A 46-year-old female with a history of diabetes and morbid obesity presents to the emergency department (ED) with difficulty walking after she tripped on a curb and fell onto her right knee. You obtain X-rays (Figure 1). What is your suspected diagnosis? What is your initial workup in the ED? What is your management and disposition?
Figure 1. AP/lateral x-ray of the right knee. Author’s own images.
A 32-year-old male with a past medical history of asthma presents with a two-day history of cracked lips and progressively worsening oral pain, associated with white discharge, foul smell, and a metallic taste. The patient presented to urgent care and was sent to the Emergency Department (ED) for a sepsis workup. The worsening sores caused him to eat and drink less, including the gum he normally chews. He endorses oral sex with one female partner one week ago. No recent dental work. He recently completed a prednisone course for the same issue. Denies fevers, tooth pain, tongue pain, dysphagia, odynophagia, chest pain, difficulty breathing, abdominal pain, genitourinary discharge or lesions, sick contacts, trismus, facial swelling, or voice changes.
Vitals: T 102°F; HR 125; BP 114/81; RR 19; SPO2 94%
General: No distress. Alert and oriented.
Skin: Warm and dry, no rash.
Ears: Hearing grossly intact.
Nose: Bilateral nares patent, no bleeding.
Neck: Soft, symmetric, no adenopathy, non-tender.
Extraoral: Ulcerations on upper and lower lips.
Intraoral: 1 small ulcer on tip of the tongue on the right. Inflamed, erythematous and bleeding gingiva and interdental papilla. Uvula midline. Maximal interincisal opening ~ 40 mm. Teeth intact.
Heart: Regular rate and rhythm, no murmur.
Lungs: Clear to auscultation, air entry to bases.
Abdomen: Soft, non-tender, no guarding.
GU: Patient denied symptoms and declined exam.
White blood cell (WBC) count: 11.4
pH: 7.386
Lactic Acid: 1.7
Urinalysis (UA): Negative Blood. Culture sent.
STI workup including HSV titers and HIV testing obtained and pending.
The differential is broad, including ANUG (acute necrotizing ulcerative gingivitis) also known as “trench-mouth” and, more commonly, primary herpes gingivostomatitis and candidal infection. Consideration of periodontitis and dental abscess/pulpitis is necessary. The spectrum of erythema multiforme, Stevens-Johnson syndrome, and toxic epidermal necrolysis is important to include, as well as autoimmune disorders which commonly have mucosal involvement such as systemic lupus erythematosus (SLE), Behcet’s, and Crohn’s disease. Scurvy, although uncommon, can also present with gingival erythema and pain.
Consider the presence of a known autoimmune disorder, chronic systemic disease, or an immunocompromised state. History should include new sexual partners, dietary changes, and changes in dental hygiene. We were concerned given this patient’s vital signs on presentation, and alongside a sepsis workup, called dental to the bedside. They immediately asked the patient about the recent use of chewing gum and its flavor, and the patient described a recent preference for cinnamon gum, which he had been using for about 1-2 weeks. The dental consultant came to the diagnosis immediately. A literature search reveals a phenomenon called “cinnamon-contact stomatitis” which is believed to be caused by a delayed T-cell-mediated hypersensitivity reaction. It is characterized by white patches on the mucosa with erythema and erosions on the buccal mucosa and lateral tongue. Treatment consists of discontinuation of the offending agent, and corticosteroids in patients with severe symptoms. Lesions can take up to two weeks to heal, and appropriate follow-up with dental is needed to monitor for resolution.
How can I keep up with so many landmark articles in Emergency Medicine (EM)? This is an often asked question we hear from interns and residents. Published in 2013 (1st edition) and 2016 (2nd edition), the “52 Articles in 52 Weeks” compendium is a compilation of 52 journal articles provided interns a list to read over a 52-week period, at an average pace of 1 journal article per week. We present the updated 2022 compilation.
