Hypoglycemia Worsened by Glucose Administration: A Case of Hypoglycemia Years After Gastric Surgery.

BACKGROUND: Noninsulinoma pancreatogenous hypoglycemia syndrome (NIPHS) is a rare syndrome characterized by postprandial hypoglycemia with neuroglycopenic symptoms occurring 1 to 3 h after a meal. Diagnosis can be elusive, as the vast majority of patients have normal fasting blood glucose levels, and onset of hypoglycemic episodes can be a late complication of gastric surgery. CASE REPORT: We report the case of a 45-year-old woman presenting to the Emergency Department (ED) with new-onset seizures and hypoglycemia worsened by glucose administration. Surgical history is pertinent for a Roux-en-Y gastric bypass approximately 10 years prior to presentation. WHY SHOULD AN EMERGENCY PHYSICIAN BE AWARE OF THIS?: Although rare, it is important for emergency physicians to be vigilant of this disease process as a traditional treatment approach for hypoglycemia may be detrimental. Although cases of NIPHS have been documented in literature, its presence in emergency medicine-specific literature is seemingly nonexistent. Noninvasive imaging techniques will be normal, and diagnosis is dependent on awareness of this disease entity coupled with a detailed history.

An Eye with a Heartbeat: Carotid Cavernous Fistula-a Case Report.

BACKGROUND: A carotid cavernous fistula is a rare type of arteriovenous (AV) fistula due to an abnormal communication between the cavernous sinus and the carotid arterial system. Normal venous return to the cavernous sinus is impeded as high-pressure arterial blood enters the cavernous sinus. The classical triad of symptoms is characterized by pulsating exophthalmos, ocular bruit, and conjunctival chemosis. However, it is important to note that some patients do not exhibit this triad of symptoms. CASE REPORT: A 49-year-old man presented to the Emergency Department (ED) with a chief complaint of "there is a heartbeat in my eye." Pertinent history included an episode of trauma 2 months prior to his onset of unilateral vision loss. Computed tomography scan of the head obtained in the ED upon his initial injury was unrevealing. Despite no identifiable pathology, his pain had gradually worsened since ED discharge. On this occasion, an ocular bruit was appreciated over the affected eye, prompting further diagnostic testing. The patient was admitted for urgent cerebral angiography and definitive endovascular neurosurgical intervention to preserve his eyesight. We discuss the clinical presentation, pathophysiology, and diagnostic modalities important to the management of this rare and potentially devastating cause of vision loss. WHY SHOULD AN EMERGENCY PHYSICIAN BE AWARE OF THIS?: A carotid cavernous fistula is a rare and easily misdiagnosed cause of unilateral ocular pain in the ED. Further, it emphasizes the importance of a detailed clinical history and physical examination to make this diagnosis and save eyesight.

Hyperkalemia and cardiac arrest associated with glucose replacement in a patient on spironolactone.

We present a case of hypoglycemia, which after intravenous glucose replacement, led to cardiac arrest secondary to a profound extracellular potassium shift. The patient was on spironolactone therapy which is known to cause aldosterone resistance (which inhibits the body's ability to prevent potassium shifts) [1]. Physicians typically review medications that cause hypoglycemia, but other medications may interfere with potassium homeostasis with administration of glucose. Knowledge of this case may prompt further monitoring, repeat lab testing, and careful medication reconciliation before discharging a patient with risk for aldosterone resistance. On our literature review, we have not found additional reports where this particular physiology led to cardiac arrest.

Exertional Near-Syncope: Pericardial Cyst as a Cause of Left Ventricular Outflow Obstruction.

CASE PRESENTATION: A 41-year-old otherwise healthy male presented to the emergency department with recurrent exertional near-syncope. He was eventually found to have a large pericardial cyst causing an outflow obstruction. After resection of the cyst by cardiothoracic surgery, he had an uneventful hospital course and was discharged seven days later with no recurrent syncopal episodes. DISCUSSION: We describe an otherwise healthy patient who exhibited symptomatic left ventricular outflow obstruction from a pericardial cyst. These cysts are usually benign and asymptomatic, although they can progress to cause significant morbidity or mortality. Surveillance is recommended if no hemodynamic compromise is present. Patients who are symptomatic or have hemodynamic compromise may undergo needle aspiration or thoracoscopy with resection.

Adult Presentation of Anomalous Pulmonary Artery from the Descending Aorta: A Rare Cause of Exertional Chest Pain.

CASE PRESENTATION: A 20-year-old female presented to the emergency department for evaluation of exertional, right-sided chest pain. The patient underwent a computed tomography angiogram of her chest as part of her workup, demonstrating the right lower-lobe pulmonary artery arising from the abdominal aorta. DISCUSSION: Anomalous pulmonary arterial supply is exceedingly rare. In adult patients, it is likely to be found incidentally during workup for more common medical conditions. Symptoms may include chest pain, exertional dyspnea, or hemoptysis. The high pressure of systemic blood in a low-pressure pulmonary system can result in right heart strain, pulmonary hypertension, and high-output cardiac failure.

An Evaluation of Non-Uniform Grade Distribution with the Emergency Medicine Off-Service Standardized Letters of Evaluation.

