Emergency Medicine Commons^™

Spontaneous Extraperitoneal Hematoma: An Unexpected Case Of Dysuria And Urinary Retention In A 77-Year-Old Male, Monica Diep, James Lee, James Espinosa, Joseph Pagano, Alan Lucerna

Rowan-Virtua Research Day

Urinary problems are common complaints in the Emergency Department and can present with any combination of lower urinary tract symptoms such as dysuria, hematuria, urgency, frequency, incontinence, or retention. We describe the case of a 77-year-old male who presented to the Emergency Department for five days of worsening dysuria. Two days prior, the patient was seen and evaluated for the same chief complaint, where he received intravenous antibiotics and was admitted to the hospital overnight for observation. The following day, the patient’s urinalysis and cultures were not consistent with a urinary tract infection (UTI) and was subsequently discharged without antibiotics. …

When Are Inpatient And Emergency Dermatology Consultations Appropriate?, Hershel Dobkin, Timothy Blackwell, Robin Ashinoff

Rowan-Virtua Research Day

Hospitalists and emergency physicians continue to struggle with the assessment of dermatologic conditions, often consulting dermatology whenever a patient has a “rash” or skin concern. Dermatology is still not emphasized in medical education and often is taught to most medical students in an abbreviated fashion, which results in physicians feeling ill-equipped to deal with any dermatologic condition—either mundane or potentially life-threatening.

Better guidelines are needed for physicians in the ED and on inpatient units to guide them on appropriate use of dermatologic consultation outside the ambulatory office and the clinic. We constructed a consultation flowchart to help guide the triage …

An Interesting Case Of Factitious Disorder Superimposed On Self: Factitious Disorder Vs Somatic Symptom Disorder, Michaela Margolis, Logan Noone, Jessica Baaklini

Rowan-Virtua Research Day

Factitious disorder superimposed on self (FDIS) was first described in 1951by Richard Asher, who associated the disorder with Baron Munchhausen, who narrated unrealistic and exaggerated stories about his life.

Suspicion for FDIS should be raised when patients with atypical presentations of medical disorders seek excessive use of healthcare services despite ongoing lack of clinical evidence. Patients with FDIS often demand hospitalization for their symptoms, leading to unnecessary tests and treatments. These patients show signs of pathological lying, deceitfulness, are obstinate with medical staff, and display erratic behavior. When medical investigation does not support their symptoms, patients often develop new “symptoms” …

A Rare Case Of Acute Appendicitis In A 21-Year-Old Male With Midsternal Chest Pain, Muhammad Noman, James Espinosa, Alan Lucerna, Andrew Caravello

Rowan-Virtua Research Day

Acute appendicitis is inflammation of the vestigial vermiform appendix. It is one of the leading causes of emergency department visits due to abdominal pain. The vermiform appendix is located at the base of cecum. The attachment does not change; however the tip may migrate to the retrocecal, subcecal, preileal, postileal and pelvic positions. Considering these normal anatomical positions, the pain presentation may vary in patients.

Even though this patient presented with midsternal chest pain, which was suspicious for GERD, it was crucial to perform a thorough head-to-toe exam to discover incidental findings that the patient did not report. In this …

Diaphragmatic Adjacencies: Pulmonary Embolism Presenting As Abdominal Pain, Joseph Piraneo, Christopher Schwartz, Russell Mordecai

Rowan-Virtua Research Day

Pulmonary embolism is a common yet potentially life-threatening diagnosis that should not be missed in the Emergency Department. Common presenting symptoms include dyspnea, pleuritic chest pain, cough, hemoptysis, syncope or pre-syncope. Less often, however, presenting symptoms can include abdominal pain. A clinician should recognize that pain adjacent to the diaphragm (including the lower chest and upper abdomen), can be secondary to underlying pathology either above or below the diaphragm. Here we describe an unusual case of pleuritic, post-prandial, right upper quadrant abdominal pain that was a result of pulmonary embolism.

