Diagnose on Sight: Bilateral Leg Rash

Erythema Nodosum

Case: A pre-teen girl, living in central California, recently started on fluconazole, now presenting with a bilateral leg rash. What is your diagnosis? Click on the image for a larger view.

Poll

 

Diagnosis

Erythema nodosum, secondary to coccidioidomycosis

Explanation

Erythema nodosum is a cutaneous reaction consisting of inflammatory, tender erythematous subcutaneous nodular lesions. The classically painful rash is located on the lower extremities and usually regresses spontaneously. It is associated with a wide variety of disease processes [1,2] including:

  • Most common cause: Streptococcal infections
  • Other causes:
    • Behcet’s syndrome
    • Oral contraceptive use
    • Pregnancy
    • Sarcoidosis
    • Tuberculosis
    • Viral infections

Coccidioidomycosis is endemic to certain arid parts of the Southwest United States. Erythema nodosum is the most characteristic reactive cutaneous manifestation of coccidioidomycosis. It presents 1-3 weeks after onset of illness and is usually self-limited [3]. While strep infections are the most common cause of erythema nodosum, in a patient who has recently visited the American southwest, suspect coccidioidomycosis.

 

Master Clinician Bedside Pearls

Stuart Swadron, MD

 

 

 

Stuart Swadron, MD – Professor of Emergency Medicine, Keck School of Medicine of the University of Southern California (provided to ALiEM and recorded by Swadron, 2014)

 

References

  1. Psychos DN, Voulgari PV, Skopouli FN, Drosos AA, Moutsopoulos HM. Erythema nodosum: the underlying conditions. Clin Rheumatol. 2000;19(3):212-6. PMID: 10870657.
  2. Schwartz R, Nervi S. Erythema Nodosum: A Sign of Systemic Disease. Am Fam Physician. 2007 Mar 1;75(5):695-700 PMID: 17375516.
  3. DiCaudo DJ. Coccidioidomycosis: a review and update. J Am Acad Dermatol. 2006 Dec;55(6):929-4.2 PMID: 1711021.

Author information

Jeff Riddell, MD
Jeff Riddell, MD
Chief Resident
UCSF-Fresno Emergency Medicine Residency

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Sternoclavicular Joint Dislocations: Diagnosis and Treatment

Image obtained from healio.com

A 16-year-old football player presents to the emergency department directly from a game. He was tackled, falling onto his right shoulder. The patient is complaining of right-sided chest pain. On exam, there is tenderness over the right sternoclavicular joint (SCJ) with a prominent medial clavicle. Range of motion is limited in the right arm. What diagnostic studies need to be performed? What treatment is warranted in the emergency department?

Sternoclavicular Joint Dislocations

SCJ injuries are generally rare. However, due to the increasing amount of contact sports being played, emergency physicians must be aware of how to diagnose and treat these injuries.

The SCJ serves as an important fulcrum for movement of the shoulder girdle. It is the only true articular attachment of the upper extremity to the axial skeleton. Dislocations account for only 3% of all dislocations around the shoulder [1].

Anatomy

The clavicle is the first bone to ossify, but the medial physis is the last fuse, typically between the ages of 23-25 years of age [1]. The medial clavicle sits in a shallow, saddle joint with the superomedial manubrium. The joint requires the subclavius muscle and four separate ligaments for stability [2]. There is an intraarticular fibrocartilanginous disc between the clavicle and the manubrium, which is analogous to the meniscus of the knee [1]. Instability of the joint may be acute, recurrent, or persistent. Displacement can be directed in an anterior, posterior, superior, or inferior direction.

 

Mechanism of Injury

Dislocations typically are the result of a motor vehicle collision or a sports-related injury. Anterior dislocations are more common that posterior dislocations, but the posterior dislocation is the more concerning injury of the two with a mortality of 3-4% [1]. This is true for two reasons [1,3]:

  1. The force required for a posterior dislocation is 1.5 times that of an anterior dislocation.
  2. There is a greater chance (about 30%) of damaging underlying structures, including the brachial plexus, vascular structures, trachea, and esophagus.

Anterior dislocations are the result of a force directed on the shoulder while the arm is held in the abducted position. Posterior dislocations can result from two different mechanisms. First, a medially directed force to the shoulder with the arm adducted and flexed can cause a posterior dislocation. Alternatively, a direct blow to the anteromedial aspect of the clavicle can cause a posterior dislocation.

