Images In Emergency Medicine

A Case of Erythema Nodosum with Coccidioidomycosis

Said, BS, et al.

Erythema nodosum (EN) is associated with many systemic diseases and infections. This case report provides an image of erythematous nodules, an overview of the various causes of EN, and the laboratory tests and imaging that can be done in the emergency department to narrow its broad differential diagnosis.

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Paratracheal Cysts

Mohebbi, MD, et al.

A 38-year-old male with no significant past medical history presented to the emergency department with pain and swelling on the left mandibular area and the right upper quadrant of the abdomen after a reported assault in which he was punched in the face and kicked in the right chest wall during a fight at a bar.

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Moyamoya: A Rare Cause of Cerebral Vascular Accident

Merritt, BS, et al.

A 20-year-old Caucasian female presented with an altered mental status that began one day prior to arrival. The patient claimed to know the answers to questions, but was only able to reply with the answers of “yes” or “I don’t know.” Her past medical history consisted of aortic insufficiency.

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Right Atrial Thrombus or Chiari Network?

Fredericks, BS, et al.

A 31-year-old African-American male with known sickle cell disease presented to the emergency department (ED) with a one-week history of chest pain and bilateral leg pain. Physical examination showed an afebrile and hemodynamically stable but uncomfortable appearing male.

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Aortoesophageal Fistula

Roten, DO, et al.

A 90-year-old female presented after sudden collapse with a Glasgow Coma Score of 3, and profound hypotension. Shortly after endotracheal intubation, the patient developed significant hematemesis, and massive transfusion protocol was subsequently instituted.

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A Man with Cyanotic Digits

Wiskel, MD, et al.

A 37-year-old right-handed male auto mechanic with a 40 pack-year smoking history presented to the emergency department with progressive digital pain, cyanosis and paresthesias to his right hand over the prior month.

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Adult Male with Neck Pain

Natsui, MD, et al.

A 19-year-old male presented to the emergency department after a fall while playing soccer. He attempted to head the ball but instead fell backwards, hitting his head and neck on the ground. He did not lose consciousness but developed immediate pain along the right side of his neck.

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Diagnosis of Septic Abortion with Point-of-care Ultrasound

Sherpa, MD, et al.

A 19-year-old recently immigrated female presented with severe lower abdominal pain, fever, and vaginal bleeding after a syncopal episode. On examination, she was febrile with diffuse tenderness to palpation of her lower abdomen with an enlarged uterus palpable to just below the umbilicus.

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Intercostal Lung Herniation

David Manthey, MD, et al.

A pleasant 51-year-old gentleman began to experience right chest wall discomfort approximately one month prior to his presentation to the emergency department (ED). He had a history of chronic obstructive pulmonary disease (COPD) and had fractured ribs secondary to coughing paroxysms.

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Adult Female with a Headache

Kelley A. Wittbold, MD, et al.

A 38 year old female with a history of a right foot drop after medial facetectomies (L4-L5, L5-S1) and micro-discectomy (L4-L5) eight weeks prior presented to the emergency department (ED) with two weeks of headache and neck pain. She denied fever or chills.

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Phytophotodermatitis

Liza G. Smith, MD, et al.

A 22-year-old college student presented to the emergency department with a painful rash to her left upper extremity. She had returned from a spring-break trip to Ecuador the day prior to presentation and the rash had developed on the third day of her six-day stay.

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Spontaneous Hemoperitoneum from Rupture of Massive Leiomyoma

Arielle Schwitkis, BA, et al.

A 34-year-old woman presented to the emergency department (ED) with acute onset of severe abdominal pain and distention with associated diffuse tenderness and guarding. Her medical history was significant for a two-year history of fibroids, which contributed to mild menorrhagia.

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Use of Ultrasound to Diagnose Pneumonia

Derek L. Monette, MD, et al.

A 31-year-old female with a history of intravenous drug use presented to the emergency department with three days of fever, cough, and pleuritic pain. She denied orthopnea, leg swelling, chest pain, back pain, urinary frequency, sore throat, exotic travel, or recent hospitalization.

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Ultrasound Detection of Patellar Fracture and Evaluation of the Knee Extensor Mechanism in the Emergency Department

Kiersten Carter, MD et al.

Traumatic injuries to the knee are common in emergency medicine. Bedside ultrasound (US) has benefits in the rapid initial detection of injuries to the patella. In addition, US can also quickly detect injuries to the entire knee extensor mechanism, including the quadriceps tendon and inferior patellar ligament, which may be difficult to diagnose with plain radiographs.

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Point-of-Care Ultrasound to Diagnose a Simple Ranula

Ili Margalit, MD et al.

An 11-year-old previously healthy girl presented to the emergency department (ED) with three weeks of a rapidly progressive swelling underneath her tongue, causing difficulty in talking and eating. Physical examination revealed a 4.5 × 3 cm sublingual mass arising from the base of the tongue, around the midline (Figure 1). The mass was soft, movable and non-tender. The contents had a bluish hue, which was covered with normal appearing mucosa. A point-of-care ultrasound (POCUS) revealed a well-circumscribed homogenous cystic mass, separated from the muscular fibers of the tongue, without extravasation towards the neck (Figure 2) and without intra-cystic flow. A diagnosis of simple ranula was made.

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Body Mass Index is a Poor Predictor of Bedside Appendix Ultrasound Success or Accuracy

Volume 17, Issue 4, July 2016
Samuel Lam, MD, et al.

