A 26 year old female comes in complaining of chronic neck pain for the past 6-8 months. She was seen in the emergency department 4-5 months ago for the same pain and was diagnosed with a neck strain. Since that time, she has had intermittent pain. She states that the pain is worse when she tilts her head forward or backward and also worse when she coughs. There is no history of trauma. She has had no fevers or difficulty swallowing. Her vital signs are normal. Her teeth are in good shape with no signs of abscess. Oropharynx is also normal. No meningeal signs are present. She can move her head about fairly easily, but does notice some pain when flexing her head forward. Neurological examination is normal. She came to the emergency department this time because when she woke up, the pain was worse and she had tingling down her back and into her fingertips when she was bending over to tie her shoes. Xrays of her cervical spine are below (the AP view was unremarkable). What is the abnormality on the x-rays? What is the name of the clinical sign that she was demonstrating? Given these two pieces of information, what was her diagnosis? I’ll post the answers under the x-rays in a couple of days. . . . . . . . . . . . . . . . . . . . . . . . . . . . Final Answer: The patient was indeed exhibiting Lhermitte’s Sign. More common in multiple sclerosis, it can also be caused by other etiologies, including trauma. The presence of this sign and her pain with coughing were what prompted me to order a c-spine x-ray. Scanman hit the x-ray results right on the nose. Atlantoaxial instability with posterior fusion of C2 and C3. The predental space (between the posterior arch of the atlas and the anterior surface of the dens) should be no more than 3mm. See more about interpreting C-spine x-rays in this AAFP article. In this patient, the predental space was 7 mm. The instability and the patient’s symptoms resulted in a sphinchter tightening moment while we scurried around to find a cervical collar. Final diagnosis from our ED was shown on CT scan below – odontoid fracture. Probably subacute, but a fracture nonetheless. This occurred in the rural ED where I moonlight, so she was shipped to a tertiary care center. By the way – I remember from my trauma training that coughing exacerbates the pain of a c-spine fracture, but was unable to find a name to go along with this sign. Anyone know of it? This is the third time I have caught an occult c-spine fracture because the patient complained of pain in the neck with coughing. . . . . . . . . . . . . . .Read More »
Tag Archives: What’s the Diagnosis?
Part of a resident’s job is to learn the ropes in preparing for independent practice. While you’re a resident, you get the benefit of having someone looking over your shoulder to critique you as you determine how you are going to manage patients. I frequently tell residents that different attending physicians practice medicine in different ways. Some practice defensive medicine more than others, some prescribe antibiotics more than others and some work harder than others. The resident’s job is to figure out whose practice they are going to emulate when they begin practicing on their own. That being said, I usually practice conservatively. I don’t tend to shotgun a lot of cases. When residents present cases to me, I make them give me a differential diagnosis and justify why they order the tests that they order. If they can’t justify why they’re doing the tests, then I won’t approve the tests. A resident rotating on the first day in our emergency department presented a case to me and his comments made me think. A woman in her 40’s came in complaining of tender lymph nodes to her neck for the previous 36 hours. That was it. She had pain in her neck when she turned her head to one side and thought she had cancer. The resident ordered a CBC, comprehensive metabolic panel, cardiac enzymes, coags, chest x-ray, urinalysis, influenza swab, and strep test. He wanted to know whether I wanted to do a soft tissue x-ray of the neck or a CT scan of the neck. “So what do you think is causing the swollen glands?” “Maybe strep, maybe cancer.” “Why the cardiac enzymes and coags?” “If it is cancer and she needs surgery, the surgeons require a baseline.” “Any other symptoms besides the swollen glands?” “Nope.” “Why the urinalysis?” “I figured they could do that while they’re getting the pregnancy test.” “Why the pregnancy test?” “She’s going to need x-rays, right?” “We can’t do an abdominal shield?” “Sure.” “Is a $200 flu swab going to be worthwhile?” “It could cause the swollen glands.” “In a patient with no fever, no cough, no pharyngitis, and the incidence of influenza sporadic according to the CDC?” “Didn’t think of that.” He was obviously getting annoyed. “Fine. What do you want me to order?” “Anything else on the physical exam?” “Not really. No nodes anywhere else. No signs of infection.” “Let’s go look.” I’m typing this case up on the fly and was going to finish describing the interaction, but then I thought that maybe you all would like to take a crack at guessing what was causing the bilateral tender lymphadenopathy in the patient’s neck. I’ll give you a couple of hints, since the diagnosis was rather obvious on examination and therefore I can’t tell you what the exam showed. First, the resident didn’t perform a good physical examination and didn’t take a good history. Both of those would have led to the correct diagnosis. Remember, the nodes were bilateral and the diagnosis was obvious. What do you think? I’ll post the answer in the comments in a couple of days. UPDATE APRIL 29, 2010 The answer is posted in the comments section. The point of the post was not to belittle the resident, but was more to make a statement about how another resident felt that residency training was lacking. Another resident in our program lamented that most of their didactic teaching doesn’t involve close physical examination or a thorough history any more. She felt that the overwhelming teaching points during the residency program were to perform procedures and to ...Read More »
