Kennedy/Walchuk       Oral Boards

Case 1. 71 yo diabetic male with fever and altered mental status.  Patient had seizures pre hospital and in ED.  Patient was given Ativan and propofol to halt seizures. Patient was intubated.  Dr. Kennedy ordered an EEG to determine if patient was still seizing while intubated/neuromuscular blocked.   Physical exam showed otitis media.  CT head showed extensive mastoiditis.  INR was supra-therapuetic so LP was contraindicated.  Patient required management of sepsis with IV antibiotics and IV fluids.  ENT consultation was also indicated.

Diagnosis was otitis media with severe mastoiditis resulting in sepsis, seizures, and encephalopathy .

Case 2.  65yo male who crashed his motorcycle and presented with neck pain and upper extremity weakness.  Mechanism of injury suggested hyperextension injury of the neck.

Diagnosis was Central Cord Syndrome.  Immobilize the neck, careful neuro exam, consult neurosurgery.  No steroids.  Decompressive surgery within 8 hours is optimal.

*2Central Cord Injury

*3 Central Cord Injury

Case 3. 35 yo female with erythematous rash after taking Bactrim.  

*erythema multiforme

Patient had no blisters or mucosal lesions.

Diagnosis is erythema multiforme.   Stop the offending agent.  Get a thorough rash history including medications, travel, and sexual history.  Perform physical exam looking for blisters and mucosal lesions, which would indicate EM major/SJS.  Treat with antihistamines and topical sterooids for itching.  Oral steroids are controversial.  Consider testing for mycoplasma, HSV, TB.  However, testing is not usually indicated unless history suggests one of these diagnoses.

*4 Causes of Erythema Multiforme

Comments:

Elise: For my rash exam I document there are no mucosal lesions and no blisters.  I also note whether the rash blanches.

Trushar: Make the statement “I will put the patient in spinal precautions”

Lambert       Soft Tissue Ultrasound

*5Cellulitis

*6 Abscess

*7 Necrotizing Fasciitis.  Look for StAF=Soft tissue thickening, Air, and Fluid.   Air shows up on ultrasound with a hyperechoic band with downward streak artifacts/shadowing.  Ultrasound sensitivity for necrotizing fasciitis is mid 80% range. Specificity though is upper 90’s%.

Mike showed multiple examples of using ultrasound to diagnose clavicle fractures, shoulder dislocations, and AC joint separations.

The supraspinatus is the most common muscle/tendon injured (97%) in a rotator cuff injury.

*8 Supraspinatus Injury .  You position the probe anterior/superior on the right shoulder.  Position the patients arm with their hand on their buttock like a “hand in a the back pocket position”  Aim the probe in the direction of the patient’s ipsilateral ear.

*9 Hip Effusion   Position the probe anteriorly with the hip slightly externally rotated.

US is very good to identify quadriceps tendon, patellar tendon, and Achilles tendon ruptures.

*10 Patellar tendon rupture

Lambert           US Guided Nerve Blocks

 Mike discussed multiple nerve block techniques.

Team Ultrasound                     Soft Tissue/MSK Ultrasound Lab