Visual Diagnosis in Emergency and Critical Care Medicine

By Christopher P. Holstege, Alexander B. Baer, Jesse M. Pines and William J. Brady

Improve your skills in visual diagnosis

Speed and accuracy of diagnosis is the key to saving lives in emergency and critical care medicine. Careful visual inspection of the patient, the data (radiography, electrocardiogram), and related clues can often help providers choose the right diagnosis and ultimately the best treatment – but this knowledge comes with experience. This book provides 110 randomly presented visual diagnosis cases for self-testing, imitating real-life situations found in the emergency department setting.

Written by distinguished emergency and critical care physicians, and thoroughly revised and updated throughout, this second edition includes 25% new cases and is an ideal aid for trainees preparing for Board examinations as well as an invaluable ‘refresher’ for qualified emergency and critical care providers.

This title is also available as a mobile App from MedHand Mobile Libraries. Buy it now from Google Play or the MedHand Store.

 

• Language: English
• Publisher: Wiley
• Release date: Jul 18, 2011
• ISBN: 9781444398007

Book preview

Part I: Case Presentations and Questions

CASE 1

Slash Wound to the Neck

Kevin S. Barlotta, MD and Alexander B. Baer, MD

Case presentation: A 35-year-old female presents to the emergency department after an altercation. She states that she was attacked with a hunting knife. She complains of pain only at the wound site. She denies voice changes or difficulty swallowing. Her injury is depicted in the illustration.

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Question: What zone of injury is represented in the image?

A. Zone I

B. Zone II

C. Zone III

D. Zone IV

E. Zone V

See page 77 for Answer, Diagnosis, and Discussion.

CASE 2

I’ve Got Blood in My Eye

Chris S. Bergstrom, MD and Alexander B. Baer, MD

Case presentation: A 22-year-old Caucasian male is evaluated in the emergency department with a complaint of marked left eye pain and blurred vision after being struck in the eye with a lead fishing weight. On physical examination, his visual acuity is 20/60 in the left eye. Pupillary examination is normal. Slit-lamp examination shows a clear cornea. The anterior chamber is deep, with suspended red blood cells in the aqueous humor, as pictured here. The iris detail is slightly obscured but otherwise normal with a central, round pupil.

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Question: What is the next best step in this patient’s management?

A. Administration of oral aspirin

B. Infusion of intravenous heparin

C. Emergent lateral canthotomy

D. Administration of oral lisinopril

E. Administration of atropine 1% ophthalmic drops

See page 78 for Answer, Diagnosis, and Discussion.

CASE 3

Forearm Fracture After Falling

Alexander B. Baer, MD

Case presentation: A 20-year-old male fell on an outstretched upper extremity while snowboarding. He presents with obvious arm deformity. Radiographs of the elbow were obtained.

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Question: What is the name of the fracture pictured in the radiographs?

A. Boxer’s fracture

B. Tear drop fracture

C. Tillaux fracture

D. Galeazzi fracture

E. Monteggia fracture

See page 79 for Answer, Diagnosis, and Discussion.

CASE 4

A Neonate with Fever and Rash

David L. Eldridge, MD

Case presentation: A 10-day-old male is brought to the emergency department by his mother. He has not eaten well for the past 24 hours and has reportedly been very sleepy. Yesterday he began to develop a rash that now appears red at the base and is progressively blistering with clear fluid on his legs and face (pictured). Tonight he has had two episodes of uncontrollable shaking movements of his arms and legs, each lasting for a few minutes. He was born 3 weeks prematurely, and his mother claims no problems or issues with the pregnancy. He is afebrile but appears lethargic on physical examination.

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Question: Which of the following tests would be least helpful in the clinical management of this patient given the likely diagnosis in this case?

A. Serologic testing

B. Viral cultures of the conjunctivae, rectum, and nasopharynx

C. Polymerase chain reaction testing of cerebrospinal fluid

D. Liver transaminase levels

E. Viral cultures of the skin lesions

See page 80 for Answer, Diagnosis, and Discussion.

CASE 5

A Missing Button Battery

Brendan G. Carr, MD and Sarah E. Winters, MD, MSCE

Case presentation: A 2-year-old boy presents to the emergency department with a complaint of food intolerance of abrupt onset. His mom reports that he was seen playing with a small calculator just before lunch. She has subsequently noticed that the calculator is missing its back, and she is concerned that he has swallowed the battery. On examination, he is in no apparent distress and is tolerating his secretions. His vital signs are normal. An X-ray is obtained and is noted here.

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Question: What is the next most appropriate management strategy at this time?

