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 loperami...
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...
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 ...
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...
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

An Uncommon Bug Bite
​BY RYAN LYNCH, MD, & MARK SUPINO, MDA 2-year-old girl was playing outside when she spotted a furry caterpillar. Like her stuffed animals, it was fluffy and had long hair. She let the insect crawl on her legs, but then suddenly screamed in pain. Her parents brought her to the ED, though she was no longer in distress by the time she arrived.The patient had a large urticarial lesion on her inner right thigh and a smaller one on her left thigh. (Photo.) There were no puncture wounds, bite marks, or barbs visible or palpable. Her vital signs and physical exam were within normal limits. The patient's father had captured t...
Source: The Case Files - March 13, 2019 Category: Emergency Medicine Tags: Blog Posts Source Type: research

A Sneaky Symptom
​BY JEFFREY LOMBARDO, MD, & MARK SUPINO, MDThe progressive suprapubic pain was a cunning symptom.The 38-year-old man had had five days of that pain and dysuria. By the time he presented to our ED, his pain had spread to the right lower quadrant as well. He had a history of diverticulitis after a laparoscopic left hemicolectomy four years earlier.He reported no fevers, but complained of nausea and diarrhea. He was afebrile at 36.8°C with a pulse of 76 bpm. All other vital signs were normal. Physical exam was significant for suprapubic pain and right lower quadrant tenderness to palpation without rebound, guarding,...
Source: The Case Files - February 26, 2019 Category: Emergency Medicine Tags: Blog Posts Source Type: research

An Unusual Hypoxia Patient
​BY GORDON MURPHY, PA-C, MPHThe patient was blue, her primary care physician noted. Quite literally, in fact.The 38-year-old woman had sought care for a recurrent urinary tract infection, and that's when her primary care physician found her pulse oximetry to be 74%. He was concerned about hypoxia and asked us to evaluate her.The patient reported taking an SSRI for anxiety and having a hormone-eluting IUD. She had previously had a Roux-en-Y gastric bypass. She said she had a headache, but had been instructed not to take NSAIDs. She said she had just finished a course of Cipro for her UTI, but continued to be symptomatic w...
Source: The Case Files - February 20, 2019 Category: Emergency Medicine Tags: Blog Posts Source Type: research

Right Upper Arm Pain in an Older Woman
​BY GREGORY M. TAYLOR, DO, & DAWN ZELENKA-JOSHOWITZ, DOAn 81-year-old woman with a past medical history of atrial fibrillation, three coronary artery bypass graft surgeries, and a prior cerebrovascular accident presented to the emergency department with right arm pain. Her symptoms had grown worse for two days, and she experienced paralysis about two hours before arrival.Her initial vital signs were a temperature of 97.7°F, a blood pressure of 196/43 mm Hg (left arm), a heart rate of 60 bpm, and a respiratory rate of 18 bpm. She had obvious pallor to her right upper arm with no brachial or radial pulses. She was ...
Source: The Case Files - February 12, 2019 Category: Emergency Medicine Tags: Blog Posts Source Type: research

Epigastric Pain, Nausea, and Vomiting in a Young Man
BY KATHRYN M. DEPRIMO & KHALID MALIK, MDA 30-year-old man with no previous medical history presented with one day of epigastric pain, nausea, and vomiting. He described the pain as moderate, aching, and nonradiating. He said Tylenol provided minimal relief.The patient reported vomiting four or five times since the start of his symptoms and described the vomit as yellow in color. He had no history of recent travel, recent sick contacts, trauma, pain with eating, fever, chills, shortness of breath, chest pain, headaches, dizziness, changes in bowel movements, or urination. The patient confirmed a past surgical histo...
Source: The Case Files - February 12, 2019 Category: Emergency Medicine Tags: Blog Posts Source Type: research

A Diagnostic Challenge for a Rare Condition
​BY GREGORY TAYLOR, DO, & SCOTT LAGERVELD, DOA 54-year-old man with a significant past medical history of atrial fibrillation and congestive heart failure presented to the ED with a chief complaint of difficulty walking. He was evaluated at an outside hospital two months earlier, and was found to have methicillin-resistant Staphylococcus aureus bacteremia, lower extremity cellulitis, and acute decompensated congestive heart failure (CHF). He clinically improved over one week, his autoimmune workup was negative, and he was discharged. He failed to follow up with nephrology, cardiology, and dermatology, and s...
Source: The Case Files - January 22, 2019 Category: Emergency Medicine Tags: Blog Posts Source Type: research

