em@3am

A 37-year-old G2P2 female presents to the ED with a 2-day history of intermittent fever and foul-smelling vaginal discharge. She was discharged 3 days prior after a cesarean delivery to a single, full term, live born infant complicated by premature rupture of membranes. She notes associated chills and abdominal tenderness. On exam, she is ill appearing, tachycardic, and febrile. Her surgical incision is clean, dry, and intact. She has significant tenderness to the lower abdomen on palpation. On pelvic exam, she has moderate thick, foul-smelling purulent discharge. What is the diagnosis?

A 37-year-old G5P4 at 33 weeks presents to the ED after being brought in by ambulance. She had a precipitous delivery while the ambulance was pulling in. The newborn is doing well, but the mother is complaining of shortness of breath and chest pain. VS include BP 88/45, HR 121, T 97.1, RR 28, SpO2 89% on 6L NC. On exam, she appears pale and anxious. She is tachycardic and tachypneic with diffuse wheezing and rhonchi. You notice precipitous vaginal bleeding and blood oozing from her IV site. What is the diagnosis?

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?

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? 

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?

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?

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?

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?

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?

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?