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161-180 of 245 results with category "Visual Diagnosis"

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Title: What's the Diagnosis?

Category: Visual Diagnosis

Posted: 4/17/2013 by Haney Mallemat, MD

Question

35 year-old female presents with fever and hypotension. Bedside ultrasound is performed and is shown here. What's the diagnosis? 

Show Answer

Answer: Aortic valve vegetation secondary to infective endocarditis. 

Show References

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Title: What s the Diagnosis? Case by Dr. Zachary Dezman

Category: Visual Diagnosis

Posted: 4/8/2013 by Haney Mallemat, MD

Question

64 year-old female presents with chest pain following an argument with her husband. Her echocardiogram (apical four-chamber view) and ECG are shown. Her initial troponin is 10. What's the diagnosis?

 

Show Answer

Answer: Takotsubo (a.k.a Stress) cardiomyopathy (TC)

TC is left ventricular dysfunction (hypokinesia, akinesia, or dyskinesia) secondary to catecholamine surge (e.g., physical / emotional stress) causing myocardial stunning; it is not due to acute coronary occlusion. TC disproportionately affects postmenopausal women, occurring in up to 90% of cases.

Patients often present with chest pain or dyspnea; 85% of patients will have an abnormal ECG (e.g., ST elevation or T wave inversions), making diagnosis difficult to differentiate between TC and acute coronary syndrome (ACS). TC has been found to be the diagnosis in 2.5% of patients initially worked up for ACS.

Diagnosis can usually be confirmed with echocardiography but cardiac catheterization (with ventriculogram) is sometimes performed if ACS is strongly suspected. Catheterization demonstrates normal coronary arteries with an abnormal ventriculogram (click for video), typically in mid-to apical portion of the left ventricle.

Treatment is symptomatic and similar to congestive heart failure (e.g., diuretics, beta-blockers, etc.); 95% of patients have full recovery within one month. 

Refer to this prior PEARL by Dr. Tewelde for additional information

 

Reference

T Pilgrima, T Wyss, Takotsubo cardiomyopathy or transient left ventricular apical ballooning syndrome: A systematic review, Int J Card 2008 Mar 14;124(3):283-92

Show References

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Title: What's the Diagnosis?

Category: Visual Diagnosis

Posted: 4/1/2013 by Haney Mallemat, MD

Question

What's the Diagnosis?

Show Answer

Answer: Normal CXR...April Fool's Day ;) 

Our international friends can learn more about April Fool'sDay here

Show References

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Title: What's the Diagnosis? Case by Dr. Zachary Dezman and Dr. Phillip Stafford

Category: Visual Diagnosis

Posted: 3/25/2013 by Haney Mallemat, MD

Question

35 year-old male presents after a motor vehicle crash. No blood seen at the meatus of the penis and a Foley catheter is placed (see photo below). What's the next diagnostic step?

Show Answer

Answer: Retrograde cystogram

Traumatic bladder rupture

Gross or microscopic hematuria (>50 RBCs per high-power field) following blunt trauma requires a retrograde cystogram to evaluate for bladder injury. If blood is present at the meatus, however, urethral injury (not discussed) should be suspected and retrograde urethrogram should be performed before passing a Foley catheter.

A retrograde cystogram is performed by infusing diluted contrast into the bladder (200-400 mL) to gently distend the bladder and allow visualization of potential rupture(s). A CT scan of the abdomen and pelvis is then performed to determine if any contrast has leaked from the bladder; alternatively an AP pelvis can also be used, but is not as sensitive as CT.

Traumatic bladder ruptures are categorized as either intra-peritoneal or extra-peritoneal (note: X-ray below demonstrates extra-peritoneal rupture).

Treatment for bladder rupture:

  • Extra-peritoneal bladder rupture typically requires only 1-3 weeks of Foley catheter; the catheter can be removed after a successful voiding trial.  
  • Intra-peritoneal bladder rupture requires an exploratory laparotomy because this injury does not heal on its own. Urine draining into the abdominal cavity may cause complications such as urinary ascites and electrolyte imbalances.  

Prognosis is typically good for either injury.

