Archives

Increase in Non-Contrast Computerized Tomography Scans of the Head Following Popular Media Stories About Head Injury

Introduction: On March 18, 2009, actress Natasha Richardson died after a head injury. It is possible that the rate of patients presenting with mild head injury and receiving computed tomographies (CTs) may have been influenced by the Richardson event. We hypothesized that there was a statistically significant increase in the rate of census-adjusted head CTs performed for mild trauma after March 16, 2009, compared to prior to this date.

Conclusion: The percentage of all ED patients seen with mild trauma tested with head CT almost doubled when comparing the pre-Richardson accident vs. post time periods. There was an increase in media reports of the accident that occurred rapidly after the event and peaked on day 3.

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Visual Hallucinations: Charles Bonnet Syndrome

The following is a case of Charles Bonnet syndrome in an 86-year-old woman who presented with visual hallucinations. The differential diagnosis of visual hallucinations is broad and emergency physicians should be knowledgeable of the possible etiologies.

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Adie’s Tonic Pupil

A 33-year-old woman with no past medical history presented to the emergency department with asymmetric pupils. At 7:30am while putting on makeup, she noted her pupils were equal in size. One hour later, she developed light sensitivity in her right eye, and soon after noticed her right pupil was significantly enlarged. She denied headache, facial or extremity weakness, dysarthria, or ataxia. On exam…

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Holiday Plants with Toxic Misconceptions

Several plants are used for their decorative effect during winter holidays. This review explores the toxic reputation and proposed management for exposures to several of those, namely poinsettia (Euphorbia pulcherrima), English holly (Ilex aquifolium), American holly (Ilex opaca), bittersweet (Solanum dulcamara), Jerusalem cherry (Solanum pseudocapsicum), American mistletoe (Phoradendron serotinum), and European mistletoe (Viscum album).

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The psychopharmacology of agitation: consensus statement of the American association for emergency psychiatry project BETA psychopharmacology workgroup.

We were excited to read the article by Michael Wilson et al1 in the March 2012 issue of theWestern Journal of Emergency Medicine regarding pharmacologic strategies for the management of agitated patients in the emergency setting. This article highlights several important points including the optimal management of stimulant-induced agitation and the feasibility of and reasons for differentiating acute alcohol intoxication from withdrawal, as optimal pharmacologic interventions for each might vary.

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Grade III or Grade IV Hypertensive Retinopathy with Severely Elevated Blood Pressure

Introduction: Hypertensive retinopathy describes a spectrum of retinal changes in patients with elevated blood pressure (BP).We examined risk factors for grade III/IV hypertensive retinopathy among patients with hypertensive urgency in the emergency department (ED) and compared healthcare utilization and mortality between patients with and without grade III/IV hypertensive retinopathy.

Conclusion:Younger patients may be at higher risk for grade III/IV hypertensive retinopathy among patients with hypertensive urgency. Chronic compensatory mechanisms may have not yet developed in these younger patients. Alternatively, older patients with retinopathy may be underrepresented secondary to increased mortality among these patients at a younger age (survivorship bias).

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Unusual Cause of Cardiac Compression in a Trauma Patient: Cystic Thymoma

A 29-year-old man with sudden onset of dyspnea and chest pain with impairment of the general status after falling down from five meters was transferred to our emergency department. He was completely asymptomatic before the injury, but hypotensive (80/50 mmHg) and tachycardic (112 beats/minute) after the injury. Chest radiograph revealed a bulging cardiac silhouette on the right paracardiac region with an increased cardiothoracic ratio of 70%.

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Transjugular Intrahepatic Portosystemic Shunt (TIPS) Migration to the Heart Diagnosed by ED Ultrasound

A 57-year-old man presented to our emergency department with altered mental status. He had a past medical history significant for cirrhosis and previous placement of a transjugular intrahepatic portosystemic shunt (TIPS). On cardiac auscultation, a new heart murmur and an unexpected degree of cardiac ectopy were noted. On the 12-lead electrocardiogram, the patient was…

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Sonographic Consensual Pupillary Reflex

Patients suffering from severe orbital trauma are at risk for numerous complications, including orbital compartment syndromes. This can result in an afferent pupillary defect, which must be evaluated for on physical examination. Unfortunately, these at-risk patients are often challenging to examine properly due to surrounding edema. Point-of-care ultrasonography can be used as an adjunct to the standard examination in this situation.

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Bladder Bulge: Unifying Old and New Sonographic Bladder Wall Abnormalities in Ureterolithiasis

Approximately 1% of all emergency department (ED) visits are for treatment of urinary tract stone disease (renal colic, kidney stones, urolithiasis). Renal colic is a common condition affecting approximately 7–13% of the population during their lifetime and those who are afflicted are likely to have recurrent attacks throughout their lives. Through the following case series, we present sonographic bladder wall findings in patients with renal colic.

