J Emerg Med
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Case Reports
Ruptured Appendicitis and Retrocecal Abscess Masquerading as Knee Pain in a Pediatric Patient: A Case Report.
Knee pain has a variety of etiologies in the pediatric population, including septic arthritis, osteomyelitis, fracture, ligamentous injury, and neoplasms. Extrinsic sources of knee pain may also be intra-abdominal, although abdominal pathology is much more likely to manifest as hip or proximal thigh musculature pain. ⋯ A 5-year-old healthy male presented with atraumatic right knee pain, discomfort with weightbearing, fever, and elevated inflammatory laboratory markers. Physical examination and magnetic resonance imaging findings of the knee were benign, leading to low clinical suspicion for knee septic arthritis. Blood cultures were positive for a gastrointestinal organism, Granulicatella adiacens, suggesting abdominal pathology leading to referred pain. Ultrasound evaluation and computed tomography (CT) of the abdomen revealed a large abscess secondary to perforated appendicitis, which was treated with CT-guided drainage and i.v. antibiotics. The patient's musculoskeletal pain subsided with treatment of the appendicitis. WHY SHOULD AN EMERGENCY PHYSICIAN BE AWARE OF THIS?: Acute appendicitis may present as knee pain, with other signs and symptoms mimicking septic arthritis, such as fever, inability to bear weight, and elevated inflammatory markers. Considering an array of differential diagnoses in pediatric patients with apparent knee septic arthritis is crucial to prevent delay in diagnosis of alternative infectious sources.
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Efficacy of medical student substance use interventions in the emergency department (ED) setting remains unstudied. ⋯ It is feasible for medical students to perform a substance use intervention in the ED setting. Medical student contributions as a part of the team response to this public health crisis provide an opportunity for further discussion and research.
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Case Reports
Hemorrhagic Cholecystitis: A Case of Expedited Diagnosis by Point-of-Care Ultrasound in the Emergency Department.
Hemorrhagic cholecystitis is a rare complication of acute cholecystitis and is a potentially fatal diagnosis. It may be difficult to detect because the symptoms are similar to more common diagnoses. Point-of-care ultrasound is a useful imaging technique in the emergency setting and is readily available to allow for immediate interpretation and application of the results to guide medical decision making. ⋯ We report a 76-year-old man with a history of hypertension, hyperlipidemia, diabetes, atrial fibrillation on warfarin, and coronary artery disease presenting with epigastric pain radiating to the back, nausea, and vomiting who was found to have hemorrhagic cholecystitis with gallbladder perforation. Ultrasound of the abdominal right upper quadrant showed a large, hyperechoic, nonshadowing, globular structure visualized within the lumen of the gallbladder extending from the neck through the body. The gallbladder wall was noted to be 0.72 cm with wall edema, focal pericholecystic fluid, and a positive sonographic Murphy sign suggestive of acute cholecystitis. The abnormal appearance of the gallbladder contents was suspected to be blood. Computed tomography angiography was performed and confirmed the diagnosis of acute hemorrhagic cholecystitis with perforation. Blood was noted to track from the cystic duct to the gallbladder lumen. WHY SHOULD AN EMERGENCY PHYSICIAN BE AWARE OF THIS?: To our knowledge, this is a unique case of hemorrhagic cholecystitis visualized on bedside ultrasound. This case shows that the use of point-of-care ultrasound by emergency medicine providers can facilitate the rapid recognition and treatment of specific, life-threatening hepatobiliary pathology while excluding alternate diagnoses.
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Case Reports
Upper Cervical Epidural Abscess Resulting in Respiratory Compromise After Lumbar Steroid Injection.
Spinal epidural abscesses have a prevalence of 3 out of every 10,000 admissions. Abscesses above the level of C2, defined as upper cervical epidural abscesses, are even rarer still. ⋯ We discuss a case in which a 45-year-old male patient developed an upper cervical epidural abscess 48 h after receiving a lumbar steroid injection. The patient presented with diminished strength in all four extremities and respiratory distress secondary to the space-occupying lesion near his spinal cord. His hospital course included surgical decompression and antibiotics. He was eventually discharged to rehabilitation, but never regained full strength in his arms or legs. WHY SHOULD AN EMERGENCY PHYSICIAN BE AWARE OF THIS?: Patients who present with back or neck pain, fever, and neurologic deficits may have epidural abscess. In some patients, neurologic deficits may include respiratory distress if the upper cervical region is involved, and these patients have the possibility of airway decompensation. The diagnostic imaging modality of choice in patients with epidural abscess is MRI with gadolinium. Management involves supportive care, broad-spectrum antibiotics, which include coverage for methicillin-resistant Staphylococcus aureus, and early neurosurgical consultation.