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EM@3AM: Genitourinary Trauma

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A previously healthy 32-year-old male presents to the ED via EMS following a high-speed motor vehicle collision on the interstate. The lower part of his abdomen hit the steering wheel. He reports significant pain in the perineum and groin. He has the urge to urinate but is unsure if he is able to. Vital Signs on arrival to the ED: HR 110, RR 18, blood pressure of 120/80, temperature (oral) of 99.1F, with an oxygen saturation of 99% on room air. On secondary survey, the patient has mild diffuse lower abdominal tenderness. His pelvis is stable.  There is no testicular swelling or pain; however, you observe blood at the urethral meatus.

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EM@3AM: Tachycardia

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A 70-year-old male with presents with 5 days of fever and 3 days of anuria and malaise.  He also notes worsening abdominal distention and shortness of breath. He found and removed a tick 3 weeks ago and another one 1 week ago. Labs reveal WBC 2,200 cells/microL, HGB 11.2 g/dL, Plt 21 × 109/L, BUN 86 mg/dL, Creatinine 6.8 mg/dL, AST 350 U/L, ALT 119 U/L.

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EM@3AM: Ehrlichiosis

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A 70-year-old male with presents with 5 days of fever and 3 days of anuria and malaise.  He also notes worsening abdominal distention and shortness of breath. He found and removed a tick 3 weeks ago and another one 1 week ago. Labs reveal WBC 2,200 cells/microL, HGB 11.2 g/dL, Plt 21 × 109/L, BUN 86 mg/dL, Creatinine 6.8 mg/dL, AST 350 U/L, ALT 119 U/L.

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EM@3AM: Corneal Transplant Complications

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A 61-year-old male with a history of bilateral corneal transplants due to Fuchs’ endothelial dystrophy presents with progressive visual decline in his right eye over the past three days. He describes associated redness, photophobia, and mild foreign body sensation. He denies trauma but acknowledges inconsistent use of his prescribed steroid eye drops. He has decreased visual acuity in the right eye, mild conjunctival redness, and absence of purulent discharge. Slit-Lamp reveals corneal swelling with scattered keratic precipitates and mild anterior chamber inflammation.

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EM@3AM: Thyrotoxic Periodic Paralysis

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A 28-year-old otherwise healthy male presents for an acute episode of bilateral lower extremity weakness causing him to fall in the bathroom. The episode started approximately 30 minutes prior to arrival. He had a similar episode three months prior which resolved quickly during his ED visit. Neuro exam includes intact sensation in all distributions to light touch.  Hip flexion ⅖ bilaterally, knee extension ⅗ bilaterally, plantar and dorsiflexion ⅘. Bilateral upper extremities shoulder flexion, elbow flexion, and extension 5/5. Labs reveal low potassium, phosphate, magnesium, TSH.

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EM@3AM: Bradypnea

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A 53-year-old male with hyperlipidemia and cervical stenosis presents with dyspnea, which has been worsening since his cervical spinal fusion 6 days ago. He states he is very fatigued and feels as though he cannot get a deep breath. Vital signs revealed a BP of 136/76, HR of 88, RR of 9, SpO2 of 94% on room air, and a temperature of 97.6 F. On physical exam, the patient is lethargic, has nasal flaring, and is using accessory muscles to breathe. Lung sounds are clear. On cardiac exam, there is normal rate and rhythm without murmur, rubs, or gallops. His capillary refill is 2 seconds. His surgical incision looks clean and without any signs of infection. An ABG is drawn and reveals pH of 7.53, pCO2 of 58, and PO2 of 83. Chest X-ray shows some mild atelectasis but no acute infiltrates. What is the diagnosis?

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EM@3AM: Systemic Lupus Erythematosus

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A 23-year-old female presents to the ED with slurred speech, left lower leg weakness, and confusion. A friend is with her and states that the patient does not take any medications, has no past medical history, but has been complaining of various symptoms over the past year.
On exam, the patient has 0/5 strength in her left lower extremity, has slurred speech, and is unable to answer most of your questions. You code stroke the patient. CT head/CTA head and neck are unremarkable, but MRI brain reveals stroke.

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EM@3AM: Inflammatory Bowel Disease

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A 24-year-old male with no past medical history presents with several days of oral ulcers and throat pain. He also notes multiple months of diarrhea and hematochezia. He has lost roughly 30 lbs over the preceding 6 months. He has normal vital signs but appears malnourished, with a weight of 48 kg. He has dry oral mucous membranes, abdomen is diffusely tender, and he has ulcers on the uvula and soft palate. Labs reveal anemia, leukocytosis, electrolyte abnormalities, and elevated inflammatory markers. What is the diagnosis?

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EM@3AM: Systematic Approach to Massive Hemorrhage and Nuances in Special Patient Populations

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A 32-year-old female presents with chief complaint of “abdominal pain”. Her pain started 8 hours ago and became severe within the last 30 minutes. Initial vitals demonstrate a blood pressure of 88/48 mm Hg, HR 122 bpm, Temp 36.4 C, and 20 respirations/min. On your physical exam she has tenderness to palpation in the left lower pelvic region with rebound tenderness. You note her hypotension and perform RUSH exam. During your exam you note free fluid in the rectouterine pouch. As you finish your exam, she is now pale, clammy, and minimally responsive to pain with repeat blood pressure 64/33 mm Hg. What is the systematic approach to a patient with signs of massive hemorrhage?

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