Clinical Practice and Cases in Emergency Medicine

INTRODUCTION: Neurogenic pulmonary edema is a rare and potentially life-threatening condition that can present as severe pulmonary edema after significant neurologic insults. This is the first documented instance that shows a plausible causal link between cannabis consumption, psychogenic polydipsia, and the subsequent development of neurogenic pulmonary edema associated with status epilepticus secondary to acute hyponatremia. CASE REPORT: We report a case of a 34-year-old female who presented to the emergency department altered and postictal after a witnessed new-onset seizure...

INTRODUCTION: Compressive neuropathy of the brachial plexus is a common issue following laparoscopic and robotic surgeries. CASE REPORT: A 71-year-old male, post-lumbar spinal surgery, presented with excruciating right upper extremity pain and paresthesias. A supraclavicular brachial plexus (SBP) block with bupivacaine provided significant pain relief, lasting 36 hours. Subsequent physical therapy led to gradual pain and weakness improvement in compressive neuropathy...

INTRODUCTION: Osteomyelitis can occur at various osseous locations and commonly presents in the emergency department (ED). The incidence of osteomyelitis is 21.8 cases per 100,000 persons annually.1 Hematogenous osteomyelitis typically occurs in the vertebrae; however, it may seldomly occur in the manubrium. Hematogenous osteomyelitis can be seen in patients with complicated thoracic surgery, radiation, fracture, diabetes, immunosuppression, steroid therapy, and malnutrition.2 Because signs and symptoms of osteomyelitis may be nonspecific, clinicians must have high suspicion based on history and physical...

INTRODUCTION: Recognizing testicular torsion is extremely important in patients presenting to the emergency department (ED) with acute scrotal pain. Traditional manual detorsion techniques are frequently employed by emergency physicians but are not always successful. Delays in detorsion increase the risk of testicular infarction and infertility, and the need for orchiectomy. Novel techniques such as the testicular traction technique have been described as a potential solution for difficult-to-detorse testicles...

INTRODUCTION: Opioid use is an epidemic that plagues the United States. Patients frequently present to the emergency department (ED) after opioid toxicity, which can lead to respiratory failure, apnea, and death. Although there is an effective antidote, naloxone, the current guidelines surrounding post-naloxone administration monitoring are loosely defined. CASE REPORT: We present a case in which an individual was administered naloxone after an intentional opioid overdose and was monitored for four hours, as is standard in our institution...

INTRODUCTION: Pit viper envenomation may cause coagulopathy. The coagulopathy has been treated with crotalidae polyvalent immune fragment antigen-binding (Fab) ovine antivenom for the last few decades in the United States and usually corrects the acute coagulopathy within hours. Days after receiving Fab, coagulopathy may recur in approximately half of the patients. Another divalent antivenom, crotalidae immune F(ab')2 (equine)-F(ab')2 -was approved by the US Food and Drug Administration for the treatment of pit viper envenomation...

INTRODUCTION: Wünderlich syndrome (WS) refers to subcapsular, perirenal, or pararenal hemorrhage due to non-traumatic and iatrogenic conditions. Neoplasms, vascular disease, renal etiology, and anticoagulant use are underlying risk factors. CASE REPORT: We describe a case of WS in a 79-year-old male who was undergoing hemodialysis, which resulted in hemorrhagic shock requiring multiple transfusions and embolization by interventional radiology. CONCLUSION: Most commonly, patients present with flank pain; a computed tomography with contrast of the abdomen is essential for diagnosis...

INTRODUCTION: Acute hematogenous osteomyelitis may have significant morbidity and mortality if undiagnosed. Because it is uncommon in developed countries and has variable presentations, the patient may undergo several healthcare visits prior to diagnosis. CASE REPORT: We report the case of a 9-year-old male who presented with hip and knee pain with associated fevers and was found to have osteomyelitis and intraosseous abscess in the diaphysis of the right femur...

INTRODUCTION: Acute confusional migraine (ACM) is a rare variant of migraine that is benign and self-resolving but difficult to diagnose. Without known causative pathophysiology and a lack of recognition in the International Classification of Headache Disorders (ICHD-3), ACM offers a puzzling clinical presentation. There currently is no standardized treatment for ACM, but with a growing anecdotal dataset there is the opportunity to formally recognize and establish protocols to improve patient care and outcomes...

INTRODUCTION: Acute mountain sickness, high-altitude pulmonary edema (HAPE), and high-altitude cerebral edema (HACE) are a spectrum of high-altitude conditions, with HACE being the most life-threatening. Most cases develop at altitudes of greater than 4,000 meters (∼13,000 feet) above sea level and after one to five days. CASE REPORT: A previously healthy 46-year-old female presented to the emergency department with ataxia, altered mental status, and vomiting that developed after rapidly ascending to ∼2,400 meters (∼7,800 feet) above sea level...