An Unexplained Short-Term Memory Loss
​BY JORDAN DEMCHUKA 59-year-old Caucasian man with a past medical history of well-controlled hypertension, hyperlipidemia, and gout presented to the ED with altered mental status. His wife reported that he was found two hours earlier in his home office confused, unable to recall plans made that morning, the current time and date, and his brother's death a year and a half earlier. She stated that the patient was repeating, “I don't know what's happening,” while anxiously pacing around the room. She said he had a history of falls and head injury at age 7, which was accompanied by brief amnesia that had not recu...
Source: The Case Files - January 22, 2019 Category: Emergency Medicine Tags: Blog Posts Source Type: research

MDMA-Induced Pneumomediastinum with an Unusual Presentation
​BY CLAUDIA BORNIA & KHALID MALIK, MDAn 18-year-old healthy man presented to the ED with a sore throat. He said the pain had started a day earlier when he took three capsules of Molly and drank heavily at a music festival.The patient reported pain while swallowing, shortness of breath, and pain in his left rib cage after playing basketball a few days earlier. The patient had no jaw or neck pain, coughing, fever, chills, nausea, vomiting, and diarrhea. He had a blood pressure of 126/76 mm Hg, temperature of 98.2°F (orally), heart rate of 70 bpm, respirations of 18 bpm, and oxygen saturation of 100% on room air. Th...
Source: The Case Files - January 16, 2019 Category: Emergency Medicine Tags: Blog Posts Source Type: research

Atypical CT Finding in the Scrotum
​BY DILEM POLAT & KHALID MALIK, MDA 50-year-old man with hypertension presented to the emergency department with an exacerbation of his lower back and perianal pain that he had had for two weeks, with a new onset of active fecal draining and difficulty urinating for four hours. He said he had no headache, nausea, vomiting, weakness, fatigue, fever, and chills, and all other reviews of systems were negative.His temperature was 98.5°F, blood pressure was 108/57 mm Hg, pulse rate was 113 bpm, respiratory rate was 20 bpm, and oxygen saturation was 97% on room air. His abdomen was soft, mildly distended, and not tende...
Source: The Case Files - December 27, 2018 Category: Emergency Medicine Tags: Blog Posts Source Type: research

What Is This International Traveler's Diagnosis?
​BY GREGORY TAYLOR, DO; DAWN ZELENKA-JOSHOWITZ, DO; & ANDREW TAECKER, DOA 34-year-old man presented with intermittent fever and body aches for 10 days. He had been visiting family in India, and the symptoms began when he returned home. His fever had been as high as 104°F, and he was experiencing nausea, two episodes of bilious emesis, body aches, nonspecific abdominal pain, and multiple episodes of watery, nonbloody diarrhea.He said he knew of no tuberculosis exposure or ill contacts, and he was current on his routine influenza and hepatitis A vaccines. His temperature was 101.4°F (he had taken acetaminophen ...
Source: The Case Files - December 12, 2018 Category: Emergency Medicine Tags: Blog Posts Source Type: research

Warning Signs in Acute Toxicity of an Uncommon Drug
​BY ARJUN BHARADWAJ; CHRISTOPHER RUSSELL; MARGARET GAVOR, MBCHB, MPH; & KHALID MALIK, MDA 63-year-old man presented with hand tremors, dizziness, and expressive aphasia. His symptoms had started a month earlier, and this was his third visit to the ED for these symptoms, though the aphasia was a new symptom. He said his symptoms had been growing worse.The patient's symptoms had been previously attributed to alcohol intoxication. He also said he had been experiencing vomiting, dry heaving, bilateral tinnitus, and dizziness but no fever, chills, chest pain, abdominal pain, shortness of breath, vision and hearing problem...
Source: The Case Files - December 12, 2018 Category: Emergency Medicine Tags: Blog Posts Source Type: research

Fool Me Once: An Uncommon Presentation of PE
​BY FREDDIE IRIZARRY-DELGADO; VAROON KAKAIYA; & AHMED RAZIUDDIN, MDAn 86-year-old African-American woman was brought to the ED by her daughter after two days of nutritional neglect, abdominal pain, and altered mental status. Her daughter said her mother felt lightheaded, appeared dehydrated, and vomited nonbilious watery fluid once. The patient had a history of diabetes mellitus type 2, DVT/PE, dementia, and early signs of parkinsonism.Her vital signs were remarkable only for tachypnea (24 bpm). Her troponin I was markedly elevated at 1.7 ng/mL. A D-dimer was ordered because of her history of unprovoked DVT/PE, and i...
Source: The Case Files - November 27, 2018 Category: Emergency Medicine Tags: Blog Posts Source Type: research

