EM@3AM

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?

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?

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?

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?

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 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?

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?