We primarily build off of the original list from 2016. These 52 articles were refreshed such that newer landmark articles replaced those on the same topic. Additional publications were considered if they were cited on MDCalc’s site or reviewed on clinical EM websites like REBEL EM, Wiki Journal Club, and The Bottom Line during 2016-2022. A panel of 7 EM faculty with a niche in graduate medical education could also add publications for consideration. A total of 71 articles were scored by these 7 faculty using the Best Evidence in Emergency Medicine (BEEM) score with an EM intern audience in mind.
Question for reviewer: Assuming that the results of this article are valid, how much does this article impact on EM clinical practice?
| BEEM Score | Description (revised for EM intern audience) |
|---|---|
| 1 | Useless information |
| 2 | Not really interest, not really new, changes nothing |
| 3 | Interesting and new, but doesn’t change practice |
| 4 | Interesting and new, has the potential to change practice |
| 5 | New and important: this would probably change practice for some EM interns |
| 6 | New and important: this would change practice for most EM interns |
| 7 | This is a “must know for EM interns |
The final list of the top 52 articles, based on the mean BEEM scores, are presented below in descending rank order. A bonus 53rd article is also listed because there was a 4-way tie for articles #50-53. Feel free to copy-paste this list into your own Google Sheets or Excel spreadsheet for list sortability.
Welcome to the AIR Neurology 2022 Module! After carefully reviewing all relevant posts in the past 12 months from the top 50 sites of the Social Media Index, the ALiEM AIR Team is proud to present the highest quality online content related to related to neurologic emergencies in the Emergency Department. 5 blog posts met our standard of online excellence and were approved for residency training by the AIR Series Board. More specifically, we identified 2 AIR and 3 Honorable Mentions. We recommend programs give 3 hours of III credit for this module.
In an effort to truly emphasize the highest quality posts, we have 2 subsets of recommended resources. The AIR stamp of approval is awarded only to posts scoring above a strict scoring cut-off of ≥30 points (out of 35 total), based on our scoring instrument. The other subset is for “Honorable Mention” posts. These posts have been flagged by and agreed upon by AIR Board members as worthwhile, accurate, unbiased, and appropriately referenced despite an average score.
Interested in taking the AIR quiz for fun or asynchronous (Individualized Interactive Instruction) credit? Please go to the above link. You will need to create a free, 1-time login account.
| Site | Article | Author(s) | Date | Label |
|---|---|---|---|---|
| EMDocs | Cauda Equina Syndrome: Why do we miss it? How to improve? | John H. Priester, MD; Mark Bisanzo, MD | 13 Jun 2021 | AIR |
| EMCrit | Spinal Epidural Abscess | Josh Farkas, MD | 25 Feb 2022 | AIR |
| Clinical Monster | Must Be Blood on the Brain | Molly Piccione, DO | 3 June 2021 | HM |
| EMCrit | Neuro emergencies in pregnancy | Josh Farkas, MD | 23 Feb 2022 | HM |
| EMCrit | Neuro-onc emergencies | Josh Farkas, MD | 2 June 2022 | HM |
(AIR = Approved Instructional Resource; HM = Honorable Mention)
If you have any questions or comments on the AIR series, or this AIR module, please contact us! More in-depth information regarding the Social Media Index.
Thank you to the Society of Academic Emergency Medicine (SAEM) and the Council of EM Residency Directors (CORD) for jointly sponsoring the AIR Series! We are thrilled to partner with both on shaping the future of medical education.
Welcome to the AIR Orthopedic Upper Extremity Module! After carefully reviewing all relevant posts from the top 50 sites of the Social Media Index, the ALiEM AIR Team is proud to present the highest quality online content related to related to Orthopedic Upper Extremity emergencies in the Emergency Department. 3 blog posts met our standard of online excellence and were curated and approved for residency training by the AIR Series Board. We identified 1 AIR and 2 Honorable Mentions. We recommend programs give 2 hours (about 40 minutes per article) of III credit for this module.
