Best Case Ever 29 Carr’s Cases – Drug Induced Aseptic Meningitis

Dr. David Carr presents his third of EM Cases' Carr's Cases. This series features potentially debilitating diagnoses that may be thought of as 'zebras', but actually have a higher incidence then we might think - and if diagnosed early, can significantly effect patient outcomes. Dr. Carr tells the story of young woman with an MRSA supra pateller abscess who was put on trimethoprim sulfamethoxazole and presents looking very ill with a severe headache.

Not only has trimethoprim sulfamethoxazole been implicated in aseptic meningitis, but NSAIDS, immunomodulators and antibiotics have also been implicated. The reason this is so important for ED practitioners to know, is that case reports of drug-induced aseptic meningitis have shown that symptoms will resolve completely within 24 hours, once the offending drug has been stopped. Not only that, but if the patient receives the drug again in the future, they are at risk for a more severe case of drug induced aseptic meningitis.

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Diagnose on Sight: “I feel like I am having a heart attack”

Pneumothorax-Deep-SulcusCase: A 18-year-old male with no medical history presents to the emergency department (ED) complaining of “feeling like I am having a heart attack” which started suddenly 1 hour ago. The patient ate from a food truck the night before and developed several episodes of forceful vomiting prior to arrival in the ED. What finding in this supine chest radiograph aids in the diagnosis? Click on image for a larger view.




Deep Sulcus Sign


The deep sulcus sign was first described by Gordon in 1980 as a deep lateral costophrenic angle on the involved side [1]. In this example, it is on the patient’s left side (arrow). It is an important radiograph finding to be aware of in making the diagnosis of pneumothorax, because it may often be the only abnormal finding [2]. The cause of the sign is air tracking anteriorly and caudally along the pleural space and can be found on supine films. Which makes this finding particularly important for SUPINE critically ill patients. Air appears as a hyperlucency on radiographs which leads to the appearance of a deep lateral costophrenic angle on the side with the pneumothorax.


Wrong Answers

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  1. Gordon R. The deep sulcus sign. Radiology. 1980 July;136(1):25-7. PMID: 7384513
  2. Smally AJ. Suozzi JC. Images in emergency medicine. Deep sulcus sign. Ann Emerg Med. 2007 May;49(5):717;725. PMID: 17452270
  3. Bhardawaj B. Bhardwaj H. Air-fluid level in the right lung. Lung India. 2014 Apr;31(2):179-81. PMID: 24778488
  4. Koga T. Fujimoto K. Images in clinical medicine. Kerley’s A, B, and C lines. N Engl J Med. 2009 Apr 9;360(15):1539. PMID: 19357409
  5. Lai V. Tsang WK. Chan WC. Yeung TW. Diagnostic accuracy of mediastinal width measurement on posteroanterior and anteroposterior chest radiographs in the depiction of acute nontraumatic thoracic aortic dissection. Emerg Radiol. 2012 Aug;19(4):309-15. PMID: 22415593

Author information

Nikita Joshi, MD

Nikita Joshi, MD

ALiEM Associate Editor

Editorial Board Member

ALiEM-CORD Fellowship Director

ALiEM-EMRA Fellowship Director

Clinical Instructor

Stanford University, Division of Emergency Medicine

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Why Do Doctors Commit Suicide?

Hello everybody, my dear friends.

Published in the pages of the opinion of the New York Times on September 4, 2014 by Pranay Sinha, I present this impresive article  the suicide of two residents during the month of September.

Photo by Anna Parini

The statistics are chilling: doctors commit suicide twice as the rest of the population, and whether they are women, three times. In United States, 400 doctors commit suicide a year being the most vulnerable young doctors at the beginning of its formation (up to almost 10% of the students have suicidal thoughts, according to a recent study).

The training programmes test the mental and physical stability of doctors: we work more than 80 hours a week during the residency. In a very few places consider this fact, since there are no programs that concern the welfare of workers.

Stress, social isolation, physical and mental exhaustion. Pressure from your superiors and from the system. Responsibility increased exponentially in a short space of time, from student to exercise the Medicina. And lack of knowledge of limit situations, since it is common to think that a doctor does not need help and and can no doubt.

The first months are filled with fatigue, which derives in clinical errors and need close supervision. And often all this ends in self-isolation and unrecognized depression. And more doubts.

Perhaps we have to admit that sometimes we need help, like the rest of humans.
That we can put voice to silenced doubts and those fears. The sadness of certifying the first death of a patient, to the mortification of mistakes of prescription, to the shame of not knowing an answer.

We are not alone.

A tired and depressed doctor may never take good care of their patients. 

We will take care of us to be able to care for others.

Happy Tuesday,

The NEW Glascow Coma Scale.

Download PDF

Its 40 years since the Glasgow Coma Scale (GCS) was first introduced into our clinical assessment skills as a practical way to communicate altered levels of consciousness.

Used in more than 80 countries worldwide, there is now a push by the originators of the scale to deliver a more structured and accurate approach to assessing patients GCS.

The new GCS:

The focus is now on reporting each of the 3 components of the scale rather than just the total sum.

OUT: the patients GCS=13
IN:     the patients GCS = 13 (E3,V4, M6)
Assessment of each of the components is against a specific and standardised criterion.

Eye and Verbal Scales.

Eye opening to pressure has replaced ‘opening to pain’ to reflect the accuracy of the stimulus that is used.

Stimulus is applied via:
* Finger tip pressure.
* Trapezius Pinch.
* Supraorbital notch pressure.

For more information on this, read my post on applying noxious stimuli.

‘Words’ & ‘Sounds’ offer a simplified replacement to ‘inappropriate words’ and ‘incomprehensible sounds’.

Motor Response:

More clear directions for assessing motor response replace the ever confusing normal and abnormal flexion.

Download the Glasgow Coma Scale assessment aid as a pdf.


Reference: 1. What’s new – Glasgow Coma Scale [Internet]. [cited 2014 Sep 23]. Available from: