FacebookRssTwitterInstagramSoundCloud
Generic filters
Exact matches only

SAEM Clinical Images Series: Didn’t See That Coming

hyphema

A 23-year-old healthy male presented to the emergency department with left eye pain, soreness, and blurry vision after being hit in the left eye with a Nerf gun bullet two days prior. He had no prior ophthalmologic history and does not wear corrective lenses.

Left eye: Visual acuity 20/30. Intraocular Pressure 17. Pupil 3mm, irregular, minimally reactive. Slit lamp exam revealing 3+ RBCs, vertical layering of blood along the nasal aspect.

None

Vertical hyphema

Blunt trauma induces shearing forces upon the vasculature of the ciliary body and iris, resulting in the accumulation of red blood cells (RBCs) in the anterior chamber. This space normally contains only clear, aqueous humor. RBCs slowly settle to the bottom of the anterior chamber in a gravity-dependent manner. Classically this develops in a horizontal pattern, but patients who subsequently sleep on their side may experience vertical hyphema formation. Although trauma is the most common etiology, hyphema can occur due to any hematologic abnormality. It is a frequent complication of sickle cell disease. As in all cases of ocular trauma, globe rupture must be immediately ruled out before proceeding with a comprehensive ophthalmologic examination.

The patient had a Grade I hyphema.

Grade 0: No visible layering, but red blood cells within the anterior chamber (microhyphema)

Grade I: Layered blood occupying less than one-third of the anterior chamber

Grade II: Blood filling one-third to one-half of the anterior chamber

Grade III: Layered blood filling one-half to less than total of the anterior chamber

Grade IV: Total filling of the anterior chamber with blood (also known as 8-ball hyphema)

Take-Home Points

  • A hyphema is a collection of blood in the anterior chamber of the eye.
  • Before measuring intraocular pressure, remember to inspect the anterior ocular anatomy with consideration for globe rupture. If this is not excluded, avoid tonometry as it can cause extrusion of aqueous humor and further damage to the globe.
  • Blunt trauma is the most common cause of hyphema. However, non-traumatic hyphema should prompt investigation for hematologic disorders such as Sickle cell disease.

  • Brandt MT, Haug RH. Traumatic hyphema: a comprehensive review. J Oral Maxillofac Surg. 2001 Dec;59(12):1462-70. doi: 10.1053/joms.2001.28284. PMID: 11732035.
  • Gragg J, Blair K, Baker MB. Hyphema. 2022 Dec 26. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2024 Jan–. PMID: 29939579.

Copyright

Images and cases from the Society of Academic Emergency Medicine (SAEM) Clinical Images Exhibit at the 2023 SAEM Annual Meeting | Copyrighted by SAEM 2023 – all rights reserved. View other cases from this Clinical Image Series on ALiEM.

By |2024-09-28T21:19:11-07:00Sep 30, 2024|Ophthalmology, SAEM Clinical Images|
Read More

Diagnosis on Sight: “Stabbing Belly Pain”

A 24-year-old male with a history of microscopic hematuria presented to the emergency department (ED) with left lower quadrant abdominal pain. His pain started about two weeks ago and has been intermittent. He describes the pain as stabbing. He decided to come to the ED today because of the persistent nature of the pain. He denies chest pain, cough, shortness of breath, fevers, nausea, vomiting, diarrhea, constipation, rectal bleeding, dysuria, and increased urinary frequency. His exam revealed a well-appearing male in no acute distress. His abdomen was soft with left lower quadrant tenderness on palpation but no rebound or guarding. A CT Abdomen/Pelvis with IV contrast was obtained with the following images:

Axial view.

Axial View

Coronal View

What is the diagnosis?

Intussusception

Explanation:

Intussusception is a telescoping of a proximal segment of the GI tract into the lumen of the adjacent distal segment of the GI tract.

The axial image of the left side of the abdomen shows a dilated small bowel loop with a target-like appearance, typical of intussusception.  Coronal imaging shows that the intussusception is approximately 4.5 cm long.

Intestinal intussusception is classically a diagnosis associated with childhood. Adult cases of intussusception are quite rare and only account for about 5% of all cases [1]. Only 1-5% of all cases of bowel obstructions are secondary to adult intussusception [1-2].

Etiologies of adult intussusception include [2]:

  • Inflammatory bowel disease
  • Adhesions due to past surgeries
  • Meckel’s diverticulum
  • Benign tumors
  • Malignant tumors
  • Iatrogenic (e.g., intestinal tubes, feeding tubes, gastric surgery)
  • Idiopathic (8-20% of cases)

CT Abdomen/Pelvis is the diagnostic modality of choice [3].

Treatment typically involves surgery with surgical resection. The possibility of a malignant lesion also needs to be assessed.

Case Conclusion:

Surgery was consulted.  The patient’s pain was resolved when they saw the patient in the emergency department.  Therefore, the surgeon did not believe that the patient needed urgent surgery.  However, surgery did recommend a fluoroscopic small bowel series for further evaluation, which ultimately came back unremarkable.  Subsequently, the surgeon’s recommendation was to discharge the patient home with a plan for an outpatient colonoscopy to assess for malignancy.  The colonoscopy was completed only a few days later which only revealed benign polyps.

Want more visual stimulation? Check out the Diagnosis on Sight archives!

References

  1. Marinis A, Yiallourou A, Samanides L, Dafnios N, Anastasopoulos G, Vassiliou I, Theodosopoulos T. Intussusception of the bowel in adults: a review. World J Gastroenterol. 2009;15(4):407.  PMID 19152443.
  2. Zubaidi A, Al-Saif F, Silverman R. Adult Intussusception: A Retrospective Review. Dis Colon Rectum. 2006 Oct;49(10):1546-51. PMID 16990978.
  3. Azar T, Berger DL. Adult intussusception. Ann Surg. 1997;226:134–138.  PMID 9296505.
By |2024-09-18T06:51:17-07:00Sep 25, 2024|Diagnose on Sight, Gastrointestinal, Radiology, Uncategorized|
Read More

SAEM Clinical Images Series: Below the Chin, Badness Lies Within

neck swelling

A 50-year-old male with insulin-dependent Type 2 Diabetes presented to the emergency department with three days of pain and swelling on the right side of his neck. He endorsed progression of his symptoms, reporting that he was now having fevers, myalgias, and intermittent difficulty swallowing solid foods.

 

Vitals: BP 153/96; HR 110; T 100.0°F; RR 16; O2 sat 97%

General: Appears uncomfortable

HEENT: Mild right-sided facial swelling. No trismus. No gingival inflammation or swelling or induration to suggest abscess. There is focal swelling and tenderness to palpation, without overlying erythema, throughout the right submandibular triangle, and along the sternocleidomastoid.

MSK: Limited active right shoulder range of motion secondary to pain

WBC: 10.4

Hgb: 14.4

Plts: 213

Na: 131

K: 3.7

A1C: 13

Lemierre syndrome (LS) is a rare complication of bacterial pharyngitis/tonsillitis and involves an extension of the infection into the lateral pharyngeal spaces of the neck with subsequent septic thrombophlebitis of the internal jugular vein (as seen on CT). Patients may present with trismus, dysphagia, and fever. Due to the possibility of widespread septic emboli, patients may experience sequelae of systemic infection with dyspnea, focal neurologic deficits, and abdominal pain. Treatment consists of prompt antibiosis and rapid source control.

Most cases of bacteremia in Lemierre syndrome are caused by Fusobacterium necrophorum, an anaerobic gram-negative rod that colonizes the oropharynx. This bacterium causes platelet aggregation and thrombus formation through hemagglutinin production and direct activation of the coagulation cascade. However, up to one-third of patients are found to have a polymicrobial infection with streptococcus and staphylococcus species frequently present.

Take-Home Points

  • Lemierre syndrome (LS) is a rare infection. However, the incidence of LS has been increasing in recent decades due to more judicious use of antibiotics for pharyngitis.
  • A high index of suspicion must be maintained to diagnose Lemierre syndrome, with special attention to alternative diagnoses such as Ludwig angina, retropharyngeal abscess, or meningitis.
  • A thorough investigation of associated symptoms is imperative as these may represent sequelae of septic emboli.

  • Foo EC, Tanti M, Cliffe H, Randall M. Lemierre’s syndrome. Pract Neurol. 2021 Oct;21(5):442-444. doi: 10.1136/practneurol-2021-002928. Epub 2021 May 7. PMID: 33963085.
  • Forrester LJ, Campbell BJ, Berg JN, Barrett JT. Aggregation of platelets by Fusobacterium necrophorum. J Clin Microbiol. 1985 Aug;22(2):245-9. doi: 10.1128/jcm.22.2.245-249.1985. PMID: 4031037; PMCID: PMC268368.

Copyright

Images and cases from the Society of Academic Emergency Medicine (SAEM) Clinical Images Exhibit at the 2023 SAEM Annual Meeting | Copyrighted by SAEM 2023 – all rights reserved. View other cases from this Clinical Image Series on ALiEM.

By |2024-09-06T22:10:20-07:00Sep 20, 2024|ENT, Infectious Disease, SAEM Clinical Images|
Read More

SAEM Clinical Images Series: Dusky Feet

dusky

A 94-year-old female with a past medical history of hypertension, coronary artery disease, chronic venous stasis, and permanent pacemaker placement initially presented to triage complaining of left hip pain in the setting of a fall shortly prior to arrival. Upon further evaluation, she endorsed developing sudden bilateral lower extremity weakness causing her to fall to the floor. She then experienced excruciating pain from her umbilicus down to her groin, hips, and legs (left greater than right), describing it as “being in labor.” She denied any recent fevers, chills, chest pain, shortness of breath, leg swelling, back pain, urinary symptoms, or bloody stools,

 

Vitals: BP 109/58; Temp 36°C; Pulse 89; RR 18; SpO2 96%

Constitutional: Uncomfortable

Abdominal: No tenderness to palpation or distension No visible or palpable hernias.

Neuro: Awake, alert, oriented x 3. 0/5 strength in bilateral lower extremities. 5/5 strength in bilateral upper extremities.

Extremities: Bilateral radial pulses intact and palpable. Bilateral feet with chronic venous stasis. They are dusky in appearance. They are cool to the touch with poor capillary refill. Palpable left dorsalis pedis pulse, absent right dorsalis pedis pulse. Within 10 minutes of initial exam, bilateral lower extremity pulses are no longer palpable or dopplerable.

Hemoglobin/Hematocrit: 13.2 g/dL, 41.5%

BUN/Creatinine: 27 mg/dL, 0.99 mg/dL

Troponin: 20 (reference range <40)

Lactic acid: 3.61

This is a case of a Type A aortic dissection. An aortic dissection is a vascular emergency that occurs when the inner wall of the aorta is weakened to the point where it tears and causes blood to accumulate between the inner and middle layers. The type of aortic dissection depends on the location of the tear; Type A dissections involve the ascending aorta whereas Type B dissections involve the descending portion of the aorta. Patients most commonly present with severe chest and back pain, however, a combination of these symptoms with abdominal and neurological complaints are sometimes seen. The exam can include hypertension, wide pulse pressure, diastolic murmur, muffled heart sounds, loss of pulses, and even neurological deficits. While a history and physical exam can strongly suggest the diagnosis, a Computed Tomography Angiography (CTA) of the chest, abdomen, and pelvis can confirm it.

Aortic dissection malperfusion syndromes imply end-organ ischemia to the vascular distributions being compromised. There can be renal, mesenteric, neurological, and even extremity malperfusion. If malperfusion is already present during the diagnosis of the aortic dissection, this can increase the patient’s mortality. In the case of this specific patient, there was lower extremity malperfusion and thus ischemia secondary to the extension of her dissection from the diaphragm to the bilateral external iliac arteries with likely occlusion of the vessels by the dissection flap. This explained her lower extremity discoloration and pulse deficits.

Take-Home Points

  • The diagnosis of an aortic dissection is made via a CTA of the chest, abdomen, and pelvis.
  • Aortic dissections with malperfusion syndromes have increased mortality.
  • Lower extremity malperfusion includes loss of extremity pulses with pain, paresthesias and/or paralysis.

  • Levy D, Goyal A, Grigorova Y, Farci F, Le JK. Aortic Dissection. StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing. 2023 Jan.
  • Crawford TC, Beaulieu RJ, Ehlert BA, Ratchford EV, Black JH 3rd. Malperfusion syndromes in aortic dissections. Vasc Med. 2016 Jun;21(3):264-73. doi: 10.1177/1358863X15625371. Epub 2016 Feb 8. PMID: 26858183; PMCID: PMC4876056.
  • Harris C, Croce B, Cao C. Type A aortic dissection. Ann Cardiothorac Surg. 2016 May; 5(3):256. doi: 10.21037/acs.2016.05.04. PMID: 27386417; PMCID: PMC4893534.
  • Gargiulo M, Bianchini Massoni C, Gallitto E, Freyrie A, Trimarchi S, Faggioli G, Stella A. Lower limb malperfusion in type B aortic dissection: a systematic review. Ann Cardiothorac Surg. 2014 Jul; 3(4):351-67. doi: 10.3978/j.issn.2225-319X.2014.07.05. PMID: 25133098; PMCID: PMC4128931.
  • Hasan I, Brown JA, Serna-Gallegos D, Zhu J, Garvey J, Yousef S, Sultan I. Lower-extremity malperfusion syndrome in patients undergoing proximal aortic surgery for acute type A aortic dissection. JTCVS Open. 2023 May 6;15:1-13. doi: 10.1016/j.xjon.2023.04.015. PMID: 37808049; PMCID: PMC10556830.

Copyright

Images and cases from the Society of Academic Emergency Medicine (SAEM) Clinical Images Exhibit at the 2023 SAEM Annual Meeting | Copyrighted by SAEM 2023 – all rights reserved. View other cases from this Clinical Image Series on ALiEM.

By |2024-09-06T22:00:28-07:00Sep 16, 2024|Cardiovascular, SAEM Clinical Images|
Read More

SAEM Clinical Images Series: What’s Coming Out of Your Eye?

open globe

A 32-year-old male with no significant past medical history presented to the emergency department (ED) from an outside hospital for further management of right eye pain and vision loss sustained after he was struck by a metal wire while at work. The patient presented to an outside “eye doctor” and was told to go to the nearest hospital for evaluation. At the outside hospital, he was given analgesia, antiemetics, and a tetanus booster, and transferred to our hospital for ophthalmologic evaluation. On arrival to our emergency department, the patient expressed continued eye pain with bloody discharge as well as blurry vision from his right eye. He had no other complaints and denied any other trauma or loss of consciousness during the event.

 

eye

Right Eye: 12 mm corneoscleral laceration with superior iris prolapse through the laceration at the 12 o’clock position, approximately 6 mm in length. Pupil 3 mm, teardrop shaped, and reactive without relative afferent pupillary defect. Seidel test positive on fluorescein stain. Conjunctival injection superiorly. Visual acuity: able to count fingers. Extraocular movements intact. Ocular pressure deferred. 1 mm superior eyelid laceration.

CT Orbits/Sella w/ IV Contrast: No acute orbital fracture. No evidence of retrobulbar hematoma or emphysema. Intraconal and extraconal fat planes are preserved. Extraocular muscles are symmetric and normal in position. The globes are grossly unremarkable. Absent right lens.

Open Globe Injury

In the photo, you can see the teardrop shape of the pupil, conjunctival injection, corneal laceration, and superior iris prolapse.

Tonometry and ocular ultrasound (US) are generally not recommended as you could squeeze more liquid out of the eye or increase the intraocular pressure even more, pushing the iris further out. An emergent ophthalmology consult is needed to plan for operative repair. The patient should be given an eye shield, IV antibiotics, and tetanus prophylaxis. Avoid increasing intraocular pressure by using anti-emetics, analgesia, and bed elevation. Recommended antibiotics are vancomycin and a third-generation cephalosporin to prevent endophthalmitis. Postoperatively, these patients need IV antibiotics x 48 hours, steroid eye drops, antibiotic ointment, an eyepatch, and recommendations for no heavy lifting, bending, or strenuous activity, and head of bed should be elevated at 45 degrees.

Take-Home Points

  • Open globe injuries present as eye pain, vision loss, teardrop pupil, afferent pupillary defect, and a corneal laceration.
  • Avoid ocular US or tonometry in these patients as these could increase intraocular pressure further and worsen the injury.
  • Management includes an eye shield, head of bed elevation, avoiding ocular manipulation, analgesia, and antiemetics. Update tetanus and start IV antibiotics – vancomycin and a third-generation cephalosporin. Consult ophthalmology emergently.

  • Open globe injury: Assessment and preoperative management. American Academy of Ophthalmology. (2023, March 23). https://www.aao.org/eyenet/article/open- globe-injury
  • Ahmed Y, Schimel AM, Pathengay A, Colyer MH, Flynn HW Jr. Endophthalmitis following open-globe injuries. Eye (Lond). 2012 Feb;26(2):212-7. doi: 10.1038/eye.2011.313. Epub 2011 Dec 2. PMID: 22134598; PMCID: PMC3272210.

Copyright

Images and cases from the Society of Academic Emergency Medicine (SAEM) Clinical Images Exhibit at the 2023 SAEM Annual Meeting | Copyrighted by SAEM 2023 – all rights reserved. View other cases from this Clinical Image Series on ALiEM.

By |2024-09-06T22:03:57-07:00Sep 13, 2024|Ophthalmology, SAEM Clinical Images|
Read More

SAEM Clinical Images Series: An Unusual Foreign Body

vp shunt

A 61-year-old female with a past medical history of hypertension, hyperlipidemia, type 2 diabetes, and normal pressure hydrocephalus s/p VP shunt (last revision nine months ago) presented to the Emergency Department (ED) for evaluation after noticing a “string” coming out of her anus today. Associated symptoms included nausea and a mild headache for one day, and one episode of vomiting prior to arrival. The patient denied abdominal pain, dizziness, fever, chills, diarrhea, and constipation. She had no other complaints on a complete review of systems. Past surgical history was significant for laparoscopic ventral hernia repair with mesh and lysis of adhesions (three years ago), as well as prior appendectomy, cholecystectomy, c-section, and right nephrectomy.

 

bowel

Vitals: Temp 98.4°F (36.9°C); BP 110/56; HR 64; RR 16; SpO2 100%

General: No acute distress, well appearing.

Neck: Supple, non-tender, no meningismus, full and painless range of motion.

Abdomen: Soft, nontender, nondistended. No peritoneal signs.

Neuro: Awake, alert and oriented x3, no focal neurologic deficits.

Rectum: Narrow lumen tube-like structure protruding from anus. Soft stool present at anus with no blood or melena. Non-tender rectal exam.

Complete Blood Count (CBC): No leukocytosis, no anemia

Comprehensive Metabolic Panel (CMP): Within normal limits

Ventriculoperitoneal shunt erosion into the intestinal tract

Diagnosis can be established with abdominal imaging including VP Shuntogram X-ray series. A CT abdomen/pelvis would also be confirmatory imaging while assisting in ruling out other intra-abdominal complications such as bowel perforation, abscesses or other diseases.

Broad-spectrum empiric antibiotics with CNS coverage should be started for treatment of presumed intra-abdominal, bloodstream, and/or CNS infection. General surgery and neurosurgery should be consulted emergently for evaluation. Bloodwork and a full infectious workup including blood cultures should be done. CSF cultures should be considered as well, in consultation with a neurosurgeon. Patients are at high risk of bacterial spread to the abdomen or retrograde spread up the ventriculoperitoneal shunt leading to peritonitis, peritoneal abscess, ventriculitis, meningitis, or sepsis. Further indicated invasive/surgical interventions should be deferred to general surgery and neurosurgery consultants. Our patient had a confirmatory CT abdomen/pelvis showing the VP shunt catheter perforation into the sigmoid colon and exiting through the rectum. The patient was started on vancomycin, cefepime, and flagyl. General surgery and neurosurgery were consulted and the patient was taken the same day to the OR for laparoscopy and externalization of VP shunt from bowel.

Take-Home Points

  • Bowel perforation is a rare but serious complication of ventriculoperitoneal shunts.
  • Diagnosis should be considered even in patients who present with no meningeal or peritonitic signs.
  • Imaging should be obtained to confirm diagnosis, and broad-spectrum antibiotics with CNS coverage should be started early.
  • General surgery and neurosurgery should be consulted emergently for further operative interventions.

  • Paff, M, Alexandru-Abrams, D, Muhonen, M, Loudon, W. (2018). Ventriculoperitoneal shunt complications: A review. Interdisciplinary Neurosurgery, 13, 66-70.
  • Bales J, Morton RP, Airhart N, Flum D, Avellino AM. Transanal presentation of a distal ventriculoperitoneal shunt catheter: Management of bowel perforation without laparotomy. Surg Neurol Int. 2016 Dec 28;7(Suppl 44):S1150-S1153. doi: 10.4103/2152-7806.196930. PMID: 28194303; PMCID: PMC5299151.

Copyright

Images and cases from the Society of Academic Emergency Medicine (SAEM) Clinical Images Exhibit at the 2023 SAEM Annual Meeting | Copyrighted by SAEM 2023 – all rights reserved. View other cases from this Clinical Image Series on ALiEM.

