This study shows that limited extremity MRI can safely exclude clinically important injury. Significant symptoms do persist, however, for many patients with a normal MRI.
A 63-year-old right-handed man presented to the emergency department with a 3-week history of pain, swelling and redness of his right ring fingertip. Examination revealed a hot, red, fluctuant tender swelling in his lateral nail fold consistent with a paronychia. He had no medical history other than an oesophagogastrectomy for squamous cell carcinoma in 2006 without recurrence. Incision and drainage was attempted, but no pus was extruded. At that point, other diagnoses were considered and radiographs were requested. These revealed bony destruction of the distal phalanx (figure 1). Further radiographs revealed evidence of metastatic disease. He had the fingertip amputated and positron emission tomographic scanning revealed a bronchiogenic carcinoma. Paronychia is a common infection presenting to the emergency department. Diagnosis is clinical, usually easy and rarely requires radiographs. This case demonstrates that vigilance is required to exclude important differential diagnoses such as osteomyelitis and primary or secondary malignancy.A 79-year-old woman complained of sharp epigastric pain for 2 days. She also had fever with chills before being brought to the emergency department. At arrival, her vital signs were stable, and haemogram showed leucocytosis (white cell count, 18.3310 9 /litre; normal range in our institution, 4e10310 9 /litre). The level of C reactive protein was 8.9 mg/dl (normal range, 0e1.0 mg/dl). Diffuse abdominal tenderness with muscle guarding was detected on physical examination. Supine plain film of the abdomen revealed an obvious linear density at the upper abdomen (figure 1A, black arrows), known as the falciform ligament sign and Rigler sign (figure 1A, arrowheads), indicating the presence of air on both sides of the bowel wall. Besides, the Figure 1 X-ray of right ring finger.Figure 1 A) Plain film of the abdomen showed intraperitoneal air, falciform ligament sign and Rigler sign of pneumoperitoneum. (B) CT confirmed pneumoperitoneum and air in the fissure for the ligamentum teres.
A short-cut review was carried out to establish whether cardiac compressions are beneficial in children in traumatic cardiac arrest. Forty-eight unique papers were found using the reported searches but none were relevant to the clinical question. It is concluded that there is no evidence available to answer the question posed and that local guidelines should be followed.
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