A. Discharge home and follow with serial outpatient abdominal X-rays

B. Administer 25 g activated charcoal orally

C. Admit the patient for intravenous hydration, serial abdominal X-rays, and stool checks to confirm passage

D. Infuse 1 mg glucagon intravenous to decrease lower esophageal sphincter pressure and monitor over the following 6 hours

E. Emergent gastroenterology consultation for endoscopic removal of foreign body

See page 80 for Answer, Diagnosis, and Discussion.

CASE 6

Anorexia, Hair Loss, and Fingernail Bands

Christopher P. Holstege, MD

Case presentation: A 62-year-old man has been hospitalized 10 times during the previous 5 years. He has been treated for gastrointestinal disturbances, cardiomyopathy, leucopenia, and paresthesias. He presents again after several days of uncontrollable diarrhea and vomiting. His glove and sock paresthesias have rapidly progressed. He is having significant hair loss and is experiencing weakness of the upper and lower extremities. A picture of his nails is noted below.

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Question: What substance is most likely responsible for his signs and symptoms?

A. Arsenic

B. Barium

C. Aluminum

D. Chromium

E. Bismuth

See page 82 for Answer, Diagnosis, and Discussion.

CASE 7

Wide Complex Tachycardia in a Young Adult

William J. Brady, MD

Case presentation: A 24-year-old female patient with no medical history of significance, transported to the emergency department via paramedics, had been complaining of sudden weakness and palpitations. All her symptoms had resolved prior to the paramedics’ arrival at the scene. In the emergency department, the patient noted a recurrence of her symptoms; examination at that time demonstrated an alert patient with minimal distress. The vital signs were: blood pressure 100/70 mmHg, pulse 240 beats/minute, and respiration 38 per minute. The moni­tor revealed a rapid, wide complex rhythm (pictured).

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The patient received amiodarone intravenously. During the infusion, she become lethargic with a sudden reduction in blood pressure. Immediate electrical cardioversion was undertaken with a return of a normal mental status and the second ECG noted here. The remainder of the examination normalized as well.

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Question: Of the listed interventions, the most appropriate initial intervention is:

A. Intravenous diltiazem

B. Oral metoprolol

C. Intravenous procainamide

D. Oral amiodarone

E. Intravenous potassium

See page 83 for Answer, Diagnosis, and Discussion.

CASE 8

Wide Complex Tachycardia in an Older Male Patient

William J. Brady, MD

Case presentation: A 57-year-old male with a history of angina and coronary artery disease experienced a sudden syncopal event. The patient regained consciousness minutes later and noted only palpitations and weakness. He was transported to the emergency department via a private vehicle. On arrival, he was pale and diaphoretic with a blood pressure of 80 mmHg by palpation and a pulse of 190 beats per minute. The cardiac monitor demonstrated a wide complex tachycardia, as shown here, in leads II and V. The patient was sedated and cardioverted, with the return of sinus rhythm and an adequate blood pressure.

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Question: In the setting of a wide complex tachycardia, select the correct statement:

A. Urgent therapy is dependent upon a precise rhythm diagnosis

B. Ventricular tachycardia and supraventricular tachycardia with aberrant conduction are easily distinguished

C. Certain electrocardiographic features suggest the diagnosis of ventricular tachycardia

D. Patient age is an absolute indicator of rhythm diagnosis in a wide complex tachycardia

E. Wide complex tachycardia due to drugs is easily distinguished from other causes

See page 84 for Answer, Diagnosis, and Discussion.

CASE 9

Muscle Spasms Following a Spider Bite

J. Michael Kowalski, DO and Adam K. Rowden, DO

Case presentation: A 25-year-old female presents to the emergency department with severe back and abdominal pain. She also complains of nausea and chest tightness. She reports a pinprick sensation to the sole of her right foot while putting her shoes on about 20 minutes prior to her arrival. Upon inspection of her right shoe, she discovered the creature pictured here. Over the next 60 minutes, her pain first intensified in her right leg and then moved into her groin and into her back. She took ibuprofen without relief. Her physical examination is significant for a red target lesion approximately 1 cm in circumference on the plantar aspect of her right foot, hypertension (180/100 mmHg), tachycardia (145 beats per minute), and marked spasm of her lumbar and thoracic paraspinal muscles.

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Question: Which of the following is an indication for the administration of antivenin?

A. Presence of erythema at the suspected site of skin penetration

B. Immediately upon correct identification of the offending creature

C. Clinical improvement in the patient’s condition following the administration of intravenous opioids and benzodiazepines

D. Pain and muscle spasms that progress proximally from the extremity to the trunk

E. Uterine contractions in a pregnant female

See page 86 for Answer, Diagnosis, and Discussion.

