A Rare Case of Gastric Volvulus with Hiatal Hernia
BY FAHAD SHAH & AHMED RAZIUDDIN, MDA 68-year-old woman presented with acute abdominal pain that had started three hours earlier. She said she had constant upper abdominal pain that was sharp and stabbing, and she rated her pain as 8/10.The patient said the pain did not radiate, and she was clearly in acute distress. She reported that her last meal had been four hours before and that she was nauseated and had had three to four episodes of dry heaves.She had no other concerning symptoms, and her pain was unaffected by eating, drinking, or position. She had a paraesophageal rolling hiatal hernia and was aware of her ch...
Source: The Case Files - October 16, 2019 Category: Emergency Medicine Tags: Blog Posts Source Type: research
A Rare Complication of Diabetes Caused by Treatment
BY WESTLEY REINHART MCMILLAN, DOA 34-year-old woman with a history of type 2 diabetes mellitus presented to the emergency department with achy abdominal pain, vomiting, and diarrhea for two days. She also reported decreased appetite, chills, and a productive cough. She was compliant with her diabetes medications, insulin, Jardiance, and Janumet.The patient was afebrile with a heart rate of 133 bpm and a blood pressure of 129/88 mm Hg. She had dry mucous membranes, and her abdomen was mildly tender in the epigastrum and upper quadrants but otherwise soft and not distended. Fingerstick glucose was 213 mg/dL. (Fig. 1.)Fig....
Source: The Case Files - September 24, 2019 Category: Emergency Medicine Tags: Blog Posts Source Type: research
An Uncommon but Serious Diagnosis Disguised as a UTI
BY MATTHEW WU, & DEANDRE WILLIANS, MDA 2-year-old girl presented to the emergency department for abdominal pain with urination. She had been diagnosed with a urinary tract infection three days earlier, and was in the process of completing a course of antibiotics.The pain with urination made it difficult to void urine even when soaking in warm baths, according to the patient's parents. Her mother said the patient had to be bribed to drink anything. Their daughter did not urinate for 14 hours before arriving at our ED. They were concerned about dehydration due to the lack of fluid intake. The patient also refused to t...
Source: The Case Files - September 18, 2019 Category: Emergency Medicine Tags: Blog Posts Source Type: research
A Death from Consuming 'Alcohol'
BY MICHELE STYBEL; LAURIE-ANN ANTOINE; JENNIFER TUONG; AHMED RAZIUDDIN, MDA 54-year-old man with a past medical history of COPD presented to the ED with shortness of breath that had started an hour earlier. He was alert and oriented, but also agitated, combative, and unable to provide an adequate history.He said he was a heavy smoker and drinker and that he had been smoking and consuming alcohol when the symptoms started. He also reported past Cannabis use.He was in acute respiratory distress with BiPAP in place, restless, and diaphoretic. Respiration was labored with bilateral expiratory wheezing but no signi...
Source: The Case Files - September 10, 2019 Category: Emergency Medicine Tags: Blog Posts Source Type: research
A Rare Case of Paralysis
BY ALEXANDRA SALAS; JENNIFER TUONG; IVAN KHARCHENKO; VICTOR RIVERA; & AHMED RAZIUDDIN, MDA 27-year-old man with a past medical history of ADHD managed with Adderall presented to the emergency department with bilateral upper leg weakness associated with soreness since the day before. He had run 2.5 miles before his symptoms started.The symptoms progressively worsened until he was not able to walk or get up from a sitting position. He was also experiencing weakness in his arms. He had no associated trauma, headache, vision changes, chest pain, shortness of breath, fever, abdominal pain, nausea, vomiting, diarrhea, or ...
Source: The Case Files - August 27, 2019 Category: Emergency Medicine Tags: Blog Posts Source Type: research
To Resuscitate or Not: The EP's Dilemma
BY ROSHAN MATTHEW, MD A 40-year-old man arrived in an unresponsive state, his carotid pulse not palpable. His initial rhythm was asystole, prompting us to start CPR.Prehospital care is virtually nonexistent in our part of India, so no resuscitative measures were performed before arrival, and we were told that the patient had been unresponsive for 20 minutes.Five minutes into our resuscitation, we attempted to intubate the patient, but laryngoscopy revealed a mass protruding through the glottis. We decided to do a surgical cricothyrotomy, my first attempt on an actual patient after practicing on manikins about 100 t...
Source: The Case Files - July 24, 2019 Category: Emergency Medicine Tags: Blog Posts Source Type: research
Trust the Physical Exam
BY ALI OZCAN, MD; AYUSH GUPTA, MD; ISABEL NEACATO, MD; DAVID DONALDSON, DO; & SHANNA JONES, MDA 17-year-old boy presented to the pediatric emergency department complaining of a right shoulder injury and right clavicular pain for two hours. The pain started after he checked another player into the boards while playing hockey. He had no head injury, loss of consciousness, or other trauma. He took 600 mg of ibuprofen with no relief, so he came to the ED.He had no past medical or surgical problems, and reported his pain as 4/10 over the clavicle region. His review of system was otherwise negative. The patient's vitals w...
Source: The Case Files - June 25, 2019 Category: Emergency Medicine Tags: Blog Posts Source Type: research
Why is This Patient Dizzy, Weak, and Tachycardic?
BY ANGEL BERMUDEZ, MD, & WESLEY EILBERT, MDAn 81-year-old woman with a history of metastatic lung cancer, hypertension, and COPD presented with dizziness that she described as lightheadedness, generalized weakness, and mild shortness of breath for three days. She also reported recent anorexia and a sensation of impending loss of consciousness.She was thin and appeared ill, and she was unable to stand unsupported. She was afebrile with a heart rate of 101 bpm and a blood pressure of 92/55 mm Hg.Her initial ECG is shown. What else could this be if not ST-elevation myocardial infarction?Our patient was found to have a ...