Physical Examination

The examination of the patient with a potential SCJ injury should be completed in the seated or standing position. Supine positioning may exacerbate severe pain, as may arm motion. The patient will have localized pain and swelling to the joint. Many times the arm will be held across the chest to minimize glenohumeral and scapulothoracic movement. Anterior dislocations will often have a prominent lump from the dislocated medial clavicle. Differentiating the anterior SCJ dislocation from a fracture of the medial clavicle can be challenging. A posterior dislocation can be quite subtle. There may be depression over the SCJ. Associated symptoms such as stridor, dysphagia or shortness of breath indicate compression of the trachea or esophagus, requiring urgent reduction.

Diagnostic Imaging

Standard antero-posterior radiographs may be difficulty to interpret due to the confluence of other bony structures. However, a chest x-ray should be performed to exclude other pathology, including pneumothorax, pneumomediastinum, or hemopneumothorax. The addition of the Serendipity view (40 degree cephalic tilt) allows visualization of a SCJ dislocation on plain radiographs [3]. CT has superseded plain films in the diagnosis of SCJ dislocations. CT provides a definitive diagnosis and shows the dislocation in relation to the underlying mediastinal structures.

 

Image obtained from msdlatinamerica.com

 

Serendipity View

Treatment

The goals of treatment are:

  1. Provide adequate pain control
  2. Reduce or immobilize joint
  3. Address associated injuries
  4. Minimize complications
  5. Arrange appropriate referral

Potential complications of SCJ injuries include:

  • Arthritis
  • Esophagel injury
  • Pneumothorax
  • Poor cosmesis
  • Vascular injury
  • Voice changes

Reduction of dislocations can be done either closed or open. Indications for early surgical intervention include failure of closed reduction and any sign of neurovascular compromise [3].

Image obtained from drguide.mohp.gov.eg

Closed Reduction Technique of Anterior Dislocation

Acute dislocations (within 7-10 days) are amenable to closed manipulation under procedural sedation in the ED or in the operating room. A bolster should be placed between the scapulae of a supine patient. Traction should be applied to the abducted ipsilateral arm. Pressure is then applied to the medial clavicle. With successful reduction, sling support with scapular protraction should be provided for up to 4 weeks. It is important to remember that there is a greater than 50% rate of repeat dislocation.

 

Closed Reduction Technique of Posterior Dislocation

Closed reduction of a posterior dislocation is indicated within 10 days of injury. After 10 days, open reduction in the operating room is recommended [1]. There are multiple methods for reducing a posterior dislocation in the literature.

Probably the most well known is the technique of using a towel clip to grasp the medial clavicle and pulling anteriorly until reduction is complete. There is also the abduction-traction technique, where the ipsilateral arm is abducted to ninety degrees and traction is applied. This extension force may translate the medial clavicle anteriorly [1].

Deren et al. described another method which involved extending the ipsilateral arm and abducting it with traction applied. Anterior-posterior pressure is then applied to both shoulders, over the glenohumeral joints [2]. No matter the technique used, a figure of eight splint is recommended for 6 weeks to encourage scapular retraction. Also, some authors recommend that all posterior SCJ dislocations should be admitted for observation, due to the close proximity of vital structures [2].

Case Resolution

You suspect an anterior SCJ dislocation based on the history and physical exam in this football player. You obtain a CT scan of the chest, which confirms the diagnosis. After obtaining consent and under procedural sedation, you easily reduce the dislocation. The patient is placed in a sling and follow up is arranged with orthopedics.

Clinical Bottom Line

Traumatic dislocations of the SCJ are rare, but with increased involvement in contact sports, these injuries will be seen in the ED. Maintain a high clinical suspicion for these injuries, given the proper mechanism. Also be on the look out for associated injuries for posterior dislocations. Reduction can be completed in the ED with subsequent immobilization and orthopedic referral.

References

  1. Sewell MD et al. Instability of the sternoclavicular joint: current concepts in classification, treatment, and outcomes. Bone Joint J 2013; 95-B: 721-31. PMID: 23723264
  2. Deren ME et al. Posterior sternoclavicular dislocations: a brief review and technique for closed management of a rare but serious injury. Orthopedic Reviews 2014; 6: 5245. PMID: 24744842
  3. Balcik BJ et al. Evaluation and treatment of sternoclavicular, clavicular, and acromioclavicular injuries. Prim Care Clin Office Pract 40 (2013): 911-923. PMID: 24209725

 

Images from:

  1. healio.com
  2. wikipedia.org
  3. msdlatinamerica.com
  4. drguide.mohp.gov.eg
  5. boneandjoint.org.uk

Author information

Matt Astin, MD
Matt Astin, MD
ALiEM Guest Contributor
Clinical Assistant Professor of Emergency/Internal Medicine
Mercer University School of Medicine
Houston Medical Center (Warner Robins, GA)

The post Sternoclavicular Joint Dislocations: Diagnosis and Treatment appeared first on ALiEM.

I am Victoria Brazil, Academic Lead for Clinical Skills and Simulation at Bond University: How I Work Smarter

How I Work Smarter LogoIn the first post for the “How I Work Smarter” series, I called out one my favorite, accomplished clinician-educators Dr. Victoria Brazil, because she makes extreme-productivity look easy. Victoria was kind enough to provide her trade secrets, and it is with great pleasure that I share her responses to the questions in this series.

 

  • Name: Victoria Brazil
  • victoria brazil photo 2012Location: Gold Coast, Australia
  • Current job: Emergency Physician, Gold Coast Emergency Department Associate Professor and Lead for clinical skills and simulation, Bond University (aka ‘Bond girl’)
  • One word that best describes how you work: Enthusiastically (mostly)
  • Current mobile device: iPhone 5 (… there are other devices?)
  • Current computer: ASUS Ultrabook 13’ (that’s right… not a Mac)

 

What’s your office workspace setup like?

It’s definitely ‘the cloud.’ I have 5 ‘offices’ – two different EDs, 2 different university sites, and home. My satchel carries a laptop or ipad, phone, portable laptop speaker, earphones, remote clicker, iPhone microphone adaptor, and adapters for lightning to everything AV, and occasionally lipstick.

Vic's office

What’s your best time-saving tip in the office or home?

Inefficiency is not necessarily poor productivity…. I spend a lot of ‘office time’ just chatting with people But I do use Dropbox, Any.Do, and Mozy back up to manage projects/ activities/ documents.

What’s your best time-saving tip regarding email management?

  • Delete most.
  • Ferociously ‘unsubscribe’.
  • I use tags in Gmail. An email has to earn getting into my ‘AAA to do’ to be given attention.

What’s your best time-saving tip in the ED?

Try and build relationships with everyone, so you can delegate effectively and safely to junior staff, nurses, orderlies and even patients.

ED charting: Macros or no macros?

No macros. Write less. Disclaimer: our billing is not tied to our documentation in Australia.

What’s the best advice you’ve ever received about work, life, or being efficient?

  1. Armani is always worth it (from my mother).
  2. Self discipline is far better than self esteem (also from my mother, I think)
  3. Very successful people are absurdly selective (from a random self-help blog)

Is there anything else you’d like to add that might be interesting to readers?

  1. I choose projects, jobs, and talks all based on who is involved – mates should always take precedence over prestige.
  2. Running is my creative time.

Who would you love for us to track down to answer these same questions? (list up to 3 names)

  1. Hillary Clinton
  2. Chris Nickson
  3. Natalie May

Author information

Michelle Lin, MD
Michelle Lin, MD
ALiEM Editor-in-Chief
Editorial Board Member, Annals of Emergency Medicine
UCSF Academy Endowed Chair for EM Education
UCSF Associate Professor of Emergency Medicine
San Francisco General Hospital

The post I am Victoria Brazil, Academic Lead for Clinical Skills and Simulation at Bond University: How I Work Smarter appeared first on ALiEM.

I am Michelle Lin, ALiEM Editor in Chief: How I Work Smarter

How I Work Smarter LogoIn this inaugural post of the series “How I Work Smarter,” I wanted to share my thoughts and efforts towards working smarter and not always necessarily harder. I have been the Editor-in-Chief of ALIEM since 2009 where I first was only managing myself and now I working with an all-star team of very motivated and capable medical educators in EM. Three moving parts rapidly became thirty moving parts with thirty different deadlines. Here are my responses to the series questions.

