Volume 2, Issue 2, 2018
CPC-EM Full-Text Issue
Clinicopathological Cases from the University of Maryland
Medical Legal Case Report
Many emergency physicians view informed consent as a necessary component of treatments or procedures to be performed on their patients. When such procedures are necessary, often there is a discussion of risks, benefits and alternatives with forms signed to validate the discussion. Two Wisconsin emergency department medical-legal cases have expanded liability of the duty of informed consent. These cases have focused on withholding medication and diagnostic tests.
Pregnancy can obscure signs and symptoms of acute appendicitis, making diagnosis challenging. Furthermore, avoiding radiation-based imaging due to fetal risk limits the diagnostic options clinicians have. Once appendicitis has been diagnosed, performing appendectomies has been the more commonly accepted course of action, but conservative, nonsurgical approaches are now being considered. This report describes the latest recommendations from different fields and organizations for the diagnosis and treatment of appendicitis during pregnancy.
Intra-abdominal Rupture of a Live Cervical Pregnancy with Placenta Accreta but Without Vaginal Bleeding
We describe an unusual ruptured ectopic pregnancy. The unique features of the case include abdominal pain without vaginal bleeding; cervical implantation and a placenta accreta; and the late presentation at 16 weeks of gestation without prior symptoms. Both the initial point-of-care ultrasound and the formal ultrasound were interpreted as showing an intrauterine pregnancy. The clinical presentation was misleading; the correct diagnosis was made by magnetic resonance imaging. We show the ultrasonic images. We discuss cervical ectopic pregnancies, their diagnosis and management. The woman survived but required emergency hysterectomy and many units of blood.
Trigeminal trophic syndrome is a rare condition that develops from trigeminal nerve damage causing dysesthesias that result in self-mutilation. Facial and nasal destruction develops from self-destructive behavior (repetitive picking or scratching) secondary to the altered skin sensation created by the damaged trigeminal nerve. Early recognition of this condition is crucial to the prevention of the detrimental complications of facial ulceration and nasal tissue necrosis that can lead to corneal ulcerations, full-thickness eyelid defect, and canthal lesions. This case demonstrates a previously unreported complication: orbital cellulitis.
Point-of-care ultrasound (POCUS) has the potential to diagnose papilledema, a sign of increased intracranial pressure, through optic disc elevation as well as optic nerve sheath diameter measurements. Idiopathic intracranial hypertension (IIH) is a syndrome resulting in increased intracranial pressure. We present a case of IIH where the emergency physician diagnosed papilledema by POCUS via presence of both optic disc elevation and a widened optic nerve sheath diameter.
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Lactic acidosis is a clinical entity that demands rapid assessment and treatment to prevent significant morbidity and mortality. With increased lactate use across many clinical scenarios, lactate values themselves cannot be interpreted apart from their appropriate clinical picture. The significance of Type B lactic acidosis is likely understated in the emergency department (ED). Given the mortality that sepsis confers, a serum lactate is an important screening study. That said, it is with extreme caution that we should interpret and react to the resultant elevated value. We report a patient with a significant lactic acidosis. Though he had a high lactate value, he did not require aggressive resuscitation. A different classification scheme for lactic acidosis that focuses on the bifurcation of the “dangerous” and “not dangerous” causes of lactic acidosis may be of benefit. In addition, this case is demonstrative of the potential overuse of lactates in the ED.
We present three cases of hand injury by intravenous drug users in which point-of-care ultrasound, using a specific water bath technique, was able to quickly and efficiently delineate severity of injury. This technique benefited these patients by allowing a painless assessment of their injury for soft tissue injury vs. abscess formation and allowed providers to determine at the bedside whether these patients required immediate surgical intervention.
We report a case of a 55-year-old male who experienced unilateral facial muscle paralysis upon ascent to altitude on a commercial airline flight, with resolution of symptoms shortly after descent. The etiology was determined to be facial nerve barotrauma, or facial baroparesis, which is a known but rarely reported complication of scuba diving, with even fewer cases reported related to aviation. The history and proposed pathogenesis of this unique disease process are described.
Cecal bascule is a rare subtype of cecal volvulus where the cecum folds anterior to the ascending colon causing intestinal obstruction. It is a challenging diagnosis to make in the emergency department, as the mobile nature of the cecum leads to a great deal of variation in its clinical presentation. Our discussion of a 78-year-old female who presented with abdominal pain and was found to have a cecal bascule requiring right hemicolectomy, demonstrates how emergency physicians must expand their differential diagnosis for patients reporting signs of intestinal obstruction. Though cecal bascule does not present often, the need for early surgical intervention necessitates a high level of clinical suspicion to prevent life-threatening complications.
Acute urinary retention is a common problem in the emergency department. Patients can present in significant distress, necessitating the placement of a urinary catheter. Foley catheter placementcan be difficult to accomplish depending on the etiology of the retention and the degree of the obstruction. In the case presented here, we used ultrasound guidance, a guidewire, and a Foley catheter to successfully relieve a patient’s urinary retention after multiple failed attempts.
Although the causes have changed, scurvy (vitamin C deficiency) is still diagnosed in developed countries. We report a case of an 18-year-old female who presented to our emergency department with thrombocytopenia, sinus tachycardia, hypotension, fatigue, gingival hyperplasia, knee effusion, petechiae and ecchymosis in lower extremities. The differential diagnosis included hematologic abnormalities, infectious etiologies, vasculitis and vitamin deficiency. A brief dietary history was performed revealing poor fruit and vegetable intake, thus increasing our suspicion for vitamin C deficiency. This experience illustrates the importance of a dietary history and reminds us to keep scurvy in the differential diagnosis.
Spontaneous spinal epidural hematoma (SSEH) is a rare diagnosis. One known risk factor is anti-coagulation medication. We present a case of SSEH in a 74-year-old male on rivaroxaban therapy who clinically presented with an intermittently resolving and then worsening neurological exam. Due to the extremely high morbidity and mortality associated with this diagnosis, it is important to be aware of the various presentations and adverse effects related to novel anticoagulation.
Clozapine is an atypical antipsychotic drug prescribed for treatment-resistant schizophrenia. The risk of adverse hematologic, cardiovascular, and neurologic effects has tempered its use, and reports of overdoses remain rare. We report a case of accidental acute clozapine intoxication in a clozapine-naïve patient, who presented with symptoms mimicking acute stroke and later developed status epilepticus. Clozapine intoxication is a rare presentation in the emergency department with potential for iatrogenic harm if not correctly identified.
Takotsubo cardiomyopathy (TCM) is an important condition for the emergency physician to consider in patients with cardiovascular symptoms. A70-year-old woman presented with chest pain and nausea following emotional trauma. She had an elevated troponin and a normal electrocardiogram (ECG) with no history of previous cardiac disease. Point-of-care focused cardiac ultrasound (FOCUS) showed reduced left ventricular systolic function with mid to apical hypokinesis. Cardiac catheterization revealed clean coronary arteries and confirmed the suspected diagnosis of TCM. Few reports emphasize the importance of FOCUS in the diagnosis and management of TCM in the emergency department. We detail FOCUS findings that assisted with diagnosis of TCM and describe how this quick, noninvasive imaging modality can be used to assess and manage emergent conditions.
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Images in Emergency Medicine
- 1 supplemental video