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em@3am

EM@3AM: Monkeypox

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A 26-year-old female patient comes to the ED with an 8-day history of progressive weakness, fevers, and body aches. She reports that 4 days ago she noticed “bug bites” on her face, neck, arm, and hands. Sixteen days ago, she returned from a trip to Los Angeles where she shared a bed with her friend who was ill and had a rash at the time. The patient’s medical history is unremarkable, and she takes no medications. She is in a monogamous relationship with her long-term boyfriend and uses condoms consistently. Her temperature is 38.1º C (100.6ºF). Examination shows bilateral anterior cervical lymphadenopathy, and the lesions appear to be papular in appearance. The lesion resembles others on her face, neck, right upper arm, and other hand.   What is the most likely diagnosis?

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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: Dental Bleeding

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A 38-year-old male with no history presents to the ED for dental bleeding. He was at the dentist earlier today for a simple tooth extraction but noticed that the bleeding has not stopped. He complains of only mild pain at the extraction site and has never had issues with bleeding before. On inspection of the bleeding site, it appears he had a right mandibular molar (Tooth #30) extracted with visible blood clots and active oozing. His airway is patent, breath sounds are normal, and the patient appears well-perfused. What is the diagnosis and your approach for bleeding control?

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EM@3AM: Mitral Regurgitation

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A 63-year-old male presents to the ED complaining of sudden onset shortness of breath for the past 2 hours. He has a history of CAD, HTN, and T2DM He states that he has been compliant with his medications. BP 97/68, HR 108, RR 21, 92% RA. Physical exam is notable for a holosystolic murmur most prominent over the apex and radiating to the axilla, mild bibasilar rales, JVD, and 2+ lower extremity pitting edema. 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: Impaled Objects

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A 60-year-old female presents to the ED with an impaled object in her arm. She stabbed herself in the left arm as an act of self-harm, prior to calling EMS. The object was wrapped in gauze by EMS. On ED evaluation, she is stable and alert and oriented. On your primary and secondary evaluation, there is only one injury. Under extensive gauze wrapping, there is a large, serrated knife impaled in the distal aspect of the left flexor forearm. It is superficial and can be easily palpated along the skin. There are no other injuries identified on primary and secondary surveys. She is neurovascularly intact. What is the next step in your evaluation and management?

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EM@3AM: Bleeding Disorders

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A 23-year-old female with no past history presents with prolonged bleeding from her tooth extraction earlier the same day. Her dentist was planning on removing all her wisdom teeth but stopped after the first extraction due to inability to achieve hemostasis. She has never experienced this kind of bleeding before but notes that recently her gums often bleed when brushing her teeth and describes her last few menstrual cycles as “heavier” than usual. She is not on any blood thinners and was adopted at birth without record of family medical history. She is stable. Tooth number 17 appears to have been extracted, and there is blood-soaked cotton balls and gauze between the buccal mucosa and the cavity where tooth 17 used to be. Upon removal of the gauze, you notice a slow oozing of blood from the extraction site. What are some of the bleeding disorders on your differential given this clinical presentation?

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EM@3AM: Cerumen Impaction

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A 17-year-old male with no past medical history presents to the ED with a complaint of right ear fullness and hearing loss which has been present for the last month. He reports that he tried to clean out his ear 3 days ago with a cotton-tipped swab but has had worsening of the pain and hearing loss after attempting this. HEENT exam reveals normal external auditory canal and tympanic membrane on the left, but you are unable to visualize the right tympanic membrane due to cerumen impaction. What is the next step in management of this patient?

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EM@3AM: Bladder Rupture

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A 30-year-old male presents to the ED via EMS with severe hip and groin pain after an accident. He denies loss of consciousness, is not on any blood thinners, and currently complains of pain in his hips/groin. Initial assessment on arrival includes vital signs BP 134/86, HR 94, RR 16, SpO2 98% on room air, and temperature 99.0F. He is speaking and mentating appropriately but in significant discomfort when you exam his pelvis. Blood is seen at the urethral meatus, and the pelvis is unstable. There is no obvious perineal ecchymosis at this time. The rest of the exam is unremarkable. What type of injury should be considered with blood at the urethral meatus and suspected pelvic fracture?

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