Case Files: Diagnosing Opportunistic Infection in HIV-Positive Woman
By Halaweh, Tamara MD & King, Andrew, MD
Fear consumes the emergency physician when HIV-infected patients present to the emergency department. These patients often present extremely ill, tachycardic, and febrile, and they are likely infected with some sort of opportunistic infection that we are not used to diagnosing. Luckily for us yet unfortunately for the patient, we are able to delineate sick from not sick in this population. We are able to recognize a serious infection because vital signs, cachectic appearance, and symptomatology lead us in that direction.
HIV-infected patients are prone to opportunistic in...
Source: The Case Files - June 17, 2014 Category: Emergency Medicine Tags: Blog Posts Source Type: research
The Case Files: A Rare Case of Labial Fusion
By Prahl, Robert DO; Gebhard, Michelle DO; McGerald, Genevieve DO, and Klein, Richard MD
An 85-year-old woman presented to the emergency department complaining of lower abdominal pain and the inability to urinate for two days. The patient was previously seen in the emergency department for urinary difficulties and diagnosed with labial adhesions and urinary tract infection; she was discharged with a prescription for ciprofloxacin.
Her review of systems was otherwise negative on this visit. She was taking oxybutynin for urinary incontinence but denied use of any other medications. The patient had suprapubic tenderness wi...
Source: The Case Files - June 16, 2014 Category: Emergency Medicine Tags: Blog Posts Source Type: research
The Case Files: Myocardial Infarction Secondary to Myocardial Bridging
By Swartzel, Gina DiAntonio; Neltner, Kurt MD; Dick, Michael MD
A 49-year-old, male smoker with a past medical history of hypertension and transient ischemic attack presented to the emergency department with a one-day history of severe, persistent substernal chest pain. He had been seen in the emergency department two weeks prior to this visit for elevated blood pressure secondary to medication noncompliance, and he was not complaining of chest pain and had a nonspecific ECG at that time.
He had been having intermittent, brief, nonexertional chest pain every two to three days after that encounter, and it became const...
Source: The Case Files - June 13, 2014 Category: Emergency Medicine Tags: Blog Posts Source Type: research
The Case Files: A Patient with Not-So-Benign Low Back Pain
By Chung, Arlene S. MD; Raukar, Neha P. MD
A 20-year-old man with a history of schizophrenia and polysubstance abuse presented to the ED complaining nonradiating, left-sided low back pain for one week. He denied any trauma, inciting event, intravenous drug use, tuberculosis exposure, or prior history of back pain or surgery. He also denied systemic symptoms such as fevers, sweats, abdominal pain, nausea, vomiting, leg pain, or difficulty walking.
He was taking risperidone and lithium, smoked a pack of cigarettes a day, did not drink alcohol, and occasionally used marijuana. Family history was negative for malignancy....
Source: The Case Files - June 12, 2014 Category: Emergency Medicine Tags: Blog Posts Source Type: research
The Case Files: The Killer Ticker: Left Neck Pain
By Ung, Lyncean DO; Sattler, Steve DO; Segerivas, Doni Marie DO
A 50-year-old man with a history of coronary artery disease, multiple myocardial infarctions, and diabetes mellitus presented with persistent left-sided neck pain for three weeks after having an implantable cardioverter-defibrillator (ICD) placed via his left subclavian vein. His pain was described as constant, nonradiating, and 5/10 on the pain scale. There were no modifying factors. He was evaluated one week prior for the same pain, which included an electrocardiogram, chest x-ray, and measurement of cardiac markers (Troponin I, CKMB, and CPK). All result...
Source: The Case Files - June 10, 2014 Category: Emergency Medicine Tags: Blog Posts Source Type: research
The Case Files: Brachytherapy Seed Embolization
By Hays, Hannah L. MD; Neltner, Kurt MD; Espy-Bell, Laura MD
A 57-year-old man with a past medical history of prostate cancer presented to the emergency department with a one-day history of fever, chills, and left lower quadrant abdominal pain. His temperature was 102.1°F, and his abdomen was moderately tender in the left lower quadrant with no associated peritoneal signs.
The patient denied any chest pain, shortness of breath, diarrhea, constipation, or urinary symptoms including dysuria, increased frequency, or urgency. An acute abdominal series was obtained in the emergency department, and it incidentally reveale...
Source: The Case Files - June 9, 2014 Category: Emergency Medicine Tags: Blog Posts Source Type: research
The Case Files: Unusual Headache
By Al-Hashimi, Siddhartha DO; Leavens, John MD
A 23-year-old woman with a history of migraine headaches presented to the emergency department for a different-than-usual headache. She had a six-day history of intermittent headaches. The onset was at rest, and there was no history of trauma.
The headache was located behind her left eye, and it radiated into the posterior portion of her head. She characterized it as being 8/10 in intensity. Bright lights were reported as an exacerbating factor. The headache was associated with nausea and multiple episodes of emesis. She had 10 episodes of vomiting the evening prior to arri...
Source: The Case Files - June 5, 2014 Category: Emergency Medicine Tags: Blog Posts Source Type: research
The Case Files: A Deflected Blow: A Mimic of Necrotizing Fasciitis
By London, Hollis DO; Havasy, Stephen MD; Zimmerman, Steven MD
A 31-year-old woman presented to the emergency department with facial swelling and pain secondary to a dog bite that occurred earlier in the day. Immediately after the bite had occurred, she reported cleaning her face with tap water, blowing her nose, and applying antibacterial ointment. She reported that the swelling had developed rapidly as had a “crunching” sensation under her skin that seemed to spread to her neck. She denied fever, chills, nausea, vomiting, diarrhea, discharge from facial wounds, difficulty moving her eyes, or changes in vision.