  • logo-squareName: Michelle Lin, MD
  • Location: San Francisco Bay Area, CA
  • Current job: Editor in Chief of ALiEM and UCSF-San Francisco General Hospital Associate Professor of Emergency Medicine
  • One word that best describes how you work: Creatively
  • Current mobile device: iPhone 5
  • Current computer: MacBook Air

 

What’s your office workspace setup like?

I am big fan of the second monitor set-up at home and at the hospital office. I pair it a lightweight, portable laptop so that I can be portable, since I am often working in various coffee shops for inspiration. Ergonomically, this set-up works best for me with a separate keyboard and trackpad. I use the Apple brand ones, which connect via bluetooth (I have no financial disclosure).  I also have a USB Audio-Technica 2020 microphone to record podcasts (thanks EM:RAP!).

Office Setup

 

What’s your best time-saving tip in the office or home?

Think about how many times your write certain phrases or text over and over on different websites and email programs. I love text expanders. I use aText ($5) on my Mac, although I recently learned that you might be able to do this for free in the most recent Mac OS (System Preferences > Keyboard >Text). I have keystrokes for my various emails, work and non-work email signatures, phone numbers, and some stock phrases. For instance, typing “eee” inserts my work email automatically. These few saved seconds save lots of time in the long run.

What’s your best time-saving tip regarding email management?

I am an advocate of David Allen’s Getting Things Done philosophy and “Inbox Zero” philosophy by Merlin Mann, although I honestly haven’t been able to achieve it yet. Currently, I have 21 messages still in my inbox! Nonetheless, I have rigged my Gmail so that I can quickly sort my inbox immediately into actionable items of:

  • To Do Today
  • To Do Soon
  • Scheduled for Meeting
  • Awaiting Reply
  • Non-Urgent Tasks

I used this tutorial to create “multiple inboxes” through smart uses of labels. Plus it’s important to learn keyboard shortcuts in Gmail to quickly move messages around.

GmailInboxes Small2

What’s your best time-saving tip in the ED?

I created my Paucis Verbis cards to maintain a repository of topics that I commonly need to look up (e.g. vasopressor doses, PECARN for pediatric blunt head trauma) or commonly use to teach students/residents on shift. These on-demand resources save me tons of time.

ED charting: Macros or no macros?

I think I am in the minority when it comes to using macros. I find that they are high-risk for documentation error, depending on what macros you create. The few macros that I do use are:

  1. ED Boarding Patients: I state that I am only watching over a patient who has already been admitted to an inpatient service and await a bed.
  2. Negative FAST (and E-FAST) ultrasound
  3. Negative gallbladder ultrasound
  4. Negative renal ultrasound
  5. Negative DVT ultrasound

What’s the best advice you’ve ever received about work, life, or being efficient?

Before taking on a new project, think about whether it is aligned with your long-term professional goals. If so, commit to a finite amount of time whereupon then you can re-new your commitment, if time allows. When I first started out as an attending, I volunteered to help and lead projects, which had no end in sight with annual recurring responsibilities. People were surprised when I wanted to transition to other projects.

Is there anything else you’d like to add that might be interesting to readers?

I am a visual brainstormer. When planning out projects and organizing my thoughts, I like to draw. I find that analog tools foster creativity. So one of my favorite purchases is a large whiteboard for my home office. Instead of spending hundreds of dollars on a fancy, large whiteboard, I bought two white showerboard panels (can get from Home Depot or Lowe’s), which are made of melamine. It’s a little bit harder to erase the pen marks, but you can’t beat $15 (instead of $150-250). Read more in this Primer Magazine post.

Whiteboard PIVOT

Who would you love for us to track down to answer these same questions? (list up to 3 names)

  1. Salim Rezaie
  2. Esther Choo
  3. Victoria Brazil

Author information

Michelle Lin, MD
Michelle Lin, MD
ALiEM Editor-in-Chief
Editorial Board Member, Annals of Emergency Medicine
UCSF Academy Endowed Chair for EM Education
UCSF Associate Professor of Emergency Medicine
San Francisco General Hospital

The post I am Michelle Lin, ALiEM Editor in Chief: How I Work Smarter appeared first on ALiEM.

New Series: How I Work Smarter

How I Work Smarter LogoWe are all busy individuals trying to juggle various projects, a multitude of responsibilities, and balancing work and home life. “Work smarter, not harder” is often heard to remind us that we should be looking to improve our working styles to be more efficient. It is easier said than done. One place that I have drawn inspiration from is in LifeHacker’s “How I Work” series, which highlights the personal working habits of successful entrepreneurs and leaders.

