77 year-old man presents to the ED with pain to his right hand following an accident on his motor scooter 4 days prior to arrival. He states he swerved into a field to avoid being struck by another motorist, lost control of his scooter, and as he laid the bike down his right hand was crushed by the scooter. He was wearing a helmet and sustained no other injuries.
Afebrile, vitals signs stable.
Examination of the right hand reveals a mildly edematous hand (diffusely along the dorsal surface of the metacarpals) with no point tenderness of the metacarpals or the carpal bones. No scaphoid tenderness. Skin examination is warm and dry, capillary refill is <2s. The 1st & 3rd-5th digits are nontender and have full ROM at the IP joints and the MCP joints. The 2nd digit is diffusely edematous with the IP joints held in partial flexion. There is tenderness along the volar aspect of the finger and the PIP joint is unable to be actively extended whatsoever. The DIP joint is able to be actively extended approximately 5-10 degrees. The skin of the 2nd digit has two small abrasions on the dorsal surface of the middle phalanx and the distal phalanx, and a small puncture wound on the volar surface of the base of the middle phalanx. The 2nd digit is diffusely tender to palpation. No purulence from the wounds, no induration, no fluctuance. Continue reading →
A 77 year old male with no known medical conditions presented to the emergency department (ED) with a chief complaint of food being stuck in his throat. He states that he was eating chicken 2 hours prior to arrival and felt it get stuck in his neck after swallowing. This has happened to him in the past, but he had always been able to either vomit the stuck food or to force it further down, but this time he was unable to. He is having a hard time managing his secretions and speaking but is otherwise asymptomatic.
AFVSS. He appears uncomfortable but not distressed. He is drooling & dysphonic.
He has a normal cardiopulmonary examination. He has no abdominal distention or tenderness. Throat exam reveals no abnormalities. External examination of the neck is normal, but the patient indicates that he feels the impacted food between his hyoid and cricoid.
53yo female with DM and COPD presents to your ED approximately 20 minutes after stepping on what she believes to be a toothpick, however since this foreign body is now trapped beneath the skin of the sole of her foot (at least according to her), she is actually not certain precisely what she stepped on. She was barefoot at the time of the incident and offers no other complaints.
Extremity exam: small puncture wound on plantar surface of forefoot near the heads of the 1st and 2nd metatarsals. Beneath the puncture wound a soft mass measuring approximately 2cm in diameter with mild tenderness is palpable. No erythema, warmth, fluctuance, crepitance or purulence.
History: 20 year old male presents with a one hour history of left testicular pain and swelling which began acutely after he got out of the shower. He denies dysuria, urethral discharge or trauma. He states that this has never happened before and says this is the worst pain he has ever had in his entire life. Since arriving to the ED he has become nauseous and has vomited several times.
Afebrile, vitals signs stable.
GU exam reveals a horizontal lie to his left testicle with significant tenderness. Absent cremasteric reflex. Remainder of the GU exam is normal. No inguinal lymphadenopathy and the abdominal exam is unremarkable.
Evaluation and Management: The patient was seen nearly immediately after arrival via EMS and we were concerned for a possible testicular torsion and therefore elected to perform a manual detorsion procedure. While preparing for this we grabbed the ultrasound machine, paged urology and had the nurse place a peripheral IV to administer 1mg of Dilaudid. Although emergency point of care (POC) scrotal ultrasound (US) is not a standard US exam done in the Emergency Department (ED), we decided to attempt the exam to see if there was blood flow to the affected testicle prior to attempted detorsion and then to repeat the exam after the procedure.
US image Review: POC Scrotal US was performed using the high frequency linear probe. The bilateral testes were scanned in transverse and sagittal planes:
55yo female presents to your ED with a 1 month history of progressive dyspnea. She has a history of HTN and schizophenia, is on multiple antihypertensive medications (admits to “occasional” non-compliance) as well as Geodon (claims to be much better about taking this med than the others). Denies illicit drugs. Other than fatigue she really has no other symptoms including chest pain or fever and has an unremarkable exhaustive review of systems.
Exam: Afebrile, BP is 185/90, HR 72, RR 16, SpO2 97% RA. Other than 1+ edema in the LE’s her exam was unremarkable; of note, neck veins were difficult to assess because of her body habitus (obese), her lungs were clear and no murmurs were appreciated. Distal pulses were full and equal bilaterally.
35yo female presents to your ED with acute right flank pain. The pain is severe and intermittent, x approx 24h, associated with intermittent nausea and 2 episodes of non-bloody, non-bilious emesis. No diarrhea, constipation, anorexia. No fever. Urine reported to be dark, denies hematuria, no vaginal discharge or bleeding. LMP 1 wk ago. PMH notable for nephrolithiasis with 1 previous episode of ureteral colic that was managed conservatively 2 yrs ago.
Afebrile, BP 160/85, HR 105, RR 22, SpO2 98% RA. Her exam reveals right mid-abdomen mild tenderness, neg Murphy’s/McBurney’s point tenderness. Mild right flank tenderness and a normal pelvic examination.