The Importance of Accurate Blood Pressure Measurement
Summer 2009 - Volume 13 Number 3
A woman, age 72 years, has blood pressures of 150/70 mm Hg and 150/80 mm Hg, obtained by a medical assistant (MA), on consecutive office visits and does not have a history of hypertension. The blood pressure cuff is properly sized, the MA is inquiring about the patient’s last mammogram while obtaining the blood pressure, and the patient is helping to hold her arm up within the MA’s grasp. The mean of a dozen blood pressure readings that the patient has obtained at home is 128/64 mm Hg. Does this patient have white-coat hypertension?
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The “Party Drug” Crystal Methamphetamine: Risk Factor for the Acquisition of HIV
Monday, 12 July 2010
By Michael Allerton, MS; William Blake, MD Winter 2008 - Volume 12 Number 1 Introduction The abuse of crystal methamphetamine (CM) has reached epidemic proportions in the US, with widespread health consequences for a wide segment of the population. Of US residents older than 12 years, almost 5% (12 million) have reported using CM at least once. Between 1993 and 2003, the rate of admissions for treatment for CM abuse in the US increased from 13 to 56 admissions per 100,000 individuals.1 CM, a stimulant street drug, is closely associated with party use in an attempt to increase the sociability of party participants. Its use is an independent risk factor for both acquisition of and propagation of HIV infection.2-4
Image Diagnosis: Ankle Fractures and Dislocations
Thursday, 01 July 2010
Sundeep R Bhat, MD; Gus M Garmel, MD, FACEP, FAAEM Summer 2010 - Volume 14 Number 2 Figure 1. Anterior-posterior view of the ankle Standard radiographs for suspected ankle injury include anteriorposterior (AP), lateral, and mortise views.1,2 On this AP radiograph, the solid white arrow demonstrates a subtle fracture of the distal fibula; the ankle mortise is intact. On AP ankle films, cortical disruption or talar tilt should be identified. If tibiofibular overlap (TFO)—the distance between the lateral border of the tibia and the medial border of the fibula—is less than 10 mm, or the tibiofibular clear space (TCS)—the distance between the medial border of the fibula and the lateral aspect of the posterior tibial malleolus—is greater than 5 mm, associated syndesmotic injury is likely. Greater than 2 mm difference between the lateral and medial joint space above the talus indicates talar tilt suggestive of medial or lateral disruption of this joint.1,2 Figure 2. Bimalleolar Ankle Fracture Anterior-posterior (AP) view (left) of the ankle demonstrates fracture of the fibula visualized as cortical disruption along the lateral border and a subtle distal tibia fracture seen approximately 2 mm above the distal tip, with preservation of the posterior border of the tibia (seen on lateral view [right]). In addition, the AP view reveals widening of the medial aspect of the superior talar joint space compared with the lateral space, suggesting talar tilt. This pattern of distal fibula fracture with medial malleolus involvement is often due to supination-external rotation injury and is likely associated with significant joint instability if the deltoid ligament is disrupted.1 A small avulsion of the talar neck is also seen along the medial border, opposite the site of the distal tibia fracture. Figure 3. Trimalleolar Ankle Fracture Anterior-posterior (AP) (left) and lateral (right) views demonstrate fracture of the distal fibula, medial malleolus, and posterior tibial malleolus with associated shortening. Note the decreased tibiofibular overlap (TFO) and significant talar tilt on the AP radiograph. Fractures that can’t be reduced or which involve widening of the ankle mortise require urgent orthopedic consultation for possible open reduction internal fixation (ORIF) to prevent complications of avascular necrosis, malunion, or nonunion. Subtle nondisplaced fractures or displaced ankle fractures that have been anatomically reduced can be treated with a posterior splint and stirrup, crutches and nonweight-bearing, with close orthopedic follow-up.1 Figure 4. Talar neck fracture-dislocation Slightly oblique anterior-posterior radiographs show a talar neck fracture-dislocation with associated subluxation of the subtalar joint pre- and postreduction. The talus was reduced into better anatomic position, but talar tilt and joint instability are still evident postreduction. Open ankle fractures (such as this case) are surgical (orthopedic) emergencies, requiring immediate reduction, irrigation and antibiotics, and tetanus vaccination if indicated. This Hawkins Type IV fracture has a near 100% likelihood of avascular necrosis due to the extreme level of displacement.3 References 1. Ankle fractures. In: Koval KJ, Zuckerman JD. Handbook of fractures. 3rd ed. Philadelphia, PA: Lippincott Williams & Wilkins; 2006. p 398-423.2. del Castillo J. Foot and ankle injuries. In: Adams JG. Emergency medicine. 1st ed. Philadelphia, PA: Saunders Elsevier; 2008. p 897-909.3. Talus. In: Koval KJ, Zuckerman JD. Handbook of fractures. 3rd ed. Philadelphia, PA: Lippincott Williams & Wilkins; 2006. p 435-42.