Debilitating Headache after an Excited Reaction
​BY GREGORY TAYLOR, DO, & MATTHEW WARPINSKI, DOA 35-year-old man with a history of uncontrolled hypertension and medical noncompliance was brought to the emergency department by EMS complaining of a headache. The family said the patient was watching football and developed an acute headache after he stood up screaming in excitement.His family said he had not taken his blood pressure medication for years. He was afebrile, his blood pressure was 245/129 mm Hg, his respiratory rate was 18 bpm, his heart rate was 68 bpm, and he weighed 340 pounds. The patient was obtunded with a Glasgow Coma Scale score of 4 and was subse...
Source: The Case Files - November 20, 2018 Category: Emergency Medicine Tags: Blog Posts Source Type: research

An Unusual Presentation of Rhabdomyolysis
​BY DAVID DIAZ; JONATHAN HAVERTY, DO; & JORGE DIAZ, DOA previously healthy 20-year-old woman presented to the emergency department with three days of bilateral thigh pain. The pain had initially started in a focal area of the anterior aspect of the lower thighs bilaterally. The next day, her pain had progressed to involve a larger area of her thighs, and she noticed redness and swelling in the same area.She had difficulty walking and bending her legs due to the pain. She said no other muscle groups were involved and she had never experienced this before. The patient had no history of vigorous physical activity or tra...
Source: The Case Files - November 13, 2018 Category: Emergency Medicine Tags: Blog Posts Source Type: research

A True Gastrointestinal Emergency
​BY GREGORY TAYLOR, DO, & SHERIF EL-ALAYLI, DOA 60-year-old man with a significant history of alcohol abuse, metastatic hepatocellular carcinoma, and cirrhosis presented to the emergency department complaining of vomiting up bright red blood. The patient was reportedly supposed to have an esophagogastroduodenoscopy (EGD) six months earlier but failed to follow up.He had two episodes of melena the night before and two episodes of hematemesis that morning. He was also experiencing fatigue, weakness, and abdominal pain, which he described as achy and localized to the epigastric region. He had refused treatment for his h...
Source: The Case Files - October 24, 2018 Category: Emergency Medicine Tags: Blog Posts Source Type: research

An Unusual Diagnosis for Abdominal Pain
​BY ARJUN BHARADWAJ; MARGARET GAVOR, MBChB, MPH; & KHALID MALIK, MDA 65-year-old man presented to the emergency department complaining of sudden-onset left-sided abdominal pain followed by a “seizure.” His abdominal pain started a few hours prior to presentation, was sharp in nature, and radiated to his back and umbilicus. The pain waxed and waned, worsened when he walked or sat up, and at its worst was a 10/10. He took a laxative and two antacids, but received no relief.Each “seizure” episode lasted about 30 seconds and occurred every five minutes. He said he felt drained after each event but...
Source: The Case Files - October 24, 2018 Category: Emergency Medicine Tags: Blog Posts Source Type: research

Torsion of a Large Adnexal Mass after Intercourse
​BY GREGORY TAYLOR, DO, & FRANK SCHELL, DOA 30-year-old woman presented to the ED complaining of pelvic pain. She said she felt an acute onset of sharp lower right pelvic pain during intercourse two days earlier. The pain continued to worsen, becoming diffuse. She was also experiencing nausea, vomiting, malaise, anorexia, and vaginal spotting. She had no history or concern for sexually transmitted disease, and had no fever or vaginal discharge. She had had a previous Cesarean section and bilateral tubal ligation.Her vital signs were a heart rate of 110 bpm, a respiratory rate of 25 bpm, a blood pressure of 113/88 mm ...
Source: The Case Files - October 16, 2018 Category: Emergency Medicine Tags: Blog Posts Source Type: research

