Rachel Bridwell

A 25-year-old male is brought to the ED by EMS after sudden onset right testicular pain. He denies any trauma or contact to his scrotum or perineum; however, he endorses severe, sudden pain associated with nausea and non-bloody, non-bilious emesis. He additionally complains of mild lower right abdominal tenderness. Review of systems is otherwise unremarkable. On exam he is uncomfortable appearing and has a nontender abdomen. He has a normal penile exam, but the the right hemiscrotum has mild erythema, a horizontal lie, and it is exquisitely tender. What’s the next step in your evaluation and diagnosis?

A 13-year-old male presents to the ED for aggressive behavior which progressed to confusion and decreased level of consciousness. He initially was very agitated and aggressive and refused to drink any water. He then became disoriented and is now difficult to rouse. The parents note that he had recently had a fever, sore throat, and general malaise prior to this behavior but those symptoms resolved, although they note excessive salivation. Review of systems is remarkable for a bat bite for which he never sought care. He is tachycardic, tachypneic, febrile, and appears toxic. What’s the most likely diagnosis?

Today on the emDOCs cast with Brit Long and Rachel Bridwell, we cover Lemierre’s syndrome and retropharyngeal abscess.

A 33-year-old male presents to the ED for odynophagia and mild dyspnea. He has had pain with swallowing for the past 24 hours and it has gotten progressively worse. He is having difficulty tolerating oral secretions. VS include BP 91/49, HR 130, T 102.2 temporal, RR 25, SpO2 91% on room air. He appears toxic.  The ENT exam reveals a midline uvula; cervical lymphadenopathy; soft mouth floor, and no evidence of dental infection, no neck erythema, though voice changes. He has severe pain with palpation of the hyoid bone. What’s the most likely diagnosis?

A 3-year-old male is brought in by his mother for severe throat pain and lethargy. She notes that he is playing less, refusing to eat, and preferring to lie supine. Review of systems is remarkable for a recent small fall with his toothbrush in his mouth. Triage vital signs include BP 91/49, HR 141, T 103.1 temporal, RR 25, SpO2 96% on room air. He appears toxic and is lying supine. The oropharyngeal exam is normal, but the patient has prominent generalized cervical lymphadenopathy, torticollis, and a painful tracheal rock. The patient has no voice changes but does not want to extend his neck. What’s the most likely diagnosis?

A 23-year-old male presents for severe throat pain and cough. He states that his neck hurts, with left sided redness and pain. Vital signs include BP 91/49, HR 130, T 102.2 temporal, RR 25, SpO2 91% on room air. He appears toxic. The ENT exam reveals a midline uvula; soft mouth floor; prominent generalized cervical, submandibular, and submental swelling with corresponding lymphadenopathy; but no voice changes or difficulty tolerating secretions. His neck is red and tender, with mild swelling overlying the left side of neck and a painful tracheal rock. What is the most likely diagnosis?

Rachel Bridwell is back to discuss another ENT emergency: peritonsillar abscess.

A 42 year-old male presents with abdominal pain and fevers for 72 hours, with nausea and vomiting for 24 hours. He has a history of ESRD and has been on peritoneal dialysis for 5 years. Triage vital signs (VS): BP 105/60, HR 121, T 101.4 temporal, RR 24, SpO2 98% on room air. Pertinent physical examination findings include a tender peritoneal dialysis site and diffuse abdominal tenderness, but no erythema overlying the PD site. What’s the next step in your evaluation and treatment?

This week Rachel Bridwell and Brit Long cover Ludwig’s Angina, a potential ENT and airway nightmare.

A 42-year-old male undergoing recent radiation therapy for colorectal cancer presents with pelvic and anal pain and pain with defecation. He experiences extreme pain prior to and during defecation. He has had mucous and blood in his stool. He denies a history of hemorrhoids. Pertinent physical examination findings include fever, tachycardia, and lower abdominal pain to palpation. Rectal exam reveals reveals tenderness. What’s the next step in your evaluation and treatment?