Show References

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Title: What's the Diagnosis? Case written by Dr. Zachary Dezman

Category: Visual Diagnosis

Posted: 3/19/2013 by Haney Mallemat, MD

Question

A 56-year-old woman with a history of psoriasis presents with fever, nausea, and painful pin-point pustules on an erythematous base. Her dermatologist recently reduced her prednisone dose. What's the diagnosis?

Show Answer

Answer: Pustular psoriasis

Pustular psoriasis

Occurs in patients with psoriasis, classically occurring after a decrease in dose or cessation of systemic steroids

Symptoms include:

  • Acute eruption of painful small pustules (2-3 mm in diameter) that rapidly become confluent into large “lakes of pus”
  • Systemic symptoms may also occur (e.g., fever, malaise, nausea, or arthritis).

These lesions can eventually drain and desquamate, leaving large patches of exposed dermis.

Complications include:

  • Super-infection (most common)
  • ARDS
  • AKI
  • Hypothermia secondary to loss of epidermis
  • Hypovolemia secondary to fluid losses from the skin

Patients may be admitted for supportive care and treatment with disease-modifying antirheumatic drugs (DMARDs) such as cyclophosphamide or methotrexate.

 

REFERENCE

L Naldi, D Gambini, The clinical spectrum of psoriasis, Clinics in Dermatology, Volume 25, Issue 6, November–December 2007, Pages 510-518

Show References

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Title: What's the Diagnosis? Case submitted by Dr. Ali Farzad

Category: Visual Diagnosis

Posted: 3/11/2013 by Haney Mallemat, MD

Question

40 year-old female requiring intubation for altered mental status. CXR is below with something under the left diaphragm. What’s the diagnosis? 

Show Answer

Answer: Loop of colon.

Show References

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Title: What's the Diagnosis? Case submitted by Dr. Ali Farzad

Category: Visual Diagnosis

Posted: 3/4/2013 by Haney Mallemat, MD

Question

65 year-old male with acute pulmonary edema. Ultrasound at the bedside shows this. What's the diagnosis?

Show Answer

Answer

Show References

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Title: What's the Diagnosis? Case by Bethany Radin

Category: Visual Diagnosis

Posted: 2/18/2013 by Haney Mallemat, MD

Question

68 year-old female presents with stridor and palpable goiter. Here's a clip from CT of the chest. What's the diagnosis?

Show Answer

Click here for answer.

 

Sharma, A. et al. Benign cervical multinodular goiter presenting with acute airway obstruction: a case report. J Med Case Rep 2010 Aug 10;4:258.

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Show References

 

 

 



Title: What's the Diagnosis? Case submitted and written by Dr. Mak Moayedi

Category: Visual Diagnosis

Posted: 2/11/2013 by Haney Mallemat, MD (Updated: 2/11/2013)

Question

A 25 year-old female presents complaining of a "net-like" rash bilaterally on her medial thighs. She denies any pain but states that the rash looks “pretty scary” What's the diagnosis?

Show Answer

Answer:  Erythema ab igne (a.k.a. "toasted-skin syndrome")

 

Erythema ab igne

  • Heat-induced dermal melanosis
  • Occurs secondary to chronic exposure of a heat source on skin (e.g., laptop computer, heating pad, hot water bottle, etc.).
  • Prolonged exposure leads to permanent hyperpigmentation and a small risk of carcinoma.
  • With respect to the current case, the heat exposure occurred secondary to a space heater that she kept between her legs to keep warm while working as a parking lot attendant.

Show References

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Title: What's the Diagnosis? Case submitted by Dr. Bethany Radin

Category: Visual Diagnosis

Posted: 2/4/2013 by Haney Mallemat, MD (Updated: 3/20/2013)

Question

40 year-old male presents with fever, chills, & cough. What’s the diagnosis and the MOST likely cause? 

