The Case Files: Carbon Monoxide Intoxication Disguised as Atrial Fibrillation
By Punam Patel, DO, & Steven Sattler, DO
A 62-year-old Caucasian woman presented to the emergency department with palpitations that had started that morning. She had no history of similar symptoms and denied medications, allergies, and alcohol or drug use. She had quit smoking cigarettes 13 years earlier.
She initially denied all other symptoms, but staff overheard the patient and spouse complaining of headaches. They reported that they had been awakening with headaches and fatigue since moving into a new home a week earlier.
Vital signs upon arrival were respiration, 20 breaths per minute; heart rate, 156 beats per mi...
Source: The Case Files - August 21, 2013 Category: Emergency Medicine Tags: Blog Posts Source Type: research
The Case Files: Severe Gastrointestinal Bleeding in a Pancreatorenal Transplant Patient
By Omer Richman, DO, and David Levy, DO
Pelvic angiography demonstrating right external iliac artery aneurysm with active extravasation of contrast into the jejunum.
A 54-year-old woman presented to the emergency department twice within one week for melena, hematemesis, and weakness. Between these ED visits, the patient underwent a colonoscopy, upper endoscopy, and wireless capsule endoscopy as an outpatient, which showed a non-bleeding arteriovenous malformation in the jejunum but were otherwise non-diagnostic.
The patient had a past medical history of end-stage renal disease secondary to type I diabetes mellit...
Source: The Case Files - July 16, 2013 Category: Emergency Medicine Tags: Blog Posts Source Type: research
The Case Files: Polyarthralgias, Rash, Swelling of Joints
By Alice Chao, MD, and Ayesha Khan, MD, MPH
A 44-year-old previously healthy woman presented to the emergency department with chest pain and shortness of breath. The patient reported a two-month history of polyarthralgias and rash. She initially noted swelling and pain of her ankles that progressed to her knees, wrists, and shoulders.
The patient also reported a non-pruritic rash with erythematous borders on her extremities that would come and go (Figure 1), nodules in her skin, and intermittent fevers.
Figure 1.
She denied any insect bites or recent travel, and had no personal or family history of autoimmune ...
Source: The Case Files - April 29, 2013 Category: Emergency Medicine Tags: Blog Posts Source Type: research
The Case Files: Methanol or Ethanol Poisoning? Correct Diagnosis Influences Treatment
By Hossein Sanaei-Zadeh, MD.
A 23-year-old man presented with agitation and decreased level of consciousness four hours after consuming homemade alcohol. He was brought in by a friend who had also ingested the same alcohol and was completely symptom-free. The patient had a history of seizures controlled by sodium valproate and a ventricular septal defect repaired in childhood.
He was irritable, lethargic (Glasgow coma score: 12), and hypothermic. His pulse rate was 80 bpm, his respiratory rate was 20 bpm, and his blood pressure was 70/40 mm Hg. His pupils were midsized and reactive. Radial pulse was not detected, and...
Source: The Case Files - April 24, 2013 Category: Emergency Medicine Tags: Blog Posts Source Type: research
The Case Files: Syncope
Sarin, Ritu MD; Habboushe, Joseph MD, MBA
A 29-year-old woman waiting to be seen in the emergency department went to the bathroom to provide a urine specimen. While on the toilet, she vomited and then had a syncopal episode. Her husband prevented her from hitting her head when she fell off the toilet, and he called for help as she started to wake up.
The nursing staff, attending, and resident came to the bathroom to help the patient onto a stretcher. Initial vital signs showed the patient was tachycardic at 101 bpm, normotensive at 123/99 mm Hg, and afebrile at 98°F, with a respiratory rate of 22 bpm and an oxygen s...
Source: The Case Files - January 2, 2013 Category: Emergency Medicine Tags: Blog Posts Source Type: research
The Case Files: Syncope and Undiagnosed Addison's Disease
Bober, Wojciech DO; Levy, David DO; Rosenthal, Cynthia DO
A 15-year-old girl was brought by her mother to the emergency department with several days of weakness, non-bloody vomiting, and syncope. She had four syncopal episodes, all without premonitory symptoms. She had a past medical history of asthma, for which she was prescribed albuterol. She denied any past surgical history, allergies to medications, and taking any other medications. She denied complaints of chest pain, palpitations, and shortness of breath.
Her temperature was 97.6°F, pulse 110 beats per minute, blood pressure 94/68 mm Hg, and respiratory rate 18 bea...
Source: The Case Files - October 26, 2012 Category: Emergency Medicine Tags: Blog Posts Source Type: research
The Case Files: Masquerading Shoulder Pain
Weinstein, Shannon DO; Saadatmand, Babak MD; Sattler, Steven DO; Levy, David DO
A 62-year-old woman with a past medical history of breast cancer presented to the emergency department with three weeks of intermittent left scapula pain. The onset was at rest, and she had no history of trauma. The pain was not made worse or relieved by change in position. She denied any associated symptoms, but a review of systems revealed a few episodes of abdominal fullness over the preceding three weeks.
She denied chest pain, shortness of breath, abdominal pain, nausea, vomiting, diarrhea, fever, chills, leg pain or swelling, and re...
Source: The Case Files - October 19, 2012 Category: Emergency Medicine Tags: Blog Posts Source Type: research
The Case Files: Right Flank Pain and Nausea
Bremjit, Prasheeda MD; Sheele, Johnathan M. MD, MPH
A 27-year-old woman with a history of recurrent urinary tract infections presented to the emergency department with right-sided flank pain and nausea. She denied fevers, chills, urinary symptoms, diarrhea, and constipation, though she did report some mild dyspnea and cough. She reported that she had had a normal spontaneous vaginal delivery of a healthy infant two weeks earlier. Pregnancy was complicated only by a urinary tract infection.