...
Source: The Case Files - June 4, 2014 Category: Emergency Medicine Tags: Blog Posts Source Type: research
The Case Files: Disease Traveling by Plane
By Hirashima, Eva Tovar MD, MPH; Crucio, Ted MD
A 34-year-old woman presented to the ED complaining of nausea, vomiting, and body tingling. She had just returned from a one-week stay in Haiti. Four days prior to presentation, she had eaten red snapper in a local restaurant. A few hours after the ingestion, she had colicky abdominal pain, watery non-bloody diarrhea, and circumoral tingling, which later progressed to generalized itching, tingling, and intense burning.
The patient reported on arrival at our ED improvement of the diarrhea, but the generalized itching and tingling had worsened, and she complained of fatig...
Source: The Case Files - June 4, 2014 Category: Emergency Medicine Tags: Blog Posts Source Type: research
The Case Files: Traumatic Carotid Dissection
By Hsiao, Jonie MD
A 30-year-old man who was right-hand dominant presented 10 days after sustaining left-sided face and head trauma from a fall from a skateboard at an unknown speed. He lost consciousness for several seconds, and initially developed a headache with nausea and vomiting. A non-contrast head CT performed at another hospital done two days after the incident was reportedly negative.
He now presents primarily with concerns about the appearance of his left eye. He has notable anisocoria and a droopy eyelid. His left pupil is notably smaller, 2 mm, compared with the right eye, 5 mm. Both are reactive. The re...
Source: The Case Files - June 4, 2014 Category: Emergency Medicine Tags: Blog Posts Source Type: research
The Case Files: Angioinvasive Mucormycosis: Quicker than the Blink of an Eye
By Nguyen, Dan MD; Shah, Payal MD
A 52-year-old woman with history of insulin-dependent type II diabetes mellitus presents with left-sided facial pain with swelling for the past three days. The pain started as tenderness over the left side of the nose and eye and has progressively worsened. She also complains of mild left ear pain and cheek numbness and nausea, and she has vomited several times. She denies any vision changes, dental or gum pain, fever, recent upper respiratory infection, headache, or neurologic deficits.
The patient was normotensive and tachycardic with a heart rate of 113 bpm. Respiratory rate was 20...
Source: The Case Files - June 4, 2014 Category: Emergency Medicine Tags: Blog Posts Source Type: research
The Case Files: Ingestion of Zinc Phosphide
By Sanaei-Zadeh, Hossein MD
An 18-year-old man presented one hour after the suicidal ingestion of approximately 10 g of steel-gray crystalline powder of zinc phosphide (Zn3P2) dissolved in fruit juice, after which he immediately vomited. He was conscious and had no chief complaint, but he presented to the emergency department because he feared death.
His vital signs were normal. We inserted a nasogastric tube, and administered gastric lavage, charcoal, and sorbitol. He was hospitalized for cardiac monitoring. Lab tests, including arterial blood gases, serum sodium, potassium, blood urea nitrogen, creatinine, blood g...
Source: The Case Files - June 3, 2014 Category: Emergency Medicine Tags: Blog Posts Source Type: research
The Case Files: Severe Knee Pain in a 90-Year-Old Man
By George Issa, MD, & Robert McKie, MD
A 90-year-old man presented to the emergency department with left knee pain of one-day duration. The pain started when he woke up that morning, and was severe; he rated it 10/10 on the pain scale. He also reported limited mobility of the leg, fever, and rigors. He denied any other symptoms.
Past medical history was remarkable for a hospital admission for Escherichia coli two years earlier. The source of the sepsis was not determined, and the patient was initially treated during that hospitalization with ceftriaxone and azithromycin. Blood cultures grew pan-sensitive E. coli,...
Source: The Case Files - May 23, 2014 Category: Emergency Medicine Tags: Blog Posts Source Type: research
The Case Files: Case Report of Sialolithiasis
By Scott Goldstein, DO
I recently saw an 87-year-old African American woman with past medical history of rheumatoid arthritis on prednisone, iron, and potassium complaining of facial swelling over one or two days. She denied any history of diabetes mellitus, nausea and vomiting, headache, tooth extraction, trauma, or similar past episodes. She does admit to subman dibular swelling with pain, fever (up to 101°F at home), and anterior neck fullness. This started a “couple of days ago,” and her son was worried enough to bring her to the ED.
Upon arrival, she was in mild distress, hypertensive at 151/84 mm Hg, hea...
Source: The Case Files - October 1, 2013 Category: Emergency Medicine Tags: Blog Posts Source Type: research
The Case Files: Febrile Pediatric Hypocalcemic Seizure
By Andrew Park, DO, MPH, & Jeremy Hunter, DO
A 6-month-old boy was brought to the emergency department by his parents for seizure activity just prior to arrival. They reported that the baby had been feverish for two days, and was evaluated in a different ED. He was given Tylenol there.
He was eventually diagnosed with a viral syndrome and then discharged home. The parents reported that he had been febrile but otherwise normal since being discharged from the ED, but he began shaking his arms and appeared to be having a seizure approximately five minutes before arrival at our ED. The parents denied any previous seizur...
Source: The Case Files - September 26, 2013 Category: Emergency Medicine Tags: Blog Posts Source Type: research