Show Answer

 

Answer: Pneumatocele from MRSA pneumonia

 

Pneumatocele

Pneumatoceles are thin-walled, air-filled cysts with lung parenchyma; they may be solitary or multiple

Most commonly a sequellae to pneumonia secondary to Staphylococcus aureus (up to 85% of cases), although other etiologic agents have been found (Streptococcus pneumonia, E. coli, Klebsiella, Adenovirus and Tuberculosis). Non-infectious causes include trauma, hydrocarbon ingestion, and positive pressure ventilation.

Pneumatoceles are typically asymptomatic and require treatment of the inciting etiology (e.g., antibiotics for pneumonia), but complications may occur including tension pneumatocele, pneumothorax, and secondary infection of the pneumatocele. 

Surgical resection is typically not needed but percutaneous catheter drainage may be required if the pneumatocele involves >50% of the hemithorax

Advise patients against exposure to high altitudes, skydiving and scuba diving until pneumatocele(s) resolve, to avoid progression to pneumothorax.

Show References

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Title: What's the Diagnosis?

Category: Visual Diagnosis

Posted: 1/28/2013 by Haney Mallemat, MD (Updated: 1/29/2013)

Question

40 year-old female drove into a ditch. Right sided chest pain and stable vitals. Here's the CT but what do you think the initial CXR showed (Hint: it's a trick)?

Show Answer

Here's the initial CXR. Click here for the video presentation.

Show References

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Title: What's the Diagnosis? Case by Dr. Michael Abraham

Category: Visual Diagnosis

Posted: 1/21/2013 by Haney Mallemat, MD

Question

45 year-old male complains of chest pain and cough. He also tells you, "...oh, and by the way doc, I just smoked something." What's the diagnosis?

Show Answer

Visual pearls is two years old!!! I want to take this time to thank you all for your support....and now, your answer. 

 

Restrepo, C. et al. Pulmonary complications from cocaine and cocaine-based substances: imaging manifestations. Radiographics. Jul-Aug 2007; 27(4): 941-56

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Title: What's the Diagnosis? Case submitted by Dr. Nikki Alworth

Category: Visual Diagnosis

Posted: 1/14/2013 by Haney Mallemat, MD

Question

50 year-old male with cough and dyspnea. What's the diagnosis?

Show Answer

Here's your answer: http://www.youtube.com/watch?v=Z4yxqRoKX04&feature=youtu.be

Show References

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Title: Spinal Deformity

Category: Visual Diagnosis

Keywords: spinal, international, tuberculosis, scoliosis, kyphosis, pulmonary, neurologic (PubMed Search)

Posted: 1/9/2013 by Andrea Tenner, MD

Question

These two Ethiopian boys present with “back problems”.  What are the diagnoses and what do you need to worry about with each of them?

 

 

Show Answer

The boy on the left has spinal tuberculosis (Pott's Disease) while the one on the right has severe scoliosis.

Pott's Disease:

  • Kyphosis caused by anterior vertebral body "wedging", usually in the thoracic spine
  • Most commonly causes motor deficits (usually leg weakness) and pain
  • Patients generally do not need respiratory isolation unless concurrent pulmonary TB is suspected.
  • Diagnosis: imaging, surgical biopsy and culture
  • Treatment: decompressive surgery for neurologic deficits and anti-TB chemotherapy

Severe Scoliosis:

  • Caused by lateral displacement and rotation of inact vertebral bodies (thus can lead to kyphoscoliosis)
  • Can cause severe respiratory impairment through decreased chest wall compliance, decreased lung compliance (due to progressive atelectaisis), and pulmonary hypertension
  • Diagnosis: clinical, imaging
  • Treatment: Pulmonary dysfucntion, once it occurs, is considered irreversible. Surgery may prevent further worsening.

Bottom Line:

Spinal tuberculosis most commonly causes anterioposterior (AP) deformity and can cause severe neurologic deficits. Anti-TB medication is needed for treatment.

Severe scoliosis involves lateral as well as AP deformity and can cause severe pulmonary dysfunction. 

University of Maryland Section of Global Emergency Health

Author: Andi Tenner, MD, MPH

 

Show References

Center for Disease Control and Prevention. Guidelines for Preventing the Transmission of Mycobacerium tuberculosis in Health-Care Settings.  MMWR 2005;54(No. RR-17):1-144.

