An Uncommon Bug Bite
BY RYAN LYNCH, MD, & MARK SUPINO, MDA 2-year-old girl was playing outside when she spotted a furry caterpillar. Like her stuffed animals, it was fluffy and had long hair. She let the insect crawl on her legs, but then suddenly screamed in pain. Her parents brought her to the ED, though she was no longer in distress by the time she arrived.The patient had a large urticarial lesion on her inner right thigh and a smaller one on her left thigh. (Photo.) There were no puncture wounds, bite marks, or barbs visible or palpable. Her vital signs and physical exam were within normal limits. The patient's father had captured t...
Source: The Case Files - March 13, 2019 Category: Emergency Medicine Tags: Blog Posts Source Type: research
A Sneaky Symptom
BY JEFFREY LOMBARDO, MD, & MARK SUPINO, MDThe progressive suprapubic pain was a cunning symptom.The 38-year-old man had had five days of that pain and dysuria. By the time he presented to our ED, his pain had spread to the right lower quadrant as well. He had a history of diverticulitis after a laparoscopic left hemicolectomy four years earlier.He reported no fevers, but complained of nausea and diarrhea. He was afebrile at 36.8°C with a pulse of 76 bpm. All other vital signs were normal. Physical exam was significant for suprapubic pain and right lower quadrant tenderness to palpation without rebound, guarding, or...
Source: The Case Files - February 26, 2019 Category: Emergency Medicine Tags: Blog Posts Source Type: research
An Unusual Hypoxia Patient
BY GORDON MURPHY, PA-C, MPHThe patient was blue, her primary care physician noted. Quite literally, in fact.The 38-year-old woman had sought care for a recurrent urinary tract infection, and that's when her primary care physician found her pulse oximetry to be 74%. He was concerned about hypoxia and asked us to evaluate her.The patient reported taking an SSRI for anxiety and having a hormone-eluting IUD. She had previously had a Roux-en-Y gastric bypass. She said she had a headache, but had been instructed not to take NSAIDs. She said she had just finished a course of Cipro for her UTI, but continued to be symptomatic w...
Source: The Case Files - February 20, 2019 Category: Emergency Medicine Tags: Blog Posts Source Type: research
Right Upper Arm Pain in an Older Woman
BY GREGORY M. TAYLOR, DO, & DAWN ZELENKA-JOSHOWITZ, DOAn 81-year-old woman with a past medical history of atrial fibrillation, three coronary artery bypass graft surgeries, and a prior cerebrovascular accident presented to the emergency department with right arm pain. Her symptoms had grown worse for two days, and she experienced paralysis about two hours before arrival.Her initial vital signs were a temperature of 97.7°F, a blood pressure of 196/43 mm Hg (left arm), a heart rate of 60 bpm, and a respiratory rate of 18 bpm. She had obvious pallor to her right upper arm with no brachial or radial pulses. She was una...
Source: The Case Files - February 12, 2019 Category: Emergency Medicine Tags: Blog Posts Source Type: research
Epigastric Pain, Nausea, and Vomiting in a Young Man
BY KATHRYN M. DEPRIMO & KHALID MALIK, MDA 30-year-old man with no previous medical history presented with one day of epigastric pain, nausea, and vomiting. He described the pain as moderate, aching, and nonradiating. He said Tylenol provided minimal relief.The patient reported vomiting four or five times since the start of his symptoms and described the vomit as yellow in color. He had no history of recent travel, recent sick contacts, trauma, pain with eating, fever, chills, shortness of breath, chest pain, headaches, dizziness, changes in bowel movements, or urination. The patient confirmed a past surgical histo...
Source: The Case Files - February 12, 2019 Category: Emergency Medicine Tags: Blog Posts Source Type: research
A Diagnostic Challenge for a Rare Condition
BY GREGORY TAYLOR, DO, & SCOTT LAGERVELD, DOA 54-year-old man with a significant past medical history of atrial fibrillation and congestive heart failure presented to the ED with a chief complaint of difficulty walking. He was evaluated at an outside hospital two months earlier, and was found to have methicillin-resistant Staphylococcus aureus bacteremia, lower extremity cellulitis, and acute decompensated congestive heart failure (CHF). He clinically improved over one week, his autoimmune workup was negative, and he was discharged. He failed to follow up with nephrology, cardiology, and dermatology, and s...
Source: The Case Files - January 22, 2019 Category: Emergency Medicine Tags: Blog Posts Source Type: research
An Unexplained Short-Term Memory Loss
BY JORDAN DEMCHUKA 59-year-old Caucasian man with a past medical history of well-controlled hypertension, hyperlipidemia, and gout presented to the ED with altered mental status. His wife reported that he was found two hours earlier in his home office confused, unable to recall plans made that morning, the current time and date, and his brother's death a year and a half earlier. She stated that the patient was repeating, “I don't know what's happening,” while anxiously pacing around the room. She said he had a history of falls and head injury at age 7, which was accompanied by brief amnesia that had not recurred.The...
Source: The Case Files - January 22, 2019 Category: Emergency Medicine Tags: Blog Posts Source Type: research
MDMA-Induced Pneumomediastinum with an Unusual Presentation
BY CLAUDIA BORNIA & KHALID MALIK, MDAn 18-year-old healthy man presented to the ED with a sore throat. He said the pain had started a day earlier when he took three capsules of Molly and drank heavily at a music festival.The patient reported pain while swallowing, shortness of breath, and pain in his left rib cage after playing basketball a few days earlier. The patient had no jaw or neck pain, coughing, fever, chills, nausea, vomiting, and diarrhea. He had a blood pressure of 126/76 mm Hg, temperature of 98.2°F (orally), heart rate of 70 bpm, respirations of 18 bpm, and oxygen saturation of 100% on room air. The p...