Case Report: Segmental Testicular Infarction, Nicholas Coan, Ronald Clearie, Amanda Maciag, Joseph Pagano, James Espinosa, Alan Lucerna, Neelesh Parikh

Rowan-Virtua Research Day

We report a case of a 45-year-old male who presented to the Emergency Department with acute onset left testicular pain and was diagnosed with left sided segmental testicular infarction. The differential diagnosis of acute onset testicular/scrotal pain can include critical urological diagnoses such as testicular torsion and testicular tumors. In the absence of global flow disruption on ultrasound Doppler, emergent surgical intervention is not needed. While ultrasound aids in the Emergency Department’s management of acute testicular pain, it does not rule out the need for an additional outpatient work-up or imaging. Conservative management with pain control, outpatient scrotal MRI, and …

Case Report: Epigastric Abdominal Pain From Beverage Ingestion Of Freshly Squeezed Juice Of The Hardy Orange Flying Dragon Plant (Poncirus Trifoliata), James Espinosa, Alan Lucerna, David Ho

Rowan-Virtua Research Day

We report the case of a 25 year old male who presented to the ED with epigastric abdominal pain after ingesting a freshly squeezed beverage form of Flying Dragon Hardy Orange plant (Poncirus trifoliata). Poison control was contacted and recommended symptomatic treatment only. The patient’s pain resolved while in the emergency department. Seed and rind preparations have been used as an herbal remedy in East Asia. Freshly squeezed Poncirus trifoliata can cause significant abdominal pain.

Complications Of Fitz-Hugh-Curtis Syndrome In A Teenage Female: A Case Presentation, Marina Cugliari, Trupti Pandit

Rowan-Virtua Research Day

Fitz-Hugh-Curtis Syndrome is a manifestation of Pelvic Inflammatory Disease (PID) associated with Chlamydia trachomatis infections and less frequently with Neisseria gonorrhea.

PID affects sexually active women (15-30 years old) and accounts for 750,000 cases each year.

The case presented illustrates a female who presented with a small bowel obstruction and appendicitis, who was incidentally found to have Fitz-Hugh-Curtis Syndrome on laparoscopic exam.

Case Report: Thyrotoxic Hypokalemic Periodic Paralysis, Kelly Schuitema, Wayne Tamaska, Robin Lahr

Rowan-Virtua Research Day

Thyrotoxic crisis, or thyroid storm, is an acute, life threatening event caused by hyperthyroidism with mortality up to 8-25% that can present with multi-system organ involvement. It is a rare, but well studied complication in the emergency department but can lead to further, less common complications. In this study we will discuss a case of thyrotoxic hypokalemic periodic paralysis. Thyrotoxic hypokalemic periodic paralysis (TPP) most commonly affects Asian men. The key features of the syndrome include acute onset of hypokalemia and paralysis. The hypokalemic aspect of the disorder is secondary to the shift intracellularly by thyroid hormones’ sensitization of Na+/K+-ATPase …

Case Report: Unintentional Edible Thc Ingestion (Gummi Worms) In A Child, James Espinosa, Kelly Hamilton, Alan Lucerna, David Ho, Henry Schuitema

Rowan-Virtua Research Day

We report the case of a 4 year male who presented to the ED with what his mother described as unusual fatigue and sleepiness. The mother related that family and friends had some to her house for a holiday gathering and that one of the guests had an accessible and open handbag that contained gummi worm THC. The guest observed the child eating the gummi worms and immediately notified the patient’s mother. Poison control was contacted. The child was observed for 6 hours and left the ED in good condition without any specific treatment needed. Awareness of the potential of …

Case Report: The Heart Breaking Tale Of Takotsubo In The Ed, Richard Baluyot, James Espinosa, Alan Lucerna, Sergey Medlenov, Joseph Pagano, Bhumi Shah

Rowan-Virtua Research Day

Chest pain is one of the most common chief complaints that emergency room physicians deal with on a daily basis. Here we present a rare cause of chest pain on a patient diagnosed with takotsubo cardiomyopathy. This is a condition that has been on the rise since its initial discovery and therefore clinicians should consider this on their differential when assessing patients with chest pain, especially postmenopausal women.

Syncope Masquerading As Pulmonary Embolism, Melissa Itidiare Locke, Andrew Caravello, Melanie Angelo, Andrew Vasta

Rowan-Virtua Research Day

Syncope is a clinical syndrome that occurs due to a period of inadequate cerebral blood flow that cause a transient loss of consciousness that usually resolves within 8-10 seconds) [1] Our case demonstrates a 56-year-old female who experienced syncope for the first time. The patient had an unwitnessed fall and subsequently had imaging studies performed. A discovery of a Sub-Massive Pulmonary embolism was revealed.