Koumbourlis AC.  Scoliosis and the respiratory System.  Paediatric Respiratory Reviews 2006;7:152-160.

Turgut M.  Spinal tuberculosis (Pott’s disease): its clinical presentation, surgical management, and outcome.  A survey study on 694 patients. Neurosurg Rev 2001;24:8-13.

 

Attachments

  • 1301090035_IMG_2102.JPG (2,130 Kb)


Title: What's the diagnosis? Written by Dr. Jennifer Guyther

Category: Visual Diagnosis

Posted: 1/7/2013 by Haney Mallemat, MD

Question

4 year-old female with the post-procedural CXR shown below. What's the diagnosis? (Hint: use the zoom...this one is tricky)

 

Show Answer

Answer: Nasogastric tube in the left mainstem bronchus. Patient was asymptomatic but ironically bubbling was heard when air was injected into the NG tube.

 

Nasogastric tube (NGT) pearls

The risk of NGT misplacement is 4% in adults, but is 21-43% in children.

Risk factors for misplacement are:

  • Younger age
  • Altered mental status
  • Abdominal distention
  • Dysphagia

The ability to aspirate gastric contents, pH testing of the aspirated fluid, and the auscultation of “bubbling” over the epigastrium have all been suggested as reliable methods to confirm proper placement; unfortunately, they are often unreliable.

Visualization of the NGT by X-ray is the only way to be 100% certain of placement.

The risks of misplacement include pneumonia and pneumothorax.

Farrington et al. Nasogastric tube placement verification in pediatric and neonatal patients. Pediatric Nursing. Jan-Feb 2009. Vol 35. Issue 1.

Show References

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Title: What's the Diagnosis? Written by Zachary Dezman

Category: Visual Diagnosis

Posted: 12/31/2012 by Haney Mallemat, MD

Question

31 year-old male with recently diagnosed hypertension presents with rapid lip swelling. He started taking an unknown medication for his hypertension last week. Further history reveals that he has had prior, although milder, episodes previously. Name two medications that may help treat him.

Show Answer

Answer: The patient has hereditary angioedema with an episode triggered by an ACE inhibitor. Treatment includes the usual cocktail of histamine blockers and steroids plus:

  • Fresh frozen plasma
  • C1 inhibitor concentrate
  • Danazol (modified testosterone)
  • Ecallantide (kallikrien inhibitor)

The precipitant cause is unknown in most cases, but common etiologies include drugs (e.g. ACE inhibitors), infections, dental work, or stress.

Serum C4 level may assist in the diagnosis, but are rarely helpful acutely.

Fifty percent of patients will have laryngeal swelling at one point in their lives and asphyxiation is the leading cause of death; mortality is ~14-33%

The airway must be emergently evaluated to determine the need for intubation. If required, the most skilled person should take the first look.

If access to the oropharynx is limited (secondary to lip and tongue swelling) fiberoptic nasolaryngoscopy may be considered however, always be prepared to perform an emergent surgical airway.

Bonus Pearl: Check out this months V-Cast hosted by Dr. Amal Mattu. Dr. Jim Roberts (of Roberts and Hedges fame) reviews angioedema. Check out this great review here: http://cmedownload.com/lecture/angioedema-v-cast

 

References

Joseph J. Moellman, and Jonathan A. Bernstein. Diagnosis and Management of Hereditary Angioedema: An Emergency Medicine Perspective. Journal of Emergency Medicine 2012 http://www.jem-journal.com/article/S0736-4679(11)01116-4/abstract

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Title: What's the Diagnosis?

Category: Visual Diagnosis

Posted: 12/24/2012 by Haney Mallemat, MD

Question

52 year-old male with diabetes complains of severe left foot pain for one month and now inability to ambulate. Vital signs are normal and X-rays are shown below. What's the diagnosis and why should you get a biopsy early?  

 

Show Answer

Answer: Osteomyelitis and a bone biopsy (with culture) should be obtained early and before starting antibiotics.

Osteomyelitis is inflammation of a bone secondary to an infecting organism.

