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The ultrasound images reveal hepatomegaly and an increased echogenicity of the liver parenchyma that is diffuse. The increased echogenicity can be best appreciated by a comparison to surrounding structures. It is important to note that the increased echogenicity is non-focal and consistent throughout the entire liver in multiple views. These findings can be consistent with nonalcoholic steatohepatitis as well as glycogenic hepatopathy.
In the image, one can see significant tracheal deviation around the right side of the mass (black arrows). This degree of deviation would make ventilation in a paralyzed patient extremely difficult, if not impossible.
An ultrasound (US) of the abdomen was obtained to evaluate for possible pyloric stenosis (see US transverse/dopper imaging). While imaging showed a normal pyloric channel, it revealed an unexpected finding: a complex cystic mass arising from the right adrenal gland (yellow outline), measuring 5.8 by 4.0 by 6.4 cm with calcifications peripherally and mass effect on the kidney without evidence of vascular flow (blue arrow). Computed tomography (CT) of the abdomen/pelvis with IV contrast was subsequently obtained and measured the lesion as 2.8 by 4.6 by 4 cm without evidence of additional masses, lymphadenopathy or left adrenal gland abnormality (see CT axial, coronal, and sagittal imaging).
At the end of this practice oral boards case, the learner will: 1) assess a patient with altered mental status in an oral boards format; 2) review appropriate laboratory testing and diagnostic imaging; 3) identify signs and symptoms of thyroid storm and 4) review appropriate pharmacologic therapies with the proper sequence and timing.
Two photographs of patients neck, both showcasing no obvious erythema, bruising, or swelling which is noteworthy because there is potential for airway compromise but there was nothing visible to indicate that on exam. CTA of neck showing thyroid nodule and potential thyroid hemorrhage (outlined in orange) on the left without evidence of airway compromise at the time of CT scan. Official read by attending radiologist states there is a “heterogeneous left thyroid nodule measuring 3 cm. Findings are suggestive of multinodular goiter with possible acute hemorrhage. Adjacent tract of soft tissue stranding in the anterior left neck with mild adjacent fascial thickening. This could represent small amount of hemorrhage or could be inflammatory.”
ED work-up: BMP within normal limits (WNL), white blood cell (WBC) 27.4, ECG showed sinus tachycardia, nonspecific ST segment abnormalities, BNP and troponin were within normal limits, HR 146 beats/minute, CT abdomen/pelvis showed a 10-cm-heterogenous enhancing left adrenal mass (anterior-posterior view [shown in red], lateral view [shown in blue]).
By the end of this simulation session, the learner will be able to: 1) understand the essential physical exam components necessary to evaluate for etiologies of acute encephalopathy, 2) review laboratory and imaging studies to obtain for evaluation of acute encephalopathy and/or suspected thyroid storm, as well as the rationale behind ordering each study, 3) identify underlying etiologies or pathologies for developing thyroid storm, 4) discuss treatment for thyroid storm.
By the end of this simulation-based session, the learner will be able to: 1) Recognize the signs and symptoms of thyroid storm and appropriately diagnose a patient with thyroid storm. 2) Choose appropriate medications for the treatment of thyroid storm. 3) Determine the appropriate disposition for a patient presenting in thyroid storm. 4) Discuss the rationale behind each drug used to treat thyroid storm. 5) List at least three precipitants of thyroid storm.
Novel Emergency Medicine Curriculum Utilizing Self-Directed Learning and the Flipped Classroom Method: Endocrine and Metabolic Emergencies Small Group ModuleDOI: https://doi.org/10.21980/J8792M
We aim to teach the presentation and management of endocrine emergencies through the creation of a flipped classroom design. This unique, innovative curriculum utilizes resources chosen by education faculty and resident learners, study questions, real-life experiences, and small group discussions in place of traditional lectures. In doing so, a goal of the curriculum is to encourage self-directed learning, improve understanding and knowledge retention, and improve the educational experience of our residents.
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By the end of this simulation session, learners will be able to: 1) Discuss the challenges associated with in-flight emergencies. 2) List what is available in United States (US) commercial airline medical kits. 3) Discuss an appropriate differential diagnosis for a patient with altered mental status (AMS). 4) Demonstrate appropriate treatment of hypoglycemia. 5) Describe possible complications in diabetic patients with insulin pumps when flying. 6) Review the legal ramifications of responding to an in-flight emergency.