When influenza (flu) season arrives, it is easy for emergency department clinicians to anchor on the diagnosis of flu, sending patients on their way with or without anti-influenza medication. It is important not to miss the outlier – the patient who seems to have typical symptoms of influenza but with certain subtleties that should make one consider expanding the differential diagnosis.
Carotid artery dissection is a rare but serious condition manifesting with signs and symptoms that closely overlap with other more benign medical diagnoses. This vascular injury, however, can result in debilitating sequelae, including thromboembolic cerebrovascular accidents.
Takotsubo or stress cardiomyopathy is a syndrome of transient left ventricular systolic dysfunction seen in the absence of obstructive coronary artery disease.
Pheochromocytomas and paragangliomas are rare neuroendocrine tumors that secrete catecholamines. Symptoms of these tumors are related directly to catecholamine excess but can be intermittent and easily misattributed to other, more common pathologies. Identification in the emergency department (ED) is inherently difficult. During the coronavirus 2019 (COVID-19) pandemic, physicians have had to account for both the disease itself as well as associated increased prevalence of cardiac, pulmonary, and vascular complications. Such shifting of disease prevalence arguably makes rarer diseases like pheochromocytoma less likely to be recognized.
Nonketotic hyperglycemia-associated chorea is a rare condition that upon presentation to the emergency department can be easily misdiagnosed as a seizure or a stroke. Although uncommon, identification of this condition can aid emergency physicians in avoiding unnecessary and potentially harmful treatments for other neurological pathology. Furthermore, prompt hyperglycemic control can result in reversal of symptoms within days.
Stroke mimics are a major diagnostic challenge during the initial evaluation of patients presenting with an acute focal neurological deficit. This case reviews a patient who presented to the emergency department (ED) with homonymous hemianopsia, a rare manifestation of focal status epilepticus of the occipital lobe. Her initial brain computed axial tomographic perfusion scan and magnetic resonance imaging revealed novel findings associated with this diagnosis.
Patients with history of abdominal aortic aneurysm (AAA) undergoing surgical repair can have a myriad of surgical complications including compromise to large arteries branching from the aorta. Secondary hyperaldosteronism, characterized by high levels of aldosterone and renin, can be due to a multitude of causes, including renal artery stenosis, and presents with nonspecific symptoms of fatigue, increased thirst, and muscle spasms. While it can initially be difficult to diagnose given its multitude of metabolic abnormalities, secondary hyperaldosteronism is important to consider in patients presenting with uncontrolled hypertension, hypokalemia, and metabolic alkalosis.
Ultrasound-guided nerve blocks (UGNB) represent a procedural skill set that can be used to treat acute pain by physicians in the emergency department (ED). However, limited access to education and training represents a barrier to widespread adoption of this core skill set. The implementation of UGNBs within the ED can aid in resource allocation, particularly in limited-resource settings.
Many patients present to the emergency department (ED) with nonspecific, acute-on-chronic complaints. It requires a thorough diagnostic approach and broad differential diagnosis to determine whether there is serious, undiagnosed pathology.
A 38-year-old with suicidal ideation and alcohol intoxication received conducted energy from a conducted energy weapon (CEW) and subsequently was found to have a transient electrocardiogram (ECG) abnormality consistent with Brugada waveform that resolved over a period of three hours.
A previously healthy 45-year-old man presented to the emergency department with bilateral knee pain and inability to extend his knees after a slip and fall on ice. The clinical diagnosis of bilateral quadriceps tendon rupture was confirmed by computed tomography (CT) of bilateral knees. The patient underwent successful operative repair the following day.
A 20-year-old female presented to the emergency department for evaluation of exertional, right-sided chest pain. The patient underwent a computed tomography angiogram of her chest as part of her workup, demonstrating the right lower-lobe pulmonary artery arising from the abdominal aorta.
A seven-year-old male presented to the pediatric emergency department with one day of abdominal pain. His physical exam was significant for rebound, guarding, and tenderness in the right lower quadrant, and his labs demonstrated a leukocytosis. Both a point-of-care ultrasound and radiology-performed ultrasound were concerning for acute appendicitis with a periappendiceal abscess, but on emergent laparoscopy the patient was found to have an infected urachal cyst.
A 73-year-old male presented to the emergency department complaining of pain in his right eye for four weeks. He denied any trauma, and the pain was accompanied by ptosis, proptosis, swelling, redness, blurred vision, and a frontal headache. On examination, conjunctival arterialization was also appreciated. Magnetic resonance imaging and angiography showed evidence of a carotid cavernous fistula for which the patient underwent successful transvenous coiling and embolization.
An 88-year-old female presented to the emergency department (ED) with complaints of painful vision loss four days after an intravitreal injection for her neovascular macular degeneration. Her right eye visual acuity was markedly diminished with an absence of red reflex. A point-of-care ocular ultrasound was performed and demonstrated hyperechoic vitreous debris concerning for endophthalmitis.
A 32-year-old man with a history of hemophilia A presented to the emergency department with right shoulder pain, swelling, and decreased range of motion.
Acute upper gastrointestinal bleeding is a common emergency presentation. The United States Centers for Disease Control and Prevention 2018 survey of emergency department (ED) visits reported 436,000 ED visits for unspecified gastrointestinal bleeding that year.1
A vulvar hematoma is a hemorrhagic fluid collection in the female external genitalia. The majority occur as an obstetrical complication, especially during labor. Non-obstetrical vulvar hematomas are usually the result of trauma, with coitus being the most common etiology.
Weakness is a common chief complaint in the emergency department, and the use of glucocorticoids is pervasive in medicine. Muscle weakness, or myopathy, is a well documented side effect of chronic glucocorticoid use. However, acute myopathy, with an onset shortly after initiation of glucocorticoids, is much rarer.
Brown-Séquard syndrome is a rare neurological disorder due to hemisection of the spinal cord that can occur from a variety of causes, most commonly trauma.
Arterial dissection is well known as a potential cause of stroke in young patients. Vertebral artery dissection occurs most commonly in the setting of minor trauma but has been seen in cases of cervical manipulation. With advances in at-home therapeutic modalities for neck pain came the advent of handheld massage guns. These massage guns have gained considerable popularity in recent years, but their safety for use in the cervical region has not been well studied.
Point-of-care ultrasound (POCUS) has great sensitivity in the diagnosis of abscesses and swollen lymph nodes. Many studies outline the characteristics that distinguish abscesses from lymph nodes on POCUS.
Achilles tendon ruptures often occur during physical activity where the tendon is frequently stressed. Although rare, rupture can also result from electric shock.
Traumatic carotid artery dissections (CAD) are rare but produce potentially devastating injuries. Most patients develop symptoms within 72 hours of traumatic injury.
