2-3 days.  Recently finished antibiotics for an ear infection.  Mom said she was doing well until 2-3 days ago, when she developed some nausea, non bloody, nonbilious vomiting, loose stools, and a fever as high as 104 at home.  She was seen at another hospital last night, diagnosed with a virus and told her to take Motrin and Tylenol, 10 cc of each alternating.

Apparently, there was some miscommunication between mom and the previous hospital.  She has been giving 10 cc of Tylenol and Motrin Infant Drops instead of the child formula and so there is a concern for overdose.  She has had 2 doses of each, last dose of Motrin was about an hour and a half ago, Tylenol was about three and half hours ago.  The patient is eating and drinking, awake, interactive, slightly decreased urine output.  Mom said the urine is very foul smelling and darker than normal.

PAST MEDICAL HISTORY: Reflux.

HOSPITALIZATIONS: None.

PAST SURGICAL HISTORY: None.

MEDICATIONS: Zantac.

ALLERGIES: None

IMMUNIZATIONS: Up to date.

FAMILY HISTORY: None

SOCIAL HISTORY: Positive for sick contacts.

BIRTH HISTORY: Full term, no complications.

Physical Exam and Vitals

BP 97/52, P 148, RR 32, Temp 39.0 (temporal), repeat 40.2 axillary.

HEENT:

Head:  Normocephalic, atraumatic.

Eyes:  Extraocular movements intact.  Pupils are equal, round, and reactive.  No conjunctival pallor or scleral icterus.

Mouth:  Mucous membranes pink, moist.  No intraoral lesions.

NECK:  Supple.

CARDIOVASCULAR:  S1, S2 regular.  No murmurs, rubs, or gallops.

RESPIRATORY:  Clear bilaterally.  No wheezing, rales, or rhonchi.

ABDOMEN:  Soft, nontender, nondistended.

MUSCULOSKELETAL:  No gross deformity.

EXTREMITIES:  No cyanosis, clubbing, or edema.

SKIN:  Warm, dry, and intact.

NEUROLOGIC:  The patient is awake, alert, interactive, and has a normal gait

Labs:

WBC: 18

Hgb: 12.2

Hct: 36.5

Plts: 243

Fecal leukocytes: negative

Ova and parasites: negative

Stool culture: negative

C diff: negative

Blood culture: negative

UA:

pH 7.5

sp gr 1.009,

blood 1+

LE 3+

Nitrites neg

WBC’s 50-100

Bacteria 1+

UCx: >100,000 E Coli

Abd U/S Final Read:

1.  Unremarkable ultrasound examination of the kidneys.

2.  Two splenules in the left upper quadrant.

Side note:

This is a 23-month-old who had fever for 2 days.  She was seen previously at another hospital, and no urine was obtained.   Also, she had approximately 2 g of Tylenol over 2 hours.  Her 24 hour dose calculates to be approximately 80 mL/kg per dose which is below the toxic level.  The patient has also had approximately 400 mg of Motrin which calculates about 30 mg/kg which is below the toxic level as well.  Toxicology should be (and was) consulted (with no acute intervention).

Questions:

1)    What is the most common source of UTI in Pediatrics?

  1. E coli
  2. b. Fungi (Candida species)
  3. Staphylococcus saprophyticus
  4. Streptococcus group B
  5. Adenovirus

2)    How should the urine analysis be obtained in this non toilet trained child?

  1. Sterile bag collection
  2. Bladder catheterization
  3. Suprapubic catheterization
  4. Wring out the diaper
  5. Wait for the child to urinate

3)    What is the concentration/dosage of Children’s Tylenol?

  1. 80 mg / 0.8mL
  2. 160 mg  /5 mL
  3. 100 mg / 5mL
  4. 50 mg / 1.25 mL
  5. 150 mg / L

Please submit your answers to the questions in the “leave a reply” box or click on the “comments” link.  Your submission will not immediately post.  Answers with a case discussion will post on Friday.  If you have any difficulty, please contact the site administrator at arosh@med.wayne.edu. Thank you for participating in Receiving’s: Intern Report.

radER vol. 1.6

Case 1.6

A 49-year old man fell off a ladder 4 days ago and continues to have pain in his right wrist. He denies pain in other parts of his body.  On examination, there is tenderness and swelling at the dorsal medial aspect of his wrist.  The patient receives a dose of oral analgesic medication.  The following radiograhs are obtained.

Questions

1.  What is the radiographic diagnosis?

2.  What is the most appropriate ED treatment and follow up?

radER is a weekly contest, hosted by Dr. Kerin Jones’ “Fracture”,  consisting of a radiograph selected from various areas of emergency medicine that are central to the education of medical students and residents in training.

case 1.2 answer

morrisons-pouch-redo2

Presented by Dr. Debia Kim

NICE JOB

Dan Seitz

Kyle Perry

Richard Gordon

47 y/o woman presents with pain and swelling in her right underarm for the past few days.  She says she first noticed an itchy “bug bite” in her armpit which gradually became larger but never “came to a head.”  She has not tried anything at home to relieve the pain, and her strength and range of motion are unaffected by the swelling.  No fevers/chills.  The patient has a history of DM2 and is a cigarette smoker.

Her physical exam reveals normal vital signs, and a 6cm x 4cm very tender, raised erythematous area of induration in the R axilla.  Peripheral pulses and neuro exam are normal.  No fluctuance.  You decide to do an ultrasound examination of the right (abnormal) underarm and also the left (normal) for comparison.

Image 1

Image 2

Image 3

Image 4

Questions:

  1. What is the diagnosis?
  2. Which images show pathology?
  3. What are the structures highlighted in the color-flow images?case

Answers:

  1. Celluitis and abscess
  2. Images 1 and 3
  3. Lymph nodes

This case prepared by Dr Debia Kim, PGY-1 Emergency Medicine Resident, Detroit Receiving Hospital

“Morrison’s Pouch” is an educational module that utilizes ultrasound video clips from case presentations in the Emergency Department.

Case 1.2

morrisons-pouch-redo2

Presented by Dr. Debia Kim

47 y/o woman presents with pain and swelling in her right underarm for the past few days.  She says she first noticed an itchy “bug bite” in her armpit which gradually became larger but never “came to a head.”  She has not tried anything at home to relieve the pain, and her strength and range of motion are unaffected by the swelling.  No fevers/chills.  The patient has a history of DM2 and is a cigarette smoker.

Her physical exam reveals normal vital signs, and a 6cm x 4cm very tender, raised erythematous area of induration in the R axilla.  Peripheral pulses and neuro exam are normal.  No fluctuance.  You decide to do an ultrasound examination of the right (abnormal) underarm and also the left (normal) for comparison.

Image 1

Image 2

Image 3

Image 4

Questions:

  1. What is the diagnosis?
  2. Which images show pathology?
  3. What are the structures highlighted in the color-flow images?

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!

This case prepared by Dr Debia Kim, PGY-1 Emergency Medicine Resident, Detroit Receiving Hospital

“Morrison’s Pouch” is an educational module that utilizes ultrasound video clips from case presentations in the Emergency Department.