In recent years studies have been published on the use of beside ultrasound (BUS) to diagnose appendicitis in the emergency department (ED). Its popularity is likely due to the improving ultrasound skills of emergency physicians, as well as the obvious BUS advantages of no ionizing radiation emission, and ease of performance and interpretation at the bedside. Use of ultrasound in suspected appendicitis is also supported by American College of Radiology recommendations, especially in the pediatric population.

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Diagnostic Acumen

Tachyarrhythmia in Wolff-Parkinson-White Syndrome

Volume 17, Issue 4, July 2016
Kelly Kesler, MD, et al.

A 29-year-old female with no significant past medical history presented with palpitations, nausea, diaphoresis and lightheadedness. Symptoms began 15 minutes prior to arrival. She reported several similar episodes previously that self-resolved within seconds, but had no previous medical evaluations for these symptoms. Initial vital signs were significant for blood pressure of 93/61, irregular heart rate between 180 and 200, respiratory rate of 18, and oxygen saturation of 99% on room air. Physical examination was otherwise unremarkable. The electrocardiogram (ECG) is shown in Figure 1. This was interpreted as atrial fibrillation with rapid ventricular rate, and the patient was treated with rate control with no effect. The patient later spontaneously converted to normal sinus rhythm and repeat ECG was notable for delta waves concerning for Wolff-Parkinson-White Syndrome (WPW) as seen in Figure 2. She was admitted to cardiology for cardiac ablation.

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Diagnostic Acumen

A Woman with Vaginal Bleeding and an Intrauterine Device

Volume 17, Issue 4, June 2016
Zachary Dezman, MD, MS, et al.

A sexually active 35-year old woman presented to the emergency department with intermittent vaginal spotting and pelvic cramping over the preceding four weeks. She had an intrauterine device (IUD) placed three months prior and has never been pregnant. The threads of the IUD and a small amount of blood coming from the cervix were seen on pelvic exam. Laboratory testing revealed a β-human chorionic gonadotropin level of 70,000 mIU/mL. Pelvic ultrasound imaging showed the IUD and a viable intrauterine pregnancy.

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Point-of-Care Ultrasound Diagnosis of Left-Sided Endocarditis

Author Affiliation Charles W. Bugg, MD, PhD Keck School of Medicine, LAC+USC Medical Center, Department of Emergency Medicine, Los Angeles, California Kristin Berona, MD Keck School of Medicine, LAC+USC Medical Center, Department of Emergency Medicine, Los Angeles, California Supplementary information A 56-year-old male presented to the emergency department (ED) with fatigue, generalized weakness, cough without […]

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Diagnostic Acumen

Traumatic Arthrotomy with Pneumarthrosis on Plain Radiograph of the Knee

Volume 17, Issue 2, March 2016.
Timothy D. Roberts, MBChB

An eight-year-old boy presented to the emergency
department (ED) with a 2cm-long laceration over the
prepatellar region of his left knee after falling over and
cutting his knee on broken glass. Physical examination
demonstrated the laceration breached the dermis but
otherwise there was no obvious defect in the deep fascial
layer.

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Diagnostic Acumen

Young Woman with a Fever and Chest Pain

Volume 17, Issue 2, March 2016.
Kristin H. Dwyer, MD, MPH, et al.

A 26-year-old female presented to the emergency
department with three days of subjective fevers, dry cough
and pleuritic chest discomfort. On exam, her vital signs
were significant for a heart rate of 106/minute and oxygen
saturation of 95% on room air. Her lung exam revealed
decreased breath sounds at the right base. A bedside lung
ultrasound and a chest radiograph were performed.

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Diagnostic Acumen

Bullosis Diabeticorum

Volume 17, Issue 2, March 2016.
Meina J. Michael, BS, et al.

A 63-year-old female with insulin-dependent type II
diabetes mellitus and end-stage renal disease presented to the
emergency department with spontaneous blistering to the tips
of her left index and middle fingers. The blisters had gradually
become tense and mildly painful over the preceding 10 days.
She denied burn injury, trauma, fever, or new medications.
On physical exam, the patient was noted to have a tense,
nontender bullae on the pad of the left middle finger, and a
collapsed, hemorrhagic bullae on the left index finger. There
were no signs of inflammation or infection. A radiograph of
the left hand, complete blood count, and basic metabolic panel
were unremarkable. The diagnosis of bullosis diabeticorum
was made, and supported by a consulting endocrinologist.

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Diagnostic Acumen

Turbid Peritoneal Fluid

Volume 17, Issue 2, March 2016.
Samuel L. Burleson, MD, et al.

A 58-year-old female with a past medical history of
hepatitis C virus-induced cirrhosis presented to the emergency
department with three days of increasing abdominal pain,
chills, and nausea and vomiting. Abdominal physical
examination revealed gross ascites with fluid wave. Diagnostic
paracentesis resulted in the aspiration of approximately 60mL
of white turbid peritoneal fluid (Figure).

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Phone: 1-714-456-6389
Email: editor@westjem.org

Our Philosophy

Emergency Medicine is a specialty which closely reflects societal challenges and consequences of public policy decisions. The emergency department specifically deals with social injustice, health and economic disparities, violence, substance abuse, and disaster preparedness and response. This journal focuses on how emergency care affects the health of the community and population, and conversely, how these societal challenges affect the composition of the patient population who seek care in the emergency department. The development of better systems to provide emergency care, including technology solutions, is critical to enhancing population health.