A Significant Injury with Just a Speck of Pain
​BY ARJUN BHARADWAJ & KHALID MALIK, MDA 58-year-old man who lived at a nursing facility came to the emergency department complaining of abdominal pain for three days. His pain was localized to the epigastrium and periumbilical regions. The nursing home staff indicated that he was hypotensive and possibly hypoxic.The patient said he never had similar pain before, which he said pain was mild and constant in severity and did not radiate to the chest, back, pelvis, or shoulders. He also reported nausea but no trauma, falls, vomiting, fever, chills, dizziness, chest pain, shortness of breath, trouble walking, or change in...
Source: The Case Files - October 16, 2018 Category: Emergency Medicine Tags: Blog Posts Source Type: research

An Elbow Injury and a Lesson in Supracondylar Fractures
​BY GREGORY TAYLOR, DO, & JACKLYN MCPARLANE, DOAn 87-year-old woman presented with left elbow pain after a fall. She was walking down the stairs when she tripped where the hardwood stairs met the carpet, and she felt her elbow twist as she hung onto the rail.Her vitals were stable and within normal limits, but she had diffuse swelling, ecchymosis, and tenderness around the left elbow joint. There were no open wounds, abrasions, or skin breakdown, but her left elbow was grossly unstable. Motor and sensory skills were distally intact to the anterior interosseous, posterior interosseous, median, ulnar, and radial nerves...
Source: The Case Files - October 10, 2018 Category: Emergency Medicine Tags: Blog Posts Source Type: research

Pneumatosis Intestinalis with a Curious Etiology
​BY ALISON BROOMFIELD​; ARJUN BHARADWAJ; KHALID MALIK, MDA 68-year-old woman was brought to the emergency department from a nursing home with a complaint of abdominal distention. The patient had no focal pain, just overall diffuse discomfort in her abdomen and upper pelvis. She and the nursing home staff did not know when her symptoms started. The patient had taken acetaminophen, but it had no effect on her discomfort.The discomfort did not radiate to her chest, back, or shoulders. The patient and nursing home indicated no recent trauma or falls, but the patient reported two episodes of non-bilious, non-bloody vomiting...
Source: The Case Files - September 25, 2018 Category: Emergency Medicine Tags: Blog Posts Source Type: research

Uremic Encephalopathy Secondary to Medical Noncompliance
​BY GREGORY TAYLOR, DO, & CHRISTOPHER COOLEY, DOA 66-year-old woman with a history of type 1 diabetes, hypertension, and end-stage renal disease (ESRD) on hemodialysis presented via EMS to the emergency department with altered mental status. She lived with her family, and they noted that she refused to go to dialysis for her past four sessions and had increasing lethargy for two days.She was afebrile, and her other vital signs were blood pressure 136/92 mmHg, heart rate 77 bpm, respiratory rate 20 bpm, and oxygen saturation 96% on room air. She was agitated and reaching for objects in the sky. Her cardiopulmonary exa...
Source: The Case Files - September 18, 2018 Category: Emergency Medicine Tags: Blog Posts Source Type: research

An Unusual Cause Behind Diffuse Itching and Redness
​BY MARISEL ​​VAZQUEZ​; ARIEN KASRA; & AHMED RAZIUDDIN, MDA 70-year-old woman with a history of breast cancer and a lumpectomy and lymph node dissection 20 years before presented to the ED because of redness and itching for two weeks covering the entire surface of her skin. Two weeks before that, she went for a Pap smear and was prescribed fluconazole for Candida vulvovaginitis infection. She took one dose of the fluconazole and an hour later became itchy and red and felt as if her entire body were burning.The itching and redness were diffuse and had persisted for two weeks, neither worsening nor...
Source: The Case Files - September 10, 2018 Category: Emergency Medicine Tags: Blog Posts Source Type: research

A Pregnancy Complication to Look out for even after Pregnancy
​BY GREGORY TAYLOR, DO, & SHERIF G. EL-ALAYLI, DOA 30-year-old G5P3 presented to the ED with bilateral lower-extremity edema and headache for three days. She presented one week after an uncomplicated full-term vaginal delivery with an unremarkable pregnancy course and no prior requirement for antihypertensive therapy. The headache was described as achy to sharp, with associated photophobia. She also noted occasional vaginal spotting, which was common a few weeks after delivery. She denied any chest pain, shortness of breath, nausea or vomiting, abdominal pain, or any other symptoms. She admitted to occasional mild cr...
Source: The Case Files - August 28, 2018 Category: Emergency Medicine Tags: Blog Posts Source Type: research

