70 something year old male who slid out of his hospital bed, | Figure 1

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70 something year old male who slid out of his hospital bed, scraping his rib cage on the way down. One day later, he started acting a bit off and he was hypotensive to 70s over 40s. He was transported to the ER where this CT Chest and abdomen showed this finding. I estimate about a liter of blood loss into his chest wall.

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Clinical Cases

A 43-year-old male presented with significant exercise intolerance. He was very short of breath and limited in his daily activities. Attempts to exercise led to palpitations and profuse sweating. On cardiopulmonary testing, his maximal oxygen uptake was 42% of predicted. At age 7 years, he had undergone a modified Ravitch procedure to correct a pectus excavatum defect, which entailed removal of the cartilage between the sternum and ribs. In his case, this procedure had resulted in destruction of the growth plates so that his ribs had stopped growing. This essentially had left him with the rib cage of a 7-year-old with adult-sized organs squeezed within. The clinicians he had seen previously believed he had a recurrence of the pectus excavatum, as his sternum looked low on imaging, as if the defect had perhaps not been corrected entirely. However, CT scans revealed the telltale sign of acquired thoracic dystrophy: a bell-shaped chest associated with a restrictive pattern on his lung function studies. Moreover, axial images showed his organs to be visibly crowded in the chest, restricting space for his lung tissue. In addition, the normal cartilage between his ribs had been replaced by bone, reducing his chest wall flexibility. The patient was operated on. We resected the rib portions that had calcified, taking care to preserve the soft tissue underneath. We then cut his sternum and bent it forward since there was still a residual component of his pectus excavatum. Next, a titanium plate was inserted to hold his sternum in its new, normal position. Because his organs were so restricted, a bar was used to cross his chest and push the sternum forward to create even more volume in the chest. We generally avoid use of bars in adults when correcting previously untreated pectus excavatum, but in this case the patient’s need for additional chest wall expansion was clear. The bar will be removed after the patient has had it in for two years. The plate will remain permanently.

Male patient in his 60s arrived by pov at the ER with fluttering in his chest. Initial heart rate in the 160s, reduced to 130-140 with beta-blockers. Pt stated last time this happened was 8yrs ago and they shocked him. He wants to be shocked again so he can go home. Pt sedated with 25mg etomidate and cardioverted at 200J. Kept overnight for observation, remained in NSR at 70.

Male patient 35 years old came to the ER complaining from severe fatigue, dizziness, blurred vision and slightly chest pain for 1 week ago. On examination we found that the patient had severe dyspnea, tachycardia 120, hypotension 70/40, po2 is 92%. His blood sugar is 80, no history of any disease but he said that when he felt that in the work, he took a time off of 3 days. He can't do work, so when he didn't able to stand up, his friend brought him to the ER. Smoking.

18/M. Px was riding a motorcycle and at a standstill, while another motorcycle hit his vehicle, causing px to swerve and twist his body to the right side. Px didn't fall, no noted head injuries. However he complains of pain on deep inspiration especially on his right side. PE: stable VS, 98% o2 sat on room air. Equal chest expansion, clear breath sounds. Above photo shows T-cage x-ray. Any thoughts?

A 52-year-old man presented with a 20-minute history of chest pain radiating to the left shoulder and neck, associated with dyspnea and diaphoresis. He had a history of hypertension, long-term smoking and a sedentary lifestyle. On physical examination, bibasilar crackles were noted on lung auscultation. An electrocardiogram (ECG) was performed in the primary care setting, and the patient was promptly referred to the emergency department.

A 28-year-old woman presented with a 3-day history of intense pruritus over the lower back. She reported no recent travel or exposure to new environments. She cares for a small kennel with approximately eight dogs rescued from the streets. Physical examination revealed multiple small vesicles, some clustered and others scattered, predominantly involving the lumbar region and the left gluteal area.

A 4-month-old male infant presented with skin lesions localized to the chin for the past 3 days. Physical examination revealed multiple small pustules with surrounding inflammatory signs on the chin, along with a few scattered papules on the chest.

Patient in late teens presenting after a collapse, no chest pain, no previous cardiac history, no history of sudden death in family. Are there any features in this EKG that would warrant further work-up or is this just a pediatric EKG?