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54 yo F with no PMHx, but admittedly has not been seen by an MD in many years, presents after her daughter visited from our-of-town and found her slightly confused. The patient is disoriented, but able to provide some history. She describes progressive fatigue over several weeks. Vitals signs are remarkable for hypothermia 94F, HR 52, BP 150/90, RR 12, SpO2 100%RA. Exam is notable for AAO2, no focal neuro deficits, prominent facial swelling, and non-pitting lower extremity edema. FS glucose 160. Laboratory analysis is concerning for mild hyponatremia and severe hypothyroidism.

Myxedema

This patient is suffering from myxedema coma. Contrary to its name, myxedema coma does not require your patient be in a comatose state. It refers to AMS in the setting of severe hypothyroidism. Additionally, patients may also be hypothermic, bradycardic, hypotensive, hypoglycemic, and hyponatremic. It is important to rule out more common causes of AMS, while keeping hypothyroid high on the differential in this patient. Checking a fingerstick, as always, should be done at arrival in patient’s with new AMS.

This patient should be admitted and receive IV thyroid replacement. Oral medications may not be fully absorbed secondary to gastrointestinal edema. Finally, myxedema (a dermatologic condition) does not necessarily need to be present in myxedema coma.

Credit: This article is largely based on http://www.nejm.org/doi/full/10.1056/NEJMicm1403210

Aortic Stenosis

56 yo F with no PMHX, presents complaining of increased DOE and orthopnea for several weeks. She also reports intermittent, mild mucosal bleeding. She denies syncope. Physical exam is notable for an obvious crescendo- decrescendo murmur over the right sternal border. CXR shows an enlarged heart and pulmonary congestion.

The patient is suffering from severe aortic stenosis. There is evidence that patient’s with severe AS have an increased risk of bleeding. This increased risk of bleeding is likely related to an acquired vWF disease. vWF multimers are thought to be disrupted when exposed to turbulent flow across the aortic valve, and thus, the degree if vWF disease is related to the severity of AS.

Heyde’s Syndrome is another bleeding disorder described in patients with AS. It refers to bleeding in the GI tract caused by angiodysplasia. However, unlike vWF disease, the relationship between Heyde’s Syndrome and AS is not firmly established.

Summary: Patient’s with AS are at a higher risk of several diseases including sudden cardiac death, atrial fibrillation and other arrhythmias, endocarditis, CAD, and increased bleeding tendency.

The Bends

You are fed up with the big city, so you decide to take a job as an ‘island doc’ in the Caribbean. Life is good. It’s your second day on the job, and an 18 year old man is carried into your clinic with severe knee pain and shortness of breath. He’s just been diving. You examine the patient and note  clear lungs bilaterally and that the knee pain is not affected by movement of the knee. Aagh, he’s like a living board question! Congratulations, you correctly suspect decompression sickness.
Now what do you do?
- ABC’s (assess pt for need to intubate, assess for PTX)
- initiate 100% FiO2
- consider giving ASA (theorectical basis, no evidence).
- get this guy to a recompression chamber
Recompression therapy is the definitive treatment for DCS-related gas embolism.  In this make-believe scenario, there is no HBO chamber on your island. Thus, the patient need to be emergently transferred. You will need help.
Call International DAN, as a consult. They will help you locate a HBO and help arrange transfer.
DAN America/World – 1-919-684-9111 (accepts collect calls)
Covers – North, Central, and South America; Caribbean; US territories; Central Pacific Basin (Except Fiji); Anywhere else not covered below
For routine, nonemergency questions or information, call 1-919-684-894 during East Coast of United States business hours (Monday-Friday during the daytime).

A 30 year old male presents to your ED, complaining of wrist pain following a fall while playing roller hockey. He denies wearing protective gear. On exam he has point tenderness over the dorsal aspect of his R wrist. You order an plain film:

Content_x-ray_-_scapholunate_dislocationa

What is your diagnosis?

Scapholunate dissociation (SLD) refers to a disruption in the Scapholunate Interosseus Ligament (SLIL).

http://radsource.us/carpal-instability/
http://radsource.us/carpal-instability/

SLD can be seen alone, but also frequently with distal radial fractures and scaphoid fractures. It is the most common form of carpal instability, but frequently missed. Diagnosis can be made on plain film. Typically, separation between the scapula and lunate of >3mm raises suspicion. This is often referred to as the “Terry Thomas” sign.

Terry Thomas was “an English comedian and character actor during the 1950s and ’60s. He often portrayed disreputable members of the upper classes, especially cads, toffs and bounders, using his distinctive voice; his costume and props tended to include a monocle, waistcoat and cigarette holder.” (1) He also happened to have a very pronouced gap between his two upper central incisors.

This is also commonly referred to as the “David Letterman” sign, to keep up with the times.

These patients should be placed in a thumb spica and given urgent referral to a hand specialist or orthopedic surgeon.
(1) Credit: Wikipedia

I Can’t See!

32 year old male with history of HTN, presents to your ED complaining of progressive R eye pain and decreased visual acuity after a wooden plank stuck him in the face at work about 2 hours prior. He denies other injuries, denies LOC, denies vomiting, focal neurological deficit, and takes no anticoagulation medications. Vitals normal with GCS 15.

Here is a representative picture of your patient:
725830-fig1

EYE EXAM:
R pupil is sluggishly reactive, 5mm
L pupil reactive to light, 3mm
R eye proptotic
EOMI limited by severe pain
VA: no sensation of light in R eye
Conjunctiva: 360 degree subconjunctival heorrhage
IOP: 70mmHg

Diagnosis?

The patient is most likely suffering from orbital compartment syndrome from a traumatic retrobulbar hemorrhage. Due to the risk of progressive, irreversible vision loss, orbital compartment syndrome should be a clinical diagnosis in this case (no need to confirm with imaging prior to intervention).

Ophthalmology is consulted, but cannot get to the hospital for another 2 hours. The patient is at risk of permanent blindness without immediate intervention. Emergent lateral canthotomy is indicated. This is a procedure emergency doctors are expected to know and perform when necessary.

Please follow the link below for details of the procedure:

Pearl: remember to re-assess VA and IOP after the inferior crux is transected. If VA does not improve or IOP remains >40, transection of the superior crux is indicated.


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