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 [+]
SAEM Clinical Images Series: Unidentified Intrauterine Object
A 31-year-old female G3P2 presented to the emergency department with vaginal spotting for one week and worsening lower abdominal cramping. She tested positive on a home pregnancy test one day prior to presentation. On the day of presentation, she passed a small blood clot and bled through one pad. She had not yet seen an OB for this pregnancy. Her last menstrual period was one month and three days prior. The current pregnancy is undesired. She denied fevers, chills, urinary symptoms, lightheadedness, palpitations, shortness of breath, nausea, or vomiting. Vitals: BP [+]
SAEM Clinical Images Series: Didn’t See That Coming
A 23-year-old healthy male presented to the emergency department with left eye pain, soreness, and blurry vision after being hit in the left eye with a Nerf gun bullet two days prior. He had no prior ophthalmologic history and does not wear corrective lenses. Left eye: Visual acuity 20/30. Intraocular Pressure 17. Pupil 3mm, irregular, minimally reactive. Slit lamp exam revealing 3+ RBCs, vertical layering of blood along the nasal aspect. None Vertical hyphema Blunt trauma induces shearing forces upon the vasculature of the ciliary body and iris, resulting in [+]
Diagnosis on Sight: “Stabbing Belly Pain”
A 24-year-old male with a history of microscopic hematuria presented to the emergency department (ED) with left lower quadrant abdominal pain. His pain started about two weeks ago and has been intermittent. He describes the pain as stabbing. He decided to come to the ED today because of the persistent nature of the pain. He denies chest pain, cough, shortness of breath, fevers, nausea, vomiting, diarrhea, constipation, rectal bleeding, dysuria, and increased urinary frequency. His exam revealed a well-appearing male in no acute distress. His abdomen was soft with left lower quadrant tenderness on palpation but no rebound or [+]
SAEM Clinical Images Series: Below the Chin, Badness Lies Within
A 50-year-old male with insulin-dependent Type 2 Diabetes presented to the emergency department with three days of pain and swelling on the right side of his neck. He endorsed progression of his symptoms, reporting that he was now having fevers, myalgias, and intermittent difficulty swallowing solid foods. Vitals: BP 153/96; HR 110; T 100.0°F; RR 16; O2 sat 97% General: Appears uncomfortable HEENT: Mild right-sided facial swelling. No trismus. No gingival inflammation or swelling or induration to suggest abscess. There is focal swelling and tenderness to palpation, without overlying erythema, throughout [+]
SAEM Clinical Images Series: Dusky Feet
A 94-year-old female with a past medical history of hypertension, coronary artery disease, chronic venous stasis, and permanent pacemaker placement initially presented to triage complaining of left hip pain in the setting of a fall shortly prior to arrival. Upon further evaluation, she endorsed developing sudden bilateral lower extremity weakness causing her to fall to the floor. She then experienced excruciating pain from her umbilicus down to her groin, hips, and legs (left greater than right), describing it as “being in labor.” She denied any recent fevers, chills, chest pain, shortness of breath, leg swelling, [+]