ECG Diagnosis: Hypothermia
Monday, 30 August 2010
Joel T Levis, MD, PhD, FACEP, FAAEM Fall 2010 - Volume 14 Number 3 An Osborn wave (also referred to as the J wave) is a characteristic ECG finding for hypothermia consisting of an extra deflection on the ECG at the terminal junction of the QRS complex and the beginning of the ST-segment takeoff.1 Osborn waves usually occur when the core body temperature falls below 90°F (32°C), and are believed to result from an exaggerated outward potassium current leading to repolarization abnormality.2 They can also be found in other conditions such as hypercalcemia.3 Other ECG findings in patients with hypothermia can include prolongation of the PR, QRS and QT intervals, T wave inversions, and various dysrhythmias including atrial fibrillation, sinus bradycardia, atrioventricular block, and ventricular fibrillation. Fatal ventricular fibrillation or asystole can occur in hypothermic patients when core body temperature falls below 82.4°F (28°C).1 References 1. Mareedu RK, Grandhe NP, Gangineni S, Quinn DL. Classic EKG changes of hypothermia. Clin Med Res 2008;6(3-4):107-8. 2. Olgers TJ, Ubels FL. The ECG in hypothermia: Osborn waves. Neth J Med 2006 Oct;64(9):350,353. 3. Van Mieghem C, Sabbe M, Knockaert D. The clinical value of the ECG in noncardiac conditions. Chest 2004 Apr;125(4):1561-76.
Focus on Living: Portraits of Americans with HIV and AIDS
Saturday, 21 May 2005
Photographs and interviews by Roslyn Banish; introduction by Paul M Volberding, MD Review by Richard Wolitz, MD Winter 2005 - Volume 9 Number 1 More than 900,000 Americans are now living with HIV. This statistic adds little to our understanding of their lives. Focus on Living is about 40 people, each with a story about living with HIV. They come from different parts of the country and from different economic, racial, and ethnic backgrounds. They are young and old, gay, straight, bisexual, and transgender. Each has a reason for participating in this moving project by San Francisco photographer Roslyn Banish, who has compiled riveting portraits with verbatim interviews. Each subject takes the stage, as it were, to give out a message--for example, the person whose partner died without leaving a will--or simply tells that person's story so that others might not feel so alone in their struggle. Thus, each participant leaves a legacy.
Image Diagnosis: Foot Fractures
Tuesday, 06 July 2010
Gus M Garmel, MD, FACEP, FAAEM Winter 2009 - Volume 13 Number 1 Figure 1. (above, left) Anteroposterior (AP) view of the foot and Figure 2. (above, right) Oblique radiograph of the same foot. Two views of an injured foot demonstrates disruption of the Lisfranc joint consistent with a Lisfranc fracture-dislocation. Although it is difficult to see a fracture fragment in these films, significant force is needed to disrupt this strong joint which stabilizes the midfoot, often resulting in a fracture at the base of the 2nd metatarsal or one of the cuneiforms. If the diagnosis is in question, a weight-bearing anteroposterior view or a computed tomography scan of the foot may identify this injury. Surgical repair is generally necessary. Compartment syndrome of the foot is a possible complication. Figure 3. Lisfranc joint illustration. Used with permission, Sonia Y Johnson, MD. Figure 4. Arrows identify a fracture through the calcaneus. Angle formed by the intersection of the line connecting the tuberosity and the highest point of the posterior facet with the line connecting the posterior facet and the posterior process of the calcaneus determine Bohler’s angle. This angle is normally 20-40 degrees, but can be reduced in some fractures of the calcaneus. In this image, Bohler’s angle measures just less than 20 degrees, as this fracture is only minimally displaced. Clinical Pearl: Calcaneus fractures can be associated with vertebral body fractures of the spine. They carry the eponym “lover’s fracture” due to jumping from a height (such as a balcony or second-floor window). Figure 5. Arrow points to a horizontal fracture line as well as surrounding soft tissue swelling. As this fracture is due to an acute injury, the area of swelling is likely to be tender to palpation. Jones fracture is due to an acute injury to the lateral midfoot. The fracture line should be located within 1.5 cm distal to the tuberosity of the 5th metatarsal in a horizontal plane. This fracture should not be confused with the more common avulsion fracture at the base of the 5th metatarsal styloid, as treatment differs.
