bounceback: vision loss

Two bounceback cases highlighted the importance of considering occipital stroke and examining for visual field defects CASE 1 47F HTN/lipid c/o decreased vision left eye O/E decreased visual field left eye, sent to ophtho Ophtho found homonymous hemianopsia, send back for CT: occipital infarct   CASE 2 61M HTN/smoke c/o decreased peripheral vision right eye…

missed appendicitis

Appendicitis classically presents as RLQ pain, fever, vomiting without diarrhea, a high WBC and normal UA. But pattern recognition is a great way to miss appendicitis–especially in children, women and the elderly–as the following studies makes clear.   CHILDREN The implications of missed opportunities to diagnose appendicitis in children. Acad Emerg Med 2013 Jun;20(6):592-6. In…

POCUS: early diagnosis of ruptured ectopic

A healthy woman at 5 weeks pregnancy presents with one day of recurring syncope and abdominal pain, no vaginal bleeding, BP 80/40. On POCUS With an unstable early pregnant patient with free fluid in the abdomen, I was able to diagnose a presumed ruptured ectopic at the bedside, cross-match blood and call Gynecology. This was…

Association between waiting times and short term mortality

Association between waiting times and short term mortality and hospital admission after departure from emergency department: population based cohort study from Ontario, Canada. BMJ 2011;342:d2983. As the authors noted, “long waiting times can delay every stage of the visit, from initial assessment to treatment to final decision making to admission or discharge (patient disposition) and…

Re-read: ECG for syncope

Here are three bounceback cases who presented with recurring syncope CASE 1: 80yoF presented with syncope, normal labs and the following ECG. Sent home and came back after another syncopal episode CASE 2: 60yoM presented with syncope, sent home and came back with recurring syncope CASE 3: 70yoF with syncope, sent home and came back…

missed cerebellar infarction

Pitfalls in the Diagnosis of Cerebellar Infarction. Acad Emerg Med 2007;14:63-68. This retrospective review of 15 cases of misdiagnosed cerebellar infarction sheds light on a number of preventable errors. 28yo with headache, vertigo, nausea, fall to left, vision loss. Left sided weakness on exam but no documented gait. Normal CT/MRI. Diagnosed as migraine 38yo with…

missed long QT syndrome

Misdiagnosis of Long QT Syndrome as Epilepsy at First Presentation. Ann Emerg Med. 2009;54:26-32 This retrospective review of 31 patients (median age 21) with proved long QT syndrome found 39% experienced diagnostic delay after presenting with syncope or seizure, with a median delay of 2.4 years. A third of patients had EEGs and a sixth…

approach to POCUS

Point of care ultrasound (POCUS) is revolutionizing emergency medicine, providing faster and more accurate diagnosis and safer procedures. It’s a skill in both image generation and interpretation, with each scan involving 5 steps that I’ve summarized as POCUS Probe position: chose probe type and starting position on patient Orientation: generate image, using accoustic windows and…

approach to the alcoholic patient

Alcoholic patients are at high risk for emergencies from acute intoxication, chronic effects of substance use and complications like falling/intoxications. It’s a recipe for error to assume that the patient’s agitation, somnolence or vomiting is from alcohol alone and not a complication or other medical emergency. It can help to have a systems-based approach: A…

approach to the pregnant patient

Pregnant patients undergo many physiological changes that can result in fatigue, edema and shortness of breath. But these can also be signs of emergencies, which we can consider using a systems-based approach A more difficult airway management in third trimester B C: CARDIOVASCULAR RV strain: risk of PE from hypercoagulable Dysfunctional LV: risk of peripartum…