Celiac Artery Aneurysm: A Rare Cause Of Abdominal Pain, Duwayne Campbell, Wayne Tamaska, Kevin Dwyer

Rowan-Virtua Research Day

Celiac artery aneurysm is a very rare vascular lesion accounting for only 5.1% of all splanchnic artery aneurysms. Etiology for celiac artery aneurysm includes, but not limited to, infectious diseases, atherosclerosis, trauma, congenital conditions such as median arcuate ligament syndrome and iatrogenic causes.

Etiology for abdominal pain is extensive. Patients should be evaluated for both intra-abdominal and extra-abdominal causes for pain, as presentations of a different pathophysiology vary widely. CT scan has become a mainstay part of the work for abdominal pain in the Emergency department, and often elicit pathologies that would otherwise be missed on blood work and other …

Literature Review: Palliative Care In The Emergency Department, Alice Chang, James Espinosa, Alan Lucerna, Neelesh Parikh

Rowan-Virtua Research Day

With current medical advances, our patient population continues to age. This poses new challenges for healthcare practitioners to provide for elderly patients with complex and multifactorial medical needs. Particularly, this is a growing challenge in the emergency department (ED), where patients often present towards the last months of their lives. A study conducted by UCSF indicates 75% of patients in their last 6 month of life visited the ED. 56% to 99% of older adults do not have advance directives available at ED presentation. Therefore, ED visits towards the end of life is an opportune teaching moment for physicians to …

Management Of Late-Stage Ewingoid Dedifferentiated Liposarcoma Of The Spermatic Cord With Emergent Complications: A Case Report, Raeann Dalton, Abdullah Junayed, Brian Thomas, Young Son, Megan Donlick, Kathryn Goettle, Lance Earnshaw, Thomas Mueller

Rowan-Virtua Research Day

Liposarcoma (LS), a malignant tumor of adipose origin, is the most common soft tissue sarcoma (STS), and can develop within any soft tissue. It rarely occurs in the paratesticular region, and accounts for 3-7% of spermatic cord tumors. Dedifferentiated liposarcoma (DDLS) and well-differentiated liposarcoma (WDLS) account for two of the five subtypes of LS, with dedifferentiation occurring in 20% of cases. There have been 66 cases of DDLS of the spermatic cord reported to date, but none present with a 22/22q trisomy without the fusion or rearrangement that commonly produces these aggressive tumors.

Accurate diagnosis of LS of the spermatic …

Lung Hernia: An Uncommon Cause Of Pleuritic Chest Pain, Brittany Fera

Rowan-Virtua Research Day

Lung hernia is a rare but important consideration in the differential diagnosis of chest pain in patients with recent thoracic trauma or a history of thoracic surgery. Patients who undergo an anterior approach to thoracotomy, as was the case with our patient, are at a higher risk for developing lung herniation as a result of inherent anatomical weakness and wider intercostal spaces anteriorly and inferiorly.

Robotripping: The Dangers Of Abusing Dextromethorphan, Tiffany Sin, James Espinosa, Dana Fichter

Rowan-Virtua Research Day

Dextromethorphan (3-methoxy-N-methylmorphinan), also known as “DXM,” is a synthetically produced drug available in many over-the- counter (OTC) cough and cold medications as a centrally acting cough suppressant that binds to NMDA receptors. In a 2006 national survey of 50,000 students, 4, 5, and 7% of 8, 10, and 12th graders reported DXM abuse in the past year. In high doses, DXM can cause euphoria, hallucinations, dissociations, and distortion of cognition and perception. DXM abuse is also known as “Robotripping,” “Robodosing,” “Dexing,” “Tussin,” or “Triple Cs” because Robitussin® and Coricidin® Cough and Cold are most frequently abused. DXM has replaced codeine …

Posterior Reversible Encephalopathy Syndrome (Pres), Brittany Fera, Andrew Caravello

Rowan-Virtua Research Day

Posterior reversible encephalopathy syndrome (PRES) is a clinical and radiographic syndrome that describes certain neuroimaging findings in association with clinical symptoms such as headache, seizure, encephalopathy and vision changes. Classically, PRES is associated with poorly controlled hypertension, and patients present with elevated blood pressure in addition to their symptoms. Most importantly, imaging findings and symptoms are typically reversible, and are a separate entity from ischemic or hemorrhagic cerebrovascular accidents or autoimmune causes of similar symptoms, such as multiple sclerosis.

