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SAEM Clinical Images Series: Rash and Fever in a Returned Traveler

A 21-year-old otherwise healthy female presented to the Emergency Department with a fever after recently returning from Ghana. She reported intermittent fever, headache with photophobia, diarrhea, joint pains, and generalized weakness. She also noticed a diffuse, intermittently pruritic rash on her trunk and extremities. While in Ghana, she volunteered at a refugee hospital, ate street food, and was exposed to local animals. Prior to her stay in Ghana, she spent a week in Bali. She reported receiving vaccines before leaving but was unsure which vaccines she received.

petechia

Vitals: Temp 102.9°F; HR 126; BP 114/78; RR 18; O2 sat 98% on room air

General: Uncomfortable-appearing with her eyes closed on initial exam.

HEENT: PERRL, EOMI, Normal conjunctiva without erythema; Full ROM of neck without neck stiffness/rigidity.

GI: Abdomen soft, non-tender, nondistended. No palpable masses, hepatomegaly or splenomegaly.

MSK: No evidence of joint effusion, erythema or tenderness.

Skin: Diffuse maculopapular rash to all four extremities and chest with confluent erythema noted in some areas intermixed with small areas of spread skin, scattered papules around the ankles consistent with mosquito bites.

White Blood Cell (WBC) Count: 2.78 k/mm3

Hemoglobin: 12.9 gm/dL

Hematocrit: 38 %

Platelets: 125.3/mm3

ESR: 10 mm/hr

CRP: 9.37 mg/L

AST: 42 U/L

ALT: 58 U/L

This is a case of Dengue Fever. This diagnosis should be considered in a returning traveler from an endemic region (i.e., Asia, India, Latin America, Africa) with a fever above 40°C, retro-orbital headache, myalgias, nausea, vomiting, and/or rash. The characteristic rash associated with dengue is described as “islands of white in a sea of red”, with confluent erythema and small areas of spared skin. A bedside tourniquet test can also be performed by inflating a blood pressure cuff around the upper arm for five minutes at a pressure halfway between the patient’s systolic and diastolic blood pressure. This test is deemed positive if more than 10 petechiae are present within a square inch of skin, suggesting capillary fragility.

Although mild cases of dengue can be treated supportively, more severe cases typically require hospitalization. Some warning signs of severe disease include abdominal pain or vomiting, hepatomegaly, signs of volume overload including ascites or pleural effusion, and an increase in hematocrit with rapid thrombocytopenia. Severe dengue can present with shock, volume overload, severe bleeding, encephalopathy, and liver failure. Emergency physicians must keep a broad differential when evaluating fever in return travelers and prioritize history and physical exam findings to help narrow the diagnosis and provide appropriate management and supportive care while awaiting further confirmatory testing.

Take-Home Points

  • Consider Dengue Fever in patients returning from endemic regions with classic symptoms including fever, retro-orbital headache, nausea, vomiting, myalgias, and rash.
  • Gold standard diagnostic testing such as ELISA is often unavailable in resource-limited settings and even when available, this confirmatory result won’t be available in the acute care/emergency setting.
  • In patients for whom a diagnosis of Dengue Fever is suspected based on history and physical exam, the tourniquet test provides a rapid beside analysis to aid in patient diagnosis and management.

  • Schaefer TJ, Panda PK, Wolford RW. Dengue fever. StatPearls. Updated November 14, 2022. Accessed August 5, 2023. https://www.ncbi.nlm.nih.gov/books/NBK430732/? report=reader.
  • Kenzaka T, Kumabe A. Skin rash from dengue fever. BMJ Case Rep. 2013: bcr2013201598.

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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 |2024-12-02T21:29:46-08:00Dec 6, 2024|Infectious Disease, SAEM Clinical Images|
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SAEM Clinical Images Series: This Rash Came Out of No Where

crusting

A 26-year-old male with a past medical history of eczema presented to the Emergency Department with a rash for two days. The patient stated he first noticed a rash on his right arm that rapidly spread to his face, chest, and left arm. He reported having similar rashes before but never to this extent. The patient stated he was given Bactrim and amoxicillin about one month ago for another rash, though he was unsure of the diagnosis. He denied any known allergies or exposures to new foods or hygiene products. He had no chest pain, SOB, nausea, or diarrhea. He lives in a correctional facility and does not know of anyone with any rashes.