Source: The Case Files - June 25, 2019 Category: Emergency Medicine Tags: Blog Posts Source Type: research
A Costly Way to Get a Cheap High
BY KATIE TAUSCH, MD; ELAINA CLARK; KIMBERLY KRESS GETZINGER, MD; SHANNA C. JONES, MDA 25-year-old man with a history of depression and narcotic abuse presented to the ED seven hours after ingesting 200 loperamide 2 mg tablets. He was found unresponsive at home. He was somewhat somnolent but oriented on arrival.His blood pressure was 76/43 mm Hg, pulse rate was 62 bpm, respiratory rate was 20 bpm, temperature was 35.7°C orally, and SpO2 was 98% on room air. His physical examination was otherwise normal. He said he took the loperamide "to get high and relax." He normally took 150–200 loperamide tabl...
Source: The Case Files - June 18, 2019 Category: Emergency Medicine Tags: Blog Posts Source Type: research
What's the Connection between Fever and Atraumatic Leg Pain?
BY ADRIANA PORTO, MD; KELLY LEVASSEUR, DO; & SHANNA JONES, MDA 7-year-old girl presented to the emergency department with intermittent low-grade fever over the previous six days. She also had a sore throat, cough, and nasal congestion. Her mother reported a fever of 105°F with vomiting, cough, and congestion on the day of her presentation. She also noted that the patient complained of right leg pain and refused to walk or bear weight on her right leg, which was new the day of presentation. The patient pointed to the back of her right calf when asked where the pain was located. Her mother said the patient did not ha...
Source: The Case Files - June 18, 2019 Category: Emergency Medicine Tags: Blog Posts Source Type: research
A Rare Cause of Postprandial Pain
BY DHIMITRI A. NIKOLLA, DO; BRENDAN A. MICCIO; MELODY L. MILLIRON; & BRETT FOREHAND, MD, PHDA 49-year-old woman with a past medical history of chronic obstructive pulmonary disease presented to the emergency department with epigastric pain. She said the pain radiated to her chest and had been intermittent for six months, but it had been progressively worsening over the previous three weeks. Her pain was exacerbated by eating, and was associated with early satiety and nausea. She complained of a 30-pound weight loss over the preceding three months.Her vital signs included a blood pressure of 116/80 mm Hg, a heart rat...
Source: The Case Files - June 12, 2019 Category: Emergency Medicine Tags: Blog Posts Source Type: research
A Serious Diagnosis Lacking Common Symptoms
BY JENNIFER TUONG; IVAN KHARCHENKO; JEAN LUC AGARD; & AHMED RAZIUDDIN, MDA 65-year-old man who had HIV well-controlled with highly active antiretroviral therapy, hypertension, sciatica, and restless leg syndrome presented to the emergency department with left leg pain. He also had had chemotherapy and radiation for anal cancer. The patient said the pain had started 45 minutes earlier when he was sitting on the toilet.He described the pain as sore in quality and 10/10 on the pain scale. He reported that it had started in his lower back and radiated to his left leg. He said he had had no trauma or weakness to the regi...
Source: The Case Files - May 28, 2019 Category: Emergency Medicine Tags: Blog Posts Source Type: research
A Rare and Painful Byproduct of ESRD
BY HABIR MANDAIR; KEYUR KURANI; & KHALID MALIK, MDA 62-year-old obese woman with end-stage renal disease (ESRD) who was on hemodialysis, hypertension, diabetes mellitus, and chronically elevated serum calcium levels presented to the ED with altered mental status. Nursing home staff stated that she was unable to answer questions coherently and seemed confused.Her vitals were within normal limits except for a body temperature of 99.9°F. Several necrotic lesions of various sizes were found on her left and right buttocks and the medial aspects of both thighs. The patient also had severe necrosis of the third finger on ...
Source: The Case Files - May 22, 2019 Category: Emergency Medicine Tags: Blog Posts Source Type: research
An Incidental Finding While Placing a Central Line
BY STEVEN CRUZ; CLAUDIA BORNIA; & ERIC MIZUNO, MDA 68-year-old male nursing home resident with a history of hypertension, cerebrovascular accident, COPD, and chronic respiratory failure with a tracheostomy presented to the ED with a 101°F fever of four days that didn't respond to Tylenol. The patient was alert and oriented x0. His Glasgow Coma Scale score was 5.The patient was tachypneic at 30 bpm, and three systolic blood pressures fell below 100 mm Hg. An initial chest x-ray revealed bilateral pulmonary infiltrates and a left-sided pleural effusion, raising suspicion for pneumonia as the most probable cause of se...
Source: The Case Files - May 14, 2019 Category: Emergency Medicine Tags: Blog Posts Source Type: research
What's Behind This Tension Pneumothorax?
BY KYLE NADEL & PAUL SILKA, MDThe older woman was short of breath and experiencing epigastric abdominal pain. She was an ex-smoker in her mid-70s with a past medical history of COPD, pulmonary fibrosis, breast cancer, and intermittent home oxygen. Her symptoms had started gradually a few hours earlier.The patient's vital signs on arrival were a blood pressure of 122/80 mm Hg, heart rate of 101 bpm, respiratory rate of 42 bpm, and 91% SpO2 on 2 L/min via nasal cannula. She was tachypneic with accessory muscle use, and breath sounds were clear bilaterally but diminished on the left hemithorax.The patient was prom...
Source: The Case Files - April 9, 2019 Category: Emergency Medicine Tags: Blog Posts Source Type: research
