Physical exam was initially significant for swelling isolated to the right sided cheek and upper lip. There was no edema to lower lip, uvular swelling, or swelling to the submandibular space. She was speaking full sentences and did not endorse any voice changes. Initial vital signs were as follows: BP 125/77, HR 74, RR 16, and oxygen saturation of 100% on room air. Approximately 40 minutes later, after 125 mg solumedrol intravenous (IV) and 50mg diphenhydramine by mouth, swelling had spread to the entire upper lip and the patient reported spreading to her jaw (Photo 1). Although no jaw or submandibular edema was appreciated on physical exam, a flexible fiberoptic laryngoscope was used to evaluate the patient’s airways given worsening symptoms. Viscous lidocaine was applied intranasally five minutes prior to the procedure. The patient was positioned in a seated position on the stretcher. A flexible fiberoptic laryngoscope was then inserted through the nares and advanced slowly. Laryngoscopy showed diffuse edema of the epiglottis, arytenoids, and ventricular folds (see photos 2-4). Vital signs and respiratory status remained stable both during and after the procedure.
Physical exam revealed a comfortable-appearing male patient with tachycardia and a regular cardiac rhythm. The genitourinary exam indicated significant erythema and fluctuance of the bilateral lower buttocks with extension to the perineum. Black eschar and ecchymosis were also noted at the perineum. There was significant tenderness to palpation that extended beyond the borders of erythema. There was no palpable crepitus on initial examination. Physical exam was otherwise unremarkable.
A Case Report of the Rapid Evaluation of a High-Pressure Injection Injury of a Finger Leading to Positive OutcomesDOI: https://doi.org/10.21980/J8TD2X
On exam the patient was noted to have a punctate wound to the ulnar aspect of his right index finger, just proximal to the distal interphalangeal joint. The finger appeared pale and taut, with absent capillary refill. The patient displayed diminished range of motion with both extension and flexion of the joints of the finger. Sensation was absent and no doppler flow was appreciated to the distal aspects of the finger. X-ray of the hand was obtained and showed many small foreign bodies in the soft tissue and extensive radiolucent material consistent with gas or oil-based material to the palmar aspect of the index finger tracking up to the level of the metacarpal heads.
At the time of presentation to the ED, laboratory results were significant for leukocytosis to 11.8 x 109 white blood cells/L and a partial pressure of carbon dioxide of 52 mmHg on venous blood gas. Computed tomography (CT) of the soft tissue of the neck with contrast showed edematous swelling of the epiglottis and aryepiglottic fold with internal foci of gas (blue arrow) and partial effacement of the laryngopharyngeal airway and scattered cervical lymph nodes bilaterally (Figure 1). Findings were consistent with epiglottitis containing nonspecific air. Additionally, the pathognomonic “thumbprint sign” (yellow arrow) was found on lateral x-ray of the neck (Figure 2). The CT findings as shown in figure 3 illustrate lateral view of the swelling of the epiglottis, gas, and blockage of the airway.
ABSTRACT: A 39-year-old previously healthy male presented with three days of right eye pressure and one day of binocular diplopia. He denied history of trauma, headache, or other neurological complaints. He had normal visual acuity, normal intraocular pressure, intact convergence, and no afferent pupillary defect. His neurologic examination was non-focal except for an inability to adduct the right eye past midline
Episodic tender, warm, erythematous swelling of the extremity experienced by this patient is typical of erythromelalgia. Erythematous streaking on the volar surface of the left forearm (red arrow) and tender, warm, erythematous blanching swelling was present on the palmar hand (yellow arrow). Most patients with erythromelalgia also have lower extremity involvement including the dorsum or sole of the foot and toes.1
Close visual examination revealed erythematous linear papules on her upper and lower back. No bullae, drainage, or sloughing of the skin was present. The rest of her body, including palms, soles, and mucosa, was spared.
Facial ultrasound revealed local inflammatory changes such as increased echogenicity and heterogeneity in the soft tissues of the right cheek, suggestive of soft tissue edema. There was evidence of a prominent right parotid gland with increased heterogeneity suggestive of a traumatic injury. Additionally, facial ultrasound demonstrated a 6mm ill-defined anechoic collection within the right cheek without increased doppler flow (green arrow), thought to represent a focal area of edema instead of an abscess.
On physical examination, there was erythema, swelling, warmth, and general exquisite tenderness of the superior aspect of the left pinna (the outer ear) but excluding the ear canal, lobe, tragus, and crus. There was no facial involvement. There was no fluctuance about the ear and no drainage of fluid. The preauricular lymph nodes were enlarged and tender, but the anterior cervical lymph nodes were not tender. There was no mastoid tenderness, protrusion of the ear, or interruption of the postauricular crease.
The physical exam revealed globalized pallor of his skin as well as conjunctival pallor. Mucous membranes were found to be dry and pale with dried gingival hemorrhages apparent between teeth (image). Additionally, mild hepatosplenomegaly was noted. While in the ED, the patient’s urine was dark reddish-brown, which he then reported had been similarly discolored for the past 7 days.