EM@3AM

A 15-year-old male presents to the pediatric ED for worsening sore throat and fevers for 5 days. He complains of right sided throat pain, odynophagia, and a muffled voice. He is tachycardic, febrile, uncomfortable appearing, and sitting upright.  You note trismus, swollen right tonsil, erythematous and elevated soft palate, and uvula deviated towards the left tonsil. What’s the next step in your evaluation and treatment?

A 39-year-old female presents with severe epigastric pain, nausea, and several episodes of non-bloody, non-bilious emesis. The pain is sharp and radiates to her back. On examination, she is tachycardic and tachypneic with diffuse abdominal tenderness, but afebrile. Her lipase returns at 1100 U/L. What is your next step in evaluation and management?

A 10-day-old female presents with her parents with poor feeding and increased work of breathing. Her urine output has been poor, but her parents have not observed fevers. She is afebrile, but her HR is 188, RR is 61, and oxygen saturation is 94% on room air. She demonstrates increased work of breathing and retractions and appears lethargic. Her serum glucose is 48. What is your next step in evaluation and management?

A 65-year-old with a history of ESRD and renal transplant presents to the ED with lower abdominal pain and fevers. On exam, his vitals include HR 112, BP 101/62, RR 22, T 101.1, SpO2 98% on RA. His is tachycardic with lower extremity edema and lower abdominal tenderness to palpation. What’s the next step in your evaluation and treatment?

A 59-year-old man presents to the ED for acute onset low back pain that started immediately after he moved furniture. He states his lumbar pain has been unrelenting, with mild pain radiating to down both legs.  He appears in pain and has mild midline and bilateral paraspinal tenderness to palpation over his lumbosacral spine.  He has bilateral loss of strength in the distal lower extremities, notably in dorsiflexion.  What diagnoses should you consider?

A 38-year-old male presents from triage in a hospital wheelchair with his head slumped to one side. You immediately move him into bed and assess his ABCs. He wakes briefly, but he seems to be hallucinating. Vital signs: BP 154/110, HR 110, T 102.1, RR 20, SpO2 100% on room air. Physical exam reveals mydriasis and diaphoresis. He has track marks on his arms and you find packets of what appears to be mixed prescription drugs, heroin, and methamphetamine in his pocket. What’s this presentation most consistent with? What’s your next step in evaluation and treatment?

A 34-year-old male presents with intermittent, sharp, left-sided flank pain. He took ibuprofen with minimal relief, but came to the ED when he noticed blood-tinged urine. He has also experienced severe nausea without emesis. He appears uncomfortable, writhing in bed. What is the patient’s diagnosis? What’s the next step in your evaluation and treatment?

A 31-year-old G3P2 female at 32 weeks gestation is brought in by EMS after a fall with complaint of lower abdominal pain. Exam reveals gravid abdomen with lower abdominal tenderness and no signs of bruising. External pelvic exam shows no signs of trauma, but there is scant blood at the introitus. Fetal heart rate is measured at 110 bpm with bedside ultrasound. What is the patient’s diagnosis? What is the next step in your evaluation and treatment?

A 2-year-old male is brought to the ED by his mom for right ear pain and high fevers. His right ear is notably pushed forward. On exam, he is alert but fussy, with auricular proptosis and mastoid redness. What’s the next step in your evaluation and treatment?

A 29-year-old female presents with generalized weakness and vision problems. The weakness is worse at the end of the day, and she has noted double vision. The symptoms worsen with heat. She denies any other neurologic deficits, including paresthesias. What is the likely diagnosis, and what is your next step in evaluation?