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 never lost cons...
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 BHARADWAJ & AHMED RAZIUDDIN, MDA 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. She did not have...
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 ANUMEHA 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's were c...
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
