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EM@3AM: Lemierre’s syndrome

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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?

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EM@3AM: Pheochromocytoma

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A 23-year-old male presents with recurrent episodes of global headache, flushing, sweating, and palpitations. These episodes first started 1 month ago. They occur several times per day and last less than one hour. He has also noted a 10-pound weight loss since these episodes started. Exam reveals blood pressure 183/108 mm Hg, HR 1114 beats per minute, RR 18, temperature 98.4 C, saturation 98% on room air. His skin is flushed. Your cardiovascular, pulmonary, abdominal, and motor and sensory exams are otherwise normal. What is the likely diagnosis?

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EM@3AM: Celiac Disease

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A 32-year-old female presents to the ED with worsening diarrhea for 2 months. The diarrhea is non-bloody but is bulky, foul-smelling, and floats. She has had a 9-pound weight loss. She has ulcers along the buccal mucosa. Her abdomen is soft and nontender, and while she appears tired, the rest of the exam is normal. What is the patient’s diagnosis? 

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EM@3AM: Botulism

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A 3-month-old female is brought into your ED by her mother for constipation and decreased PO intake for 3 days. She was born full term without complications and is breastfed along with some soft foods. When asking about changes in diet, her mother states they only eat organic and grow most of their own food on their farm. They also can some food to prevent spoiling. Vital signs are unremarkable. It takes longer than expected for her to open her eyes, and she appears to have head lag. She will not feed while in the ED despite multiple attempts. What is the diagnosis?

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EM@3AM: Peritoneal Dialysis Emergencies

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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?

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EM@3AM: Pediatric Acute Lymphoblastic Leukemia

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A 3-year-old male presents with pallor and nosebleeds. On exam, the patient looks pale and has petechiae across his arms and back. His spleen is palpable. Labs reveal white blood cell count 20,900/μL, absolute neutrophil count 10,400/μL, absolute lymphocyte count 1800/μL, hemoglobin 5.9 g/dL, and platelet count 20 × 10^3/μL. What’s the diagnosis?

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EM@3AM: Transfusion Related Acute Lung Injury

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A 67-year-old female with a history of ALL comes into the ED for weakness, stating her oncologist sent her for her semi-regular transfusion. From review of the EMR, her hemoglobin in 5.9 mg/dL and her platelet count was 1,000 cells/uL. A transfusion of platelets was initiated, though within approximately 1 hour of starting the transfusion, the patient became acutely short of breath and stated she was having severe difficulty breathing. She is in distress with rhonchi bilaterally. What’s the next step in your evaluation and treatment?

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EM@3AM: Transfusion Associated Circulatory Overload

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A 67-year-old female with a history of CHF and CKD was brought in by ambulance from her nursing home for a gastrointestinal bleed. The patient’s total fluid balance from her nursing home was 2.5L over the past 24 hours. Her point of care hemoglobin is 4 g/dL and a transfusion of 2U pRBC and 1 FFP was initiated, though within approximately 1 hour of starting the transfusion, the patient became acutely short of breath and stated she was having severe difficulty breathing. What’s the next step in your evaluation and treatment?

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EM@3AM: Heat Stroke

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A 72-year-old female is brought to the ED during a heat wave. Her daughter found her confused in her home. She believes the power has been out for several days. The patient appears lethargic and is intermittently confused. A rectal temperature reads 105.1F. The patient’s skin is warm and dry. She is confused, but the rest of her exam is unremarkable. What is the patient’s diagnosis? What’s the next step in your evaluation and treatment?

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