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“It’s all about how you play the game,” you explain to your intern. “As an EM physician, you are a healer, an educator, a detective, a diagnostician, and a master strategist all rolled into one.” He still appears rather frustrated that the internal medicine team is trying to “block” his admissions for the 65-year-old gentleman with newly diagnosed metastatic lung cancer and the 52-year-old lady with CHF and a BNP of 16,000 ng/L. They’ve told him that the patients don’t meet “admission criteria” and that they are refusing to consult on the patient. He’s tried being polite, and when that didn’t work, he tried the more assertive route, to no avail. You and your senior residents provide your eager intern with some helpful hints about how to sell a better story and reiterate that we must be our patient’s best advocates – especially in their time of need. You offer to talk to the consultant yourself, but your intern decides he wants to try to take care of it himself. He says he’s going to go see one more patient, calm down, and then redirect his energy into getting the first two admitted.

After about 10 minutes, you go and check on your intern with the new patient he’s picked up in room 33. The patient is a 41-year-old male who presents to the ED with concerns that his left eye is progressively getting more swollen. He’s had some increasing eye pain and purulent drainage over the past six days. At first he thought that he was just having really bad seasonal allergies, but today, he started feeling a “pulling sensation” on the medial aspect of his left eye. He denies any headache, diplopia, sinus pain, rhinorrhea, nausea, vomiting, or recent trauma. He does note a subjective fever at home, and his temperature is 38.2°C in the ED. His vital signs otherwise demonstrate tachycardia to 123 bpm, but a normal blood pressure, oxygen saturation, and respiratory rate.

Your intern has asked the nurse to obtain a visual acuity on the patient and he is systematically going through his ocular exam when you walk by the room to check on him. He comes out of the room to give you an update on what he’s discovered so far. The patient has tenderness to palpation over his left medial orbit and possible entrapment on ocular exam. He has no additional pain with extraocular movement and no diplopia, but has so much periorbital edema that it wasn’t possible to get a consistent Tonopen measurement. There doesn’t appear to be any fluorescein uptake on the slit lamp exam, and other than conjunctival injection and the lid swelling, the patient has a normal ocular exam.
It is now about 4:30 pm and you know that in 30 minutes, all consultants turn into pumpkins and their pagers magically stop working. As you are about to ask your intern what he wants to do next, the medical student pulls up the ultrasound machine that the intern asked her to wheel over and hands it to him. He takes the linear array transducer and performs an ocular ultrasound at the bedside. He saves the following images: what do you see?

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What do you see on the ultrasound images?
Conclusion on NEXT page

 

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