 

Vitals: Temp 102.7°F; BP 134/81; HR 137; RR 17; O2 100% on room air

Cardiac: Tachycardic, no murmurs

Lungs: CTABL

Skin: Pustular vesicles with scattered areas of confluency on face, upper extremities and torso. Yellow crusting on face, no mucosal involvement.

WBC: 17

Platelets: 261

Blood cultures: One of two positive

CMP and UA WNL

Non-bullous Impetigo

Impetigo is a rash that effects the epidermis. There are two main types, bullous and non-bullous. S. Aureus and S. Pyogenes are the most common causes of non-bullous impetigo with S. Aureus accounting for up to 80% of cases. Impetigo is highly contagious and patients often self-inoculate other areas of their skin after the initial lesion develops. As papules develop, they fill with pus and once ruptured a classically characterized honey-colored crust is left on the skin. It is more common in immunocompromised patients, diabetics, patients with poor hygiene, and those patients who spend time in crowded dwellings such as daycare or prison. Systemic antibiotics are recommended in all cases of bullous impetigo and in non-bullous impetigo if there are more than five lesions, signs of deeper tissue involvement, or systemic symptoms as was the case with this patient. Beta-lactamase-resistant antibiotics such as Keflex or Augmentin are often the first line and if the patient resides in an area with a high prevalence of MRSA, doxycycline or clindamycin are recommended. Once diagnosed, it is important to wash any clothing, bedding, or infected surfaces to prevent further household or community spread. In the case of this patient, he developed systemic symptoms ultimately becoming septic, and required admission with IV antibiotics. He made a full recovery.

Take-Home Points

  • Suspect in patients who are immunocompromised or have contact with crowded dwellings such as daycare or jail.
  • The classic skin finding is a honey-colored crust.
  • Patients with systemic symptoms or more than five lesions need systemic antibiotics.

  • Nardi NM, Schaefer TJ. Impetigo. [Updated 2023 Jul 31]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2023 Jan-. Available from: https:// www.ncbi.nlm.nih.gov/books/NBK430974/

  • Group A Strep Infection. (n.d.). Group a Strep Infection. https://www.cdc.gov/group-a-strep/?CDC_AAref_Val=https://www.cdc.gov/groupastrep/diseases-%2520hcp/impetigo.html

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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 |2024-12-02T21:22:36-08:00Dec 3, 2024|Dermatology, Infectious Disease, SAEM Clinical Images|
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SAEM Clinical Images Series: Rectal Bulge

rectal bulge

A 13-month-old, full-term male presented due to intermittent emesis over a 3-week period. He and his parents had COVID one week prior to presentation. He had multiple episodes of non-bloody, non-bilious vomit the day before and the day of presentation. Parents noted he had been listless and unable to tolerate food. The mother was also concerned that he was straining to have bowel movements and that a mass was coming out of his bottom on the ride to the hospital. Parents reported decreased activity, decreased appetite, and decreased urine output. He was born via cesarean section due to breech presentation but had an otherwise uncomplicated prenatal history.

 

Constitutional: Fatigued.

Gastrointestinal: Diffuse abdominal tenderness. Reducible rectal bulge.

Skin: Pale.

Anion Gap: 19

COVID-19: Positive

WBC: 11.9

Limited Abdominal Ultrasound: A large intussusception is noted, which appears to extend at least to the descending/sigmoid colon.

XR Abdomen: Few prominent, featureless bowel loops with air-fluid levels. No gastric distention.

Air or hydrostatic enemas have a 70-85% success rate in current literature. These are often done under either fluoroscopic or ultrasound guidance. A delayed repeat enema can be done in cases where the initial enema resolved some of the intussusception. If the initial measures are unsuccessful, the patient is unstable, or the patient is exhibiting signs of peritonitis or bowel perforation, surgical management is the next step. This can either be done laparoscopically or open. In this patient’s case, an air enema was attempted but he ultimately required surgery. The surgery was laparoscopic, and he was discharged the same day.

