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EM@3AM

EM@3AM: Auricular Hematoma

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A 24-year-old male presents to the ED from a mixed marital arts competition after being struck on the side of the right head by a fist earlier today. The patient denies any loss of consciousness, neck pain, vomiting, or use of blood thinners. His vital signs include BP 133/82, HR 76, T 97.5, RR 15, SpO2 99% on room air. On exam there is no periorbital ecchymosis, eye trauma, hemotympanum, facial tenderness, or trismus. On evaluation of the right ear a fluctuant and tender area is noted to the superior portion of the ear. The area of fluctuance measures approximately 3 cm in diameter. What is the diagnosis?

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EM@3AM: Thoracic and Lumbar Spine Trauma

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A 70-year-old female with a past medical history of osteoporosis, atrial fibrillation, and hypertension presents with acute thoraco-lumbar back pain after a ground-level fall. She is stable, but she does have pain at the T-12/L-1 region of her back.  She has full motor strength and sensory function in the lower extremities. Her patellar reflexes are 1+ bilaterally, no ankle clonus is noted, and she denies any saddle anesthesia or bowel/bladder incontinence. 

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EM@3AM: Pneumocephalus

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A 58-year-old female presents with severe headache and nausea. Her symptoms started shortly after leaving the office of her pain management doctor, where she had an epidural steroid injection to alleviate her chronic back pain approximately 30 minutes before she arrived in the ED. The patient denies any trauma to the head, fevers, nuchal rigidity, changes in vision, focal weakness, paresthesia, or anticoagulation use.  On arrival, she is awake and alert and in obvious distress. Her vitals signs include temperature of 98.8F, HR of 64, BP 133/78, and O2 saturation of 98% on room air with a respiratory rate of 18. Her exam, including a complete neurological exam, is grossly benign. Given her acute complaint and recent history, labs and CT of the head are obtained. The clinician orders analgesics. The CT shows intracranial air.

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EM@3AM: Periorbital Cellulitis

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An 8-year-old boy presents with left eyelid swelling for 2 days. Parents report the swelling has progressively worsened and is greater in the upper eyelid. It is associated with erythema, warmth, and tenderness. They also note subjective fevers. For the past week, the patient had watery rhinorrhea, dry cough, and nasal congestion. Parents deny recent trauma or known insect bite. The patient’s vitals include T 100.2F, BP 113/67, HR 123, RR 26, SpO2 of 99% on room air. On physical exam, the patient is non-toxic appearing. His eye exam is significant for edema and erythema to the left periorbital region greater in the upper eyelid. There is mild warmth but no crusting or active drainage.  His extraocular movements are intact and painless, and there is no conjunctivitis or chemosis. What is the diagnosis?

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EM@3AM: Polyarteritis Nodosa

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A 59-year-old male presents to the ED with abdominal pain, hematuria, and rectal bleeding for the 5 days. His symptoms have been associated with unintentional weight loss, intermittent fevers, skin rash, and fatigue over the past 3 months. He has a past history of hepatitis B, hypertension, diabetes, and hyperlipidemia. Vital signs include blood pressure 162/103 mm Hg (last measured 118/82 5 months ago, per records), HR 101, RR 18, SpO2 98% on room air. Exam is notable for generalized abdominal tenderness, guaiac positive stool, and generalized purpuric rash over bilateral lower extremities. Labs demonstrate Cr 2.9 (baseline 1.1) and elevated ESR and CRP. What is the most likely diagnosis, and what are the next steps in management?

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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: 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: 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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