**Source:** http://www.svuhradiology.ie/case-study/mediastinal-widening-cxr/

The Cheese - A Predictive Clinical Tool for Aortic Dissection

September 20, 2024

Picture the following encounter: A 52-year-old male presents with chest pain. He seems comfortable and is slightly hypertensive to 156/83, but the rest of his vital signs are normal. He admits to using cocaine prior to the onset of chest pain. He denies any radiation of pain or other associated symptoms. When you are going through your differential, you consider aortic dissection, and you wonder if there are any tools to help you decide if this patient should get a CT angiography (CTA) study to further evaluate for aortic dissection.

Taylor Wahrenbrock, MD and Kathryn McGregor, MD

**Figure 1.** Point-of-care echocardiogram demonstrating the D-sign and a trace pericardial effusion.

Consider The Probe: ILD Sign

September 13, 2024

The Case:

The patient is a 64-year-old female with an unknown past medical history who presented to the ED with altered mental status. Her BP was 100/80 mmHg, HR 101 BPM, RR 21 bpm, SPO2 63% on room air, and T 36.8ºC (98.3ºF). The patient was placed on a non-rebreather mask at 15L, and her oxygen saturation improved to 97%. She was given sedatives for acute agitation and delirium. On exam, the patient was tachypneic and had bilateral crackles and decreased breath sounds throughout all lung fields. Her cardiac exam was notable for a regular rhythm without murmur. The remainder of the physical exam was unremarkable.

Michael Hohl, MD

**Figure 1.** Adapted from Dr. Smith's EKG Blog. Source: http://hqmeded-ecg.blogspot.com/2013/10/polymorphic-ventricular-tachycardia.html

Cool County Cases - Recurrent and Refractory Torsades de Pointes

December 8, 2023

The Case:

A 40-year-old female presents to the emergency department for palpitations and lightheadedness. She has a history of depression on citalopram, migraines on amitriptyline, and was recently prescribed tramadol after she broke her wrist. She is well-appearing, and while being placed on the monitor, she becomes anxious, stating the symptoms are recurring. An ECG is performed, with Figure 1 serving as a representative EKG. The patient is awake and talking. Defibrillator pads are placed and 2 g IV magnesium is administered twice each over ten minutes resulting in the termination of the prior rhythm. A repeat EKG is obtained and is similar to that in Figure 2. The patient remains stable, but then degenerates again into an aberrant rhythm. What do you do next?

Adam Roussas, MD and Robert Feldman, MD

the County Consult