em@3am

A 24-year-old female G4P1 who is 9 weeks pregnant presents with abdominal pain and vaginal bleeding for 3 days. Vital signs include HR 115, BP 100/76, T 38.7, RR 13, SpO2 99% on RA. She is ill-appearing and has tenderness to palpation of the bilateral lower quadrants and suprapubic region. Pelvic exam reveals blood in the vaginal vault and foul-smelling discharge from the cervix with no other abnormalities. What is the likely diagnosis?

The EM@3AM series returns with amyloidosis.

A 58-year-old male presents with 1 day of severe vertigo associated with nausea and vomiting, tinnitus, and sudden-onset hearing loss. He reports several days of left-sided ear pain and discharge from his left ear. Vital signs reveal T 38.9C, HR 120, BP 138/96, RR 18, SpO2 99% on room air. He is ill-appearing with an HEENT exam notable for an inflamed left external auditory canal with purulent drainage and an erythematous tympanic membrane with evidence of perforation. He has left-sided hearing loss, left-beating horizontal nystagmus, and a mildly unsteady gait. He has leukocytosis with bandemia. CT head shows no acute intra-cranial process. What is the most likely diagnosis?

A 42-year-old male with a past medical history of substance use presents to the ED for chest pain, shortness of breath, nausea, and vomiting. He reported snorting fentanyl two days ago and has a remote history of IV drug use. Vital signs include 98.8°F, HR 150, RR 23, SpO2 98% on RA, and BP of 180/100. He is anxious-appearing and diaphoretic, with dilated pupils (6mm, equal, round, and reactive) and full body rigors; ankle clonus is absent. Labs demonstrate a potassium of 2.8 mEq/L and a lactate of 3 mg/dL. He receives electrolyte repletion, fluid resuscitation, and broad-spectrum antibiotics. Concerned for opioid withdrawal, the treating physicians orders multiple doses of buprenorphine and full opioid agonists, without evidence of clinical improvement. What is the diagnosis?

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 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?