Factitious disorder with physical manifestations: pitfalls of diagnosis and management

Münchausen's syndrome is a chronic form of factitious disorder in which fabricated physical manifestations are used to attain multiple hospital admissions. Patients with this disorder are exposed to unnecessary invasive studies, and their entire life may come to revolve around attainment of hospitalization. In addition, medical personnel are subjected to confusion and frustration, scarce resources are wasted, and institutions are left with enormous unpaid bills. Using an illustrative case, we demonstrate pitfalls in the diagnosis and management of these patients, with emphasis on breaking the cycle of repeated hospitalizations, and discuss the enormous human and economic costs of their insatiable quest for medical attention.     

Risk management and avoiding legal pitfalls in the emergency treatment of high-risk orthopedic injuries

Avoiding legal pitfalls of orthopedic injuries in the emergency department (ED) requires an understanding of certain high-risk injuries, their presentation, evaluation, and disposition. Various pitfalls pertaining to both upper and lower extremity injuries are discussed in detail, with recommendations regarding the history, physical examination, and radiographic techniques that minimize the risk inherent in these injuries. When approaching these injuries in the ED, a high level of suspicion coupled with appropriate evaluation and management will allow the practitioner to avoid mismanagement of these potential pitfall cases.     

Orthopedic pitfalls in the ED: lunate and perilunate injuries

Occult dislocations at and around the lunate can accompany wrist trauma. When left unrecognized and untreated, these injuries lead to a high incidence of long-term functional disability and chronic pain. Emergency medicine practitioners need to be vigilant for both lunate and perilunate dislocations. This review article examines the clinical presentation, diagnostic techniques, and management options applicable to the emergency practitioner.     

Ectopic pregnancy: Ten common pitfalls in diagnosis

Ectopic pregnancy (EP) is a common, life-threatening complication of pregnancy. Modern technology (ultrasonography and improved pregnancy tests) should facilitate the diagnosis of EP. However, in a retrospective review of 65 cases of confirmed EP managed over 18 months at an urban teaching hospital, only 37 of 65 patients (57%, Cl95 = 44%, 69%) received prompt diagnosis and treatment; delays occurred in 28 patients (43%). In 10 of the 27 delayed cases, the diagnosis of EP was not even considered at the time of the first visit. In patients with a delayed diagnosis, morbidity (transfusions, cardiovascular instability, progression of illness) did occur. Diagnostic pitfalls that resulted in delayed care were reviewed, delays most commonly occurred in patients with a benign examination or "atypical" pain. Risk factors for EP were missed (7 patients, 25%), subtle clues to blood loss were often ignored (10 patients, 36%), and passage of tissue was thought to exclude EP (2 patients). Ultrasound was only helpful for half of the diagnoses and was misinterpreted in 27%. A dry or serous culdocentesis occurred frequently. In five patients, a falling or low quantitative human chorionic gonadotropin level was believed to indicate a completed abortion. The authors conclude that almost half of EPs are still missed on the first physician visit; errors and pitfalls in diagnosis are still common in the 1980s.     

Sonography of anencephaly: pitfalls in early diagnosis

A case in which the diagnosis of anencephaly was missed on a standard obstetrical sonogram performed at 12.5 menstrual weeks is described. Prompted by this case, we retrospectively reviewed the appearance of the cephalic pole of normal fetuses in 47 pregnancies ranging in menstrual age from 11 weeks to 16 weeks. Results indicate that the abnormal cephalic pole in the index case was similar to the appearance of many normal fetuses of similar menstrual age. We conclude that while anencephaly may be diagnosed as early as 11 menstrual weeks to 12 menstrual weeks, this defect may be difficult to diagnose on sonograms using standard sonographic techniques prior to 14 menstrual weeks.     

Orthopedic pitfalls in the ED: pediatric growth plate injuries.

Musculoskeletal injuries are frequently the reason children and adolescents seek care in the emergency department. In the skeletally immature patient, injury to the open growth plate can occur. When missed or mismanaged, these injuries can result in growth plate arrest. The emergency physician needs to remain vigilant for these injuries. This review article examines the clinical presentation, diagnostic techniques, and management options applicable to the emergency physician.     