So in homage to that series, we are creating a new series on ALiEM called How I Work Smarter, whereby invited individuals share their practices about being more efficient in time management and filtering information overload. The individuals will answer these questions:

Introductions

  • Location
  • Current job
  • One word that best describes how you work
  • Current mobile device
  • Current computer

Questions about yourself:

  • What’s your office workspace setup like?
  • What’s your best time-saving tip in the office or home?
  • What’s your best time-saving tip regarding email management?
  • What’s your best time-saving tip in the ED?
  • ED charting: Macros or no macros?
  • What’s the best advice you’ve ever received about work, life, or being efficient?
  • Is there anything else you’d like to add that might be interesting to readers?
  • Who would you love for us to track down to answer these same questions? (list up to 3 names)

Author information

Michelle Lin, MD
Michelle Lin, MD
ALiEM Editor-in-Chief
Editorial Board Member, Annals of Emergency Medicine
UCSF Academy Endowed Chair for EM Education
UCSF Associate Professor of Emergency Medicine
San Francisco General Hospital

The post New Series: How I Work Smarter appeared first on ALiEM.

AIR Series: Infectious Disease, Hematology, Oncology 2014

AIR Series Thumbs Up SmallWelcome to the first ALiEM Approved Instructional Resources (AIR) Module! In an effort to reward our readers for the reading and learning they are already doing online, we have created an Individual Interactive Instruction (III) opportunity utilizing FOAM resources for US Emergency Medicine residents. For each module, the board curates and scores a list of blogs and podcasts. A quiz is available to complete after each module to obtain residency conference credit. Once completed, your name and institution will be logged into our private Google Drive database, which participating residency program directors can access to provide access.

AIR Series: Infectious Disease, Hematology, Oncology

Below we have listed our selection of 7 blog posts related to infectious diseases, hematology, and oncology, curated and approved of by the AIR Series Board. A broad spectrum of blogs were searched from the top 25 blogs per the Social Media Index, but this list is by no means comprehensive.

Descriptor
Article title
Author
Date
Blog source
Link
A four-minute video on the PROCess Trial resultsThe Process Trial is Here!Mel HerbertMar 18, 2014HippoEM A ProCESS Trial Review
A thorough review of antibiotic recommendations for uncomplicated UTI's including side effect profiles/pros/cons of each antibiotic.Uncomplicated Urinary Tract Infections in Older Adults: Diagnosis and Treatment (Part 2)Christina ShenviApr 2, 2014ALiEMUTI in older adults
Abscess treatment review including: packing, loop drainage, primary closure, antibiotics, and wound culturesAbscess, “Answers”Anand SwaminathanMar 31, 2014EMLyceumAbscess
Approach to and risk stratification of neutropenic feverPaucis Verbis: Neutropenic Fever in Cancer PatientsMichelle LinOct 7, 2011ALiEMNeutropenic fever with cancer
CMS and JCAHO rules for blood cultures in pneumonia in the EDBlood Cultures in PneumoniaAndy GrockFeb 17, 2014ALiEM Blood cultures and pneumonia
Review of 2012 ACCP guidelines of ED management of supratherapeutic INR.Paucis Verbis: Overanticoagulation and supratherapeutic INRMichelle LinAug 10, 2012ALiEMSupratherapeutic INR
Updated report on new (2009) recommendations for vancomycin dosing.New Year’s Resolution: Let’s Dose Vancomycin Correctly in the EDBryan HayesJan 1, 2014ALiEMProper Vancomycin Dosing

After reading, please take the quiz. Feel free to ask questions in the blog comment section and the faculty on the Editorial Board will answer them within 48 hours of posting. Be sure to include your email or contact information where requested in the Disqus blog comment area, so that you will be notified when we reply.

red_pencil_horizontal_pc_400_clr_3248

Take the quiz below, or click HERE to take you to the quiz site.
Be sure to enter your name and program, if you desire III credit.

Author information

Andrew Grock, MD
Andrew Grock, MD
Associate Director/Co-Founder of ALiEM Approved Instructional Resources (AIR)
PGY-4 EM resident
Kings County Hospital Emergency Medicine Residency

The post AIR Series: Infectious Disease, Hematology, Oncology 2014 appeared first on ALiEM.