em@3am

A 30-year-old female presents after sustaining a motorcycle collision at highway speeds. She was wearing protective equipment, including a helmet, gloves, knee and elbow pads, and riding boots. She denies loss of consciousness but reports severe right lower extremity pain rated as 10 out of 10. Vital signs reveal BP 93/78 mmHg, HR 122 bpm. During the secondary survey, a rapidly expanding mass is noted over the right lateral thigh. The overlying skin is tense and tender to palpation.

A 15-year-old female with PCOS, obesity, asthma, and recurrent otitis media with bilateral tympanostomy tube placement reports three weeks of increasing sanguineous drainage, ear pain, fevers, and worsening left-sided headaches not improving with NSAIDs.  She localizes the pain behind the left eye and additionally reports loss of lateral vision in her left eye, as well as double vision when looking to the left. On exam, she has a thickened, inflamed appearing left tympanic membrane with sanguinopurulent drainage from the left tympanostomy tube. She additionally has tenderness and swelling to the left mastoid process. Examination of the eyes reveals normal, symmetric, and reactive pupils.  The patient has binocular horizontal diplopia on left lateral gaze and downgaze, which resolves with covering either eye.  She has decreased vision in the lateral visual fields of the left eye on confrontational field exam.

A 62-year-old male presents to the ED with bilateral lower extremity weakness. He states that for the last few months, he has had an increasingly difficult time climbing stairs. He notes progressively worsening neck pain and stiffness for the past year. This morning, his wife urged him to come in because she noticed he was having trouble holding a cup of coffee in his hand.

A 70-year-old female presents with left lower quadrant abdominal pain for 2 days, gradually worsening until it was no longer controlled with over-the-counter meds. She also mentions that she has not had a bowel movement for two weeks but has been passing flatus. She has not taken her temperature but has felt feverish and chilly; she also vomited twice today (non-bilious and non-bloody). She has no appetite and has only managed sips of water in the past few days. On exam, she appears ill and visibly uncomfortable. She has tachycardia and mild tachypnea. Abdominal exam reveals diffuse tenderness, with maximal tenderness in the left lower quadrant as well as rebound and involuntary guarding. What is the diagnosis?

The Revamp series covers the ins and outs of acetaminophen toxicity.

A 15-year-old female with no reported past medical history presents with lower abdominal pain and possible STI symptoms. She reports living with a “friend” but cannot provide an address, does not attend school regularly, and is accompanied by an adult male who claims he’s “just a family friend” but refuses to leave her side and answers all questions for her. She is alert and oriented but appears fatigued, with mildly matted hair. She avoids eye contact with the clinician and nurse, and her story has changed multiple times since arrival. What are you concerned about outside of the abdominal pain?

A 54-year-old woman presents with right arm swelling, heaviness, and dull discomfort. She recently underwent chemotherapy via a peripherally inserted central catheter (PICC) placed two weeks ago on her right side for newly diagnosed breast cancer. She denies fever, chest pain, or shortness of breath. On exam, her right upper extremity is visibly swollen from the mid-bicep to the shoulder with mild erythema, increased warmth, and prominent, dilated superficial veins across the upper arm and chest wall. A tender, palpable cord is noted over the medial aspect of the upper arm. Radial and ulnar pulses are intact, and there are no signs of infection or fluctuance around the PICC site. 

A 72-year-old male with BPH and HTN presents from a subacute rehab facility for altered mental status and fever. He has had a Foley catheter in place for the past 10 days following hospitalization for hip fracture repair. Vital signs include BP 92/68, HR 110, T 103F rectally, RR 17, SpO2 98% on RA. Foley catheter is in place with cloudy urine in the Foley bag. Ultrasound demonstrated a non-distended bladder with Foley balloon in good position. UA from old Foley: >10 WBC per HPF. UA + Culture from new Foley: >10 WBC per HPF. What is the likely diagnosis?