By |2024-09-06T22:04:47-07:00Sep 9, 2024|Gastrointestinal, Radiology, SAEM Clinical Images|
Read More

SAEM Clinical Images Series: Pediatric Neck Mass

neck mass

A 5-year-old female presented to the emergency department (ED) with a one-year history of gradually increasing anterior neck swelling. The patient had no significant past medical history. She also endorsed three weeks of cough and congestion, and one day of muffled voice. She denied difficulty swallowing, fatigue, cold intolerance, or hair and nail changes.

Vitals: BP 87/62; Pulse 80; Temp 36°C (96.8°F); Resp 21; SpO2 99%

Constitutional: No distress. Able to speak in full sentences

HEENT: Normocephalic and atraumatic. Right Ear: External ear normal. Left Ear: External ear normal. Congestion present. Mucous membranes are moist. Tonsils 4+ bilaterally with no exudate.

Neck: Approximately 3 cm x 4 cm mass on the anterior neck that does not move on protrusion of the tongue. Mass is midline and inferior to the laryngeal prominence. No associated erythema, tenderness to palpation, or drainage. No enlarged surrounding lymph nodes on palpation.

Cardiovascular: Normal rate, regular rhythm, and normal heart sounds.

Pulmonary: Breath sounds normal, no stridor, no respiratory distress, no decreased breath sounds, and no wheezes.

Abdominal: Soft. No distention or tenderness.

Neurological: Alert and normal muscle tone.

Thyroid stimulating hormone (TSH): > 100 (ref 0.50 – 4.50 MCU/ML).

Free T4: 0.5 (ref 0.8-2.0 NG/DL)

Ultrasound of the neck revealed an enlarged thyroid gland with lobular contours and diffuse hypoechoic echogenicity, without noticeable nodules, fluid collection, or lymphadenopathy.

Differential diagnosis of a neck mass in a pediatric patient includes branchial cleft cyst, thyroglossal duct cyst, cystic hygroma, laryngocele, dermoid cyst, teratoma, thymic cyst, hemangioma, ranula (mucocele), thyroid mass, enlarged lymph node, lymphoma, rhabdomycosarcoma, neuroblastoma, and melanoma [1]. When evaluating a neck mass, reviewing whether the mass is congenital vs acquired and midline vs lateral will help with narrowing down the differential diagnosis. The photo reveals a prominent anterior lower neck mass with the outline of right lobe of the thyroid gland clearly visible.

The patient was diagnosed with hypothyroidism with goiter, likely Hashimoto’s thyroiditis. She was discharged from the ED on levothyroxine 25 mcg daily with endocrinology outpatient follow-up. Levothyroxine monotherapy is the standard of care in hypothyroidism management [2]. Thyroid peroxidase and thyroglobulin antibodies were found to be positive on subsequent labwork, which confirmed diagnosis.

Take-Home Points

  • Enlarged goiter in the setting of hypothyroidism should be considered in a pediatric patient with a midline lower neck mass.
  • When suspecting hypothyroidism, thyroid stimulating hormone (TSH) and free T4 should be included in the evaluation. An ultrasound and thyroid antibodies may also be helpful to confirm diagnosis.

  • Geddes G, Butterly MM, Patel SM, Marra S. Pediatric neck masses. Pediatr Rev. 2013 Mar;34(3):115-24; quiz 125. doi: 10.1542/pir.34-3-115. PMID: 23457198.
  • Jonklaas J, Bianco AC, Bauer AJ, Burman KD, Cappola AR, Celi FS, Cooper DS, Kim BW, Peeters RP, Rosenthal MS, Sawka AM; American Thyroid Association Task Force on Thyroid Hormone Replacement. Guidelines for the treatment of hypothyroidism: prepared by the american thyroid association task force on thyroid hormone replacement. Thyroid. 2014 Dec;24(12):1670-751. doi: 10.1089/thy.2014.0028. PMID: 25266247; PMCID: PMC4267409.

Copyright

Images and cases from the Society of Academic Emergency Medicine (SAEM) Clinical Images Exhibit at the 2023 SAEM Annual Meeting | Copyrighted by SAEM 2023 – all rights reserved. View other cases from this Clinical Image Series on ALiEM.

By |2024-08-19T10:18:25-07:00Aug 30, 2024|Endocrine-Metabolic, Pediatrics, SAEM Clinical Images|
Read More
Go to Top