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em@3am

EM@3AM: Suppurative Parotitis

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A 75-year-old male presents to the ED with right facial swelling since last night. He is also complaining of pain and subjective fevers. Initial vital signs include BP of 150/85, HR 103, T 100.8, RR 18, SpO2 97% on RA. Exam reveals the patient to be ill-appearing with a focal area of swelling medially to his right ear that is warm and tender to palpation. His oral mucosa is dry. He has multiple dental caries and poor dentition overall. Massage of the area of swelling reveals purulent drainage from the oral mucosa near the right maxillary molars.  What is the most likely diagnosis?

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EM@3AM: Erysipelas

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A 65-year-old female with a history of diabetes, hypertension, obesity, chronic lymphedema and venous insufficiency presents to the ED with redness to her right leg noted 2 days ago but worsening since yesterday. She has had pruritus and swelling to the site accompanied by a painful burning sensation and a couple “painful knots” on her right inguinal region. She denies any prior history of deep vein thrombosis (DVT, IV drug use, or any history of vascular surgeries to the lower extremities. She has also had malaise for a few days and says that the redness has markedly increased since yesterday. On examination of the right lower extremity there is a large area of intense erythema with sharply demarcated borders that appears raised with some swelling and mild tenderness to palpation. What is the most likely diagnosis?

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EM@3AM: Kawasaki Disease

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A 3-year-old male presents to the ED with one week of daily fevers >102°F associated with four days of rash on the trunk. His parents have been managing his fevers with acetaminophen and ibuprofen, but became worried today when they noticed redness and swelling of the tongue in addition to swelling in the hands and feet. Vital signs demonstrate a rectal temperature 39.5°C, BP 92/60, HR 130, RR 35, and SpO2 of 98%. Physical exam demonstrates an ill appearing child with bilateral conjunctival injection; erythematous tongue with dry, fissured lips; right sided cervical lymphadenopathy; an erythematous maculopapular rash on the chest, abdomen, and back; and nonpitting edema of the hands and feet. What is the most likely diagnosis?

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EM@3AM: Periorbital Cellulitis

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An 8-year-old boy presents with left eyelid swelling for 2 days. Parents report the swelling has progressively worsened and is greater in the upper eyelid. It is associated with erythema, warmth, and tenderness. They also note subjective fevers. For the past week, the patient had watery rhinorrhea, dry cough, and nasal congestion. Parents deny recent trauma or known insect bite. The patient’s vitals include T 100.2F, BP 113/67, HR 123, RR 26, SpO2 of 99% on room air. On physical exam, the patient is non-toxic appearing. His eye exam is significant for edema and erythema to the left periorbital region greater in the upper eyelid. There is mild warmth but no crusting or active drainage.  His extraocular movements are intact and painless, and there is no conjunctivitis or chemosis. What is the diagnosis?

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EM@3AM: Cerebellar Stroke

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A 53-year-old female with a history of hypertension presents to the ED with headache and dizziness.  Her symptoms have been constant over the last two weeks. Triage vital signs (VS) include BP 163/89, HR 78, T 98.4, RR 14, SpO2 98% on room air. On exam, no nystagmus is noted. Her extraocular movements and cranial nerves II-XII are intact, strength of all four extremities is 5/5 without any focal weakness, and there are no appreciable sensory deficits. There is, however, dysmetria of the right upper extremity. What should you consider?

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EM@3AM: Abdominal Aortic Aneurysm

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A 72-year-old male presents with left-sided flank pain for the last two weeks that has worsened over the past several hours. He also feels lightheaded when standing today. He is tachycardic to 124 beats per minute and hypotensive to 117/84 mm Hg relative to his chart baseline which has an average systolic in the 160s mmHg. You cannot reproduce his pain on your abdominal exam, but you feel a thrill with deep central abdominal palpation. What is the likely diagnosis, and what are your initial steps in evaluation and management?

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EM@3AM: Polyarteritis Nodosa

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A 59-year-old male presents to the ED with abdominal pain, hematuria, and rectal bleeding for the 5 days. His symptoms have been associated with unintentional weight loss, intermittent fevers, skin rash, and fatigue over the past 3 months. He has a past history of hepatitis B, hypertension, diabetes, and hyperlipidemia. Vital signs include blood pressure 162/103 mm Hg (last measured 118/82 5 months ago, per records), HR 101, RR 18, SpO2 98% on room air. Exam is notable for generalized abdominal tenderness, guaiac positive stool, and generalized purpuric rash over bilateral lower extremities. Labs demonstrate Cr 2.9 (baseline 1.1) and elevated ESR and CRP. What is the most likely diagnosis, and what are the next steps in management?

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EM@3AM: Testicular Torsion

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A 25-year-old male is brought to the ED by EMS after sudden onset right testicular pain. He denies any trauma or contact to his scrotum or perineum; however, he endorses severe, sudden pain associated with nausea and non-bloody, non-bilious emesis. He additionally complains of mild lower right abdominal tenderness. Review of systems is otherwise unremarkable. On exam he is uncomfortable appearing and has a nontender abdomen. He has a normal penile exam, but the the right hemiscrotum has mild erythema, a horizontal lie, and it is exquisitely tender. What’s the next step in your evaluation and diagnosis?

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EM@3AM: Impetigo

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A 9-month-old male presents with a rash and fever for 4 days. Mom reports the rash began in the axillae and groin and spread to the trunk. She notes the rash started as small, erythematous lesions that have progressed to bullae which are unroofing. The rash is associated with intermittent fevers (Tmax of 102°F) and diarrhea. The patient’s vital signs include T 101.2F, BP 93/56, HR 163, RR 40, SpO2 of 99% on room air. On physical exam, the patient appears pale with a prolonged capillary refill. His skin exam is significant for an erythematous rash with scattered ruptured bullae with brown crust and a collarette of scales across the trunk, axillae, perineal and flexural thigh areas. What is the diagnosis?

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EM@3AM: Sacral fractures

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A 75-year-old male with a history of hypertension, osteoarthritis, and diabetes mellitus presents to the ED with a chief complaint of lower back pain.  He states that he fell a few days ago and the pain is getting worse, particularly when he is sitting down. His vitals include blood pressure 150/95, heart rate 95, SPO2 99%, temperature 36.6C, and a glucose of 143. On examination, the pelvis is stable, but he endorses tenderness midline along his sacrum. He has a normal neurologic exam in all extremities. What’s the diagnosis?

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The emdocs cast with jess pelletier and brit long covers the challenging diagnosis of spontaneous cervical artery  dissection. Check out this high yield post on vertical shear fractures from core em !. emdocs podcast – episode 115 : adult meningitis.