Visual Diagnosis in Emergency and Critical Care Medicine

CHRISTOPHER P. HOLSTEGE MD, Division of Medical Toxicology, Department of Emergency Medicine, University of Virginia ALEXANDER B. BAER MD, Division of Medical Toxicology, Department of Emergency Medicine, University of Virginia JESSE M. PINES MD, Center for Health Care Quality, Department of Emergency Medicine and Health Policy, George Washington University WILLIAM J. BRADY MD, Department of Emergency Medicine, University of Virginia

List of contributors ix

Foreword xii

Preface xiv

Illustration credits xv

Part I Case Presentations and Questions 1

1 Slash Wound to the Neck 3
Kevin S. Barlotta MD and Alexander B. Baer MD

2 “I’ve Got Blood in My Eye” 3
Chris S. Bergstrom MD and Alexander B. Baer MD

3 Forearm Fracture After Falling 4
Alexander B. Baer MD

4 A Neonate with Fever and Rash 4
David L. Eldridge MD

5 A Missing Button Battery 5
Brendan G. Carr MD and Sarah E. Winters MD MSCE

6 Anorexia Hair Loss and Fingernail Bands 6
Christopher P. Holstege MD

7 Wide Complex Tachycardia in a Young Adult 6
William J. Brady MD

8 Wide Complex Tachycardia in an Older Male Patient 7
William J. Brady MD

9 Muscle Spasms Following a Spider Bite 8
J. Michael Kowalski DO and Adam K. Rowden DO

10 Necrotic Skin Lesion 8
David A. Kasper DO MBA Aradhna Saxena MD and Kenneth A. Katz MD

11 Intense Pain Following High-pressure Injection Injury 9
David T. Lawrence DO

12 Prenatal Vitamin Overdose 9
Christopher P. Holstege MD and Adriana I. Goldberg MD

13 Blurred Vision Following Yard Work 10
Allyson Kreshak MD

14 Foot Pain in a Gymnast 11
Hoi K. Lee MD

15 A Child with Bruises of Different Ages 11
David L. Eldridge MD

16 Sudden Shortness of Breath after Removal of a Central Line 12
Christopher P. Holstege MD

17 “My Eyes Are Yellow!” 13
David T. Lawrence DO

18 Pleuritic Chest Pain in a Young Adult Male 13
William J. Brady MD

19 Exposed During a Blizzard 14
Joseph D. Forrester MD and Christopher P. Holstege MD

20 FAST Evaluation of a Trauma Patient 15
John S. Rajkumar MD and James H. Moak MD RDMS

21 Chest Pain with Sudden Cardiac Death 15
William J. Brady MD

22 Wrist “Sprain” in a Child 16
Jennifer S. Boyle PharmD MD

23 Acute Eye Pain and Blurred Vision in an Elderly Female 17
Chris S. Bergstrom MD and Alexander Baer MD

24 Heel Pain Following a Fall 17
Jennifer S. Boyle PharmD MD

25 Confluent Rash on a Child 18
Sarah E. Winters MD MSCE and Brendan G. Carr MD

26 Bradycardia Following an Herbal Ingestion 18
Alexander B. Baer MD

27 A Pain-free Adult with Persistent T Wave Abnormalities 19
William J. Brady MD

28 Caustic Ingestion with Cardiotoxic Effects 20
Heather A. Borek MD and Christopher P. Holstege MD

29 Chemical Eye Exposure 21
Chris S. Bergstrom MD and Alexander B. Baer MD

30 Acute Abdominal Pain in Pregnancy 22
James H. Moak MD RDMS and John S. Rajkumar MD

31 Coma Following Head Trauma 22
Andrew L. Homer MD and William J. Brady MD

32 Tongue Swelling in a Hypertensive Female 23
Kevin S. Barlotta MD and Alexander B. Baer MD

33 Purulent Eye Discharge in an Adult 24
Chris S. Bergstrom MD and Alexander B. Baer MD

34 Shoulder Pain Following Direct Blow 24
Nathan P. Charlton MD

35 A Gagging Child 25
Maureen Chase MD and Worth W. Everett MD

36 Adult Male with a Sudden Severe Headache 25
Andrew L. Homer MD and William J. Brady MD

37 New Facial Droop 26
Andrew D. Perron MD and Christopher T. Bowe MD

38 Eye Pain After Tree Branch Strike 26
Chris S. Bergstrom MD and Alexander B. Baer MD

39 An Elderly Woman with Groin Pain 27
Brendan G. Carr MD

40 Rash and Joint Pain in a Child 28
Mara L. Becker MD

41 Radiology Findings after Laparoscopy 28
Munish Goyal MD

42 Postprandial Abdominal Pain in an Elderly Woman 29
Hoi K. Lee MD

43 “Pink Eye” in a Contact Lens Wearer 30
Chris S. Bergstrom MD and Alexander B. Baer MD