Take-Home Points

  • Consider intussusception in any child with a URI (including COVID-19) and a rectal bulge.
  • Although this patient had a formal ultrasound, POCUS can be a useful tool in the ED to identify and expedite intussusception treatment. The classic “bullseye sign” was seen on this patient’s ultrasound.

  • Mandeville K, Chien M, Willyerd FA, Mandell G, Hostetler MA, Bulloch B. Intussusception: clinical presentations and imaging characteristics. Pediatr Emerg Care. 2012 Sep;28(9):842-4. doi: 10.1097/PEC.0b013e318267a75e. PMID: 22929138.
  • Siafakas C, Vottler TP, Andersen JM. Rectal prolapse in pediatrics. Clin Pediatr (Phila). 1999 Feb;38(2):63-72. doi: 10.1177/000992289903800201. PMID: 10047938.

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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 |2024-11-13T09:52:52-08:00Nov 22, 2024|Pediatrics, SAEM Clinical Images, Ultrasound|
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SAEM Clinical Images Series: A Rash with Cranial Nerve Deficits

rash

A 48-year-old male with no significant past medical history presented to the Emergency Department with a left-sided facial rash and associated burning left eye pain that started four days prior. He was seen at an ophthalmology clinic when his symptoms started and given oral valacyclovir which he took for three days without improvement. He also endorsed left-sided facial weakness and diplopia for the last eight days. He denied fevers, chills, nausea, vomiting, ear pain, tinnitus, hearing changes, blurry vision, photophobia, history of malignancy or HIV, history of stroke. He reported remote use of tobacco nine months prior, cocaine use that stopped three weeks prior, and alcohol use only on weekends.

 

Vitals: Temp 36.8°C; BP 148/85; HR 80; RR 18; O2 Sat 96% on room air

General: Alert, no acute distress.

Skin: Healed vesicular rash along V2 distribution of trigeminal nerve.

Head: Normocephalic, atraumatic.

Eye: Visual acuity – right 20/40, left 20/70 without correction (at baseline per patient). Left eye viewed with fluorescein showing dendritic lesions. EOM: right intact, impaired abduction of left eye. Unable to close the left lid. Pupils: R pupil 3mm, briskly reactive to light, L pupil 3mm not briskly reactive

Ears: Without vesicular lesions bilaterally

Cardiovascular: Normal peripheral perfusion.

Respiratory: Respirations are non-labored.

Neurological: Alert and oriented to person, place, time, and situation. Cranial nerves: CN II grossly intact, CN III: left pupil reactive to light but sluggish, CN V: facial sensation to light touch intact, CN VI: impaired abduction of left eye, CN VII: left facial droop with left forehead involved, CN VIII – XII intact. 5/5 motor strength to bilateral upper and lower extremities, no sensory deficits, has a steady gait.

CBC, BMP, and ESR all within normal limits.

The patient has a left-sided painful vesicular rash in the V2 distribution of the trigeminal nerve and dendrites on fluorescein-stained exam of the left eye, concerning for herpes zoster ophthalmicus. Hutchinson sign (involvement of the tip or side of the nose, as seen in the images) indicates involvement of the nasociliary branch of the trigeminal nerve, and patients with this finding have an increased risk of ocular involvement [1]. Although this patient did not have auditory canal involvement, Ramsay Hunt Syndrome is also important to consider. The image also shows impaired abduction of the left eye, concerning for a CN VI palsy, and the physical exam showed sluggish left pupil reactivity to light, concerning for a CN III palsy. Given the patient reported diplopia and had multiple cranial nerve deficits, cavernous sinus syndrome was also a differential diagnosis.