Risk factors include:

  • Injury to bone from surgery or trauma
  • Spread via bacteremia or overlying skin infection
  • Secondary to foreign body or prosthetics

Causative bacteria typically include S. Aureus, Pseudomonas, Salmonella (classically with Sickle cell)

Diagnosis

  • X-ray may be used (periosteal or cortical changes) but lacks sensitivity; abnormalities may not be evident for up to 14 days
  • Bone scan is a better test, but false positives may occur with overlying skin infections
  • MRI is arguably the best test; delineates tissues planes and the extent of infection 

Early and long-term antibiotic treatment (4-6 weeks) is required, but should be done AFTER obtaining bone biopsy and culture; long-term antibiotics are the rule and the most narrow spectrum antibiotic should be determined.

Operative management is sometimes required; especially if secondary to infected prosthetics.

Show References

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Title: What's the diagnosis? Case written by Dr. Zachary Dezman

Category: Visual Diagnosis

Posted: 12/17/2012 by Haney Mallemat, MD

Question

50 year-old man with presents with acute-onset sharp left-sided chest pain and dyspnea. What's the diagnosis and the name of the abnormality on chest x-ray?

Show Answer

Answer: Pulmonary embolism with CXR demonstrating "Hampton Hump". 

  • Hampton Hump is a wedge-shaped opacity originating from the periphery of the lung secondary to a pulmonary infarct.
  • Although classically taught as a radiologic finding associated with pulmonary embolism, it a relatively uncommon finding
    • Sensitivity  and specificity for pulmonary embolism are 22 and 82%, respectively.

Show References

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Title: What's the diagnosis? Submitted by Dr. Bethany Radin

Category: Visual Diagnosis

Posted: 12/10/2012 by Haney Mallemat, MD

Question

64 year-old male with no past medical history presents complaining of chronic weight-loss and diffuse chest pain; CXR is shown below. What's the diagnosis, and what other disease(s) may present this way?

 

Show Answer

Answer: Sclerotic bone (osteoblastic) metastasis secondary to prostate cancer. The patient's CXR from 2 years prior is shown below for comparison.

Other malignancies associated with osteoblastic metastasis:

  • Breast cancer
  • Colon cancer (mucinous adenocarcinoma)
  • Lymphoma
  • Carcinoid
  • Neuroblastoma
  • Prostate cancer (#1 cause)

Show References

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Title: Critical Care Pearl: Do tube feeds and quinolones play well together?

Category: Visual Diagnosis

Posted: 12/4/2012 by Haney Mallemat, MD

Question

An 86 year-old nursing home resident presents to the ED with a urinary tract infection, four days after discharge from the inpatient service for the same diagnosis. She was discharged from the inpatient service with a prescription for ciprofloxacin to be given through her gastric feeding tube (she does not take anything orally). Could her tube feeds be playing a role in the relapse of her urinary tract infection?

Show Answer

Answer: Ciprofloxacin was not being properly absorbed secondary to enteral tube feeding.

Fluoroquinolones administered via enteral feeding tubes may have reduced efficacy and patient outcomes when given to patients simultaneously receiving tube feeds (e.g., PEG tube feeding).

The reduction in antimicrobial efficacy may be due to improper peak drug concentrations and variability in time to peak serum levels. Studies have demonstrated the bioavailability of Ciprofloxacin varies from 31-82% in patients receiving continuous enteral feeds.

The exact mechanism(s) responsible for the altered pharmokinetics are not completely understood but may involve the binding of divalent cations in the enteral feeds by fluoroquinolones, reducing its absorption and efficacy.

Clinicians should properly educate people who will be administering fluoroquinolones to the patient (e.g., nursing home staff, family, etc.). It is recommended that fluoroquinolones be given:

  • 2 hours before starting enteral feeds, or
  • 4 hours after enteral feeds have been held

Perhaps easiest of all, is to consider discharging patients with a prescription for parenterally administered antibiotics for the duration of the infection.

Show References

Beckwith MF, Feddema SS, Barton RG, Graves C. A guide to drug therapy in patients with enteral feeding tubes: Dosage form selection and administration methods. Hosp Pharm. 2004;39:225–37

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