社区老年摔倒病人的病例讨论

病人,女性,80岁,退休老师,是个小个子的女人.独自生活. 因摔倒后左手腕疼痛2 h被送进了急诊室.2 h前,当她取邮件时被绊倒,觉手腕疼痛,不能活动.在摔倒之前的几小时,她觉得头部非常模糊,站起来时有头晕.但无视物旋转感,无头痛,无恶心、呕吐,无昏迷,无抽搐.     

Psychogenic seizures: A review and description of pitfalls in their acute diagnosis and management in the emergency department

Patients with psychogenic (nonepileptic) seizures (PS) are frequently encountered by clinicians in the emergency medicine setting. Despite the tendency for these patients to seek frequent medical attention, the time between onset of symptoms and diagnosis is often more than 7 years. The cause of PS is multifactorial, but most patients are thought to have an?underlying dissociative condition. The diagnostic evaluation in the emergency department is challenging and relies heavily on clinical suspicion, based on historical and physical features. Laboratory testing and therapeutic maneuvers are of limited utility; prolonged video electroencephalography is the diagnostic gold standard. Once the diagnosis has been secured, the mainstay of treatment involves addressing the underlying psychological distress.     

Emphysematous cholecystitis: pitfalls in its plain film diagnosis

The clinical and radiographic findings of emphysematous cholecystitis are usually characteristic. However, on occasion the radiographic findings may be simulated by other processes. In such circumstances accurate diagnosis can usually be rapidly established by a variety of simple radio-graphic maneuvers and procedures. Five illustrative cases are presented herein and the pertinent literature is reviewed.     

不同病因腹膜后血肿的临床特点及影像诊断

目的探讨不同病因腹膜后血肿的临床特点与诊断。方法回顾性分析63例腹膜后肿,外伤性血肿组41例,术后腹膜后血肿组16例,非外伤性腹膜后血肿组6例。诊断主要是B超、腹穿和CT;比较各组血肿的发生部位、大小、动态变化、血压、临床主诉、误诊等。分析不同血肿的诊断、误诊率及原因。结果 18例外伤性腹膜后血肿有动态和血压的变化,其余23例则稳定。各组血肿部位、大小和临床症状相差不大。外伤组与术后组和非外伤组误诊率分别8%、32%、33%,前者与后两组相差显著（P〈0.05）。结论创伤组较其它组更易出现血肿动态增大和血压波动。后腹膜血肿要影像学动态观察,误诊原因主要是过分强调B超和腹穿而忽视了CT的作用。     

上期"社区老人摔倒病例"的讨论结果

24小时后，病人被送往急诊室处理手腕骨折，自诉其在取邮件时摔倒，摔倒前，她感到头晕，但无意识丧失史，平时早晨起床时也有过多次头昏眼花。     

Diagnosis and management of testicular torsion: pitfalls and perils

When a patient presents with acute scrotal pain and physical findings do not permit confident exclusion of testicular torsion, the initial step in management is immediate consultation with a urologist, pediatric surgeon, or general surgeon. Scrotal imaging is fallible and takes time that may be critical to salvage of the testis. Manual detorsion may be indicated when specialty support is not immediately available, but even if this technique is apparently successful, the patient should be transferred to specialty care without delay.     

Orthopedic pitfalls in the emergency department: closed tendon injuries of the hand

Closed tendon injuries of the hand are frequently seen in the emergency department. Unlike open tendon injuries, however, these injuries are often missed on initial presentation. Early recognition and treatment can decrease the pain, dysfunction, and long-term sequelae associated with these injuries. This review article examines the clinical presentation, historical factors, diagnostic techniques, and management options applicable to the emergency practitioner. Injuries discussed include rupture of the flexor digitorum profundus, mallet finger, central slip rupture, extensor hood rupture, and ulnar collateral ligament injury.     

Urinary bladder diverticula: sonographic diagnosis and interpretive pitfalls.

Diverticula of the urinary bladder can occasionally appear as complex pelvic masses not obviously connected to the bladder. Such presentations can lead to diagnostic confusion and interpretative error. Sonographic findings and clinical histories were reviewed in 11 patients in whom bladder diverticula were initially mistaken for other types of pathologic pelvic processes. Sonographic techniques that were helpful in elucidating the true nature of the lesions included scanning from different perspectives with increasing increments of bladder distention, postvoid images, endovaginal views, and color Doppler interrogation. The diagnosis of bladder diverticula should be considered and actively pursued when sonologists are confronted with pelvic masses of ambiguous origin.