The recommended treatment for herpes zoster ophthalmicus is oral Valacyclovir, however, if there is any concern for disseminated zoster (3 or more dermatomes involved, CNS involvement, or other extradermal complications), patients should be treated with IV Acyclovir 10 mg/kg based on ideal body weight every 6 hours [1]. Since this patient underwent a trial of Valacyclovir without improvement and there was concern for possible CNS involvement with multiple cranial nerve deficits on exam, the patient was started on IV Acyclovir. Consultation with ophthalmology is also recommended for management of zoster ophthalmicus. The presence of diplopia, CN III and CN VI palsies was also concerning for possible cavernous sinus syndrome, which can be caused by a broad range of infectious, inflammatory, neoplastic, and vascular pathologies. It can have varying presentations based on the affected neurovascular structures however the constellation of symptoms includes diplopia, ophthalmoplegia, Horner syndrome, facial sensory loss, and CN III, VI, and VI deficits. If it is suspected, MRI with and without contrast is the preferred imaging modality to determine the location and extent of disease [2]. Neurology consultation is also helpful in co-management.

Take-Home Points

  • In a patient with a facial vesicular rash, it is important to perform a full cranial nerve exam to evaluate for deficits that may indicate CNS involvement, inspect the anterior chamber to evaluate for zoster ophthalmicus, and examine the ears to evaluate for Ramsay Hunt Syndrome.
  • Start antivirals early if zoster ophthalmicus is suspected since this disease process can be vision-threatening.

  • Anderson Erik, Do-Nguyen Amy. Varicella-Zoster Virus (VZV). In: Mattu A and Swadron S, ed. CorePendium. Burbank, CA: CorePendium, LLC. https://www.emrap.org/ corependium/chapter/recV6PonFTQbz5R9c/Varicella-Zoster-Virus-VZV#h.q140vny9bkbo. Updated August 16, 2023. Accessed January 11, 2024.
  • Munawar K, Nayak G, Fatterpekar GM, et al. Cavernous sinus lesions. Clinical Imaging. 2020;68:71-89. doi:https://doi.org/10.1016/ j.clinimag.2020.06.029

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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 |2024-11-13T09:40:41-08:00Nov 18, 2024|Dermatology, Ophthalmology, SAEM Clinical Images|
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SAEM Clinical Images Series: Clot in Transit

clot

A 67-year-old male with a past medical history of CHF, MI, hypertension, and diabetes presented to the ED with complaints of headache, chest pain, and dyspnea for the past four days. He stated that he has been without his medications for the past few months due to cost. He denied any past surgical history. He stated that he primarily presented because he felt like “my blood pressure is high”.

 

Cardiovascular: Tachycardic, 2+ pedal edema bilaterally

Respiratory: Tachypneic, decreased breath sounds bilaterally, ronchi/wheezes bilaterally

Skin: Diaphoretic

Troponin I: 0.13 (elevated)

BNP: 1,504

The findings in this picture are of a phenomenon called clot in transit. Via point-of-care ultrasound we were able to visualize part of a thrombus as it journeyed from the right side of the heart to the lungs, becoming a pulmonary embolism. In studies regarding the subject, clot in transit has been found in 3-18% of patients with acute PE. Unfortunately, clot in transit is associated with higher mortality in patients with acute PE. While not fully understood, part of the reason for this may be related to the fact that the patient population that this finding is found in tends to be sicker with higher rates of CHF, cancer, and immobilization. Additionally, increased mortality may be related to PE size given that the clot must be large enough to be seen by ultrasound. Studies have recorded clot in the 30-day mortality rates for patients with acute PE and visualized clot in transit to be 9-45%.

Take-Home Points

  • Point of care US is an essential tool for quickly assessing and appropriately treating patients. This patient’s story was very consistent with a CHF exacerbation but POCUS allowed us to quickly identify a PE and get the patient on track to definitive management.
  • Clot in transit once identified requires immediate action because it is associated with such high mortality in patients.
  • There remains more research to be done on the matter but it appears that clot in transit signifies a need for advanced forms of PE management (thrombolysis or thrombectomy ) to improve mortality in comparison to normal systemic anticoagulation.