Syncope Or Seizure?, Joseph Heron, Kevin Dwyer

Rowan-Virtua Research Day

Syncope is a common complaint in the emergency departments, accounting for 1-2% of visits, and can approach admission rates of a staggering 85%. The causes and conditions can be numerous, ranging from benign to life threatening. A good background history can go a long way in determining the etiology of the patient’s syncope. We describe a case of an elderly male who presented with a reported chief complaint of seizures, another syncope-mimic seen in the emergency department. He had a history of CAD, HTN, AAA, and osteoarthritis but no prior history of cardiac arrhythmia, MI, or structural heart disease. The …

Spontaneous Splenic Laceration Presenting As Stable Angina In The Ed, Lea Rowson, James Baird

Rowan-Virtua Research Day

We present a case of a 62-year-old female who presented to the emergency department complaining of classic cardiac chest pain and was ultimately diagnosed with hemoperitoneum due to a splenic laceration sustained during recent colonoscopy. The signs and symptoms between these two diagnoses can be vaguely similar, and a missed diagnosis of either leads to increased morbidity and mortality. To make an appropriate diagnosis, a thorough history and physical examination is imperative. Observation of non-musculoskeletal left shoulder pain in addition to abdominal tenderness should lead the astute clinician down a different path towards diagnosis. Kehr’s sign is present in many …

Use Of Point Of Care Ultrasound In The Emergency Department For Diagnosis Of Femoral Pseudoaneurysm, Stephen Janssen, Jeffrey Gardecki, Giovanna Finocchio

Rowan-Virtua Research Day

Iatrogenic pseudoaneurysm after puncture or intervention of the femoral artery is a rare complication of arterial surgical intervention occurring in 0.05-0.50% of diagnostic and therapeutic catheterizations and can present weeks after initial presentation. Today we present a 57-year-old gentleman 3 months status post femoral artery stent who presented with swelling to his right groin. Point of care ultrasound was used to diagnose an actively bleeding pseudoaneurysm with hematoma that ultimately led to repeat stenting. This case shows how point of care ultrasound can expedite diagnosis and intervention and is a useful tool for the emergency physician at initial presentation.

Case Report: Covid-19 Associated Guillain-Barre Syndrome, Matthew Aharonov, Neelesh Parikh, James Espinosa, Alan Lucerna

Rowan-Virtua Research Day

We report a case of a 72-year-old female who presented to the emergency department with a complaint of generalized weakness. The patient was found to have ascending muscle weakness and subsequently diagnosed with Covid-19 related Guillain-Barre Syndrome. Our patient was negative for Campylobacter jejuni. It is noteworthy that the patient did not have fever, respiratory symptoms or loss of the sensation of taste.

The Application Of Point-Of-Care Ultrasound In Ed Intubations And Airway Access: A Systematic Review, Frank Wheeler, James Espinosa, Alan Lucerna, Jeffrey Gardecki

Rowan-Virtua Research Day

Intubation is an essential procedure performed on a routine basis in the emergency room. Unsuccessful intubations are associated with deleterious outcomes. A systematic review was performed to investigate the accuracy of point of care ultrasound (POCUS) in successful Endotracheal Tube (ET) tube confirmation, utilizing ultrasonography, identification of the cricothyroid membrane utilizing ultrasound, and dynamically during use of ultrasonography in the process of intubation. This review demonstrated high sensitivity and specificity for ultrasound confirmation of ET tube placement, high success rate in ultrasound-guided intubation, and lower than expected accuracy in identifying the cricothyroid membrane. Ultrasonography should be considered for ET tube …

Spontaneous Conus Medullary Infarction In The Absence Of Cardiovascular Risk Factors, Bavica Gummadi, Jaffer Ahmed, Swarna Rajagopalan

Rowan-Virtua Research Day

Spinal cord infarction (SCI) is rare and most often occurs in individuals with predisposing cardiovascular risk factors and traumatic injuries

As there are no distinct diagnostic criteria for SCI, diagnosis is difficult in patients presenting without predisposing factors and is often mistaken for transverse myelitis.

