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Patient is 49 yo F who presents to ED with few days of fever (T max 102F), progressive headache, neck stiffness. Patient denies any travel, rashes, sick contacts. Pt complains she can’t be in a well lit room or go outside without pain. You have a high suspicion for meningitis and so perform an LP.

CSF shows as follows:

WBC 100/mm3 (60% N, 35%L)

Protein 100

Glucose 40 (serum glucose 100)


Aside from a gram stain and culture, are there any other tools to help differentiate between viral and bacterial meningitis?

Continue reading “Meningitis” »

Sbp Pearls

Pt is 58 yo M with PMH of alcoholism, HCV with liver cirrhosis (h/o variceal GI bleeds, h/o SBP, h/o hepatic encephalopathy) presents to ED with 2-3 days of altered mental status and fever, you want to rule-out Spontaneous Bacterial Peritonitis and you send your newly minted intern over to get set up for a paracentesis and before you know-it, the intern is back, smiling brightly, with a vial of presumed ascitic fluid, although looking pretty bloody.


You do a quick check to make sure the patient is not hemorrhaging in the hall and then you get a call from the lab reporting a panic value of an INR of 2.2. How do you correct for a bloody paracentesis to get an accurate PMN count in order to diagnose SBP? Was there any contraindication to doing paracentesis in a person with INR 2.2?


Correction for a bloody tap: Continue reading “Sbp Pearls” »

Biphasic Reactions with Anaphylaxis?

“Incidence of Clinically Important Biphasic Reactions in Emergency Department Patients wit Allergic Reactions or Anaphylaxis”

Grunau BE, Li J, Yi TW, et al.

Annals of Emergency Medicine 2014; 63(6): 736-744


Background: Allergic or anaphylactic reactions are fairly common presentations to the ED.  After initial treatment and clinical improvement, a proportion of patients may develop a second “biphasic” reaction, which may actually be more severe than the initial presentation.  Because of this concern, patients are often held for observation for 6 or more hours.  This prolonged ED stay has not been shown to decrease biphasic reactions’ complications, yet incurs significant costs.  The goal of this study was to examine the incidence of clinically important biphasic reactions.

Methods: Chart review performed on data from 2 urban EDs, collected on adult patients presenting during a 5-yer period with “anaphylaxis” or “allergic reaction.”  Primary outcome was the proportion of patients with a clinically important biphasic reaction, secondary outcome was mortality.

Results: Of 428,634 ED visits, 2819 encounters (496 anaphylactic, 2323 allergic reactions) were reviewed.  185 patients had at least 1 subsequent visit for allergic symptoms.  5 clinically important biphasic reactions were identified (0.18%, 95% CI 0.07-0.44%); 2 occurred during the ED visit, and 3 were post-discharge.  2 patients with the biphasic reaction were in the anaphylaxis group (0.40%), and 3 were from the allergic reaction group (0.13%).  There were no fatalities.

Conclusion:  Clinically important biphasic reactions and fatalities were rare in ED patients presenting with allergic or anaphylactic reactions.  This study’s results suggest that it may not be necessary to conduct routine prolonged monitoring of patients whose symptoms have improved after initial treatment.

Ultrasound Signs of Appendicitis




Appendicitis on ultrasound - the first step is to identify the appendix by finding a blind-ending tubular structure arising from the base of the cecum.

The sonographic signs of appendicitis include:

  • dilated appendix > 6mm outer diameter (left image)
  • noncompressible
  • distinct appendiceal wall layers due to edema (left image)
  • target appearance (axial section)
  • appendicolith - an echogenic focus with posterior shadowing
  • periappendiceal fluid collection (right image)
  • echogenic and prominent periappendiceal and pericecal fat
  • surrounding hypervascularity on color Doppler (centre image)


Credit:  http://radiologysigns.tumblr.com/post/29603927330/appendicitis-on-ultrasound

Visual Diagnosis

52F h/o Protein C deficiency with recent PE diagnosis started on anticoagulation 5 days ago presents with the following skin lesions.  Diagnosis?




Continue reading “Visual Diagnosis” »

Jeremy Faust