  • Athappan G, Sengodan P, Chacko P, Gandhi S. Comparative efficacy of different modalities for treatment of right heart thrombi in transit: a pooled analysis. Vasc Med. 2015 Apr;20(2):131-8. doi: 10.1177/1358863X15569009. PMID: 25832601.
  • Barrios D, Rosa-Salazar V, Jiménez D, Morillo R, Muriel A, Del Toro J, López-Jiménez L, Farge-Bancel D, Yusen R, Monreal M; RIETE investigators. Right heart thrombi in pulmonary embolism. Eur Respir J. 2016 Nov;48(5):1377-1385. doi: 10.1183/13993003.01044-2016. Epub 2016 Oct 6. PMID: 27799388.
  • FREY J, BROWNBACK K. Clot in transit: A dilema of medical or surgical management. Chest. 2021;160(4):A2190. doi: 10.1016/j.chest.2021.07.1932.
  • Garvey S, Dudzinski DM, Giordano N, Torrey J, Zheng H, Kabrhel C. Pulmonary embolism with clot in transit: An analysis of risk factors and outcomes. Thromb Res. 2020;187:139-147. doi: 10.1016/ j.thromres.2020.01.006.

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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 |2024-10-28T09:54:15-07:00Nov 1, 2024|SAEM Clinical Images, Ultrasound, Ultrasound for the Win|
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SAEM Clinical Images Series: Wilma, Take a Look at This!

A 2-year, 11-month-old female with a history of constipation was brought to the ED by her mother for abdominal pain. The mother noticed that the patient’s abdomen had been enlarging for months. When they visited the pediatrician several months ago, the pediatrician also noticed a mildly enlarged abdomen but the patient was asymptomatic at that time. She was well during the interval until more recently, the patient began to complain of persistent abdominal pain and would point to the epigastric area. The patient had two episodes of unprovoked, non-bloody, non-bilious vomiting the morning prior to the ED visit. The patient had been tolerating oral intake well, passing adequate urine, having normal bowel movements, and behaving at baseline. No associated fever, diarrhea, bloody stool, dysuria, hematuria, or weight loss.

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kidney

Vitals: Temp 97.9 °F (36.6 °C); BP 103/68; Pulse 121; RR 26; SpO2 99% on room air

Constitutional: Active, well-developed, and in no distress.

HEENT: Normocephalic and atraumatic. No scleral icterus. TMs intact, no erythema. No rhinorrhea, no erythema. Moist mucous membranes, oropharynx is clear, no exudates or erythema.

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

Pulmonary: Breath sounds normal. No wheezing, no stridor, no decreased breath sounds. Normal effort, no acute respiratory distress.

Abdomen: Protuberant, distended abdomen with mild generalized tenderness to palpation. Rigid mass palpated in the upper right quadrant. Normal bowel sounds are heard.

Genitourinary: Normal anatomy. No hernias visualized, no erythema.

Skin: No jaundice or rashes visualized.

Neurological: Awake and alert. No focal deficits present.

CBC: No leukocytosis, leukopenia, anemia, or thrombocytopenia.

CMP: Electrolytes, kidney, and liver function tests were within normal limits.

The most common pediatric renal malignancy is a Wilms tumor, also known as nephroblastoma. It is an embryonal tumor due to disrupted nephrogenesis. It affects approximately 1 in 10,000 children with the median age of onset being 3.5 years (1). The most common chief complaint is abdominal pain, as in this case.

Here a large homogenous mass initially appears to be projecting from the liver, but it can also be seen protruding out of the right kidney. Pediatric abdominal organs commonly overlap so it is essential to note the origination of a mass, primarily for surgical planning. If ultrasound imaging is equivocal, CT is the next best step in differentiating the mass origination. Here, a 12 cm x 9.5 cm x 9 cm mass was noted to originate from the right kidney. If the mass becomes big enough, patients can present with vomiting due to the direct compression of the alimentary tract, such as in this case. Other presenting signs and symptoms may be fever, hypertension, anemia, hematuria, or dysuria (2).

