Emergency Medicine Commons^™

Case Report: Todd’S Paralysis In A Patient With An Extensive Stroke History, Thuc Vu, Kishan B. Patel

Rowan-Virtua Research Day

Here we present the case of a 70-year-old patient who presented to the emergency department with altered mental status, left-sided gaze preference, left-sided hemineglect, and inability to follow commands. He had a past medical history of seizure activity and cerebrovascular accident (CVA) with residual dysarthria and was on apixaban. His symptoms began after seizure activity and improved gradually. He was ultimately diagnosed by stroke neurology as having had an episode of Todd’s Paralysis. The differential diagnosis for patients for altered mental status with neurological deficits can be vast, but, in general, Todd’s Paralysis can be an ischemic stroke mimic upon …

Out Of The Blue: A Case Of Acute Limb Ischemia In A Healthy Young Woman, Julian Coz, Melanie Angelo

Rowan-Virtua Research Day

Acute limb ischemia (ALI) is a critical condition caused by arterial occlusion, often due to thrombotic or embolic events in atherosclerotic vessels. Early diagnosis and intervention are essential to prevent limb loss and complications. While typically seen in patients with known vascular risk factors, ALI can also affect individuals without them.

We present a case of a 49-year-old female with sudden-onset left foot pain and paresthesia, highlighting the importance of recognizing ALI in seemingly healthy patients. Despite the absence of typical risk factors, imaging revealed significant atherosclerosis and arterial occlusion, leading to the diagnosis of ALI. This case emphasizes the …

Case Report: Spontaneous Aortic Dissection In A 63-Year Old Male Presenting As Left Abdominal, Flank And Back Pain, Dean Austin Esma

Rowan-Virtua Research Day

Aortic dissection is a life-threatening condition in which the inner walls of the aorta tears, compromising its ability to supply blood to organs. The classic presentation involves sudden, severe, “tearing” chest pain, but subtle presentations are often overlooked as symptoms of another condition, leading to missed diagnoses. This report presents a case of spontaneous aortic dissection who presented with sudden onset of left upper abdominal pain, left flank and upper back pain while brushing his teeth.

Miller Fisher Variant Of Guillain- Barré Syndrome, Peter Killian, Kishan B. Patel

Rowan-Virtua Research Day

We present a case of a man in his 50s who was evaluated in the emergency department for right facial droop, myalgias, and right lower extremity weakness. The patient required multiple interdisciplinary specialists for treatment and diagnosis of Guillain-Barré Syndrome (GBS). The differential for weakness and facial droop is primarily aimed at ruling out an irreversible neurological cause while investigating a potential infectious etiology. Multiple variants of GBS exist and clinical presentations can vary, including the Miller Fisher Variant. This variant features a unique presentation, affecting the corticobulbar tract, evident with the ptosis commonly seen following a gastrointestinal infection.

Case Report: Pulmonary Infarction Following Recent Pulmonary Embolism, David Marconi, James Espinosa, Alan Lucerna

Rowan-Virtua Research Day

A 57-year-old man with chronic obstructive pulmonary disease (COPD), obstructive sleep apnea, and a recent pulmonary embolism (PE) on anticoagulation presented with acute pleuritic chest pain and worsening dyspnea. Computed tomographic angiography (CTA) of the chest revealed a small distal segmental PE in the left lower lobe and an adjacent irregular consolidation, raising concern for pulmonary infarction versus pneumonia. The patient was empirically started on antibiotics for possible pneumonia and admitted for anticoagulation and supportive care. He left the hospital against medical advice (AMA) before completing treatment, but returned days later with exacerbated symptoms. This case highlights the diagnostic challenge …

Targeted Ehr-Based Communication Of Diagnostic Uncertainty (Tecu) In The Emergency Department: Protocol For An Effectiveness Implementation Trial, Danielle M Mccarthy, Sara Malone, Dimitrios Papanagnou, Benjamin E Leiby, Amandy M B Doty, Phillip Watts, Rahul Yadav, Julia K Pugliese, Jonathan Woodworth, Tracy Esteves Camacho, Efrat Kean, Kristin L Rising

Department of Emergency Medicine Faculty Papers

BACKGROUND: At least 37 % emergency department (ED) patients are discharged without a definitive diagnosis, resulting in diagnostic uncertainty. Transitions of care are high-risk periods for patient safety, especially for patients discharged with diagnostic uncertainty. Effective communication between clinicians and patients improves these care transitions. Previous research developed tools to support high quality discharge in the setting of diagnostic uncertainty, including: a communication checklist, a physician training program, and a patient-facing information sheet.

