Senior Report 8.4

Case Presentation by Mike Antoniolli, MD

 

A 28-year-old male presents to the emergency department with complaints of 3 days of eye pain, photophobia, redness, and decreased vision. The pain has become so severe that he has had 2 episodes of emesis. He denies any fevers, chills, recent infections, or URI symptoms. He denies any inciting event, trauma to the eye, dust or foreign body exposure.

Physical Exam:

General: Patient is holding a hand over his left eye leaning forward. Appears uncomfortable

Eyes: Left eye reveals scleral injection, epiphora, photophobia, and blepharospasm in addition to the findings shown in the image below. A contact lens is noted in the unaffected eye. Pain/photophobia was only partially relieved with proparacaine.

 

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Questions:

1. What is the most likely outcome of this condition if he is not treated?

A. Corneal perforation

B. Intraocular hypertension

C. Dense cataract formation

D. Orbital compartment syndrome

E. Full blown AIDS

 

2. Given the patient’s corrective lens history, what is the most likely pathway that explains the above findings?

A. Bacterial keratitis->corneal ulceration->hypopyon

B. Caustic exposure->corneal abrasion->corneal liquefaction

C. Poor contact lens hygiene->bacterial keratitis->corneal abrasion

D. Rheumatologic illness->anterior uveitis->hypopyon

E. Childhood vaccinations->autism->ocular jenny mccarthitis

 

3. What additional finding would most likely be seen on slit-lamp examination of this patient?

A. Dendritic ulcerative lesions

B. Pingueculae and pterygia

C. Cell and flare in the anterior chamber

D. Very shallow anterior chamber and iridocorneal touch

E. Enucleation

 


Filed under: Senior Report

Intern Report 8.3

 

Case Presentation by John Yerkes, MD

 

Chief complaint: Confusion post fall

History:

A 55 year-old man comes to the Emergency Department after a recent fall at home. He was told to go to the ER by his housemate who thought he had not been not acting “right” recently. Patient does, in fact, appear to be slightly altered on examination. He states that he was walking and suddenly lost his balance and fell down while on a flat surface. Patient denies hitting his head or any LOC. Additionally, he says that he has suddenly lost his balance and fallen a couple of times over the last couple of days. Patient likewise denies head strike or loss of consciousness. He has a history of mitral valve replacement and CABG for which he is on warfarin. Patient also says that he was started on a new medication a couple of days ago but is unable to remember what it was. Other than some confusion patient has no other complaints.

ROS: negative except noted per HPI

PMH: Schizophrenia, hypertension, Diabetes

Surgical history: CABG and mitral valve replacement date unknown

Medication: Unknown, however, per the last entry in the electronic medical record, he was most recently documented as being on haloperidol, benzotropine, olanzapine, lorazepam, warfarin, lisinopril, and metformin

Allergies: morphine, hydrocodone

FH: unknown

Social: denies tobacco/alcohol/drugs

 

Physical Exam:

Vitals: T 99.2, HR 87, BP 145/100, RR 14, pulse ox 98% weight 150, 5’10”

General: 55 year old with who has some difficultly relaying history. He has tangential thinking and appears slightly altered, unsure if baseline mental status.

Skin: midline sternotomy scar consistent with previous CABG history, no bruising

Head: normocephalic, atraumatic

Eyes: equal and reactive to light, oculomotor muscles intact, no focal deficit in cranial nerves II, III, IV, VI

HR: RRR, S1 & S2 with opening snap heard best on lower left border

Respiratory: breath sounds equal bilaterally,

CNS: Alert and oriented to person and place but not time, cranial nerves II-XII intact no deficits or sensory loss. DTRs 2+ in all four extremities. Muscles strength 5/5 in all 4 extremities. Romberg test, heel to shin, and rapid alternating movements all normal. Patient had a slow shuffling gait, but no loss of balance

 

Labs:

BMP: Na 146mmol/L, K 4.2 mmol/L, CL 99 mmol/L, HCO3 24 mmol/L, BUN 25 mg/dl, Creatinine 1.3 mg/dl, Glucose 101 mg/dl

ALT 55, AST 24

CBC: WBC 9.4 Hemoglobin 12.3 g/dL, Hematocrit 40.1%, Platelets 250

PT >12.5 seconds

INR: unable to calculate (INR was 9.7 one week ago at outpatient clinic, pt said he was restarted on warfarin two days later).

UDS: positive for benzodiazepine, and opiates

EKG: NSR, no ST segment elevations or depressions, normal intervals, normal axis, no heart block

 

Questions:

1) You begin scrolling through the non-contrast CT of the head you ordered and note the following. What is your diagnosis?

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A) Epidural hematoma

B) Brain Mass

C) Subdural hematoma

D) Subarachnoid hemorrhage

 

2) What is the next appropriate step in management for this patient?

A) Oral Vitamin K

B) Fresh frozen plasma

C) Prothrombin complex concentrate

D) Immediate neurosurgery evacuation of hematoma

 

3) How long does it take for fresh frozen plasma to work?

