You are correct. Exam revealed a nonpulsatile, palpable mass in the mid-upper arm corresponding to the belly of the biceps muscle, consistent w/ proximal biceps avulsion. U/S confirmed the dx. The IV site showed no signs of phlebitis or extravasation. Absence of trauma ruled out bicipitoradial bursitis and Morel-Lavallee lesion. In most cases, a biceps brachii rupture occurs at the proximal insertion, involving the long head of the muscle. It is more common in the elderly w/ hx of chronic shoulder pain, recurrent microtrauma, or flexion against forced extension. Although rare, spontaneous tendon ruptures are assoc w/ DM, fluoroquinolones, statins, corticosteroids, end-stage kidney dz, hypothyroidism, hyperparathyroidism, connective tissue dz, and gout, several of which were present in this pt.

Emerg Med J 2019;36:153-162.

You are correct. A clinical dx of amyopathic dermatomyositis was made based on eye lesion w/ heliotrope rash and raised LDH, LDH1, and α-hydroxybutyrate dehydrogenase but no muscle weakness. Absence of joint pain, muscle weakness, mouth ulcers, and hand pathology made systemic lupus erythematosus or classic dermatomyositis unlikely. This pt’s lesion resolved after 3mo of hydroxychloroquine.

BMJ 2019;365:l1654

You are correct. CT angiography of the chest revealed type A aortic dissection, complicated w/ hemopericardium and near total occlusion of the descending thoracic aorta. Mottled skin can be a sign of poor perfusion related to undifferentiated shock, cold environment, vascular dz, autoimmune dz, antiphospholipid syndrome, meds, and pancreatitis. This is different from Grey-Turner sign, which is bruising of the flanks, or Cullen sign (periumbilical bruising), which can also be seen in pancreatitis, abdominal trauma, and ruptured ectopic pregnancy. The discoloration of the abdominal wall in this case was likely related to hypoperfusion due to occlusion of the descending thoracic aorta. The pt was immediately intubated and underwent surgery. After surgery, he sustained severe reperfusion injury involving compartment syndrome of the legs, severe acidosis, and multiple organ failure, and further resuscitation was stopped.

Emerg Med J 2019;36:170-196.

You are correct. Bx and immunohistochemical staining confirmed extramammary Paget dz of the axilla. CT and PET scans showed multiple mets, involving right axillary and supraclavicular nodes and the mediastinum, thoracolumbar spine, ilium, and bilateral ribs.

BMJ 2019;365:l1260