44 Suspicious Hand Pain 30
Rex G. Mathew MD

45 Fever and Rash in a Child 31
David L. Eldridge MD

46 An Alcoholic with Dyspnea 31
James H. Moak MD RDMS and John S. Rajkumar MD

47 Dark Urine from an Immigrant 32
Suzanne M. Shepherd MD

48 Chest Pain and Lead aVR ST Segment Elevation 33
William J. Brady MD

49 Hand Pain after Striking a Wall 34
William J. Brady MD and Kevin S. Barlotta MD

50 A Refugee with Skin Lesions 35
Roger A. Band MD and Jeanmarie Perrone MD

51 Pain out of Proportion to Examination 35
J. Michael Kowalski DO and Adam K. Rowden DO

52 Leg Pain Following a Motor Vehicle Collision 36
Nathan P. Charlton MD

53 Deformed Globe Following Trauma 36
Worth W. Everett MD

54 Foot Pain Following Breaking 37
Munish Goyal MD

55 Lamp Oil Ingestion 38
David L. Eldridge MD

56 Intermittent Abdominal Pain in a Female 38
John S. Rajkumar MD and James H. Moak MD RDMS

57 Hallucinations in a Botanist 39
Joseph D. Forrester MD and Christopher Holstege MD

58 Altered Mental Status with an Abnormal Electrocardiogram 40
William J. Brady MD

59 Fishing in the Stomach 41
Joseph D. Forrester MD and Christopher P. Holstege MD

60 Overdose-induced Boiled Lobster Skin 41
Heather A. Borek MD and Christopher P. Holstege MD

61 Back Pain Following a Fall 42
Andrew D. Perron MD and Christopher T. Bowe MD

62 Painful Facial Rash 42
Chris S. Bergstrom MD and Alexander B. Baer MD

63 Intense Wrist Pain Following Trauma 43
Rex G. Mathew MD

64 Fever and Drooling in a Child 44
Sarah E. Winters MD MSCE and Brendan G. Carr MD

65 Syncope and Flank Pain in an Elderly Man 44
John S. Rajkumar MD and James H. Moak MD RDMS

66 Get Them Undressed! 45
Munish Goyal MD

67 A “Blue Hue” Following Endoscopy 46
Saumil Vaghela PharmD and Christopher P. Holstege MD

68 Acute-onset Blurred Vision 46
Chris S. Bergstrom MD and Alexander B. Baer MD

69 Elbow Pain in a Child After a Fall 47
Elizabeth Cochran Ward MD and Alexander B. Baer MD

70 Confusion Anemia and Abdominal Pain in a Toddler 47
Christopher P. Holstege MD and Joseph T. Vance

71 A Ground-level Fall with Ankle Pain 48
Christopher T. Bowe MD

72 Traumatic Eye Pain and Proptosis 49
Chris Bergstrom MD and Alexander Baer MD

73 Diffuse Ankle Pain Following a Fall 49
Andrew D. Perron MD and Christopher T. Bowe MD

74 Rash Following Brush Fire 50
Christopher P. Holstege MD and Alejandro C. Stella MD

75 Abdominal Pain in a Trauma Victim 51
Esther H. Chen MD

76 Skin Target Lesion 51
Mara L. Becker MD

77 Chest Pain and a Confounding Electrocardiogram Pattern 52
William J. Brady MD

78 Sudden Sedation in a Student 53
David T. Lawrence DO

79 Skin Lesions in a Comatose Patient 53
Christopher P. Holstege MD and Matthew D. Wilson MD

80 Raccoon Eyes 54
Angela M. Mills MD