METHODS: This study aims to enhance transitions for patients leaving the ED with diagnostic uncertainty through an electronic health record (EHR)-based strategy. The intervention, the Targeted EHR-based …

Evaluating A Large Language Model’S Accuracy In Chest X-Ray Interpretation For Acute Thoracic Conditions, Adam M. Ostrovsky

SKMC Student Presentations and Publications

BACKGROUND: The rapid advancement of artificial intelligence (AI) has great ability to impact healthcare. Chest X-rays are essential for diagnosing acute thoracic conditions in the emergency department (ED), but interpretation delays due to radiologist availability can impact clinical decision-making. AI models, including deep learning algorithms, have been explored for diagnostic support, but the potential of large language models (LLMs) in emergency radiology remains largely unexamined.

METHODS: This study assessed ChatGPT's feasibility in interpreting chest X-rays for acute thoracic conditions commonly encountered in the ED. A subset of 1400 images from the NIH Chest X-ray dataset was analyzed, representing seven pathology …

Extrinsic Motivation Enhances Clinical Ultrasound Utilization Amongst Residents, Bailey Spencer, Steven Rickett, Jacob Pope, Sanna Ho-Gotshall, Casey Wilson

South Atlantic Division GME Research Day 2025

No abstract provided.

High Rates Of Avoidable Computed Tomography Angiography For Pulmonary Embolism Exclusion, Kalyan Mantha, Angelo Kantrales, Kerolos Abadeer, Pranav Bommineni, Nicholas Prewitt, Martin Wegman

South Atlantic Division GME Research Day 2025

No abstract provided.

Blunt Trauma Causing Thrombotic Occlusive Myocardial Infarction, Jace Bradshaw, Alleabelle Bradshaw, Rishab Agarwal, P. Logan Weygandt

Department of Medicine Faculty Publications

Introduction: Traumatic myocardial infarction (TMI) is a rare but serious complication of blunt chest trauma, typically arising from coronary artery dissection, intramural hematoma, or myocardial contusion. Early recognition and intervention are critical, but diagnosis can be challenging given the broad differential for chest pain in trauma patients.

Case presentation: A 66-year-old female presented to a quaternary academic emergency department after a motor vehicle collision with progressive chest pain. Initial electrocardiogram (ECG) showed hyperacute T-waves in lead III, ST depression with T-wave inversion in aVL, and ST depression in V2, with posterior leads revealing ST elevation in V7–V9. Trauma imaging ruled …

A Case Of Isolated Sma Dissection With Failed Initial Conservative Management, Salma Emara, Madison Kropp, Masoud Akbari, Kristin Cook

Rowan-Virtua School of Osteopathic Medicine Departmental Research

Isolated superior mesenteric dissection (ISMAD) is an uncommon condition, often diagnosed incidentally for presentations of acute abdominal pain. Early identification and treatment are crucial as complications such as bowel ischemia or vessel rupture can occur. There remain no established treatment guidelines, making surgical and endovascular indications controversial. A 60-year-old male presented with acute abdominal pain, and was diagnosed with ISMAD via computed tomography imaging. He was initially managed conservatively which progressed to worsening abdominal pain, hypertensive crisis, and hemoperitoneum on follow-up computed tomography angiography (CTA). A mesenteric angiogram revealed a pseudoaneurysm in the superior mesenteric artery (SMA) which was subsequently …

Transcription And Post-Translational Mechanisms: Dual Regulation Of Adiponectin-Mediated Occludin Expression In Diabetes, Yanru Duan, Demin Liu, Huahui Yu, Shihan Zhang, Yihua Xia, Zhiyong Du, Yanwen Qin, Yajing Wang, Xin-Liang Ma, Huirong Liu, Yunhui Du

Department of Emergency Medicine Faculty Papers

BACKGROUND: Occludin, a crucial component of tight junctions, has emerged as a promising biomarker for the diagnosis of acute ischemic disease, highlighting its significant potential in clinical applications. In the diabetes, Occludin serves as a downstream target gene intricately regulated by the adiponectin (APN) signaling pathway. However, the specific mechanism by which adiponectin regulates Occludin expression remains unclear.