CASE 10

Necrotic Skin Lesion

David A. Kasper, DO, MBA, Aradhna Saxena, MD, and Kenneth A. Katz, MD

Case presentation: A 57-year-old man complains of an expanding spider bite on his left pretibial area. He had noticed the lesion 3 days previously as a painful and progressively enlarging pimple. His medical history is notable for ulcerative colitis, treated with mesalamine. On physical examination, an ulcer with a rolled, violaceous border and a central black eschar is present on the left pretibial area (see illustration). There is no lower extremity edema. The patient is otherwise well.

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Question: What is the most appropriate management strategy at this time?

A. Empiric treatment with broad-spectrum antibiotics

B. Debridement of the eschar

C. Consultation of dermatology for biopsy of the ulcer for tissue culture and histology

D. Treatment with compression stockings

E. Infusion of brown recluse spider antivenom

See page 87 for Answer, Diagnosis, and Discussion.

CASE 11

Intense Pain Following High-pressure Injection Injury

David T. Lawrence, DO

Case presentation: A 30-year-old automobile technician presents to the emergency department with a complaint of pain and swelling in the dorsum of his left hand near the metacarpophalangeal (MCP) joint of his index finger after injury with a grease injector. On examination, there is slight swelling of the dorsum of the hand and a small pinpoint puncture wound just proximal to the MCP joint of the index finger as noted in the picture. There is pain with passive movement and good capillary refill of the index finger and thumb, and no neurologic deficits distal to the injury are appreciated.

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Question: What is the most appropriate management?

A. Check tetanus status, prescribe analgesics, and discharge home

B. Prescribe antibiotics and analgesics, check tetanus status, and discharge home

C. Obtain an X-ray, check tetanus status, immobilize with a splint, and discharge home with a prescription for antibiotics and analgesics and instructions to follow-up with an orthopedist in 3–5 days

D. Provide parenteral analgesia, obtain an X-ray, check tetanus status, arrange an immediate surgical consultation for exploration and decompression debridement, and provide prophylactic antibiotics

E. Insert a 14-gauge angiocatheter and aspirate the injected material

See page 88 for Answer, Diagnosis, and Discussion.

CASE 12

Prenatal Vitamin Overdose

Christopher P. Holstege, MD and Adriana I. Goldberg, MD

Case presentation: A 16-year-old female intentionally overdosed on an unknown quantity of vitamins. She arrives at the emergency department 4 hours after the overdose complaining of nausea, vomiting, and epigastric abdominal pain. Her initial vital signs reveal pulse 123 beats per minute, blood pressure 85/34 mmHg, respiration 24 breaths per minute, and temperature 37.2° C. Her examination is significant only for epigastric tenderness on palpation of her abdomen. Her laboratory studies are significant for the following: iron 567 mg/dL, serum bicarbonate 15 mEq/L, glucose 256 mg/dL, and white blood count 13.2 × 10⁹/L. A radiograph of her abdomen is pictured here.

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Question: Which of the following is the next most appropriate management step for this patient?

A. Begin an intravenous infusion of deferoxamine

B. Administer dimercaprol (BAL) intramuscular

C. Infuse calcium disodium ethylenediaminetetraacetate (EDTA)

D. Administer succimer (DMSA) orally

E. Administer D-penicillamine orally

See page 89 for Answer, Diagnosis, and Discussion.

CASE 13

Blurred Vision Following Yard Work

Allyson Kreshak, MD

Case presentation: A 66-year-old male presents with a chief complaint of blurry vision. He had been outside cleaning his yard in Central Virginia prior to developing the symptoms. He denies headache, nausea or vomiting, and has no other neurologic complaints. He also denies a history of trauma. He is otherwise healthy. His vital signs are as follows: heart rate 88 beats per minute, blood pressure 142/76 mmHg, oral temperature 37.1° C, respiration 16 breaths per minute, pulse oximetry 99% on room air. His examination is remarkable for only the finding noted in the photograph.

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Question: Which of the following is a likely cause of this patient’s condition?

A. Stroke

B. Tentorial herniation

C. Cataracts

D. Tonic pupil

E. Jimson weed exposure (Datura stramonium)

See page 90 for Answer, Diagnosis, and Discussion.

CASE 14

Foot Pain in a Gymnast

Hoi K. Lee, MD

Case presentation: A 19-year-old female gymnast presents with worsening pain in her right foot that has developed over the previous 3 days. The pain is located over the lateral aspect of her foot. Physical examination reveals mild tenderness with palpation over the fifth metatarsal and associated swelling in the area. The patient is able to ambulate with a slight limp. Her foot radiographs are shown here.

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Question: Which of the following is true regarding this injury?

A. A computed tomography scan should be obtained to rule out possible metatarsophalangeal joint