A patient presents with an itchy rash to the elbow that started a week prior to presentation. After initially becoming red, the rash developed small blisters then the blisters ruptured, leaving small sores. There is no warmth or fluctuance to the area. The patient saw his primary care physician 5 days ago and was prescribed topical steroids which had no effect on the rash. He also notes that he has been having diarrhea and stomach cramping lately. WBC count and sed rate are normal. What is the diagnosis, how is it treated, and what other disease is it associated with? I’ll post the answer below the picture on Friday. Answer: Dermatitis Herpetiformis Kudos to anon for the perfect answer. Dermatitis herpetiformis is associated with celiac disease. In fact, some clinicians assert that a diagnosis of dermatitis herpetiformis can be used as a “backdoor diagnosis” to celiac disease. DH occurs most commonly in the extensor surfaces of the joints, on the buttocks, and on the back of the neck, but can occur anywhere on the body. It is often misdiagnosed, being confused with drug eruptions, contact dermatitis, dishydrotic eczema, and even scabies. DH is diagnosed by skin biopsy, but multiple biopsies must be taken from diseased and healthy skin as at least one biopsy must show IgA deposits in the dermal layers under immunofluorescence in order to confirm the diagnosis. Long-term treatment is a gluten-free diet, but dapsone (a drug used to treat leprosy – more in-depth information here) may be used to treat the rash in resistant cases or in flares. Read more about dermatitis herpetiformis at the Celiac Sprue Association, eMedicine.com and Medline Plus.Read More »
A 3 year old child is carried into the emergency department because of pain in her left hip. Her mother stated that she woke up with the pain and has refused to walk all day because of the pain. The patient has been running a low grade fever and “just wasn’t acting right.” The mother brought the child to the pediatrician earlier in the day. The pediatrician diagnosed the patient with “double ear infections” and prescribed the child that powerful pink healing elixir otherwise known as amoxicillin. When the mother asked the pediatrician why the child’s hip was hurting, the pediatrician stated that the child “probably slept on it wrong.” The mother stated that the pediatrician never even examined the child’s leg. The child didn’t seem like she was getting better, so the mother brought her to the emergency department for another exam. When I examined the leg, the child held her hip in flexion and cried with any movement of the hip joint. Distal sensory, motor, and circulatory exams were intact to the extent that the patient would allow an exam to be done. There was no appreciable swelling over the joints. She wouldn’t even try to walk. Oh, and her otoscopic exam was within normal limits. I decided to do a few labs. Her WBC was 13,000 with 91% segs. The sedimentation rate was 120. What’s the diagnosis, how is the diagnosis made, and what’s the treatment? . . . . . UPDATE MARCH 25, 2010 Final Diagnosis: Septic arthritis of the hip. Culture showed staph aureus, which is the responsible organism in about half of all cases. Nice summary of septic hip in pediatric patients is at Wheeless’ Online Orthopaedics Kocher criteria include non-weight bearing on the affected side, sedimentation rate > 40, fever, and WBC count > 12,000. When all four criteria are present, septic arthritis has a 99% likelihood. When three criteria are present, the likelihood of septic arthritis is still 93%. Diagnosis requires joint aspiration under either ultrasound or fluoroscopy. Treatment requires surgical drainage and antibiotics. Preliminary treatment is usually a third generation cephalosporin – pending culture results. Keep in mind that MRSA is a growing problem (no pun intended) and that IV vancomycin may be necessary. Also keep in mind that sickle cell patients are prone to salmonella infections in bone and joints. Unfortunately, septic arthritis may lead to many long-term hip problems such as dysplasia, deformities in hip development, and postinfectious arthritis – even with appropriate care. As an aside, I was completely blown away by the number of thoughtful responses and differential diagnoses for this case. I intended it to be just a relatively straightforward case to jog the memories of the attendings and to teach the young grasshoppers. You guys came up with several things that even I hadn’t considered. I’ll have to post these cases more often. Thanks for the education!Read More »
A 39 year old male with a 1 pack per day smoking habit presents with acute onset of shortness of breath and right-sided chest pain. You obtain an x-ray that is shown below. What is the diagnosis? If you said “pneumothorax”, you’re right. You decompress the pneumothorax using a Cook catheter and Heimlich valve. You hear a rush of air through the needle as the patient breathes out. You obtain a second chest x-ray to confirm that the lung is re-expanded. The result is shown below. Now what is your diagnosis? Scroll down for the answer. . . . . . Bullous Emphysema with Pneumothorax When I initially saw the second x-ray, I was going to put in a second chest tube, suspecting that part of the pneumothorax had become walled off or loculated. Then I saw small septations in the right lung field and conferred with the radiologist who agreed that there was no further pneumothorax present. Absence of lung tissue is noted in the right lower lung field in the first x-ray. In the second chest x-ray, a small catheter can be seen in the right lateral 5th interspace. The remaining lung tissue is expanded, but multiple large bullae remain in the upper lung field, simulating a persistent pneumothorax. See additional information about bullous emphysema here: Link #1, Link #2, Picture linkRead More »
An intoxicated 68 year old male involved in a car accident is brought in by ambulance in full spinal immobilization. No complaints of pain, but since the patient is intoxicated you do trauma films, including this c-spine x-ray series. What’s the diagnosis and the treatment? Scroll down after the three x-rays for the answer. . . . . . . Answer: C2 Odontoid Fracture – Type II In addition to the lucency on the odontoid view, if you look close, you can also see that the ring of C2 on the lateral x-ray is disrupted. Read about C2 fractures at Maitrise Orthopedics (best explanation), Wheeless’ Textbook of Orthopedics, LearningRadiology.com, MedscapeRead More »