Source: The Case Files - January 16, 2019 Category: Emergency Medicine Tags: Blog Posts Source Type: research
Atypical CT Finding in the Scrotum
BY DILEM POLAT & KHALID MALIK, MDA 50-year-old man with hypertension presented to the emergency department with an exacerbation of his lower back and perianal pain that he had had for two weeks, with a new onset of active fecal draining and difficulty urinating for four hours. He said he had no headache, nausea, vomiting, weakness, fatigue, fever, and chills, and all other reviews of systems were negative.His temperature was 98.5°F, blood pressure was 108/57 mm Hg, pulse rate was 113 bpm, respiratory rate was 20 bpm, and oxygen saturation was 97% on room air. His abdomen was soft, mildly distended, and not tender t...
Source: The Case Files - December 27, 2018 Category: Emergency Medicine Tags: Blog Posts Source Type: research
What Is This International Traveler's Diagnosis?
BY GREGORY TAYLOR, DO; DAWN ZELENKA-JOSHOWITZ, DO; & ANDREW TAECKER, DOA 34-year-old man presented with intermittent fever and body aches for 10 days. He had been visiting family in India, and the symptoms began when he returned home. His fever had been as high as 104°F, and he was experiencing nausea, two episodes of bilious emesis, body aches, nonspecific abdominal pain, and multiple episodes of watery, nonbloody diarrhea.He said he knew of no tuberculosis exposure or ill contacts, and he was current on his routine influenza and hepatitis A vaccines. His temperature was 101.4°F (he had taken acetaminophen three ...
Source: The Case Files - December 12, 2018 Category: Emergency Medicine Tags: Blog Posts Source Type: research
Warning Signs in Acute Toxicity of an Uncommon Drug
BY ARJUN BHARADWAJ; CHRISTOPHER RUSSELL; MARGARET GAVOR, MBCHB, MPH; & KHALID MALIK, MDA 63-year-old man presented with hand tremors, dizziness, and expressive aphasia. His symptoms had started a month earlier, and this was his third visit to the ED for these symptoms, though the aphasia was a new symptom. He said his symptoms had been growing worse.The patient's symptoms had been previously attributed to alcohol intoxication. He also said he had been experiencing vomiting, dry heaving, bilateral tinnitus, and dizziness but no fever, chills, chest pain, abdominal pain, shortness of breath, vision and hearing problem...
Source: The Case Files - December 12, 2018 Category: Emergency Medicine Tags: Blog Posts Source Type: research
Fool Me Once: An Uncommon Presentation of PE
BY FREDDIE IRIZARRY-DELGADO; VAROON KAKAIYA; & AHMED RAZIUDDIN, MDAn 86-year-old African-American woman was brought to the ED by her daughter after two days of nutritional neglect, abdominal pain, and altered mental status. Her daughter said her mother felt lightheaded, appeared dehydrated, and vomited nonbilious watery fluid once. The patient had a history of diabetes mellitus type 2, DVT/PE, dementia, and early signs of parkinsonism.Her vital signs were remarkable only for tachypnea (24 bpm). Her troponin I was markedly elevated at 1.7 ng/mL. A D-dimer was ordered because of her history of unprovoked DVT/PE, and i...
Source: The Case Files - November 27, 2018 Category: Emergency Medicine Tags: Blog Posts Source Type: research
Debilitating Headache after an Excited Reaction
BY GREGORY TAYLOR, DO, & MATTHEW WARPINSKI, DOA 35-year-old man with a history of uncontrolled hypertension and medical noncompliance was brought to the emergency department by EMS complaining of a headache. The family said the patient was watching football and developed an acute headache after he stood up screaming in excitement.His family said he had not taken his blood pressure medication for years. He was afebrile, his blood pressure was 245/129 mm Hg, his respiratory rate was 18 bpm, his heart rate was 68 bpm, and he weighed 340 pounds. The patient was obtunded with a Glasgow Coma Scale score of 4 and was subse...
Source: The Case Files - November 20, 2018 Category: Emergency Medicine Tags: Blog Posts Source Type: research
An Unusual Presentation of Rhabdomyolysis
BY DAVID DIAZ; JONATHAN HAVERTY, DO; & JORGE DIAZ, DOA previously healthy 20-year-old woman presented to the emergency department with three days of bilateral thigh pain. The pain had initially started in a focal area of the anterior aspect of the lower thighs bilaterally. The next day, her pain had progressed to involve a larger area of her thighs, and she noticed redness and swelling in the same area.She had difficulty walking and bending her legs due to the pain. She said no other muscle groups were involved and she had never experienced this before. The patient had no history of vigorous physical activity or tra...
Source: The Case Files - November 13, 2018 Category: Emergency Medicine Tags: Blog Posts Source Type: research
A True Gastrointestinal Emergency
BY GREGORY TAYLOR, DO, & SHERIF EL-ALAYLI, DOA 60-year-old man with a significant history of alcohol abuse, metastatic hepatocellular carcinoma, and cirrhosis presented to the emergency department complaining of vomiting up bright red blood. The patient was reportedly supposed to have an esophagogastroduodenoscopy (EGD) six months earlier but failed to follow up.He had two episodes of melena the night before and two episodes of hematemesis that morning. He was also experiencing fatigue, weakness, and abdominal pain, which he described as achy and localized to the epigastric region. He had refused treatment for his h...
Source: The Case Files - October 24, 2018 Category: Emergency Medicine Tags: Blog Posts Source Type: research
