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CITW 15: The Red Ear

Welcome back to another Clinical Image of the Week from the case files of the Brown EM Residency!

HPI/ROS: 5 year old female with a history of recurrent otitis media who presents to the ED with right ear pain. Per the parents, she developed acute onset right ear pain and “redness” one week ago that was associated with fevers (Tm 103.2). She saw her pediatrician who started a course of Augmentin for otitis media, however, after three days of no improvement, she received IM antibiotics (unknown type) with only minimal improvement in symptoms. On the day of ED presentation, her ear redness had worsened and she had developed limited range of motion of the head and neck. Associated symptoms included headache, hearing loss, and sore throat. No congestion, runny nose, conjunctivitis, visual changes, numbness, weakness, discoordination, cough, dyspnea, wheezing, abdominal pain, vomiting, diarrhea, or rash. No sick contacts or recent travel. Shots are up to date.

Vital Signs: T 102.3, HR 156, RR 22, BP 118/72, SpO2 99% on RA

Pertinent physical exam: Patient found sitting on her mother’s lap, not playful or interactive. Right TM is erythematous and bulging. There is edema and erythema noted behind the right auricle with tenderness to palpation. Shotty cervical chain adenopathy appreciated. No ear discharge. Left TM is clear. Oropharynx is clear with moist mucous membranes. No focal or gross neurological deficits. No meningismus. Neck is supple. Heart is tachycardic. Abdomen soft, non-tender. Lungs clear to auscultation. No rashes. No other pertinent exam findings.

CT imaging was obtained:

Mastoiditis 1
Image 1: CT brain, axial cuts in bone window.
Mastoiditis 2
Image 2: CT brain, coronal cuts in bone window.

What’s the diagnosis?

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CITW 14: The Blue Man

Welcome back to another Clinical Image of the Week from the case files of the Brown EM Residency!

HPI/ROS: 57 year old male with a history of bacterial endocarditis and hypertension presents to the ED for watery diarrhea. He reports gradually worsening diarrhea over the past three weeks after starting HIV post-exposure prophylaxis medications. He does not recall the names of the medications. He’s tried Imodium without relief. Associated symptoms include shortness of breath, nausea, and dizziness. Denies fevers, chills, chest pain, vomiting, abdominal pain, urinary symptoms, rashes, or swelling. He endorses recent antibiotic use for a sinus infection, but denies recent hospitalizations and other recent medication changes. He also endorses recent ETOH use, but denies illicit drug use.

Vital Signs: T 97.1, HR 114, RR 18, BP 121/75, SpO2 89% on RA

Pertinent physical exam: Ill appearing and diaphoretic. There is perioral and digital cyanosis (see below). 3/4 systolic heart murmur (chronic). Abdomen soft, non-tender. Lungs clear to auscultation. No other pertinent exam findings.

Cyanosis Pre
I
mage 1: Provider’s hand on the left, patient’s hand on the right. 

The patient was put on 100% O2 by non-rebreather and his SpO2 improved to only 90%.

What’s the diagnosis?

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CITW 13: Itch, itch, itch

Welcome back to another Clinical Image of the Week from the case files of the Brown EM Residency!

HPI/ROS: 37 year old male with no significant past medical history presents to the ED with a rash. He states that it began one month ago and has been getting worse. Associated symptom is intense pruritus. It is not painful and nothing of note has made it better or worse. He’s never had a rash like this before. He denies any fevers, chills, shortness of breath, chest pain, myalgia/arthralgias, abdominal pain, nausea, vomiting, diarrhea, or urinary symptoms. He denies any recent exposures (environmental or chemical), medication changes, recent infections, or sick contacts.

Vital Signs: T 98.6, HR 88, RR 14, BP 156/72, SpO2 99% on RA

Pertinent physical exam: Diffuse, papular rash along upper and lower extremities including trunk and back. The neck and face are spared. It is non-blanching, non-weeping, and there are no open sores. It spares the face, lower back, and calves. Patient appears well otherwise. No other pertinent exam findings.

One

TwoWhat’s the diagnosis?

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CITW 12: The Extra Weight

Welcome back to another Clinical Image of the Week from the case files of the Brown EM Residency!

HPI: 27 year old male presents to the ED with left chest wall pain. He states he was bench pressing at the gym when he felt a “sudden twinge of pain and popping sensation” in his left upper arm and shoulder. He was unable to lift weights following this injury without experiencing excruciating pain. He subsequently noticed swelling and bruising on his left upper arm. He denies any other injuries, numbness, or weakness.

VS: HR 54, BP 112/64, RR 11, SpO2 100%, T 98.7

PE: Patient is noted to have weakness of the left arm with internal rotation and shoulder adduction. No other deficits appreciated. Neurovascularly intact.