INTRODUCTION: Capnocytophaga ochracea is found in the human oral microbiome and is a rare cause of antibiotic-resistant, opportunistic septicemia in immunocompromised hosts. The zoonotic transmission of C ochracea from canines to humans has not yet been reported in the literature. Cohabitation with people is associated with oral colonization in dogs and may be a reservoir for Capnocytophaga infections, which have a decreased susceptibility to first-line antibiotics commonly used to treat animal exposures...

INTRODUCTION: Renal artery aneurysm rupture is a rare but morbid diagnosis, often requiring emergency surgery and nephrectomy. Clinical presentation can mimic more common pathology in non-pregnant women such as ruptured ovarian cyst. CASE REPORT: We present a case of a woman with a prior history of ovarian cyst presenting with a ruptured renal artery aneurysm. Prompt computed tomography (CT) imaging revealed a left renal artery aneurysm rupture with hemoperitoneum and renal infarct...

INTRODUCTION: The use of telemedicine and ultrasound is emerging and novel in the field of community paramedicine. However, there is a paucity of data supporting its use and even less evidence that shows a morbidity and mortality benefit. This case highlights a unique way to diagnose a common medical emergency, which can lead to a good outcome. CASE REPORT: We describe the use of lung point-of-care ultrasound by a trained community paramedic that led to the identification of a pneumothorax in an 86-year-old male at a scheduled home visit...

A 77-year-old male who presented to the emergency department with generalized weakness and worsening chronic dysphagia was diagnosed with pneumonia. Shortly after receiving vascular access for his treatment, he had a rapid change in his mental status and neurological examination.

CASE PRESENTATION: A 21-year-old, otherwise healthy female presented to the emergency department with fever among other nonspecific symptoms after recently returning from Ghana. On physical exam, she had a characteristic upper extremity rash, and a tourniquet test revealed numerous petechiae. The diagnosis of dengue was suspected and subsequently confirmed. DISCUSSION: Dengue is one of many viral illnesses that should be considered in returning travelers presenting with fever and other nonspecific symptoms...

CASE PRESENTATION: A 52-year-old female presented to the emergency department with four days of right periorbital pain, ipsilateral temporal headache, diplopia, and photophobia. Physical examination of the right eye revealed painful ophthalmoplegia, cranial nerves III and VI paresis, increased intraocular pressure, and mild proptosis. Magnetic resonance venogram and magnetic resonance imaging orbits with contrast demonstrated an abnormal signal surrounding the right cavernous sinus/petrous apex...

CASE PRESENTATION: A 22-year-old female presented to the emergency department with a two-month history of worsening fatigue, unintentional weight gain, and progressive facial swelling. Physical examination findings included hirsutism, moon facies, and abdominal striae. Subsequent brain magnetic resonance imaging revealed the presence of a 2.4-centimeter pituitary macroadenoma, confirming the diagnosis of Cushing's disease. The patient was then admitted for neurosurgical tumor resection...

CASE PRESENTATION: We present the case of a six-year-old child with autism who presented with persistent vomiting in the setting of a closed head injury (CHI). Computed tomography of the head was normal, but due to persistent vomiting a radiograph of the abdomen was done, which showed multiple, rare-earth magnets in the abdomen. There was no history of witnessed ingestion. These magnets had caused enteroenteric fistula formation leading to persistent vomiting. DISCUSSION: In the setting of CHI, vomiting can be a sign of concussion or intracranial hemorrhage...

CASE PRESENTATION: We describe the presentation, evaluation, and management of a young female patient presenting to the emergency department with atraumatic orbital emphysema, a rare condition. This patient was diagnosed using point-of-care ultrasound and computed tomography and was managed expectantly. DISCUSSION: Atraumatic orbital emphysema is a rare clinical condition more common in early middle-aged female patients with certain historical features such as chronic sinusitis, facial surgery or trauma, tobacco smoking, or current upper respiratory symptoms...

INTRODUCTION: Phlegmasia cerulea dolens (PCD) is an uncommon, potentially life-threatening complication of acute deep venous thromboses that requires a timely diagnosis. The name of the condition, the visual diagnostic criteria, and the preponderance of cases in the literature referencing findings exclusively in patients with lighter skin complexions means that PCD may not be on the differential diagnosis for the patient with more melanated skin who is experiencing this time-sensitive vascular emergency...