SAEM Clinical Images Series: Rectal Bulge
A 13-month-old, full-term male presented due to intermittent emesis over a 3-week period. He and his parents had COVID one week prior to presentation. He had multiple episodes of non-bloody, non-bilious vomit the day before and the day of presentation. Parents noted he had been listless and unable to tolerate food. The mother was also concerned that he was straining to have bowel movements and that a mass was coming out of his bottom on the ride to the hospital. Parents reported decreased activity, decreased appetite, and decreased urine output. He was born via cesarean section [+]
SAEM Clinical Images Series: A Rash with Cranial Nerve Deficits
A 48-year-old male with no significant past medical history presented to the Emergency Department with a left-sided facial rash and associated burning left eye pain that started four days prior. He was seen at an ophthalmology clinic when his symptoms started and given oral valacyclovir which he took for three days without improvement. He also endorsed left-sided facial weakness and diplopia for the last eight days. He denied fevers, chills, nausea, vomiting, ear pain, tinnitus, hearing changes, blurry vision, photophobia, history of malignancy or HIV, history of stroke. He reported remote use of tobacco nine [+]
SAEM Clinical Images Series: Clot in Transit
A 67-year-old male with a past medical history of CHF, MI, hypertension, and diabetes presented to the ED with complaints of headache, chest pain, and dyspnea for the past four days. He stated that he has been without his medications for the past few months due to cost. He denied any past surgical history. He stated that he primarily presented because he felt like "my blood pressure is high". Cardiovascular: Tachycardic, 2+ pedal edema bilaterally Respiratory: Tachypneic, decreased breath sounds bilaterally, ronchi/wheezes bilaterally Skin: Diaphoretic Troponin I: 0.13 (elevated) BNP: [+]
Tranq dope (fentanyl-xylazine combination): A new horizon in opioid withdrawal treatment
‘Dope' is no longer heroin in an increasing number of our communities. The biggest change has been the gradual replacement of diacetylmorphine (heroin) by fentanyl and other synthetic opioids. Due in large part to the proliferation of anonymous chemical factories able to produce industrial volumes of inexpensive synthetic opioids without opium or other controlled precursors, fentanyl spilled into the United States, Canada, and Europe, heroin soon fell to market forces [1, 2]. Along the same time, a veterinary sedative, xylazine, became popular in Puerto Rico in individuals who used injection drugs [3]. An alpha-2 receptor agonist mechanistically similar to [+]
SAEM Clinical Images Series: Wilma, Take a Look at This!
A 2-year, 11-month-old female with a history of constipation was brought to the ED by her mother for abdominal pain. The mother noticed that the patient's abdomen had been enlarging for months. When they visited the pediatrician several months ago, the pediatrician also noticed a mildly enlarged abdomen but the patient was asymptomatic at that time. She was well during the interval until more recently, the patient began to complain of persistent abdominal pain and would point to the epigastric area. The patient had [+]
SAEM Clinical Images Series: When Needles Go Beyond Sewing and Acupuncture
A 64-year-old male with a history of bipolar 1 disorder, PTSD, anxiety, depression, obsessive-compulsive disorder, GERD, and HTN presented to the ED with the chief complaint of foreign body and self-injury. He reported years of sticking sewing needles into his right arm, most recently yesterday. He explained that inserting needles makes him feel better with mild associated pain. He endorsed suicidal ideas, elaborating that he did not want to stop injuring himself. He also reported depression and wished that he was not alive. He stated that he had told his therapist that he didn't want [+]
Trick of the Trade: Cut IV extension tubing for 2-person ultrasound guided nerve block
Ultrasound-guided procedures are difficult enough just identifying the anatomy. Performing a nerve block with the ultrasound in one hand and the needle in the other hand adds extra challenges. The simplest 1-person approach involves attaching a syringe with local anesthetic directly to the end of the procedural needle. A 2-person approach involves attach the syringe to a custom tubing-needle setup such as below. However, this custom setup may not be readily available.Trick of Trade: Cut Standard IV Extension TubingRequired equipment:Ultrasound linear probe10 cc syringeIV tubingProcedural needleShearsAlmost all standard IV extension tubing that connects IV fluid bags to a peripheral IV [+]
SAEM Clinical Images Series: Not Your Average Ear Infection
A 5-year-old generally healthy fully immunized boy presented to the ED with worsening left ear redness, swelling, and tenderness that his family noticed the day before presentation. His family had also recently noticed an abrasion over that ear. The patient was on amoxicillin for strep throat, which was diagnosed a week before the onset of his symptoms and was improving. Vitals: BP 130/68; HR 105; Temp 98.9°F; RR 22; O2 Sat 100% RA General: Alert, interactive, well-appearing HEENT: Left ear with moderate redness, swelling, warmth, and tenderness of the auricle sparing the [+]
SAEM Clinical Images Series: A Blistery Mystery
A 76-year-old female presented with a lingering cough and an oral lesion to the left lower cheek. She reported ten days of improving flu-like symptoms but had a persistent cough and nasal congestion. On the day of presentation, she developed a painful, intermittently bleeding “blood blister” to the left lower cheek that had increased in size, as well as new red spots on her arms and legs. She reported no recent trauma or history of similar lesions in the past. Vitals: 98.3°F; HR 85; BP 178/89; RR 16; SpO2 98% on RA [+]
SAEM Clinical Images Series: Doubly Double Vision
A 52-year-old female with a past medical history of hypertension and prediabetes presented to the emergency department with double vision that started one day prior to arrival. She stated that her double vision improved when she closed one eye. She denied trauma, headache, neck pain, dizziness, dysphagia, numbness, tingling, weakness, or gait instability. Vitals: BP 181/119; HR 76; RR 18; T 98.4°F; O2 saturation 96% on room air General: No acute distress, well-appearing Neurologic: AOx3; Following commands. Speech without dysarthria. PERRLA. EOM: incomplete abduction of the L and R eye. No [+]