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em@3am

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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EM@3AM: Pediatric Aural Foreign Bodies

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A 6-year-old boy with past medical history of ADHD is brought in by his parents with left sided ear pain and irritability for 12 hours. He was at his normal state of health prior to this and has been afebrile. Parents deny any history of frequent ear infections or tympanostomy tubes, and he is up to date on his vaccinations. Otoscopic exam shows a smooth round green object in the right auditory canal. The tympanic membrane is not visualized.

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EM@3AM: Cotton Fever

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A 30-year-old male with history of IVDU presents with fever. He reports last drug use was one hour prior to arrival and admits to reusing the same cotton filter on multiple occasions. He denies recent cough, chest pain, shortness of breath, abdominal pain, nausea, vomiting, or diarrhea. VS include Temp 101.0°F, HR 110, BP 130/80, RR 18, SpO2 98% on room air. On exam, he is diaphoretic and has track marks on bilateral upper extremities. Lung sounds are clear, and there are no heart murmurs. Complete blood count and metabolic panel are unremarkable. What is the likely diagnosis?

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EM@3AM: Splenomegaly

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A 20-year-old female presents to the ED with “abnormal results” found on a CT scan. She was feeling well until approximately 2 weeks ago when she began to have fatigue, malaise, loss of appetite and abdominal discomfort. She saw her primary care doctor who ordered an outpatient CT scan of her abdomen and pelvis, and upon obtaining the results showing splenomegaly, sent her to the ED for evaluation.  What is the approach to the patient with splenomegaly? 

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EM@3AM: Pertussis

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A 3-month-old male presents with persistent fever, decreased oral intake, and worsening cough associated with post-tussive emesis for the five days. Parents state that the patient’s older sibling has had similar symptoms for the past two weeks and that neither child has received vaccinations after birth. The patient presents with BP 98/64 mm Hg, HR 160, RR 62, T 38.1ºC. Physical exam demonstrates an ill-appearing infant with bilateral conjunctival hemorrhage, dry cough, and inspiratory “whooping” sound. What is the most likely cause of this patient’s symptoms and what are the next steps in management?

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EM@3AM: Crack Lung

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A 45-year-old male with a history of cocaine use presents to the ED with one day of worsening shortness of breath, cough, and fever. He is coughing up sputum streaked with blood. He endorses smoking crack cocaine the night before his symptoms started but denies injecting, using other drug use, or vaping. Vital signs include blood pressure 152/86 mmHg, heart rate 110 beats per minute, temperature 38°C, respiratory rate 23, oxygen saturation 86% on room air. Exam reveals a man in moderate respiratory distress. X-ray demonstrates diffuse alveolar infiltrates bilaterally, and CT shows diffuse ground glass opacities bilaterally. What is the most likely diagnosis?

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EM@3AM: Tetanus

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A 38-year-old male with a history of injection drug use presents with one day of progressively worsening, pressure-like chest pain radiating to his back. He appears diaphoretic and in moderate distress. He has had new difficulty opening his mouth. On exam, he is tachycardic, diaphoretic, and in acute distress. He endorses tenderness throughout his thoraco-lumbar spine. Neurological evaluation demonstrated increased tone in all extremities. Skin exam reveals two abscesses on his upper extremities. An MRI of the spine is unremarkable. Reexamination reveals new spasmodic neck stiffening, jaw clenching and arching of his back. What is the likely diagnosis?

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EM@3AM: Retropharyngeal Abscess

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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?

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