An Emergency from an Innocuous Bite
​BY GREGORY TAYLOR, DO, & ERIC MCDOWELL, DOA 47-year-old woman presented to the emergency department with a chief complaint of pain and swelling on her left index finger two days after she was bitten by her cat. Her vitals were within normal limits. Physical exam was notable for two puncture wounds to the left index finger along the radial aspect of the middle phalanx. Fusiform swelling was noted around the proximal phalanx to the level of the MCP joint, with erythema extending to the distal palmar crease. The index finger was held in slight flexion with pain during passive extension and pain with palpation of the te...
Source: The Case Files - August 21, 2018 Category: Emergency Medicine Tags: Blog Posts Source Type: research

Never Too Young to Have a Heart Attack
​BY MELINDA HUANG, DO; CATHERINE KELLY, DO; & STEVEN SATTLER, DOA 36-year-old man presented to the emergency department with chest pain that had begun 30 minutes earlier. The patient was a mechanic, and said he was working on his car when he developed sharp, constant, mid-sternal, 5/10 chest pain that radiated to his left arm. He had associated nausea and dyspnea. The patient denied fever, cough, recent travel, recent surgery, malignancy, blood clots, hormone use, calf pain, and calf swelling. He did not take any medication for the pain. He denied smoking cigarettes, and had no family history of cardiac disease.The p...
Source: The Case Files - August 21, 2018 Category: Emergency Medicine Tags: Blog Posts Source Type: research

A Common Condition with an Uncommon Presentation
​BY ARJUN BHARAD​WAJ​ & AHMED RAZIUDDIN, MD​A 41-year-old man who recently immigrated from Africa came to the ED with abdominal pain. The patient primarily spoke Tigrinya, and an interpreter was used in taking a history. The patient's abdominal pain had started four hours earlier, which he described as squeezing or cramping mid-epigastric and umbilical pain. The pain did not change or radiate.He had also had three episodes of nonbloody emesis. This was a new problem for him, and he hadn't encountered anyone sick or with similar symptoms. His last bowel movement was the previous night, and no changes in bowel or...
Source: The Case Files - August 14, 2018 Category: Emergency Medicine Tags: Blog Posts Source Type: research

Triple Trouble in the Abdomen
​BY LAURIE-ANN​ ANTOINE; MOHIT S. MAHALAN; & AHMED RAZIUDDIN, MDA 32-year-old afebrile woman presented to the emergency department in acute distress from abdominal pain, which she described as severe and crampy. The pain had begun approximately six hours prior to her visit to the hospital, and was associated with nausea and intractable, bilious vomiting. The patient consumed one dose of liquid bismuth subsalicylate, but it did not provide relief.The patient's last bowel movement was several hours prior to her arrival at the hospital and was nonbloody. Her past medical and surgical history were unremarkable. The pat...
Source: The Case Files - August 14, 2018 Category: Emergency Medicine Tags: Blog Posts Source Type: research

Abdominal Pain Yields a Devastating Diagnosis
​BY GREGORY TAYLOR, DO, & DIANE KAISER, DOA 41-year-old woman presented to the emergency department with abdominal pain, noting multiple episodes over the past year of intermittent right upper quadrant pain that she described as “achy” and “fullness.” These episodes occurred sporadically with no identifiable exacerbating factors. Associated symptoms included a 20-pound unintentional weight loss over two months with occasional nausea and vomiting. She was a former smoker of 10-pack years and had stopped two months prior to arrival, and she reported drinking two to three glasses of wine a week. ...
Source: The Case Files - July 24, 2018 Category: Emergency Medicine Tags: Blog Posts Source Type: research

The Heart and the Kidney: What One Tells You about the Other
​BY AN​UMEHA SINGH, MDA 56-year-old man presented to the ED with shortness of breath and pleural effusions diagnosed by an outside treating physician. The workup included urinalysis, which showed proteinuria, and the exam was consistent with myxedema and pedal edema. He had a history of rheumatoid arthritis, leukocytoclastic vasculitis and Sjögren's syndrome, diabetes, and monoclonal gammopathy of unknown significance (MGUS).The patient also had shortness of breath for a month and pleural effusions on outpatient chest x-ray. He had taken Humira, methotrexate (MTX), and steroids, but his arthritis and Sjögren'...
Source: The Case Files - July 17, 2018 Category: Emergency Medicine Tags: Blog Posts Source Type: research