A) 5-15mins

B) 1-4hr

D) 12-24hr

C) 24-48hr


Filed under: Intern Report, Uncategorized

Senior Report 8.2

Case Presentation by Andrew Sweeny, MD

History:

The patient is a 79-year-old female with a history of hypertension and atrial fibrillation who presents to the emergency department via EMS after falling at a social event. The patient reports that she fell stepping off the curb hitting her left face. She denies any preceding lightheadedness, shortness of breath, or chest pain. The patient denies any loss of consciousness. She denies using any alcohol, illicit drugs, or sedating medications. Currently, the patient complains of mild occipital headache and pain to her left periorbital region. She denies pain to her neck or extremities. The patient is on warfarin for her atrial fibrillation and has her INR checked regularly.

 

Physical Exam:

Vitals: Blood pressure was 157/95, heart rate 80, respiratory rate 18, temp 36.2, pulse ox 100 on room air

General: awake/alert/no apparent distress

HENT: Normocephalic, no icterus, no cervical midline tenderness, full active range of motion at the neck without pain, large contusion/ecchymosis to left orbit, small abrasion to bridge of nose without gross deformity/crepitus/intranasal hematoma, no facial crepitus, no hemotympanum

Eyes: EOMI, PERRL, large temporal subconjunctival hematoma occupying 40% of conjunctiva of left eye, significant periorbital ecchymosis/edema to L eye, patient unable to open L eyelids due to edema, no hymphema, patient able to read name badge at distance 12” bilaterally, unable to conduct full Snellen eye chart exam as patient requires assistance to hold L eyelid open due to edema

Cardio: Irregularly irregular rhythm, normal rate, no murmurs

Respiratory: clear to auscultation bilaterally

Abdomen: soft/non-tender/non-distended

Neuro: Normal speech, moving all extremities, strength 5 out of 5 and symmetric to hand grip, elbow flexion/extension, knee flexion/extension, hip extension/flexion, dorsi/plantar flexion

Extremities: No contusion/abrasion/ecchymosis/bony tenderness to upper/lower extremities

 

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Questions:
1. When performing this patient’s physical exam, what finding would indicate need for an emergent procedure?

a. Inability abduct or adduct the injured eye

b. Hyphema occupying greater than50% of anterior chamber

c. Significant loss of visual acuity of injured eye when compared to uninjured eye

d. Proptosis of injured eye
2. What physical exam finding has the highest incidence of underlying facial fracture in minor head injury?

a. Periorbital ecchymosis

b. Subconjunctival hemorrhage

c. Epistaxis

d. Decreased skin sensation
3. What is the most commonly injured portion of the orbit in a blow-out fracture?

a. Superior

b. Medial

c. Inferior

d. Lateral


Filed under: Senior Report, Uncategorized

Senior Report 8.1

Case Presentation by Dr. Daniel Hutchens, MD

History:

66 year old female presents with right ankle pain after slipping on a mat and twisting it. She was unable to bear weight on it immediately after the fall. She noticed immediate pain and swelling. She denies pain in any other joints. She denies any loss of consciousness. She has no other complaints.

 

Physical Exam:

Cardiovascular: Regular rate and rhythm, no murmurs, no S3/S4, radial and dorsalis pedis pulses present and equal bilaterally in both upper and lower extremities.
Musculoskeletal: Obvious deformity of the right ankle. Decreased range of motion in the right ankle when compared to the left. Tenderness to palpation over the right medial malleolus. No tenderness to palpation over the distal tibia or fibula. Mild tenderness to palpation over the right fibular head.
Neurologic: Alert and oriented to person, place, and time. Smile symmetric, tongue protrudes midline, uvula raises midline, eyebrows raise symmetrically, eyes close with equal strength. Sensation to light touch equal and intact in bilaterally lower extremities.

 

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Questions

  1. What musculoskeletal physical exam points must be covered in a patient with traumatic ankle pain?
    a. Assessment for deformity, range of motion, palpation of inferior and posterior edges of medial/lateral malleoli, and first 6 inches of fibula and tibia.
    b. Assessment for deformity, range of motion, palpation of inferior and posterior edges of medial/lateral malleoli, first 6 inches of fibula and tibia, and calcaneous.
    c. Assessment for deformity, range of motion, palpation of medial/lateral collateral ligaments, syndesmotic ligaments, inferior and posterior edges of medial/lateral malleoli, entire length of fibula and tibia.
    d. Assessment for deformity, range of motion, palpation of medial/lateral collateral ligaments/syndesmotic ligaments, inferior and posterior edges of medial/lateral malleoli, entire length of fibula and tibia, base of the 5th metatarsal, and calcaneous.

