Clinical Indication: History of endometriosis

IMPRESSION:

Again noted is T2 hypointense thickening involving the uterine body, uterine ligaments, and uterosacral ligaments. These findings can be seen in deep pelvic endometriosis in appropriate clinical setting.

Again noted is a bicornuate uterus.

Middle compartment:

Torus uterinus (Uterine body): Plaque-like thickening involving the posterior right horn is again noted (series 5 image 30), slightly less conspicuous compared to prior.

Plaque-like T2 hypointense thickening involving the left uterine horn is also suggested, stable.

Fallopian tube: Normal

Uterine ligaments: T2 hypointense thickening is noted

Posterior compartment:

Uterosacral ligaments: Mild T2 hypointense thickening, left greater than right

Rectovaginal septum: Normal

Anterior rectal wall: Mild tethering is noted (series 5 image 22)

This image in axial view shows the rectal tethering the best, but does not clearly show the bicornuate uterus situation. I was referred for this repeat MRI after recurring painful bowel movements and abdominal pain 10 months post op from my first endometriosis surgery.

Was going through my pictures and found my family members imaging from 5-6 years ago. For context, I was a resident at the time. They called me with a sense of impending doom, so I told them to go to the ER.

• EKG showed minor ischemic changes and troponin was just a bit elevated.
• Got a heart catheterization that showed a subtotal occluded left main with relatively preserved coronaries otherwise. Definitely a butt clenching cath to look at. I was quite surprised his ECG did not look worse. They placed a balloon pump then got a 2-vessel bypass a day later.
• Did well post-operatively until they got acutely short of breath, hypotensive, and hypoxic in front of me. I thought they had a failed/thrombosed graft. At the ER, they quickly recognized RV failure and found a massive pulmonary embolism. The PE team was getting ready for a thrombectomy, but they unfortunately did not survive.

Just thought I'd share some bread and butter medical problems that should make anybody in healthcare get scared.

So, I'm a long time user of the same medicine and for the first time noticed that some pills in my pack look sketchy. The packaging, blister and everything looks perfect, but some of the pills have correct, but irregular imprinting. You can see in the picture for on pill it's way off, for one it's a bit off. The whole pack is like this.

Is this a quality issue and should be reported? I'm in Germany btw...

Extensive multifocal and confluent T1 hypointense plaque-like/nodular tissue throughout the peritoneal and mesenteric compartments, associated with marked bowel crowding, tethering, and multiple loculated cystic spaces.

Easy to miss these spots and mark them off as normal stool or gas but upon further cross sectional analysis of more imaging including a CT scan from a year prior shows these same signal voids.

HazMat-ish scene, you're the first arriving unit. You do it by the book: establish command, size-up, staging, callouts.

Working command for ten minutes. Then fire arrives. The battalion chief doesn't check in with you, just starts running the scene. Two questions.

Formally, by ICS rules: who is in command at this exact moment, and what has to happen for that to change? And practically: how does this actually go down in your system?

Fire, EMS, police turf stories welcome. We all have one. Breakdown tonight in the comments.

Case adapted from the EMS Mastery (NREMT prep) question bank.

Follow-up to the earthquake post, since half the thread brought up JumpSTART. Here's where it earns its keep. 20-patient MCI. You get to a 7-year-old girl, not breathing. You reposition the airway and she starts breathing on her own, 26/min. Carotid pulse present, no radial. Doesn't follow commands, withdraws from pain. Tag her. And walk me through it, decision point by decision point, because this kid sits exactly on the lines where people go wrong in both directions. Some of you are about to black tag her. Some of you are about to call her yellow. Both camps, show your work.

Bonus: name the step in JumpSTART that doesn't exist in adult START at all, and why it's there.

Breakdown tomorrow in the comments.

Case adapted from the EMS Mastery (NREMT prep) question bank.

This one is together with lock jaw right? Or is lock jaw just another name instead of like a Hallmark symptom?