METHODS AND RESULTS: Endothelial-specific Ocln knockdown reduced APN-mediated blood flow recovery after femoral artery ligation and nullified APN's protection against high-fat diet (HFD)-triggered apoptosis and angiogenesis inhibition in vivo. Mechanically, we have meticulously elucidated APN's regulatory role in Occludin expression through a …

Emergency Department Slit Lamp Interdisciplinary Training Via Longitudinal Assessment In Medical Practice, Samara Hamou, Shayan Ghiaee, Christine Chung, Maureen Lloyd, Kelly Khem, Xiao Zhang

Department of Emergency Medicine Faculty Papers

INTRODUCTION: Eye emergencies make up nearly 3% of US emergency department (ED) visits. While emergency physicians (EP) should diagnose and treat these ophthalmologic emergencies, many trainees report limited ocular exposure and insufficient training throughout their residency to confidently conduct a thorough slit-lamp exam.

METHODS: We created an interdisciplinary, simulation-based mastery learning (SBML) curriculum to teach emergency attending physicians how to operate the slit lamp with multimodal learning methodology at a tertiary academic center. The EPs first demonstrate their initial slit-lamp competency with a 20-item checklist, and they then review the necessary curricular content to pass their independent readiness test before …

Clinical And Radiological Identification And Management Of Sapho Syndrome, Obyda Al-Housni, Jessica M. Alonso, Matthew Thornburg, Enny Cancio

HCA Healthcare Journal of Medicine

Introduction

Synovitis, acne, pustulosis, hyperostosis, and osteitis (SAPHO) syndrome is an autoinflammatory disease whose acronymic name stands for the symptoms commonly seen in the disease. These symptoms typically occur simultaneously, in different combinations, in patients during exacerbations of the disease. SAPHO syndrome is a rare disease, most frequently seen in patients aged 30 to 50. It is estimated to be found in 1 in 10 000 persons in White populations, with an even lower incidence seen in non-White populations.

Case Presentation

A post-menopausal woman with a medical history of SAPHO presented to the emergency department with left foot pain and …

Ekg Is Key: A Quality Improvement Project To Decrease Door-To-Ekg Time In A Rural Emergency Department, Amanda Southwell

Doctor of Nursing Practice Projects

Background: Electrocardiograms (EKGs) are the priority when evaluating patients with chest pain who present to the Emergency Department (ED). The American Heart Association and other governing bodies suggest a 10-minute door-to-EKG (DTE) time. The target facility displayed a delay in DTE times.

Purpose: The Doctor of Nursing Practice (DNP) quality improvement (QI) project aimed to decrease the average DTE time for patients over 18 years old with chest pain who presented to the ED registration area.

Methods: The DNP project consisted of an EKG suite to perform EKGs near the ED registration/triage area. Registration and ED staff were educated on …

Blunt Cerebrovascular Injury (Bcvi): Universal Cta Neck Screening At Level 2 Trauma Center, Tamine Gogel

Doctor of Nursing Practice Projects

Blunt Cerebrovascular Injury (BCVI) refers to injuries to the vessels supplying blood to the brain, primarily carotid and vertebral arteries, and can result from trauma, resulting in stroke by vessel dissection, thrombus formation, embolization, and hemorrhage. Timely identification is crucial for effective intervention and improved outcomes. This doctoral project proposes the implementation of universal screening using Computed Tomography Angiography (CTA) of the neck during initial workup for blunt force trauma at a Level II ACS-verified trauma center. The primary objective is to mitigate potential delays in diagnosing and treating BCVI, thereby reducing the likelihood of complications. Patients ≥ 15 years …

Case Report: Wellens Syndrome In 28-Year-Old With Pleuritic Chest Pain, Tucker A. Ledo

Rowan-Virtua Research Day

We report a case of a 28-year-old male with months of diffuse, pleuritic, intermittent, non-exertional chest pain. He had an elevated troponin and ECG showing Wellens’ syndrome and was found to have 80% LAD coronary artery occlusion and 100% apical occlusion. Identification and proper management of Wellens’ syndrome relies on being familiar with its ECG patterns. Other information such as age, cardiac risk factors, chest pain with exertion and at rest, and elevated troponin, are all helpful supplemental information, but as demonstrated in the following case report, presentations may vary or even cause as distractors to the diagnosis.