81 Fall on an Outstretched Hand in a Young Adolescent 55
William Brady MD and Kevin S. Barlotta MD

82 Eye Pain and Facial Swelling 55
Adam K. Rowden DO and Chris S. Bergstrom MD

83 Wrist Pain Following Fall on an Outstretched Hand 56
William J. Brady MD and Kevin S. Barlotta MD

84 Rash on a Child with Epilepsy 56
Heather A. Borek MD and Christopher P. Holstege MD

85 Abdominal Pain in an Alcoholic 57
Angela M. Mills MD

86 Chest Pain with Electrocardiographic ST Segment and T Wave Abnormalities 58
William J. Brady MD

87 A Heroin Abuser with Multiple Skin Lesions 58
Christopher P. Holstege MD and Ashley L. Harvin MD

88 Chest Pain in a Middle-aged Male Patient with ST Segment Elevation 59
William J. Brady MD

89 Fire Victim with Hoarseness 60
Kathryn Mutter MD and Christopher P. Holstege MD

90 A Gardener with a Non-healing Rash 60
Roger A. Band MD and Steve Larson MD

91 A Bite to the Leg in Tall Grass 61
Alejandro C. Stella MD and Christopher P. Holstege MD

92 An Elderly Man with Diffuse Facial Edema 62
Kevin S. Barlotta MD and Alexander B. Baer MD

93 Acute-onset Double Vision 62
Chris S. Bergstrom MD and Alexander B. Baer MD

94 Low Back Pain in a Car Accident Victim 63
Edward G. Walsh MD and William J. Brady MD

95 Pain and Rash Following Contact with a Caterpillar 64
Nathan P. Charlton MD and Mairin Smith MD

96 Moonshine-induced Basal Ganglion Necrosis and Metabolic Acidosis 64
Nathan P. Charlton MD and Christopher P. Holstege MD

97 A Rock Climber with Finger Pain Swelling and Redness 65
Joseph D. Forrester MD and Christopher P. Holstege MD

98 Vomiting and Syncope Following Ingestion of Ramps 66
Christopher P. Holstege MD and Justin H. Price MD

99 Chest Pain and Subtle ST Segment Elevation 66
William J. Brady MD

100 Herbalist with Bradycardia and Vision Changes 67
William J. Brady MD

101 Painless Penile Ulcer 68
Andrea L. Neimann MD

102 Hyperthermia Autonomic Instability and Confusion in a Traveler 68
Christopher P. Holstege MD and Alexander B. Baer MD

103 An Immigrant with Neck Swelling 69
Suzanne M. Shepherd MD and William H. Shoff MD

104 Eyelid Laceration Following a Brawl 70
Chris S. Bergstrom MD and Alexander B. Baer MD

105 Young Athlete with Back Pain 71
Edward G. Walsh MD and William J. Brady MD

106 Chest Pain and Hypotension in an Adult Male Patient 71
William J. Brady MD

107 Adult Male with Atraumatic Lower Back Pain and Leg Weakness 72
William J. Brady MD

108 Facial Swelling in a Patient with Poor Dentition 73
Alexander B. Baer MD and Christopher P. Holstege MD

109 Weakness and Bradycardia in an Elderly Female Patient 73
William J. Brady MD

110 Lightning Strike Induced Skin Changes 74
Christopher P. Holstege MD

Part II Answers Diagnoses and Discussion 75

Index 183