Abstract Proceedings EROC 2011 - New York Osteopathic Medical ...

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EROC 2011 Abstract Proceedings – March 4, 2011 Dept. of Emergency Medicine, Good Samaritan Hospital Medical Center, West Islip, NY Title: A Crabby situation: Our Limitations Authors: Kristie Busch DO, Robin Mackoff, DO, Steven Zimmerman MD, Augusto Dasilva MD. Emergency Medicine Residency Program, Good Samaritan Hospital Medical Center, West Islip NY Introduction: In medicine we use imaging technology every day. The technology has advanced, but has it advanced enough? We present a case where a foreign body should have been seen on x ray, but was only found by incision and dissection due to a few suspicious physicians. Case Description: A 61year old male presented with an injury to his right third digit after picking up a crab trap. He had a puncture wound on the volar distal aspect of the digit with streaking. Pain was worse with flexion and extension at the MCP joint. Antibiotics were started for cellulitis and suspected tenosynovitis. The patient was admitted with WBC of 12.6, and normal xray. Our patient was evaluated by plastic surgery and infectious disease with an uneventful hospital course and discharged on day 2. Patient returned 6 days later. He began having swelling, pain and erythema four days after discharge. His right third digit revealed erythema and fluctuance on the volar aspect of the MCP joint. Xray remained normal and a MRI was done in the ED to rule out osteomyelitis verses foreign body. Fluid was seen around the metacarpophalageal and it was decided to take the patient to the OR. During deep dissection the tip of a crab claw was identified piercing the flexor tendon and removed. Discussion: The exoskeleton of crustaceans is composed of calcium and chitin (polysaccharide and calcium salts) which would be expected to absorb x-rays. The fact that this foreign body was not visible makes this case unique. Literature review was unable to identify a similar case where imaging technology failed to identify a calcium containing foreign body. In retrospect using cat scan may have been a better choice to reveal the specimen. This case illustrates the importance of our clinical suspicion and examination in the emergency department verses technology. 28
EROC 2011 Abstract Proceedings – March 4, 2011 Dept. of Emergency Medicine, Good Samaritan Hospital Medical Center, West Islip, NY Title: Now That’s A Shock! Authors: Frederick Davis DO, Steven Sattler DO, Genevieve McGerald DO, Michael Gray MD. Emergency Medicine Residency Program, Good Samaritan Hospital Medical Center, West Islip, NY Introduction: Toxic shock syndrome (TSS) is a shock syndrome caused by the inflammatory response to toxins produced by various bacteria, most commonly Streptococcus and Staphylococcus species. Symptoms may include a prodromal period of 2-3 days with fever and associated chills, nausea, vomiting, diarrhea, abdominal pain, lightheadedness, syncope, myalgias, arthralgias, pharyngitis, headache, confusion, altered mental status, or pain at site of infection. Case Description: A 35 year old male presented to the emergency department for fever of two days duration. His wife reported that the patient appeared to have difficulty with concentration and conversation. Physical exam revealed a lethargic afebrile Caucasian male with mild cognitive deficits, especially problems with concentration. There was no photophobia and the patient had a supple, non-tender neck. Patient did have some mild tenderness to his right shoulder. Laboratory findings revealed a normal white count and a mild elevation in transaminases. A lumbar puncture showed an elevated protein with a negative gram strain. While in the ED the patient developed a fever of 103.0°F and became increasingly lethargic. He developed a petechial rash on his left sole that progressed to both lower legs. The patient was treated empirically for meningitis and started on Ceftriaxone and Vancomycin. Subsequently, blood cultures would grow S. Aureus. After 4 days of treatment, the patient’s mental status returned to normal and he noted persistent pain to his right shoulder. An MRI of the shoulder was consistent with bursitis and was the likely cause of this patient’s initial Staph infection. Discussion: Toxic shock syndrome is defined by a temperature higher than 38.9°C, hypotension, the typical diffuse erythroderma followed by desquamation, and involvement of at least three organ systems. This case highlights the importance of a good physical exam and the need to consider unlikely sources of infection when confronted with a septic patient. 29
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