Case Report: Dysphagia In Inclusion Body Myositis Leading To Respiratory And Gastrointestinal Complications, Veroneka Mikhail, James A. Espinosa, Alan Lucerna

Rowan-Virtua Research Day

Inclusion Body Myositis (IBM) stands as a rare and complex neuromuscular disorder (NMD) characterized by progressive muscle weakness and atrophy. Among its cardinal symptoms are dysphagia and respiratory distress, which are the most common cause of death in this disease. While the differential diagnosis of respiratory distress is vast and includes aspiration, pneumonia, acute coronary syndrome, emphysema, and congestive heart failure, a clinician should recognize that respiratory distress can also be secondary to dysphagia in NMDs like IBM and can quickly become life threating. Here we present the case of a 68-year-old female with a history of IBM who presented …

Case Report: Hidden Posterior Dislocation Of The Clavicular Head, David F. Koziel

Rowan-Virtua Research Day

Reported is a case of a 24-year-old male who presented with left shoulder pain and decreased range of motion of the same shoulder upon awakening, diagnosed with a posterior dislocation of the proximal clavicle, with the clavicular head residing in the mediastinum. In the conscious, ambulatory, young adult it is arguably much more common for major bony trauma involving the upper extremity and shoulder to present with pain, deformity, and a known mechanism. This is an example that lacks all three of these characteristics and highlights the importance of details in the physical examination as well as clinical gestalt.

Case Report: A Case Of Ttp In The Ed, Brian F. Lim, Andrew Caravello, James A. Espinosa, Alan Lucerna

Rowan-Virtua Research Day

We report a case of a 54-year-old female who presented with mild shortness of breath, lower chest discomfort, fatigue, and weakness ongoing for several days and was diagnosed with thrombotic thrombocytopenic purpura (TTP). TTP is characterized by microangiopathic hemolytic anemia and thrombocytopenia due to either an inherited or immune-mediated reduction in von Willebrand Factor (VWF) cleaving protease ADAMTS13.

Patients presenting with non-specific symptoms is becoming increasingly common and initial bias could be to attribute symptoms to viral syndrome or upper respiratory tract infection. However, the differential for non-specific complaints is extensive and thorough review of labs and re-evaluations of patients …

Unmasking A Silent Threat: Early Detection Of Elevated Hbco Levels When The Story Doesn’T Add Up, Anna M. Delancy, Eric Maddock, James A. Espinosa, Alan Lucerna

Rowan-Virtua Research Day

Carbon monoxide (CO) is difficult to detect in the surrounding environment due to its colorless, odorless, and tasteless properties. Patients acutely poisoned with CO can have a myriad of presentations including headache, dizziness, and critical illness— all with a mortality rate up to 3%. When concerned for CO poisoning, blood co-oximeter testing should be performed, with treatment surrounding the idea of providing supplemental oxygen The efficacy of hyperbaric oxygen (HBO) treatment remains unclear. Here we describe an atypical scenario of a patient ultimately found to have CO poisoning, and the importance of early identification and treatment of this elusive diagnosis …

Morel Lavallee Lesion: A Shear Fascia-Nating Soft Tissue Injury, Isaac F. Su, James A. Espinosa, Alan A. Lucerna

Rowan-Virtua Research Day

Morel-Lavallée lesions (MLLs), first described by their namesake, French physician Victor-Auguste-François Morel-Lavallée, in 1863, represent a distinct category of soft-tissue degloving injuries. These injuries occur when a shearing force disrupts the connection between subcutaneous tissue and fascia, severing lymphatic vessels and capillaries, and leading to an encapsulated collection of lymph, blood, and necrotic fat. Because this space is deep and enclosed, the fluid accumulation cannot easily drain or resolve spontaneously and often an inflammatory capsule develops, further inhibiting resorption. Undiagnosed, patients go on to develop chronic pain, infection, skin necrosis, progressive neurovascular deficits, and, in severe cases, potential loss of …

Case Report: Monkeypox Diagnosed In The Ed, Richard M. Baluyot, Joseph Pagano, James A. Espinosa, Alan Lucerna

Rowan-Virtua Research Day

Rashes are one of the most common chief complaints we see as emergency medicine physicians on a day-to-day basis. Most of them tend to be self-limited and require very little workup and can be discharged home; however, it is our job to try to identify rashes that may require isolation in order to prevent an outbreak in our communities. Here we present a case of one such rash that has gained major media attention as of late, Monkeypox.

Back From Baclofen: A Case Report Of Baclofen Overdose, Alexis M. Dunn, Andrew M. Vasta, James A. Espinosa, Alan Lucerna

Rowan-Virtua Research Day

We report a case of a 45-year-old female who presented with intentional Baclofen overdose. The patient was lethargic and then quickly unresponsive and hypotensive, intubated by EMS in the field. By the time the patient was admitted to the Intensive Care Unit (ICU), the patient was clinically brain dead. After several days of supportive care, patient slowly, and miraculously, regained full neurologic functioning and was admitted to the Psychiatric Unit.