Image Diagnosis: Appendicitis and Appendicolith
Tuesday, 06 July 2010
Gus M Garmel, MD, FACEP, FAAEM Summer 2008 - Volume 12 Number 3 A patient presents to the Emergency Room with a two to three day history of right lower quadrant abdominal pain, worsening in intensity; low-grade fever; and tenderness to palpation over the right lower abdomen, slightly toward midline. Diagnostic images show: Figure 1. Computed Tomography scan with oral and IV contrast demonstrates a large, distended tubular structure in the right lower abdomen consistent with an inflamed appendix. Figure 2. (same patient) Computed Tomography scan identifies an appendicolith within the center of the enlarged appendix. Given the clinical scenario, this provides radiographic proof of acute appendicitis.
Image Diagnosis: Foot Pain and Fever
Monday, 06 August 2012
William C Krauss, MD, FACEP Summer 2012 - Volume 16 Number 3 A 59-year-old man with a history of poorly controlled type II diabetes and hypertension presented to the Emergency Department complaining of 5 hours of severe right foot pain and drainage from the plantar surface. He denied trauma or inciting injury. The patient was unable to walk because of the pain. On physical examination, his temperature was 100.2 F; his heart rate was 105 beats/minute; and he had marked tender erythematous induration with a fluid-filled bulla over the dorsum of his foot. There was foul-smelling exudate draining from the first web space. Palpable crepitus was appreciated. Anterior-posterior (Figure 1) and lateral (Figure 2) films of the foot demonstrate subcutaneous air originating in the dorsum of his foot tracking both to the plantar surface and the posterior ankle region. The patient was treated with broad-spectrum intravenous antibiotics (vancomycin, gentamicin, and metronidazole) and taken to the operating room where an open transmetatarsal amputation took place because of necrotizing fasciitis. Tissue ischemia and “bubbly tissues in the subcutaneous layer” were noted. Tissue cultures grew Enterobacter cloacae, Streptococcus agalactiae, and Staphylococcus aureus. This patient recovered without further complications and was discharged on hospital day 7. Necrotizing fasciitis is characterized by widespread necrosis of the subcutaneous tissue and fascia (as evidenced by air on this patient’s plain films). Typical sites for this infection are the lower extremities, abdomen, and perineum.1 The incidence of such infections in the US is estimated at 500 to 1500 cases per year, with a case-fatality rate of 24% and is more commonly associated with injection drug use, diabetes mellitus, immunosuppression, and obesity.2,3 References 1. Roje Z, Roje Z, Matić D, Librenjak D, Dukozović S, Varvodić J. Necrotizing fasciitis: literature review of contemporary strategies for diagnosing and management with three case reports: torso, abdominal wall, upper and lower limbs. World J Emerg Surg 2011 Dec 23;6(1):46. 2. Anava DA, Dellinger EP. Necrotizing soft-tissue infection: diagnosis and management. Clin Infect Dis 2007 Mar 1;44(5):705-10. 3. O’Loughlin RE, Roberson A, Cieslak PR, et al; Active Bacterial Core Surveillance Team. The epidemiology of invasive group A streptococcal infection and potential vaccine implications: United States 2000-2004. Clin Infect Dis 2007 Oct 1;45(7):853-62.
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