Introduction: Standardized Letters of Evaluation (SLOEs) are designed to objectively compare medical students to their peers for completed emergency medicine (EM) rotations to be used in the EM residency match. In an attempt to adapt quickly to the lack of availability of in-person EM rotations due to COVID restrictions, "off-service" SLOEs (OSLOEs) were allowed in place of traditional SLOEs. The purpose of this study was to assess the utility of OSLOEs for candidate selection during the 2020-21 application cycle at a single EM residency. Methods: A retrospective cohort review of all OSLOEs submitted during the 2020-21 academic year to an EM residency program was performed. A total of 270 OSLOES were eligible for review. Summary statistics were calculated for the study variables recorded, including global rank, grade, categorical details, and rank. Results: Of the 270 OSLOEs reviewed, 61.9% ranked candidates in the top 10% of their class, with 95% being ranked in the top two categories. Over 90% of students were graded as honors or high pass and over 75% of students were ranked in the top 1/3 for each specific OSLOE category. Conclusion: Our findings reveal questionable utility of the objective measures in the OSLOE as there are signs it may suffer from non-uniform grade distribution, leading to low utility for candidate selection. Our data shows marked over-ranking within the highest 2 categories. EM program directors and faculty should use caution as the OSLOE may not carry the same weight as a traditional SLOE when objectively evaluating prospective students for a match into EM.

Anaphylaxis Caused by Swimming: A Case Report of Cold-induced Urticaria in the Emergency Department.

INTRODUCTION: Cold-induced urticaria is a subset of physical urticaria that presents as wheals or angioedema in response to cold exposure. While most cases are idiopathic, secondary associations with infections, medications, and certain cancers have been described. CASE REPORT: We discuss the case of a 50-year-old male with recent episodes of urticaria from cold air exposure following a flu-like illness six months prior, who presented with symptoms of anaphylaxis upon jumping into a lake. CONCLUSION: While the majority of patients develop localized symptoms, understanding this disease entity is imperative as up to one-third of patients can develop severe symptoms including anaphylaxis, particularly from water submersion during activities such as swimming.

The Case of the Lime-green Stool: A Case Report and Review of Occult Blood Testing in the Emergency Department.

INTRODUCTION: Food dyes mimicking gastrointestinal (GI) hemorrhage have been described in literature. However, reports of food additives causing melanotic stools and falsely positive fecal occult blood tests (FOBT) are uncommon in literature. CASE REPORT: We present a case of a 93-year-old with FOBT positive melanotic stool, felt to be falsely positive due to food additives. CONCLUSION: Evaluation for GI bleeding accounts for 0.3% of yearly visits to the emergency department (ED). While FOBT is commonly used, its clinical validity in the ED is not supported by guidelines. We showcase the limitations of the FOBT and review the causes of false positive FOBT.

Emergency Department Management of COVID-19: An Evidence-Based Approach.

The novel coronavirus, SARs-CoV-2, causes a clinical disease known as COVID-19. Since being declared a global pandemic, a significant amount of literature has been produced and guidelines are rapidly changing as more light is shed on this subject. Decisions regarding disposition must be made with attention to comorbidities. Multiple comorbidities portend a worse prognosis. Many clinical decision tools have been postulated; however, as of now, none have been validated. Laboratory testing available to the emergency physician is nonspecific but does show promise in helping prognosticate and risk stratify. Radiographic testing can also aid in the process. Escalating oxygen therapy seems to be a safe and effective therapy; delaying intubation for only the most severe cases in which respiratory muscle fatigue or mental status demands this. Despite thrombotic concerns in COVID-19, the benefit of anticoagulation in the emergency department (ED) seems to be minimal. Data regarding adjunctive therapies such as steroids and nonsteroidal anti-inflammatories are variable with no concrete recommendations, although steroids may decrease mortality in those patients developing acute respiratory distress syndrome. With current guidelines in mind, we propose a succinct flow sheet for both the escalation of oxygen therapy as well as ED management and disposition of these patients.

Symptomatic Vaginal Infection by Neisseria meningitidis Resulting in Meningitis with Septic Shock.

The most common infectious etiologies of vaginitis include Gardnerella bacterial vaginosis, candidiasis, and trichomoniasis. A few case reports describe symptomatic infection with Neisseria (N) meningitidis, an organism with potential for causing systemic disease with a high rate of morbidity and mortality. We describe a patient who presented with fulminant meningitis secondary to symptomatic vaginitis in which N. meningitidis was cultured. Due to the potential for significant morbidity and mortality as demonstrated by this case report, knowledge of this entity may prompt physicians to aggressively treat patients with vaginal cultures that are positive for N. meningitidis.

Incarcerated diaphragmatic hernia with bowel perforation presenting as a tension pneumothorax.

We present an interesting case of a patient with a previously known diaphragmatic hernia in which the colon became incarcerated, ischemic and finally perforated. She had no prior history of abdominal pain or vomiting, yet she presented with cardiovascular collapse. She was quickly diagnosed with a tension pneumothorax and treated accordingly. To our knowledge, this is the only case report of a tension pneumothorax associated with perforated bowel that was not in the setting of trauma or colonoscopy.

Ultrasound-guided three-in-one nerve block for femur fractures.

Femur fractures typically affect elderly patients with multiple co-morbidities. Pain control can be difficult, requiring intensive nursing and physician care as elderly patients may manifest cardiovascular and respiratory complications from opiate administration. Ultrasound (US)-guided three-in-one (3-in-1) femoral nerve block (FNB) is an option for pain management in patients with femur fractures, as it provides regional anesthesia to the femoral, obturator and lateral cutaneous nerves. Our goal is to provide medical education regarding the use of US-guided 3-in-1FNB as a rapid and easy procedure that may provide optimal patient care in patients with femur fractures.