Aseptic Viral Meningitis Secondary to Herpes Simplex Virus 2 Genital Infection.

Aseptic viral meningitis is the most common cause of meningitis in the United States. Most cases of herpes simplex virus meningitis are caused by herpes simplex virus type 2 (HSV-2), with HSV-1 primarily causing viral encephalitis. In this report, we present a case of aseptic meningitis generated by the HSV-2 in an immunosuppressed 35-year-old female with a recent diagnosis of genital herpes that was left untreated due to reported side effects of medication.

A Case of Blunt Trauma-induced ST-elevation Myocardial Infarction Sustained During a Prison Brawl.

Myocardial infarction (MI) is a serious and time-sensitive condition. MIs are typically seen in patients with coronary artery disease (CAD) and are caused by the rupture of an atherosclerotic plaque due to factors contributing to plaque instability. However, this case illustrates that plaque rupture can also be caused by blunt trauma to the chest. Considering MI as a possible result of chest trauma may decrease time from presentation to diagnosis and treatment and, therefore, improve outcomes in similar cases, particularly when patients presents unusually or with very few risk factors for MI.

A Case of an Acutely Ill Adult Athlete with Previously Undiagnosed Hypertrophic Obstructive Cardiomyopathy.

Hypertrophic obstructive cardiomyopathy (HOCM) is a genetic condition most commonly characterized by hypertrophy of the ventricular septum, which leads to left ventricle outflow obstruction. Due to the severity of the condition, it is often diagnosed in adolescents, especially in those who exercise. We describe the case of a 53-year-old male, previously undiagnosed with hypertrophic cardiomyopathy (HCM), who became dyspneic during a bike race. He was found to have elevated troponin, pulmonary edema, and was diagnosed with HOCM. The late presentation of the case, in an active individual, makes the situation unique.

Unusual etiology of gastrointestinal symptoms: the case of jojoba butter.

BACKGROUND: Jojoba butter is cyanogenic and has gained attention among herbal supplement consumers due to claims that it may aid in weight loss. Jojoba butter is extracted from the seeds of jojoba shrubs found in the Sonoran Desert. The seeds have long been recognized as inedible, however clinical symptoms following ingestion are not well documented. CASE REPORT: This report describes a patient who developed restlessness and gastrointestinal complaints following ingestion of homemade jojoba seed butter. The patient's presentation following ingestion is discussed, as well as effective workup and treatment. In our case, the patient was monitored and received fluid resuscitation, lorazepam, and diphenhydramine for symptomatic therapy. CONCLUSION: This case describes the gastrointestinal sequela and effective management following ingestion of jojoba butter.

Paediatric chest wall trauma causing delayed presentation of ventricular arrhythmia.

This report describes a paediatric patient presenting with haemodynamically stable non-sustained ventricular tachycardia 1 day after minor blunt chest trauma. Initial laboratory studies, chest X-ray and echocardiography were normal; however, cardiac MRI revealed precordial haematoma, myocardial contusion and small pericardial effusion. Throughout her hospital course, she remained asymptomatic aside from frequent couplets and triplets of premature ventricular contractions. Ectopy was controlled with oral verapamil. This case highlights how significant cardiac injury may be missed with standard diagnostic algorithms.

The Semantics of Priapism and the First Sign of Chronic Myeloid Leukemia.

Priapism is defined as an erection that persists beyond four hours, lasting beyond or unrelated to sexual stimulation (Salonia et al., 2014). Because the risk of ischemic damage and impotence is high with priapism (35%), management guidelines are directed towards rapid treatment of this condition (Salonia et al., 2014). This report describes the rare case of an 18-year-old male who presented to the Emergency Department (ED) three times with recurrent and worsening episodes of sustained penile erections. On the patient's third visit, he presented with priapism of greater than six-hour duration that was found to be the result of chronic myeloid leukemia. Clinician awareness of the diagnostic semantics and differential diagnosis surrounding priapism is pivotal in its urgent management.

First Time Seizure in the Setting of a Congenital Heart Abnormality and MCA Mycotic Aneurysms.

A 37 year-old man presented to the Emergency Department (ED) with new onset seizure and fall from standing.[...].

Prospective evaluation of the learning curve for ultrasound-guided peripheral intravenous catheter placement.

INTRODUCTION: It is unclear how many ultrasound-guided peripheral intravenous catheters (USG PIVC) one must place to become proficient at the procedure. The objective of this study was to determine the learning curve associated with PIVC placement and determine how many attempts are required for non-physician learners to reach proficiency. METHODS: This is a prospective observational study. Emergency department (ED) nurses and paramedics with competence in traditional PIVC placement underwent a USG PIVC placement training program. Their success or failure in placing USG PIVCs as part of patient care on ED patients with difficult IV access was monitored. Number of attempts (defined as one skin puncture) was recorded and success was defined as the ability to aspirate blood and flush saline. The probability of success over time was analyzed. Proficiency was defined a priori as 70% probability of success. RESULTS: Thirty-three providers with 1077 PIV access attempts on 796 patients over 1000 unique patient ED encounters were included in the study. Overall success rate for all providers was 88.24% (86.3%-90.2%). LOcally WEighted Scatter-plot Smoother (Lowess) smoothing and mixed effects logistic regression analysis both determined that a learner's probability of success would be greater than 70% after four USG PIVCs have been placed. Post hoc analysis for a more stringent 88% success rate resulted in 15 and 26 required attempts, respectively. DISCUSSION: After placement of four USG PIVCs, new learners of the procedure are capable of a greater than 70% success rate. A success rate of greater than 88% is achieved after 15 to 26 attempts.

Early quick acuity score provides more complete data on emergency department walkouts.

INTRODUCTION: Many prior studies have compared the acuity of Emergency Department (ED) patients who have Left Without Being Seen (LWBS) against non-LWBS patients. A weakness in these studies is that patients may walk out prior to the assignment of a triage score, biasing comparisons. We report an operational change whereby acuity was assessed immediately upon patient arrival. We hypothesized more patients would receive acuity scores with EQAS. We also sought to compare LWBS and non-LWBS patient characteristics with reduced bias. SETTING: urban, academic medical center. Retrospective cohort study, electronic chart review, collecting data on all ED patients presenting between 4/1/2010 and 10/31/2011 ("Traditional Acuity Score" period, TAS) and from 11/1/2011 to 3/31/2012 ("Early Quick Acuity Score" period, EQAS). We recorded disposition (LWBS versus non-LWBS), acuity and demographics. For each subject during the EQAS period, we calculated how many prior ED visits and how many prior walkouts the subject had had during the TAS period. RESULTS: Acuity was recorded in 92,275 of 94,526 patients (97.6%) for TAS period, and 25,577 of 25,760 patients (99.3%) for EQAS period, a difference of 1.7% (1.5%, 1.8%). LWBS patients had acuity scores recorded in 5,180 of 7,040 cases (73.6%) during TAS period, compared with 897 of 1,010 cases (88.8%) during the EQAS period, a difference of 15.2% (14.8%, 15.7%). LWBS were more likely than non-LWBS to be male, were younger and had lower acuity scores. LWBS averaged 5.3 prior ED visits compared with 2.8 by non-LWBS, a difference of 2.5 (1.5, 3.5). LWBS averaged 1.3 prior ED walkouts compared with 0.2 among non-LWBS, a difference of 1.1 (0.8, 1.3). CONCLUSIONS: EQAS resulted in a higher proportion of patients receiving acuity scores, particularly among LWBS. This offers more complete data when comparing LWBS and non-LWBS patient characteristics. The comparison reinforced findings from prior studies.