The patient was febrile to 38.6°C. She did not have right costovertebral tenderness or right upper quadrant abdominal pain. Urinaly...
Source: The Case Files - September 7, 2012 Category: Emergency Medicine Tags: Blog Posts Source Type: research
The Case Files: Swollen Legs
Himelfarb, Nadine T. MD; McGregor, Alyson J. MD
A patient comes to the emergency department with a seemingly simple chief complaint. “My legs are swollen,” he said.
The patient is a 52-year-old man with alcoholic cirrhosis who had experienced increased lower extremity edema over the past week. He admitted to noncompliance with his recently prescribed medications, Aldactone and Lasix. He reported a history of “fluid in his abdomen,” but denied any recent infections requiring antibiotics. He also denied fever, chills, chest pain, shortness of breath, and abdominal pain.
The patient had a temperature of 98.9°F with a...
Source: The Case Files - August 20, 2012 Category: Emergency Medicine Tags: Blog Posts Source Type: research
The Case Files: Renal Infarct
Dubrovskiy, Aleksandr DO; Levy, David DO; Saadatmand, Babak MD
A 56-year-old man with a past medical history significant for hypertension, hyperlipidemia, and sciatica presented to the ED complaining of a sudden onset of sharp, severe, right flank pain radiating to his right groin. The pain began about 30 minutes prior to arrival and had been constant since onset. He denied any alleviating or aggravating factors, trauma, or prior occurrences.
He complained of nausea without vomiting, and review of systems was otherwise negative. He had no recent surgeries and denied any alcohol, smoking, or drug use. The patient was allerg...
Source: The Case Files - August 10, 2012 Category: Emergency Medicine Tags: Blog Posts Source Type: research
The Case Files: Abdominal Pain Isn't Always Appendicitis
Hughes, Heather DO; McGerald, Genevieve DO; Daniel, Reethamma MD; Kutin, Neil MD
A 3-year-old girl presented to the emergency department complaining of abdominal pain for three days. The pain was constant and mainly located over the right lower quadrant. The symptoms had increased in severity over the past day. The patient also presented with nausea, loose bowel movements, and anorexia. Her medical history revealed hypothyroidism but no previous surgical history.
Tenderness of the entire abdomen was noted with the point of maximal tenderness in the right lower quadrant. Rebound tenderness was also noted. A laboratory...
Source: The Case Files - July 20, 2012 Category: Emergency Medicine Tags: Blog Posts Source Type: research
The Case Files: A Blue Leg
Segerivas, Doni Marie DO; Sattler, Steven DO; Amblard, Louis MD
A 49-year-old woman presented to the emergency department with a complaint of color change to her left leg while walking. She was watching a parade when she developed paresthesias to her left thigh and leg, and noticed her entire left thigh and leg were discolored and blue. She denies prior occurrence or any injury or trauma to the leg. She had no headache, weakness, change in vision, chest pain, shortness of breath, palpitations, abdominal pain, nausea, vomiting, diarrhea, or urinary symptoms. She had no history of prior thromboembolism or arterial pathology....
Source: The Case Files - July 13, 2012 Category: Emergency Medicine Tags: Blog Posts Source Type: research
The Case Files: Diagnosing with Ultrasound
Vitello, Sarah DO; McGerald, Genevieve DO; Teng, David MD
An 11-year-old boy was brought into the ED by wheelchair complaining of left hip pain after slipping and falling on the floor at home just prior to arrival. He was not able to get up. The patient also reported that he had fallen two weeks earlier while running, and had had ongoing left hip discomfort since then.
He denied any other injuries or complaints, and had no significant past medical history. He de-nied prior surgeries, allergies, and medications.
His temperature was 98.4°F, pulse 103 bpm, blood pressure 128/71 mm Hg, respiratory rate of 20 breaths per mi...
Source: The Case Files - July 6, 2012 Category: Emergency Medicine Tags: Blog Posts Source Type: research
The Case Files: Persistent Headache in Post-Partum Woman
Koehler, Kevin Scott MD; Lawrence, Matthew MD
A 27-year-old woman with no significant past medical history arrived at the emergency department complaining of persistent headache three days after a spontaneous vaginal delivery. The patient's recent hospital stay was notable for epidural anesthesia and epidural blood patch for lumbar puncture-induced headache performed the day after delivery.
The patient had complained of persistent headache since delivery. She denied any positional quality to the headache and any light or sound sensitivity. She had no nuchal rigidity or fevers, and had a nonfocal neurologic exam. All oth...
Source: The Case Files - June 22, 2012 Category: Emergency Medicine Tags: Blog Posts Source Type: research
A Blasting Impression
Girgis, Kareem MD; Winston, Lori MD
A 42-year-old man presented to the emergency department after sustaining multiple burns and abrasions from a firework accident earlier that day. His chief complaint included hearing loss and blood from his right ear.
Further history reveals that the patient and his brother, who worked with commercial grade fireworks, decided to fire off a few to celebrate Memorial Day. Before they could get a safe distance away, the commercial grade firework ignited, striking the brother in the face and killing him instantly. The patient, who was standing a few feet away, was showered with hot embers.
A ...
Source: The Case Files - May 29, 2012 Category: Emergency Medicine Tags: Blog Posts Source Type: research