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Technology in Emergency Care

Ultrasound Diagnosis of Urethral Calculi

A 35-year-old man presented to the emergency department (ED) for acute urinary retention and penile pain for 4 hours. The patient denied any significant medical history or history of trauma. Physical exam revealed testicles that were nontender, without masses. However,…

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Diagnostic Acumen

Asterixis as a Presentation of Cerebellar Ischemic Stroke

Asterixis is not yet considered a common neurological sign of cerebellum infarction, and the pathogenic mechanism for asterixis remains elusive. We report a 58-year-old male with moderate hypertension who presented to our emergency department for acute headache in both cervical and occipital regions of the left side. About 2 hours later the patient developed ipsilateral asterixis in the upper left limb; 3 days later the asterixis disappeared. Magnetic resonance imaging of the brain disclosed cerebellar infarctions at the left superior cerebellar artery.

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Diagnostic Acumen

Severe Neck Pain with Fever: Is it Meningitis?

A 58-year-old male patient presented to the emergency department with complaints of severe neck pain. He admitted to drug use but denied using intravenous (IV) drugs. On exam, he had a fever of 100.7°F, positive Kernig’s sign, and normal neurologic exam. The patient was suspected to have bacterial meningitis and was started on IV antibiotics. The next day the patient developed decreased hand grip. Magnetic resonance imaging of the spine the next day showed a soft-tissue mass impinging on the spinal canal. The patient was subsequently taken to the operating room where the epidural abscess was drained.

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Diagnostic Acumen

Electrocardiogram changes in Thyrotoxic Periodic Paralysis

Thyrotoxic periodic paralysis (TPP) attacks are characterized as recurrent, transient episodes of muscle weakness that range from mild weakness to complete flaccid paralysis. In this case study, we followed a patient’s potassium levels analyzing how they correlate with electrocardiogram changes seen while treating his hypokalemia and ultimately his paralysis.

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Diagnostic Acumen

One in a Million: A Case of Arm and Leg Pain and Deformity

A 38-year-old Hispanic woman with no known past medical or family history presented to the emergency department with severe, intractable left upper and lower extremity pain and inability to walk for 2 days. The woman reported a history of chronic, progressive left hand, arm, and leg deformity over the previous 2 years with episodic flares of severe pain. Physical exam…

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Diagnostic Acumen

An Uncommon Case of Abdominal Pain: Superior Mesenteric Artery Syndrome

Superior mesenteric artery (SMA) syndrome is a rare cause of abdominal pain, nausea and vomiting that may be undiagnosed in patients presenting to the emergency department (ED). We report a 54-year-old male presenting to a community ED with abdominal pain and the subsequent radiographic findings.The patient’s computed tomgraphy (CT) of the abdomen and pelvis demonstrates many of the hallmark findings consistent with SMA syndrome, including; compression of the duodenum between the abdominal aorta and superior mesenteric artery resulting in intestinal obstruction, dilation of the left renal vein, and gastric distension.

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Diagnostic Acumen

Purple Urine Bag Syndrome

A 67-year-old woman presented to the emergency department in congestive heart failure. She also had a history of transverse myelitis, which had caused her to be bedbound with an indwelling urinary catheter. During the physical examination, the urine in her Foley tubing and bag were noted to be bright purple. When asked…

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Diagnostic Acumen

What’s Eating Your Wishbone? Sternoclavicular Septic Arthritis with Osteomyelitis

A 63-year-old female with a past medical history of hepatitis C and cirrhosis presented to the emergency department with a four-month history of increased swelling and tenderness to the right clavicle. The patient was afebrile with a firm, warm area measuring 6 cm x 4.5 cm x 2 cm, located over the medial right clavicle. The patient had a remote history of…

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Diagnostic Acumen

Chief Complaint: Right Hip Pain

A 50-year-old woman with a history of non-insulin dependent diabetes mellitus (NIDDM) presented to the emergency department (ED) with right hip pain for 1 week. The pain was described as constant, non-radiating, and worse with weight bearing. She denied any trauma, fevers, intravenous drug use, or recent surgery. Physical exam revealed…

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Diagnostic Acumen

Definitely NOT Just another Hernia

A 77-year-old male presented to our emergency department (ED) with a 3-hour history of acute severe lower abdominal pain, inability to void, a swollen scrotum, and one episode of vomiting. His relevant past medical history included: hypertension, diabetes mellitus, and distant right inguinal hernia repair. Vital signs were: 96.4° F, 101, 22, and 205/90. Examination revealed a…

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Diagnostic Acumen

Bilateral Thalamic Infarction

A 35-year-old woman, without previous medical history except oral contraception, presented with sudden onset of stupor and clonic perseveration in the upper limbs. She was aphasic, but communicated by vertical movements of the head. Unenhanced brain computed tomography (CT) demonstrated…

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WestJEM/ Department of Emergency Medicine
UC Irvine Health

333 The City Blvd. West, Rt 128-01
Suite 640
Orange, CA 92868, USA
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.