Delay in early diagnosis contributes to the high case fatality rate of SCI.

This case highlights the importance of including SCI in the differential of a patient with acute paraparesis even in the absence of co-existing risk factors.

Triad Of Acute Pancreatitis Coexisting With Diabetic Ketoacidosis And Very Severe Hypertriglyceridemia Successfully Resolved With Insulin Therapy Alone, Akash Patel, Monica Patel, Yvette Wang

Rowan-Virtua Research Day

Diabetic ketoacidosis (DKA) is known to cause mild elevations in triglyceride levels.

Severe hypertriglyceridemia (HTG) is a well-known cause of acute pancreatitis; however, in unique cases, DKA has been shown to cause severe HTG leading to the development of acute pancreatitis (AP).

HTG causing AP only accounts for 1-4% of cases of AP

From the few cases in literature that have reported this triad of DKA, HTG, and AP, even fewer have shown to be successfully treated with insulin therapy alone with the severe degree of HTG that we discuss.

In our case, we have treated a triad of DKA, …

Stercoral Colitis Leading To Hypotension And Ivc Syndrome With Respiratory Failure Following Fecal Disimpaction, Kelly Schuitema, Nicholas Tomasello

Rowan-Virtua Research Day

Constipation is an extremely common chief complaint in the emergency department, contributing to approximately 700,000 emergency department visits in 2011. Severe constipation can result in stercoral colitis, which in turn can lead to development of ulceration and colonic perforation leading to fatal peritonitis. As a result, prompt recognition and treatment of this condition with bowel cleansing and fecal disimpaction are often recommended. Here, we will discuss a case of a 62-year-old male with a history of schizoaffective disorder who came into the Emergency Department (ED) hypotensive with stercoral colitis secondary to severe constipation. Following bedside fecal disimpaction, the patient developed …

Case Report: The Value Of Vigilance And Iterative Evaluations With An Uncooperative Patient In The Emergency Department, Duwayne Campbell

Rowan-Virtua Research Day

Discussion

A Flexible and Vigilant Approach: The initial presenting information from EMS could have led to anchoring bias. A flexible approach led to new information, which led to interative testing.

Iterative physical examination. There are cases, as seen in this case report, where the physical examination was unreliable or even impossible. Iterative evaluations ultimately led to appropriate imaging and accurate diagnosis.

Iterative testing: In the case presented, the radiologist reported a finding as being present on a prior CXR; however, given the patient’s clinical presentation, further imaging studies were necessary.

From Left Arm Numbness To Incidental Pituitary Macroadenoma, Melissa Itidiare Locke

Rowan-Virtua Research Day

Pituitary adenomas are the most common tumors in the sella turcica. The symptoms of vision loss or change is due to the anatomical location of the pituitary tumor beneath the optic nerve. (2) As the tumor grows in size it can compress the optic nerve and vision changes will occur. Our case demonstrates a 40 year old male who had one brief 1 time episode of blurry vison and dull intermittent headaches that was not debilitating in nature. A discovery of pituitary adenoma prior to onset of symptoms of constant vision changes or elevated hormones are crucial to a more …

An Unusual Ed Case: Cardiac Tamponade Presenting As Hiccups, Devleen Baksi, Nicholas Tomasello, James Espinosa, Alan Lucerna

Rowan-Virtua Research Day

Cardiac tamponade is an emergent life threating condition that depending on cause can quickly progress to death. The rate of accumulation of a pericardial effusion often can determine the clinical severity. Typically, shortness of breath and hypotension manifest; however, in this unusual case, the initial presenting complaint was persistent hiccups.

Assigning Level Of Care In Blunt Chest Trauma Patients: Applying Objective Scoring Systems, Alyssa Imperatore, Kaitlyn Oldewurtel, James Eakins

Rowan-Virtua Research Day

25% of all traumatic deaths are related to blunt chest trauma and another 50% have in-hospital morbidity and mortality. Recognizing patients with high risk of mortality is just as important as recognizing the immediate severely injured patients. Atlanticare Regional Trauma Center developed a scoring system in an attempt to properly assign these patients to an appropriate level of care. The system was developed based on a literature review but has not yet been studied to review its effectiveness in improving outcomes in chest trauma patients. Therefore, the scoring system is used as a guideline and not an official document in …