Exam

What’s the diagnosis?

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CITW 10: The Persistent Rash

Welcome back to another Clinical Image of the Week from the case files of the Brown EM Residency!

HPI: A 63 year old male with a history of hypertension and hemorrhagic CVA presented to the ED with 3 months of worsening rash. Per the patient, it is pruritic, painful, and started gradually on his upper extremities, and progressed to his lower extremities. He denies any oral or mucosal lesions. Prior to this, the patient has never experienced a similar rash. The patient initially saw his PCP who prescribed Keflex, which did not have an effect. The patient was then referred to a dermatologist who prescribed Dapsone and a “steroid cream” which he states he’s been compliant with despite the lack of relief. Of note, he states the rash appeared around the same time he started taking Enalapril. He denies fevers, chills, trauma, sick contacts, recent travel, shortness of breath, chest pain, abdominal pain, nausea, vomiting, diarrhea, dysuria, or any other infectious signs or symptoms. He has no known allergies to medications.

FH/SH: Non-contributory

VS: BP 147/72 HR 84 RR 13 T 98.9 O2 99% on RA

Notable PE: The skin examination; see below:

Arm

Arm 2

Groin

What’s the diagnosis?

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CITW 9: The Racing Heart

Welcome back to another Clinical Image of the Week from the case files of the Brown EM Residency!

HPI: A 60 year old female presents with palpitations after walking on the beach with friends. She states she was sitting at her favorite clam shack, and felt the onset of a “rapid heart rate”. Thinking she was dehydrated, she drank some water, and her palpitations resolved after five minutes. After returning home, the palpitations recurred, and after 40 minutes she felt “really tired, really washed out”, but at no point had any chest pain, dyspnea, or lightheadedness. She looked “gray” to her husband, so he called 911.

Vitals: BP 160/110, HR 210, T 98.7 °F, RR 22, SpO2 99% on RA

Notable PE: Pale and anxious appearing. On auscultation, tachycardic without murmur, rub, or gallop. Regular rhythm. Intact and equal pulses throughout. Mild increased work of breathing. Lungs are clear bilaterally. No lower extremity edema.

The following EKG was obtained:

BeforeWhat’s the diagnosis?

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CITW 8: A Painful Eye

Welcome back to another Clinical Image of the Week from the case files of the Brown EM Residency!

HPI: 47 year old male with a history of DM and HTN presents to the ED with a painful and red left eye, worsening over the past 24-36 hours.  It is associated with blurred vision, photophobia, headache, a foreign body sensation, and drainage. He tried saline drops without relief. He’s never had this before. He denies any trauma to the eye, although states he did leave his contacts in two nights ago. He denies fevers, chills, or any other associated symptoms.

Vitals: BP 156/87, HR 87, T 98.9 °F, RR 14, SpO2 100 % on RA

Notable PE: Visual acuity (R 20/30 L 20/50). EOMI intact, but painful. Pupils 3 mm and reactive. Lids everted and swept revealing no foreign bodies. Visual fields intact. Normal accommodation. Left eye findings below:

Eye
What’s the diagnosis?
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CITW 7: A Swollen Elbow

Welcome back to another Clinical Image of the Week from the case files of the Brown EM Residency!

HPI: 6 year old male presents to the ED after falling about 4 feet off the monkey bars at his school playground, landing on his right arm. He’s had worsening pain and swelling of the right elbow since the fall, resulting in limited range of motion.  He denies numbness, tingling, or weakness. He sustained no other injuries.

Vitals: BP 107/72, HR 105, T 98.7 °F, RR 22, SpO2 100 % on RA

Notable PE: There is mild swelling of the right elbow, with limited active range of motion, but intact passive range of motion.  No obvious deformity. He is tender in the lateral supracondylar region. His right upper extremity is neurovascularly intact.

Plain films were obtained:

Rad Head 1

Rad Head 2

What’s the diagnosis?

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CITW 6: A Clumsy Foot

Welcome back to another Clinical Image of the Week from the case files of the Brown EM Residency!

HPI: 74 y/o male with multiple medical problems who presents to the ED with four days of left leg pain, left foot numbness, and a new left foot drop. Additionally, his wife points out that she has noticed a new rash extending up his left foot and leg. He denies any fevers, chills, recent infections or trauma to the leg.

Vitals: BP 157/72, HR 77, T 98.8 °F, RR 16, SpO2 97 % on RA

Notable PE: Numbness and rash (see below) noted on the dorsal aspect of the left foot, extending up the lateral aspect of the left leg to the knee. 3/5 strength with dorsiflexion of the left foot.

Rash 1
Rash 2
What’s the diagnosis?

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