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EM@3AM: Aortic Stenosis

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An 83-year-old female presents to the ED with dyspnea at rest following a syncopal episode. Patient reports she was out for a walk with her husband when she began to feel lightheaded, short of breath, and then fainted. Triage vitals include BP 88/50, HR 115, RR 24, O2 98%. ECG is without signs of acute ischemia. On exam, the patient appears slightly tachypneic, with rales noted at bilateral lungs. There is a systolic murmur along with 2+ pitting edema at the lower extremities. Cardiac POCUS shows grossly decreased left ventricular EF with a hyperechoic structure at the aortic valve. What is the most likely diagnosis?

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EM@3AM: Stevens-Johnson Syndrome and Toxic Epidermal Necrolysis

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A 55-year-old male presents to the ED for a rash of 2-day duration. He had URI symptoms for 4 days preceding the rash with myalgias and subjective fevers. He notes the rash began as small painless, erythematous papules but has progressed to larger, tender bullae. The rash began on his trunk and has spread to his face and bilateral upper extremities. He is febrile and tachycardic. On physical exam, the rash affects close to 20% of TBSA, and with gentle rubbing, skin sloughing is noted. What is the diagnosis?

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EM@3AM: Bacterial Meningitis

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A 21-year-old male is brought to the ED via EMS after a reported seizure. As per girlfriend, the patient began complaining of a headache yesterday, and today he is confused. He is febrile and tachycardic. He is confused and has nuchal rigidity. However, Kernig and Brudzinki signs are negative. CT is negative. What is most likely diagnosis, and what is the next step in diagnosis?

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EM@3AM: Cushing’s Syndrome

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A 60-year-old female with diabetes and hypertension from skilled nursing facility presents with worsening mental status, shortness of breath, and muscle weakness. Vital signs include BP 175/100, HR 105, RR 22, SpO2 95% on room air, T 100.7F, and blood glucose of 275. Physical exam is remarkable for A&Ox2, obesity, striae, bilateral upper/lower extremity muscle weakness, and 2+ bilateral lower extremity edema. CMP/CBC is unremarkable, BNP is 250, and EKG shows low voltage. Outpatient random serum cortisol is 2700 nmol/L. What is the diagnosis, and urgent interventions will reduce the patient’s morbidity/mortality?

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EM@3AM: Acute Hemolytic Anemia

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A 3-year-old male with G6PD deficiency presents to your ED by ambulance with shortness of breath, found to be hypoxic with SpO2 80% on 15L NRBM. He appears pale and dyspneic. The child is placed on HFNC with no improvement of saturation. Given his persistent hypoxia on noninvasive methods, a decision is made to intubate. Bedside CXR is unremarkable, and in spite of full ventilatory support with FiO2 of 100%, the patient’s saturation remains at 85%.  You later learn he had eaten a full box of blueberries earlier that day. What is the likely diagnosis?

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EM@3AM: Rabies

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A 13-year-old male presents to the ED for aggressive behavior which progressed to confusion and decreased level of consciousness. He initially was very agitated and aggressive and refused to drink any water. He then became disoriented and is now difficult to rouse. The parents note that he had recently had a fever, sore throat, and general malaise prior to this behavior but those symptoms resolved, although they note excessive salivation. Review of systems is remarkable for a bat bite for which he never sought care. He is tachycardic, tachypneic, febrile, and appears toxic. What’s the most likely diagnosis?

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EM@3AM: Bartholin’s Abscess

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A 36-year-old female presents to the ED with vaginal pain. She initially noticed a small bump one week ago that was only painful with sexual intercourse, but it has grown and now causes discomfort even when walking. Her temperature is 98.9oF, heart rate 78, and blood pressure 126/84. On exam she has a large, soft mass protruding at the 8 o’clock position of the vaginal opening that is painful and fluctuant to touch. There is some induration around the mass, but no vaginal discharge is noted on the pelvic exam. What is most likely causing this woman’s pain? How would you manage this diagnosis to provide some relief?

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EM@3AM: Infectious Mononucleosis

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A 17-year-old male with history of asthma presents to the ED with a chief complaint of sore throat for the past 3 days, associated with decreased oral intake. He denies sick contacts. Vital signs include Temp 100.6F, BP 124/78, HR 92, RR 16, 96% on RA. On exam the patient has swollen, erythematous tonsils with grayish exudate, as well as enlarged, tender anterior and posterior cervical chain lymph nodes. What is the most likely diagnosis?

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EM@3AM: Sigmoid Volvulus

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A 75-year-old male with 4 days of abdominal distention, constipation, and decreased PO intake due to nausea. He reports that his symptoms are worse after eating or drinking and that he is able to pass gas but has not had a bowel movement in the past 4 days.  On initial presentation to the ED, he appears anicteric while his abdomen is soft, non-tender, but massively distended asymmetrically with no bowel sounds heard on auscultation. What is the most 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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