 

  1. What is your radiologic diagnosis?
    a. Pott’s fracture
    b. Maisonneuve fracture
    c. Cotton fracture
    d. Dupuytren’s fracture

 

  1. What is the best disposition of this patient with this type of fracture?
    a. Walking boot with orthopedic follow-up in 2 weeks.
    b. Surgical repair of the ankle with intramedullary rod placement in the fibula.
    c. Surgical repair of the ankle, non-weight-bearing status for 9-12 weeks.
    d. Ankle reduction in the ER, non-weight-bearing status, orthopedic follow-up in 6 weeks.

Filed under: Senior Report, Uncategorized

radER Case 13.3 (#20)

 

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Case 20 Questions

 

1. Which is true for metacarpal fractures?

 

2. Which is true of carpal fractures?

 

3. The most likely complication of the above injury includes…


Filed under: radER

Senior Report 7.14

Case Presentation by Dr. Arun Rajasekhar, MD

 

CHIEF COMPLAINT:  Right leg injury.

HPI:  A 43-year-old man stated that another person landed on his right leg.  He felt and heard a snap and then he immediately experienced severe right knee pain.  This happened within 1 hour prior to admission.  He was brought here by EMS.  He complains of severe right knee pain.  He has not done anything for his symptoms.

PAST MEDICAL HISTORY:  Denies diabetes, seizures, hypertension.
MEDICATIONS:  None.
ALLERGIES:  None.

PHYSICAL EXAMINATION:

VITAL SIGNS:  Blood pressure 184/86, pulse rate 93, respirations 20, temperature 36.3.

GENERAL:  This is a well-developed, well-nourished 43-year-old man, awake, alert but uncomfortable due to pain.

MUSCULOSKELETAL:  Normal muscle bulk and tone.  He has a deformity of the right knee.  He has normal dorsal pedis and posterior tibial pulses.  He has good popliteal pulse.  He has a deformity of the right knee.

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Questions:
1)
The above xray shows anterior displacement of the tibia on the femur.  Which ligament is most likely to have been completely torn?

a) ACL

b) MCL

c) LCL

d) PCL

 

2) Which of the following is NOT a hard sign of vascular injury associated with knee dislocations

a) absence of pulse

b) expanding hematoma

c) paresthesias in leg

d) bruit over site of wound

 

3) Patient required conscious sedation for reduction of his knee.  Decision was made to use ketamine and propofol.   Immediately after infusion, Pt starts gasping for air and immediately becomes tachycardic and tachypneic.  He has equal breath sounds.  Trachea is midline.  What is your working diagnosis and which of the two agents is most likely responsible? What should be done?

a) Acute tension pneumothorax due to propofol administration.  Needle decompression

b) Acute laryngospasm secondary to ketamine administration.  Paralyze patient and intubate immediately

c) Acute laryngospasm secondary to propofol.  Attempt to bag patient through laryngospasm

d) Acute laryngospasm secondary to ketamine.  Perform cricthyrotomy.

 

Answers & Discussion:
1) A & D
2) C
3) B

1) PCL and ACL are both acceptable answers. The patient has an anterior knee dislocation. This is the most common type of knee dislocation. It is caused by hyperextension of the knee joint. Often both he PCL and MCL will be torn. With all knee dislocations it is important to have a high index of suspicion for popliteal artery injury. Initial assessment of the leg should include palpation of the dorsalis pedis and popliteal pulses. You can also perform ABIs to assess distal blood flow. It is important to note that PT and DP pulses will be normal in 5-15% of popliteal artery injuries. CT angiography can be used to detect arterial injury.

2) Parasthesias is the answer. Hard signs of vascular injury include active hemorrhage, expanding hematoma, bruit over wound, absent distal pulses, extremity ischemia (cold to touch, paralysis, pallor). In the setting of penetrating trauma, hard vascular injuries are 100% predictive of arterial injury and patient should be taken directly to operating room for surgical exploration. In the setting of blunt trauma, hard signs are less reliable and false positives are common. Repeat physical exam should be performed after resuscitation and reduction or orthopedic injury. If hard sign persists, get CT scan. Diagnosis of popliteal artery injury is time sensitive. Amputation rate increases the long repair is delayed. Rate of amputation is 90% eight hours out from the time of injury.

3) Patient is experiencing acute laryngospasm secondary to ketamine. This is a rare but known side effect of ketamine. It has been primarily reported in the pediatric literature. Patient’s will desaturate and decompensate quickly. In my scenario, the patient had a very visible reaction to the medication but there have been case reports of patients desaturating without showing a obvious signs of distress because of the sedative effect of the ketamine and the propofol. If a patient begins to desaturate and you are uncertain as to the exact etiology, the first and simplest thing to do is a jaw thrust maneuver to see if that relieves the hypoxia. You can also bag mask the patient. However, neither of these maneuvers will relieve laryngospasm. This patient needs neuromuscular blockade to relieve the laryngospasm and once the patient is paralyzed you should immediately proceed to intubation. Some sources stated that you could bag mask the patient until the paralytic wears off but I think if you are going to paralyze a patient, then you should give them a definitive air way.


Filed under: Senior Report