Mortality High in Cardiac Arrest from Hanging
​BY GREGORY TAYLOR, DO, & ​​LAURIE WALLACE, DOA 27-year-old man with a significant past medical history of depression, multiple suicide attempts, intravenous heroin abuse, and hypertension presented to the emergency department with cardiac arrest. The patient had hanged himself with a bungee cord in his family's basement, and had been hanging for approximately 15 minutes before EMS was called. The patient was unresponsive on EMS arrival, with an initial rhythm of pulseless electrical activity (PEA). Return of spontaneous circulation (ROSC) was achieved en route following five rounds of epinephrine and cardio...
Source: The Case Files - July 17, 2018 Category: Emergency Medicine Tags: Blog Posts Source Type: research

Complications of a Ruptured Ectopic Pregnancy
​BY GREGORY TAYLOR, DO, & JACKLYN MCPARLANE​, DOA 31-year-old woman with a significant medical history for one ectopic pregnancy and five spontaneous abortions presented with abdominal pain and vaginal bleeding. Her symptoms started abruptly two days earlier, and the pain was located in the right lower quadrant, which had become diffuse and she described as sharp. She was also experiencing nausea, vomiting, and vaginal bleeding.She stated she had been spotting for five days and soaking up to four pads a day. Her last menstrual period was two months before, and a home pregnancy test was positive. Her presentation wa...
Source: The Case Files - July 11, 2018 Category: Emergency Medicine Tags: Blog Posts Source Type: research

A True Hematologic Emergency
​BY GREGORY TAYLOR, DO, & JACKLYN M​CPARLANE, DO​A 33-year-old woman with a past medical history of sickle cell SS presented to the emergency department with chest pain, difficulty breathing, and a cough for two days. Her chest pain was diffuse, without radiation, and partially reproducible. Her cough was nonproductive, and she also reported fever and chills.The patient noted this was different from her normal back and leg pain from past sickle cell crises. She was following up with a sickle cell specialist, and was compliant with her hydroxyurea treatment.Her temperature was 102.8°F, blood pressure was 94/60...
Source: The Case Files - June 26, 2018 Category: Emergency Medicine Tags: Blog Posts Source Type: research

Complications of Ketamine Abuse
​​BY STUART ETENGOFF, DO, & ABDULLAH ​BOKHARI​, AB, DOA 20-year-old Caucasian man presented via EMS with a chief complaint of withdrawal from ketamine and secondary complaints of abdominal pain, blood in his urine, and painful urination with urgency for two days.He said he had been using ketamine intravenously daily for the past five days, up to 35 grams over the past week. His last use was 24 hours prior to presentation to the ED. He stated that he had been using ketamine regularly for four years and that he has used it intravenously, orally, and intranasally.He reported a history of ADHD and a family his...
Source: The Case Files - June 19, 2018 Category: Emergency Medicine Tags: Blog Posts Source Type: research

A Curious Cause of Pulmonary Embolism
​BY BRUNA ALMEIDA, & AHMED RAZIUDDIN, MDA 30-year-old man presented to the ED with dyspnea and pleuritic chest pain radiating to his left shoulder that had started three days before. He was at a “sex party” four days earlier, and had used amphetamines and gamma-hydroxybutyric acid (GHB, also called Liquid G).The patient said deep breaths and movement worsened his pain. He also had exertional shortness of breath and occasional palpitations. He denied fever, cough, loss of consciousness, recent surgery, and prolonged immobilization. The patient had no personal or family history of DVT, PE, or cardiac condit...
Source: The Case Files - May 15, 2018 Category: Emergency Medicine Tags: Blog Posts Source Type: research

An Unusual Diagnosis Presenting as SOB and Pleural Effusions
​BY ANDRZEJ KIELTYKA, PA; PARDEEP THANDI, MD; & ANUMEHA SINGH, MDA 56-year-old man presented to the emergency department with shortness of breath for one month and pleural effusions on an outpatient chest x-ray. He had been taking adalimumab, methotrexate, and steroids for arthritis and Sjogren's syndrome.A right pleural effusion in a patient with nephrotic syndrome.His monoclonal gammopathy of undetermined significance (MGUS) was monitored annually, but no medical intervention beyond surveillance was required. He had excessive thirst but normal urine output. He noted face and hand swelling in the morning that gave w...
Source: The Case Files - May 9, 2018 Category: Emergency Medicine Tags: Blog Posts Source Type: research

