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em@3am

EM@3AM: Vaginal Bleeding

 A 22-year-old female presents with three days of vaginal bleeding. She has soaked through multiple pads and has passed clots. She endorses some lightheadedness but no syncope. Her last period was two weeks ago. She has no known past medical history, does not use hormonal contraception, and is sexually active with one male partner. On exam, she is stable, and her abdomen is soft and non-tender. The speculum exam reveals blood in the vaginal vault that appears to be coming from the cervical os. Her urine pregnancy test is negative. What is your next step in evaluation and treatment?

em@3am

EM@3AM: Pneumocephalus

A 58-year-old female presents with severe headache and nausea. Her symptoms started shortly after leaving the office of her pain management doctor, where she had an epidural steroid injection to alleviate her chronic back pain approximately 30 minutes before she arrived in the ED. The patient denies any trauma to the head, fevers, nuchal rigidity, changes in vision, focal weakness, paresthesia, or anticoagulation use.  On arrival, she is awake and alert and in obvious distress. Her vitals signs include temperature of 98.8F, HR of 64, BP 133/78, and O2 saturation of 98% on room air with a respiratory rate of 18. Her exam, including a complete neurological exam, is grossly benign. Given her acute complaint and recent history, labs and CT of the head are obtained. The clinician orders analgesics. The CT shows intracranial air.