em@3am

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?

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.

A 27-year-old woman with a history of obesity and diabetes presents to the emergency department for lesions on her axilla. The patient states that she has noticed these lesions for the past two years and assumed they were abscesses. The lesions have been tender, itchy, and with malodorous drainage. Her vital signs are T 37°C, BP 124/79, HR 89, RR 18, and SpO2 100% on room air. There are multiple hyperpigmented, palpable, tender masses on her bilateral axillae which exhibit scant drainage of fluid. What is the diagnosis?

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?