In an effort to truly emphasize the highest quality posts, we have 2 subsets of recommended resources. The AIR stamp of approval is awarded only to posts scoring above a strict scoring cut-off of ≥30 points (out of 35 total), based on our scoring instrument. The other subset is for “Honorable Mention” posts. These posts have been flagged by and agreed upon by AIR Board members as worthwhile, accurate, unbiased, and appropriately referenced despite an average score.
Interested in taking the AIR quiz for fun or asynchronous (Individualized Interactive Instruction) credit? Please go to the above link. You will need to create a free, 1-time login account.
| Site | Article | Author | Date | Label |
|---|---|---|---|---|
| EMDocs | Finger Amputation | Christopher J. Nelson, MD | 21 May 2022 | AIR |
| ALiEM | Point Tender | Justine Ko, MD; M. Terese Whipple, MD; Alexander J. Tomesch, MD | 23 May 2022 | HM |
| Peds EM Morsels | Nail Bed Lacerations | Christyn Magill, MD | 3 Sep 2021 | HM |
(AIR = Approved Instructional Resource; HM = Honorable Mention)
If you have any questions or comments on the AIR series, or this AIR module, please contact us! More in-depth information regarding the Social Media Index.
Thank you to the Society of Academic Emergency Medicine (SAEM) and the Council of EM Residency Directors (CORD) for jointly sponsoring the AIR Series! We are thrilled to partner with both on shaping the future of medical education.
A 32-year-old female presents to the emergency department with right foot pain after rolling her ankle during dance class. On exam, there is mild swelling and tenderness over the 5th metatarsal. The above x-ray was obtained (Figure 1: Case courtesy of Dr. Henry Knipe, Radiopaedia.org, rID: 28104). (more…)
Welcome to the AIR Cutaneous Module! After carefully reviewing all relevant posts from the top 50 sites of the Social Media Index, the ALiEM AIR Team is proud to present the highest quality online content related to related to cutaneous emergencies in the Emergency Department. 6 blog posts met our standard of online excellence and were curated and approved for residency training by the AIR Series Board. We identified 0 AIR and 6 Honorable Mentions. We recommend programs give 3 hours (about 30 minutes per article) of III credit for this module.
In an effort to truly emphasize the highest quality posts, we have 2 subsets of recommended resources. The AIR stamp of approval is awarded only to posts scoring above a strict scoring cut-off of ≥30 points (out of 35 total), based on our scoring instrument. The other subset is for “Honorable Mention” posts. These posts have been flagged by and agreed upon by AIR Board members as worthwhile, accurate, unbiased, and appropriately referenced despite an average score.
Interested in taking the AIR quiz for fun or asynchronous (Individualized Interactive Instruction) credit? Please go to the above link. You will need to create a free, 1-time login account.
| Site | Article | Author | Date | Label |
|---|---|---|---|---|
| EMDocs | Tattoo related complications in the ED | Nathan LaDeaux, MD and Benjamin Schnapp, MD | 5/9/22 | HM |
| EMDocs | EM@3AM: Herpes Zoster | Elizabeth Adams, MD and Samuel Parnell, MD | 3/26/22 | HM |
| RCEM Learning | Burns | Jonathan Matthews, Rajan Atwal | 11/02/21 | HM |
| RCEM Learning | Common Childhood Exanthems | Maya Naravi | 7/6/21 | HM |
| EMCrit | Anaphylaxis | Josh Farkas, MD | 8/5/21 | HM |
| Peds EM Morsels | Pediatric Ramsay Hunt Syndrome | Sean Fox, MD | 6/17/22 | HM |
(AIR = Approved Instructional Resource; HM = Honorable Mention)
If you have any questions or comments on the AIR series, or this AIR module, please contact us! More in-depth information regarding the Social Media Index.
Thank you to the Society of Academic Emergency Medicine (SAEM) and the Council of EM Residency Directors (CORD) for jointly sponsoring the AIR Series! We are thrilled to partner with both on shaping the future of medical education.