Severe Symptoms, but a Truly Treatable Disease
​BY NOURA MAHDI; DARRON LEWIS; JEREMY OSBORNE; & AHMED RAZIUDDIN, MDA 73-year-old man was brought to the emergency department from his nursing home for rectal bleeding and anemia. The patient mentioned he had had episodes of bright red rectal bleeding and constipation for a few months. A colonoscopy had been done prior to the visit, which revealed a large intestine tumor and biopsy confirming adenocarcinoma. He was awaiting an appointment with his surgeon.The patient reported bloody rectal leakage, and a CBC done at the nursing home showed a hemoglobin level of 7.2. He also complained of dyspnea but denied any other ...
Source: The Case Files - March 20, 2018 Category: Emergency Medicine Tags: Blog Posts Source Type: research

Care after Return of Spontaneous Circulation
​BY TRAVIS SMITH, MD, & MATTHEW ZUCKERMAN, MDParamedics were called for a 42-year-old woman found at a motel by her significant other. The patient was alone at the time of EMS arrival. She was pulseless and apneic, so chest compressions were started, and the cardiac monitor showed pulseless electrical activity.Initial ECG showing STE in the anterior leads with ST depression in the inferior leads.The paramedics gave her 1 mg of epinephrine IV and 1 mg of naloxone IV without obvious response. A laryngeal mask airway was placed, and oxygen was delivered by bag valve mask. She received eight rounds of chest compress...
Source: The Case Files - March 13, 2018 Category: Emergency Medicine Tags: Blog Posts Source Type: research

When the Treatment Could Lead to Death
​BY KEVAL PATEL, & AHMED RAZIUDDIN, MDA 41-year-old man with a past medical history of bipolar disorder, PTSD, and alcohol abuse presented to the emergency department for an erection that wouldn't go away. He said his erection had persisted for 28 hours and was starting to be painful. He had taken trazodone the day before but was unable to recall the dosage. He denied any erectile dysfunction in the past when he was on trazodone a year before.Physical examination showed an uncomfortable-appearing man lying supine in bed but in no acute distress. The physical exam was normal except for the genitourinary exam, which re...
Source: The Case Files - February 20, 2018 Category: Emergency Medicine Tags: Blog Posts Source Type: research

When You Can't See the Bleeding
​BY MARIA AHMAD, & AHMED RAZIUDDIN, MD​A 50-year-old woman presented to the ED at 10 a.m. one day complaining of severe left upper quadrant and left flank pain since 2 a.m. the night before. The pain was associated with nausea and four episodes of vomiting, and she described it as nonradiating, sharp, and stabbing. The patient was in obvious distress and diaphoretic. She confirmed that she had never had surgery and was not taking any medications. Her first set of vital signs included an oral temperature of 97.4°F; blood pressure of 105/92 mm Hg; pulse of 106 bpm; respiratory rate of 28 bpm; mean arterial pressu...
Source: The Case Files - February 13, 2018 Category: Emergency Medicine Tags: Blog Posts Source Type: research

A Common Emergency with an Uncommon Twist
​BY ADAM JONES, MD, & LUKE METZKER, DOAbdominal compartment syndrome is a recognized emergency following abdominal trauma and surgery, but apparently it can also be spontaneous. A 58-year-old mentally delayed and autistic man presented to the ED with acute onset severe abdominal pain, a rigid abdomen, and respiratory failure. His lower extremities were mottled, and he was obviously in acute distress. He was intubated, and an orogastric tube was placed in preparation for exploratory surgery.Initial chest x-ray showing severe gastric distension.After the tube was placed, the patient's abdomen decompressed and color ret...
Source: The Case Files - January 30, 2018 Category: Emergency Medicine Tags: Blog Posts Source Type: research

Ocular Complaint Leads to an Unusual Diagnosis
​​BY ​​​GURDEEP​ SINGH NAGI, MD; BHAVINI TAILOR, ​MD; & ​AHMED RAZIUDDIN, MDA 40-year-old man with no significant past medical history presented to the emergency department with visual problems. He said he had noticed about four days earlier a dark red circle over any object on which he tried to focus. The condition had been constant and had not improved or worsened over the past few days. He also said it did not matter whether he was focusing on an object that was near or far.The patient had seen an optometrist who recommended he have blood work done, but did not specify what exactly to ...
Source: The Case Files - December 28, 2017 Category: Emergency Medicine Tags: Blog Posts Source Type: research