In the US, the National Wilms Tumor Study Group recommends primary nephrectomy followed by a chemotherapy regimen that is tailored to the individual patient and tumor staging. With modern multidisciplinary management, curative therapy is achievable in approximately 90% of affected patients (2). This patient had a successful nephrectomy performed by general surgery and initiated chemotherapy on the medical floor. The patient was eventually discharged home with pediatric oncology follow-up.

Take-Home Points

  • Think of pediatric malignancy if the patient presents with chronic abdominal distention and pain.
  • Pediatric abdominal structures commonly overlap. Knowing the origination of an abdominal mass is essential for surgical planning. If ultrasound is equivocal, CT imaging is the next best step.
  • The definitive management of a Wilms tumor is a multidisciplinary approach, with primary nephrectomy followed by a tailored chemotherapy regimen as the gold-standard treatment in the US.

  1. Spreafico F, Fernandez CV, Brok J, Nakata K, Vujanic G, Geller JI, Gessler M, Maschietto M, Behjati S, Polanco A, Paintsil V, Luna-Fineman S, Pritchard-Jones K. Wilms tumour. Nat Rev Dis Primers. 2021 Oct 14;7(1):75. doi: 10.1038/s41572-021-00308-8. PMID: 34650095.
  2. Sonn G, Shortliffe LM. Management of Wilms tumor: current standard of care. Nat Clin Pract Urol. 2008 Oct;5(10):551-60. doi: 10.1038/ncpuro1218. PMID: 18836464.
  3. Leslie SW, Sajjad H, Murphy PB. Wilms Tumor. 2023 May 30. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2023 Jan–. PMID: 28723033.

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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 |2024-10-28T09:46:11-07:00Oct 28, 2024|Heme-Oncology, Pediatrics, Renal, SAEM Clinical Images|
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SAEM Clinical Images Series: When Needles Go Beyond Sewing and Acupuncture

needles

A 64-year-old male with a history of bipolar 1 disorder, PTSD, anxiety, depression, obsessive-compulsive disorder, GERD, and HTN presented to the ED with the chief complaint of foreign body and self-injury. He reported years of sticking sewing needles into his right arm, most recently yesterday. He explained that inserting needles makes him feel better with mild associated pain. He endorsed suicidal ideas, elaborating that he did not want to stop injuring himself. He also reported depression and wished that he was not alive. He stated that he had told his therapist that he didn’t want to present to the ED today and added that he wanted to leave the ED and did not want to be seen by the psych team. He denied homicidal ideation.

 

Extremities: When palpating the right forearm, multiple linear hard objects are felt in the subcutaneous tissue. The patient can flex/extend the wrist, supinate and pronate, and flex/extend the elbow without issue. No erythema or fluctuance. No obvious insertion site noted.

None

Numerous linear metallic foreign bodies are present throughout the right forearm; several new foreign bodies are noted. Bony exam is significantly limited due to the presence of numerous (greater than 50) linear metallic densities throughout the forearm. Mild to moderate degenerative changes of the wrist and elbow are noted.

Take-Home Points

  • Removal of metallic foreign bodies is an individualized risk vs benefit decision based on the following: signs of infection, suspected level of contamination, type of metal, cooperativeness of the patient, location nearby vital structures, cosmetic deformity, and pain. When the risk of removal outweighs the benefits or if the patient does not desire removal, foreign body removal is not always needed.
  • Regarding prophylaxis, antibiotics need not be routinely administered if the wound is clean. Tetanus vaccination status should be reviewed, and the vaccine (Tdap) and/or potentially tetanus immune globulin should be administered if indicated.

  • Rupert J, Honeycutt JD, Odom MR. Foreign Bodies in the Skin: Evaluation and Management. Am Fam Physician. 2020 Jun 15;101(12):740-747. PMID: 32538598.
  • Lane JC, Mabvuure NT, Hindocha S, Khan W. Current concepts of prophylactic antibiotics in trauma: a review. Open Orthop J. 2012;6:511-7. doi: 10.2174/1874325001206010511. Epub 2012 Nov 30. PMID: 23248721; PMCID: PMC3522105.

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 |2024-10-15T10:59:39-07:00Oct 25, 2024|Psychiatry, Radiology, SAEM Clinical Images|
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