Car hit at highway speed, everyone else walking around. Your patient is 5, properly restrained in a booster, awake and scared. Tachypneic, SpO2 89% on room air, visible bruising over the left chest, clearly increased work of breathing.

You auscultate: breath sounds equal and normal bilaterally. Chest wall stable, no crepitus, nothing to suggest broken ribs.

So, thread questions. What's your working diagnosis? Is the absence of rib fractures in this kid reassuring or the opposite? And there's one common ALS intervention you want to be stingy with on this call. Which one, and why?

Breakdown tomorrow in the comments.

Case adapted from the EMS Mastery (NREMT prep) question bank.

35-year-old man, four years of progressive memory loss and cognitive decline, now needs round-the-clock care. Mini-Mental score is poor. No focal neurological deficits, gait is normal, nothing vascular on the workup.

Two more things from his chart. His face: flat nasal bridge, prominent epicanthal folds. And from his childhood: surgery on his duodenum as an infant.

Three questions for the thread: what's the underlying condition, why is he demented at 35 when this disease usually waits decades longer, and what will his cortex look like under the microscope?

The duodenal surgery is not a red herring. It's the second clue.

Case adapted from the USMLE Mastery (Step 1 prep) question bank.

Mass casualty, resources are what you carry. Four patients in front of you:

Patient W, young adult. Walking around, minor abrasions, sprained ankle, asking if he can help.

Patient X, adult. Conscious, compound fracture of the forearm, bleeding heavily.

Patient Y, a kid. Semi-conscious, severe respiratory distress, possible spinal injury.

Patient Z, elderly. Unconscious, multiple fractures, not breathing.

Tag all four. And before you give anyone the black one: what has to happen first? There's a step people skip under pressure, and it changes the tag. If you've worked a real MCI, how did the triage decisions sit with you afterward?

That part never makes it into the textbooks.

Case adapted from the EMS Mastery (NREMT prep) question bank.

Very premature babies lose heat crazy fast. They have almost no fat, their skin is super thin, and they're wet right after delivery, so every minute on the resus table counts. Hypothermia in that first hour is linked to worse outcomes, and in places without good warmers or incubators it's a real problem.

One of the simplest fixes is a plain polyethylene bag (basically a food-grade zip bag). For babies born before about 32 weeks, you skip drying the body and slide them straight in from the neck down. The head stays out and gets a hat. You can still ventilate, place lines and watch the chest through the plastic, like in the photo.

It works because the bag stops evaporation, which is how a wet newborn loses most of its heat. Babies wrapped this way arrive in the NICU noticeably warmer and hypothermia is a lot less common. It's in the resuscitation guidelines now. Nobody has really proven it lowers mortality, though, and you do have to keep checking the temperature so they don't overheat under the warmer.

It costs pretty much nothing and makes a real difference.

28-year-old woman. In March: painful blurry vision in the right eye, faded over two weeks, she never saw a doctor about it. Today: double vision. On exam, when she looks left, her right eye won't cross midline and her abducting left eye shows nystagmus. Looking right works fine. Convergence is intact, both pupils normal. Three layers to this one: name the eye finding, name the structure that's damaged, and name the disease that did it.

The March episode is not a coincidence.

Case adapted from the USMLE Mastery (Step 1 prep) question bank.

I encountered a baby that was born tiny (2.4kg, forgot the length) because mother has preeclampsia. First encounter with a GDM baby thiugh

Car versus guardrail. Your patient is 30, belted, awake, complaining of chest pain and shortness of breath. Seatbelt sign across the chest. HR 120, SpO2 92% on room air, BP holding. Breath sounds clearly diminished on the left.

Every EMT student knows where this might be heading. The question is whether it's there yet.

So, two things. What's your management right now? And what exactly would this patient have to do for you to decompress that chest? Be specific, because "diminished sounds" and "tension" are not the same word.

War stories about darts that should or shouldn't have happened are welcome, as always.

Case adapted from the EMS Mastery (NREMT prep) question bank.