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Tag Archives: What’s the Diagnosis?

What's The Diagnosis #4

A 13 year old boy comes in after being thrown from an ATV while riding in a field. His arm is painful and deformed at the elbow. He has numbness in his thumb, index, and middle fingers. What is the diagnosis? What problems do you have to worry about? What should you monitor? What is his prognosis? Scroll down for the answer. . . . . . . . . . . . . . . . . Answer: Type III Supracondylar Elbow Fracture With sensory deficit in the first three fingers of the hand, the patient likely has a median nerve injury. Also note the darker grey fat pad immediately posterior to the distal fracture segment. Gartland Classification of Supracondylar Fractures includes Type I: non-displaced Type II: displaced, but with intact posterior cortex Type III: displaced with complete dissociation of fracture segments Vascular compromise occurs in up to 20% of children with supracondylar fractures. If missed, can develop compartment syndrome or ischemic contractures. Compartment syndrome occurs infrequently and may be difficult to diagnose in presence of an associated median nerve palsy since the pain associated with compartment syndrome is diminished. May consider applying a continuous pulse oximeter to help monitor perfusion. Median nerve injury can occur in up to half of patients with Type III supracondylar fractures. Radial nerve injury can occur in up to 25% of patients with Type III supracondylar fractures. Supracondylar fractures can often be fixed by percutaneous pinning, but may require open reduction and/or exploration if vascular injuries or if unable to achieve satisfactory reduction using closed manipulation. Neurologic deficits often, but not always, resolve in 3-6 months. Range of motion in joint may not return for up to 12 months. References: Wheeless’ Textbook of Orthopaedics Orthopaedia.com

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What's the Diagnosis #3

WARNING – GROSS PICTURE BELOW You probably know what this is, but can you spell it? What are risk factors for it? And how do you manage it? Think about it for a minute and then scroll down for the answer. Answer: Wound dehiscence with evisceration (the bulge from the wound at the 1:00-2:00 position is bowel) A good nursing article about wound dehiscence is here. The following are excerpts about wound dehiscence taken from Sabiston’s Textbook of Surgery, 18th ed. Wound dehiscence occurs in approximately 1% to 3% of patients who undergo an abdominal operation – usually 7 to 10 days postop. It may be related to technical errors in placing sutures too close to the edge, too far apart, or under too much tension. A deep wound infection is one of the most common causes of localized wound separation. Many factors contribute to wound dehiscence including technical errors in fascial closure, emergency surgery, advanced age, wound infection, obesity, chronic steroid use, previous wound dehiscence, malnutrition, radiation therapy, and other systemic diseases such as diabetes or renal failure. Dehiscence may occur without warning. Evisceration, such as in this case, makes the diagnosis obvious. Serosanguinous drainage precedes wound dehisence in 25% of patients. Probing the wound with a sterile, cotton-tipped applicator or gloved finger may also detect the dehiscence. Treatment depends on the extent of fascial separation and the presence of evisceration or significant intra-abdominal contamination (intestinal leak, peritonitis). A small dehiscence may be managed by packing the wound with saline-moistened gauze and using an abdominal binder. If evisceration occurs, cover the intestines with a sterile, saline-moistened towel and contact the surgeon immediately. The patient will require urgent surgical closure of the wound. Management of wound dehiscence may involve placing absorbable mesh, skin grafts, and/or flaps to reconstruct the abdominal wall. Wound vacuums remove interstitial fluid, lessen bowel edema, decrease wound size, reduce bacterial colonization, increase perfusion, and improve healing. Successful closure of the fascia can be achieved in 85% of cases of abdominal wound dehiscence.

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What's the Diagnosis #2

A 27 year old patient has had a sore throat for the past 10 days. He received antibiotics from his primary care physician without a lot of improvement. He comes in on a Saturday because he is out of antibiotics and wants a refill. He doesn’t appear uncomfortable. He doesn’t have any problems swallowing. No fever. He does have pain on the left side of his neck along a swollen lymph node. It hurts for him to turn his head to the left. On exam, his throat is red, but there is no pus and his airway is patent. There are several swollen and tender lymph nodes in the neck. He complains of pain turning his head to the left side. He doesn’t have any signs of meningitis. Nothing else seems abnormal on his physical exam. Think about what your differential diagnosis would be and what you’d do to work the patient up … if anything. Now look at the x-ray below. What is the calcified foreign body in the front of his neck? Are there any other abnormalities? What other test(s) would you do and who would you call? Scroll down for answers and other pictures. The calcified foreign body in the front of the neck is actually the hyoid bone. Coroners look to see whether this bone is intact during autopsy since a broken hyoid bone suggests that strangling took place. The neck x-ray shows prevertebral soft tissue swelling. Remember 7 mm at C2 and 22mm at C7. Got the diagnosis now? Answer is retropharyngeal abscess. More about the diagnosis here and here. CT scans of the neck below.

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What's The Diagnosis?

25 year old patient presents with the rash below for the previous two weeks. Started on Acyclovir for herpes by primary care physician, but not getting better.  Mouth was sore previous week but no lesions noted. Now no mouth symptoms. What’s the diagnosis? (Picture used with patient’s permission) Answer here and here.

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