J Emerg Med
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Case Reports
Neuro-Behcet's Masquerading as Status Epilepticus and Meningoencephalitis in the Emergency Department.
Behcet disease (BD) is a rare small vessel vasculitis that commonly manifests as recurrent painful oral or genital ulcerations, uveitis, and skin lesions. Some patients with BD develop neurological symptoms termed neuro-Behcet's disease. In the emergency department setting, these symptoms can be mistaken for other common acute issues including stroke, infection, epilepsy, multiple sclerosis, toxin ingestion, or psychiatric conditions. ⋯ We present a case of a 28-year-old male with neuro-BD mimicking status epilepticus and meningoencephalitis. He was actively seizing on arrival and febrile at 103.8 F. The patient also had a history of vasculitis, uveitis, and genital lesions which raised suspicion for a rheumatological process. Cerebrospinal fluid samples were obtained and computed tomography of the head revealed no acute findings. The patient was started on treatment for seizure and meningoencephalitis and admitted to neurology for continuous electroencephalogram monitoring with additional consults placed for rheumatology, ophthalmology, and infectious disease. The patient was ultimately diagnosed with neuro-Behcet's disease and treated appropriately. WHY SHOULD AN EMERGENCY PHYSICIAN BE AWARE OF THIS?: In a patient presenting with neurological symptoms and signs of rheumatological disease providers should consider neuro-Behcet's disease as a differential diagnosis. This case exemplifies the vital role of reviewing past medical history to expand differential diagnoses and early coordination with specialists so treatment can be initiated early to prevent morbidity and mortality. The case will also review different presentations of this unfamiliar diagnosis for a more comprehensive understanding.
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Case Reports
A Novel Use of Terbutaline: Persistent Genital Arousal Disorder in the Emergency Department.
Persistent genital arousal disorder/genito-pelvic dysesthesia (PGAD/GPD) is a highly distressing, multifactorial disorder characterized by persistent unwanted physiologic genital arousal in the absence of sexual desire. This poorly understood disorder is thought to be derived from a complex dysregulation of biopsychosocial factors with common underlying neurological dysfunction that has yet to be adequately studied. With frequently evolving diagnostic criteria, lack of a standardized treatment algorithm, and few evidence-based treatment options, this disease is largely unrecognized and difficult to treat once identified. ⋯ A 25-year-old woman presented to the Emergency Department (ED) with persistent and refractory symptoms of genital arousal not responsive to previously documented treatments, and the novel use of a β-adrenergic agent, terbutaline, leading to cessation of symptoms. With her initial presentation, lorazepam, haloperidol, and viscous lidocaine intravaginally provided relief for approximately 24 h until the patient returned. At her subsequent presentation, the patient received additional doses of lorazepam and intravaginal lidocaine, as well as consults with Urology and Obstetrics and Gynecology. Her symptoms eventually ceased by administration of terbutaline. WHY SHOULD AN EMERGENCY PHYSICIAN BE AWARE OF THIS?: Although presentation of PGAD to the ED is rare, emergency physicians should be prepared with treatment options to assist patients with this distressing diagnosis. This case highlights the novel use of terbutaline, a β-agonist, in cessation of PGAD symptoms when first-line benzodiazepines and antipsychotics fail.
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Case Reports
Point-of-Care Ultrasound Diagnosis of Pyocele: A Rare Complication of Testicular Infection.
Epididymo-orchitis is one of the common causes of acute scrotal pain that requires an accurate diagnosis as delayed management can result in complications such as pyocele, abscess, or testicular infarction. Point-of-care ultrasound (PoCUS) has emerged as a valuable diagnostic tool in the management of testicular emergencies in the emergency department (ED) including testicular infections CASE REPORT: Here we report a case of an elderly man who presented to the ED with a complaint of right-sided testicular pain and swelling. ⋯ WHY SHOULD AN EMERGENCY PHYSICIAN BE AWARE OF THIS?: This case underscores the important role of PoCUS in the timely and accurate diagnosis of pyocele. The prompt identification of pyocele enabled early referral to urology services, highlighting the significance of integrating PoCUS into the management of testicular emergencies in the ED.
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Case Reports
Ultrasound-Guided Erector Spinae Plane Nerve Block for Relief of Acute Cholecystitis Pain.
Acute cholecystitis is a common surgical emergency and a painful condition that often requires frequent intravenous opioid analgesia. Sometimes, pain control of patients with acute cholecystitis is challenging. In this case, we present a potential alternative to managing acute cholecystitis pain. ⋯ A 40-year-old female presented to the emergency department (ED) with right upper quadrant pain. While awaiting testing and ultrasound, she received multiple doses of opioid analgesia. A point-of-care ultrasound of the right upper quadrant was performed and demonstrated findings of acute cholecystitis. Given that her pain was challenging to manage, even with intravenous opioids, an ultrasound-guided erector spinae plane (ESP) nerve block was discussed and subsequently performed at the T7 level. Thirty minutes after the procedure, the patient reported significant relief of her pain and did not require any opioid analgesia until ten hours later on the inpatient floor. WHY SHOULD AN EMERGENCY PHYSICIAN BE AWARE OF THIS?: ESP nerve blocks can potentially offer an alternative analgesic in the management of acute cholecystitis, subsequently reducing the use of opioids in the ED. ESP nerve blocks can potentially offer patients longer-lasting analgesia. ESP nerve blocks can potentially manage visceral pain in the ED.
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Case Reports
Ultrasound-Guided Clavipectoral Plane Block for Analgesia of Acute Clavicular Fracture in the Emergency Department.
Clavicle fractures are commonly encountered in the emergency department and require effective analgesia to facilitate appropriate management and disposition. ⋯ We present the case of a 52-year-old man who presented with an acute, mildly displaced midshaft fracture of his right clavicle. After minimal improvement in pain from oral and topical analgesics, he underwent an ultrasound-guided clavipectoral plane block which completely relieved his pain. He did not require additional analgesics for 36 hours after the block. WHY SHOULD AN EMERGENCY PHYSICIAN BE AWARE OF THIS?: The ultrasound-guided CPB may be a safe and effective analgesic strategy for uncomplicated clavicle fractures in the ED.