EM Forum Case #108 "Why Can’t She
Swallow?"
by Charlene Babcock Irvin, MD, FACEP
During sign-out rounds, the leaving attending tells me that the patient in bed
number 9 is admitted to surgery after a MVA
and is waiting for transfer upstairs. Her workup did not reveal any significant
abnormalities, but she still had
tenderness in her abdomen and they were planning on admitting her to watch her.
After rounds, as I re-entered that module I noted she was using the wall suction
(Yankauer) to suction out her oral
secretions. This bothered me (why can’t she swallow?), so I went to the bedside.
She was a small oriental female, awake, alert, and looking back at me. I asked
her to open her mouth and she just looked
back at me not answering. The nurse then told me she didn’t speak English, and
should be going up stairs shortly.
I removed the anterior portion of the c-collar to inspect her neck, and realized
she had no neck. The skin seemed to go
from her chin, directly to her clavicle and manubrium, without any indentation.
As I palpated the area, she winced. There
was no subcutaneous air, but the area was very firm. I could not identify any
neck anatomy (no larynx palpated).
I asked the nurse if the swelling was new, or if that’s the way she was when she
came to the module, and the nurse informed
me she never noticed as she came from the resuscitation area with the collar on.
Questions:
1. What landmarks define the different zones of the neck?
2. What’s a quick way to find out if this is new?
3. What could be causing the swelling?
4. What does she need from me?
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