J Emerg Med
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Review Case Reports
Diplopia in a patient with carcinomatous meningitis: a case report and review of the literature.
In a patient with a history of malignancy, an isolated neurologic sign or symptom may indicate metastasis to the central nervous system. To exclude this possibility, a lumbar puncture should still be performed after a nondiagnostic cranial computed tomography (CT) scan even in the absence of signs of infection. ⋯ Cranial CT scan was normal but initial cerebrospinal fluid results were suggestive of carcinomatous meningitis, and cytology results later confirmed this diagnosis. A review of diplopia and carcinomatous meningitis is presented, along with a suggested conservative diagnostic algorithm for cancer patients presenting with neurologic signs or symptoms.
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Case Reports
Simultaneous open and closed dislocations of adjacent metacarpophalangeal joints: a case report.
Metacarpophalangeal joint (MCP) dislocations are uncommon, and when open are often complex, requiring surgical intervention for reduction. A 38-year-old man presented to the Emergency Department (ED) with simultaneous open and closed dorsal dislocations of adjacent MCP joints of the index and long fingers that were successfully treated by closed reduction in the ED. Injuries to the MCP joint can severely affect hand function when treatment is delayed and, thus, it is an accepted principle that definitive treatment should be achieved as quickly as possible for optimal functional outcome. In the case of dorsal dislocations of the MCP joints, aggressive ED intervention followed by brief immobilization and early hand therapy referral may result in dramatic clinical improvement for the patient without the need for surgery.
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Cubital Tunnel Syndrome is the second most common peripheral neuropathy of the upper extremity. It presents as elbow, forearm, or hand pain in the ulnar nerve sensory distribution and it is the result of overuse, trauma, or entrapment of the ulnar nerve at the elbow. Proper physical diagnosis can localize the site of ulnar nerve entrapment to the elbow or wrist. Both conservative and operative modalities exist to treat the Cubital Tunnel Syndrome; optimal management is still unclear.
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To record the outcome, with regard to infection rate, of patients with rattlesnake bites (RSBs) who do not receive prophylactic antibiotics, a prospective observational study was performed of patients with RSBs treated at our institution during a consecutive 18-month period. The inclusion criteria were RSBs <24 h old and completion of follow-up (telephone call, mail reply, medical toxicologist, or private physician examination) 7-10 days following envenomation. Fifty-six consecutive patients (Median age: 32.8 years [range 4-67 years]) were enrolled. ⋯ Fifty-three patients (100%) had extremity swelling and 38 patients (72%) had tender proximal lymph nodes. Of the 53 patients who completed the study, 3 (6%) received antibiotics from their primary care physicians at 7-10 day follow-up, with no cases (0%) of documented infection. Prophylactic antibiotics are not indicated in patients with rattlesnake bites.
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The majority of wound studies over the past 20 years have relied on single observer determination of infection presence or absence as a study endpoint. Nevertheless, there are few data on the reliability of those determinations. If single observer determinations are not reliable, the validity of studies using this endpoint should be questioned. ⋯ Of 125 patients enrolled, 115 wounds were available for analysis. Kappa =.57 [95%CI.39 to.75] for the primary endpoint of infection,.84 for purulence,.72 for tenderness,.48 for warmth, and.48 for erythema. Agreement on two features of infection and overall agreement on the presence or absence of wound infection was only 'moderate.' Single observer determination of wound infection by inexperienced observers using imprecise definitions, though commonly used, is an unreliable measure for scientific study.