Photograph
Erythema Migrans
DOI: https://doi.org/10.21980/J8QW7QHistory of present illness: A 28-year-old male presented to the emergency department with a chief complaint of two weeks of headache, chills, and numbness in his hands. He reported removing a tick from his upper back approximately two weeks ago, but did not know how long the tick had been embedded. His review of symptoms was otherwise unremarkable. Significant findings:
Chancre of Primary Syphilis
DOI: https://doi.org/10.21980/J83342Physical examination revealed a non-tender, erythematous lesion on the glans penis, two similar adjacent satellite lesions, as well as tender inguinal lymphadenopathy. No penile discharge was noted.
Corneal Sparing Conjunctival Abrasion
DOI: https://doi.org/10.21980/J8KG93Physical exam was significant for multiple broken teeth, multiple minor abrasions on the face, and fine shards of shattered glass on his face and hair. His right eye had conjunctival injection, with no signs of subconjunctival hemorrhage or ocular penetration. Vision, extraocular movement, and pupillary exam were grossly intact. Fluorescein staining with slit lamp exam with cobalt blue filter examination of the right eye revealed superficial bulbar conjunctival uptake of fluorescein dye staining an area of the conjunctiva inferior to the limbus 5 mm vertical by 2 mm horizontal (estimation by photo provided). No foreign bodies were visualized in the inferior fornix. These findings were consistent with superficial conjunctival abrasion. The exam noted sparing of the corneal epithelium.
Steven-Johnson Syndrome
DOI: https://doi.org/10.21980/J8661WAt presentation to the ED, a macular rash was notable on all four extremities, trunk and face, and involved mucous membranes of the oropharynx and vaginal introitus. The rash was painful, erythematous and purpuric with targetoid lesions. There were also multiple areas of sloughing and desquamation with a positive Nikolsky sign. Denudement totaled approximately 2% of total body surface area.
Open Pneumothorax
DOI: https://doi.org/10.21980/J88036A large chest wound was clinically obvious. A chest radiograph performed after intubation showed subcutaneous emphysema, an anterior rib fracture, and a right-sided pneumothorax. He was then taken to the operating room for further management.
K-9 Police Dog Bite
DOI: https://doi.org/10.21980/J8B88GThe photograph is of the anterior compartment of the right lower leg demonstrating multiple deep lacerations with exposed and torn muscle. X-ray showed no foreign body.
Open Dislocation of Fifth Digit
DOI: https://doi.org/10.21980/J8J01XPhysical exam revealed an open dislocation of the proximal interphalangeal joint (PIP) of the right fifth digit. X-ray confirmed dislocation and revealed no fractures. The patient received a tetanus booster, Cefazolin, and the dislocation was then washed out and reduced. Multiple reduction attempts were made and were only successful once the metacarpophalangeal joints were held in 90 degree flexion, which relaxed the lateral bands and enabled the finger to be reduced.
Morel-Lavallée Lesion
DOI: https://doi.org/10.21980/J88G65On physical examination, the patient was noted to have a nearly “watermelon-sized” fluctuant mass to his right lateral superior quadriceps with multiple overlying abrasions (Image 1). Computed tomography (CT) scans of the area showed a large heterogeneous collection measuring roughly 37x9.5x16 centimeters in the subcutaneous adipose layer of the lateral right thigh (Image 2), while ultrasonography revealed a complex fluid collection containing some nodular solid components and debris (Image 3). Additionally, radiographs confirmed multiple fractures including most significantly a pelvic ring fracture. Surgical debridement, evacuation, and sclerodhesis were performed nine weeks post injury to allow overlying abrasions to heal prior to intervention.