Use Of Point-Of-Care Ultrasound In The Diagnosis Of Postpartum Cardiomyopathy, Muhammad Noman, Frank A. Wheeler, James A. Espinosa, Alan Lucerna

Rowan-Virtua Research Day

Postpartum cardiomyopathy (PPCM), also known as peripartum cardiomyopathy is a rare form of heart failure (HF) that occurs in the late stages of pregnancy or in the early postpartum period. For it to be classified as PPCM, it must occur in the absence of another identifiable cause for HF and have left ventricular (LV) systolic dysfunction with an LV ejection fraction (LVEF) less than 45%. Here we present the case of a 46-year-old female G3P2 presented 5 days postpartum cesarean section delivery in acute respiratory distress where point of care ultrasound was used for assessment of the lungs to visualize …

Over The Counter Overdose: A Case Of Tylenol Toxicity, Swet M. Patel, James A. Espinosa, Alan Lucerna

Rowan-Virtua Research Day

We report a case of a 51-year-old man presenting to the Emergency Department (ED) with suicidal ideations (SI) endorsing an intentional overdose of acetaminophen. Just as important is the clinical presentation; it is equally important to obtain a detailed history of patient's presentation leading to the ED visit when evaluating a suicide attempt. Tylenol (acetaminophen) is a common over the counter (OTC) medication available to the public. Management of Tylenol overdose follows a standard outline of things to observe and intervene on. In this case, we discuss how Tylenol overdose is managed in a clinical setting through a patient who …

Case Report: Diverticulitis Involving A Meckel’S Diverticulum, Samuel M. Thalathoti, Russell A. Mordecai

Rowan-Virtua Research Day

We report a case of a 65-year-old female who presented with abdominal pain and was diagnosed with diverticulitis involving a Meckel‘s Diverticulum. The differential diagnosis of abdominal pain is vast, in this age group includes, but is not limited to appendicitis, diverticulitis, cholecystitis, and small bowel obstruction. In the absence of complicated features, conservative management with oral antibiotics and close outpatient follow is advised. However, in the case of complicated diverticulitis and a rare manifestation such as a Meckel’s Diverticulum, careful management is indicated.

Pneumocephalus – Epidural Injection Nightmare, Mohammad A. Rattu, Frank A. Wheeler

Rowan-Virtua Research Day

Pneumocephalus (pneumatocele or intracranial aerocele) is defined as the presence of air in the intracranial space and most commonly occurs after a traumatic event (most commonly head or facial injury), epidural injection, cranial surgery, However, it may also be spontaneous. Classified into simple and tension types, the presentation varies based on severity and progression. Pneumocephalus with onset less than 72 hours prior to presentation is defined as acute, in contrast to a delayed presentation greater than the given timeframe. Symptoms vary based on the amount of air that is present as well as the exact location within the cranial cavity. …

Dermoid Cyst – Presenting With Llq Abdominal Pain, Mohammad A. Rattu, James A. Espinosa

Rowan-Virtua Research Day

Ovarian cysts are fluid-filled structures that may be defined as simple or complex and are often discovered incidentally on imaging. Their etiology can range from physiologically normal (such as follicular or luteal cysts) to ovarian malignancies. They are more common in the reproductive years secondary to endogenous hormonal production however may also occur at any age. Simple cysts more commonly occur among all age groups; mixed cystic and solid and completely solid ovarian lesions however have rates of increased malignancy. The most independent risk factor is age; therefore, post-menopausal women should have proper follow-up secondary to this risk. Some risk …

A Case Of Hhv-6 Viral Meningitis, Mohammad A. Rattu, Wayne Tamaska

Rowan-Virtua Research Day

Meningitis is the inflammation of the meninges and associated with abnormal cell count in the cerebrospinal fluid (CSF). The lack of bacterial growth in cultures, most commonly referred to as aseptic meningitis, is frequently caused by viruses [2]. Viruses have become more common as the prevalence of bacterial meningitis has decreased secondary to vaccination use, with viral meningitis being the most common form among countries. Viral meningitis will present with fever, headache, photophobia, neck stiffness and nausea and vomiting. Younger children however may not show any signs of meningeal irritation. Viral meningitis is usually self-limiting and with good prognosis; however, …