J Emerg Med
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The evaluation of a febrile patient with acute abdominal pain represents a frequent yet possibly challenging situation in the emergency department (ED). Splenic infarction is an uncommon complication of infectious mononucleosis, and may have a wide range of clinical presentations, from dramatic to more subtle. Its pathogenesis is still incompletely understood, yet it may be associated with the occurrence of transient prothrombotic factors. ⋯ We report the case of a 14-year-old boy who presented with fever, sore throat, left upper quadrant abdominal pain, and splenomegaly, with no history of recent trauma. Laboratory tests revealed a markedly prolonged activated partial thromboplastin time and positive lupus anticoagulant. Abdominal ultrasonography showed several hypoechoic areas in the spleen consistent with multiple infarctions. Magnetic resonance imaging eventually confirmed the diagnosis. He was admitted for observation and supportive treatment, and was discharged in good condition after 7 days. WHY SHOULD AN EMERGENCY PHYSICIAN BE AWARE OF THIS?: Spontaneous splenic infarction should be considered in the differential list of patients presenting with left upper quadrant abdominal pain and features of infectious mononucleosis; the diagnosis, however, may not be straightforward, as clinical presentation may also be subtle, and abdominal ultrasonography, which is often used as a first-line imaging modality in pediatric EDs, has low sensitivity in this scenario and may easily miss it. Furthermore, although treatment is mainly supportive, close observation for possible complications is necessary.
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Healthcare disparities are prevalent in medicine and identifying them will provide healthcare professionals, administrators, and policy makers needed information to address this public health concern. ⋯ We observed race and ethnicity related healthcare disparities among the occupationally injured in California, with Hispanics having the highest odds of admission and annual incidence of ED treated injuries. No difference in mortality rates was observed.
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Heterotopic pregnancy is a condition in which intra- and extrauterine pregnancies occur at the same time. Spontaneous heterotopic pregnancy is a rare event, with incidences ranging from 1 in 30,000 pregnancies to as high as 1 in 6 pregnancies assisted by reproductive technology. ⋯ A 34-year-old woman presented with a 10-week history of amenorrhea, pelvic pain, and generally feeling unwell. Ultrasonography revealed a 10-week intrauterine viable pregnancy and free fluid in the abdominal cavity. Emergency laparotomy was performed and a ruptured tubal ectopic pregnancy was encountered on the right tube with hemoperitoneum. Salpingectomy was performed. Her intrauterine pregnancy was intact with positive fetal cardiac activity when she was discharged. WHY SHOULD AN EMERGENCY PHYSICIAN BE AWARE OF THIS?: Heterotopic pregnancy should be kept in the differential diagnosis of any patient with an intrauterine pregnancy presenting with abdominal pain, abdominal tenderness, or free fluid in the abdominal cavity.
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Proteinaceous esophageal food impaction typically requires endoscopic intervention. An alternative approach is the use of proteolytic enzymes. Concerns regarding the use of proteolytic enzymes include the risk of perforation and aspiration pneumonitis. ⋯ We have used proteolytic enzymes with a high success rate and with minimal complication. Further, if proteolytic enzymes fail, endoscopy can be performed safely and effectively. We recommend the use of proteolytic enzymes as the initial management in all patients with proteinaceous food impaction of the esophagus.
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Case Reports
Metformin-Associated Lactic Acidosis Presenting as Acute ST-Elevation Myocardial Infarction.
Metformin-associated lactic acidosis (MALA) is a rare but life-threatening adverse drug reaction of metformin, the most frequently prescribed medication for patients with type 2 diabetes mellitus. The diagnosis of MALA is difficult to make because of diverse clinical presentations that can masquerade as other critical illnesses. ⋯ A 52-year-old woman presented with altered mental status, hypoglycemia, and shock. A prehospital electrocardiogram showed findings consistent with posterolateral ST-elevation myocardial infarction, and the cardiac catheterization laboratory was activated before patient arrival. On arrival to the emergency department, she was found to have severe metabolic derangements and hypothermia, and the catheterization laboratory was canceled. Aggressive supportive measures and emergent hemodialysis were instituted. A metformin concentration was sent from the ED and returned at 51 μg/mL (therapeutic range 1-2 μg/mL), making MALA the most likely diagnosis. She recovered after prolonged critical illness and was discharged in good condition. No alternate diagnoses were found despite extensive work-up. WHY SHOULD AN EMERGENCY PHYSICIAN BE AWARE OF THIS?: Metformin is the most prescribed antidiabetic drug in the world. Although MALA is a rare complication, it is important for emergency physicians to keep MALA on the differential for diabetic patients presenting with severe metabolic acidosis.