Clinical Practice and Cases in Emergency Medicine

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Pediatric seizures are an alarming presentation to the emergency department (ED) that can be caused by a multitude of etiologies. It is important to differentiate life-threatening conditions from more benign causes. A 19-month-old girl presented to the ED after a witnessed seizure. This case offers a differential diagnosis for pediatric seizures and uses history, exam, laboratory findings, and imaging to hone the differential in the ED setting. The surprising final diagnosis and case outcome
are then revealed and discussed.

Introduction: Physician-in-triage (PIT) models have become increasingly common in emergency medicine. The goal is to facilitate rapid patient evaluation and improve key operational emergency department (ED) metrics. However, there is limited time for the PIT encounter, which often involves an abbreviated patient evaluation. Point-of-care ultrasound (POCUS) has been shown to improve patient care and speed diagnosis in a variety of scenarios. Although physicians working within a PIT model must remain mindful of time constraints, POCUS can help identify time-sensitive diagnoses and guide appropriate initial testing during certain encounters. Ocular POCUS can be particularly impactful on timely diagnosis and appropriate deployment of ED resources.

Case Series: We present three cases of acute monocular vision loss wherein the PIT physician used ocular POCUS to arrive at the correct initial diagnosis. This led to the appropriate deployment of ED stroke and neurology resources in the case of acute central retinal artery occlusion, while avoiding this unnecessary use of these resources in two cases where it was not indicated.

Conclusion: Use of point-of-care ultrasound in PIT models should be thoughtfully employed in cases where immediate diagnosis is required, as well as when POCUS results will likely alter subsequent diagnostic testing pathways. Ocular POCUS in PIT can rapidly differentiate neurologic causes of monocular vision loss from primary ophthalmic conditions.

Introduction: Amyand hernia is a rare condition in which the appendix is found within an inguinal hernia sac, often mimicking incarcerated or strangulated hernias. Diagnosis is typically made intraoperatively, but increasing use of point-of-care ultrasound (POCUS) is enhancing preoperative recognition.

Case Report: A 46-year-old male presented with a chronic, partially reducible inguinal hernia. Point-of-care ultrasound revealed a bowel-containing hernia with fluid. Computed tomography confirmed an inflamed appendix within the sac. Laparoscopic appendectomy and open hernia repair were performed without complications.

Introduction: Kawasaki disease is a vasculitis most commonly affecting children under five years of age but can also occur in older children and adults. When not sufficiently treated, Kawasaki disease can lead to cardiac complications such as myocarditis and coronary artery aneurysms, with aneurysms being the most serious long-term complication as it poses a risk for acute coronary syndrome.

Case Report: A 19-year-old with remote history of Kawasaki disease presented to the emergency department with chest pain, diaphoresis, and emesis after being struck in the chest by another player during a basketball game. Despite his young age and reported mild musculoskeletal trauma, an electrocardiogram and troponin were ordered. Electrocardiogram findings were concerning for ischemia, and troponin was elevated, confirming myocardial infarction and prompting a cardiology consult. Urgent percutaneous coronary intervention of the occluded aneurysm with balloon angioplasty resulted in significantly improved distal blood flow.

Conclusions: Kawasaki disease is widely recognized as a cause of cardiac complications in childhood, but the risk does not end there. Adults with a history of childhood Kawasaki disease remain at risk for complications of coronary artery aneurysm, even when they received appropriate medical treatment. Thrombosis or dissection of a coronary artery aneurysm can lead to acute coronary syndrome in otherwise healthy individuals. Therefore, emergency physicians must maintain a high level of suspicion for cardiac complications in both children and adults with a history of Kawasaki disease. In this case, prompt diagnosis and intervention were essential to achieving the best possible outcome.

Introduction: Trichobezoar is a rare gastrointestinal condition typically caused by ingestion of hair, which most often affects adolescent females. Its clinical presentation is frequently nonspecific, with symptoms such as abdominal pain, constipation, or early satiety, which can delay recognition until severe complications such as obstruction or perforation develop.

Case Report: We present the case of a 14-year-old girl who developed a massive trichobezoar resulting in gastric perforation and death. She had a three-month history of intermittent constipation and multiple healthcare visits without definitive diagnosis. On arrival to the emergency department, she was in cardiopulmonary arrest. Computed tomography revealed a large intragastric mass with associated pneumoperitoneum. Emergency laparotomy confirmed a trichobezoar with gastric perforation and diffuse peritonitis. Despite prompt surgical and resuscitative intervention, the patient could not be revived.

Conclusion: This case underscores the importance for emergency physicians to maintain clinical vigilance when adolescents present with persistent, unexplained gastrointestinal symptoms. Trichobezoar should be considered in the differential diagnosis, even in the absence of psychiatric history. A low threshold for advanced imaging is warranted, as early recognition and intervention may prevent fatal complications such as gastric perforation and septic shock.

Introduction: Paradoxical coronary embolism is a rare cause of myocardial infarction.

Case Report: A 57-year-old man presented with acute chest pain after a recent non-ST elevation myocardial infarction, during which a patent foramen ovale was identified. On readmission, the electrocardiogram showed an inferior ST-elevation myocardial infarction, and angiography revealed a distal thrombotic occlusion in otherwise normal coronary arteries. No venous thromboembolism was found, but thrombophilia testing revealed heterozygous factor V Leiden. He was managed conservatively and underwent successful patent foramen ovale closure.

Conclusion: This case highlights paradoxical embolism as a diagnostic consideration in acute myocardial infarction without coronary artery disease.

Introduction: Kratom (Mitragyna speciosa) is an unregulated herbal supplement increasingly associated with severe toxicity. Concentrated liquid formulations pose risks, with emerging reports of seizures, hepatotoxicity, and arrhythmias.

Case Report:A previously healthy 24-year-old woman ingested a highly concentrated kratom extract and developed seizure-like activity followed by pulseless monomorphic ventricular tachycardia. She underwent approximately 45 minutes of resuscitation, including multiple defibrillations, dual-sequential shocks, amiodarone, lidocaine, magnesium, calcium, sodium bicarbonate, potassium repletion, epinephrine, and esmolol. Persistent instability prompted consultation with cardiology and cardiothoracic surgery, and she was cannulated for venoarterial extracorporeal membrane oxygenation (ECMO) in the emergency department. Lab studies showed profound hypokalemia, acidosis, and elevated lactate. Urine toxicology confirmed mitragynine. She stabilized on ECMO, was decannulated on hospital day two, extubated on day three, and discharged home neurologically intact on day seven.

Conclusion: Concentrated kratom extracts can precipitate life-threatening ventricular arrhythmias in previously healthy individuals. Emergency physicians should consider kratom in unexplained cardiac arrests and recognize the role of advanced support, including ECMO, in refractory toxicologic arrests.

Introduction: Lemierre syndrome is characterized by septic thrombophlebitis of the internal jugular vein, classically caused by Fusobacterium necrophorum. It is typically seen after an episode of pharyngitis where the palatine tonsils or peritonsillar mucosa is affected. It is thought to spread locally into the pharyngeal space toward the internal jugular vein.

Case Report: A 42-year-old male with progressively worsening, atraumatic right-sided neck pain was discovered to have methicillin-resistant Staphylococcus aureus (MRSA) bacteremia, septic thrombophlebitis of the right dural venous sinuses, skull base osteomyelitis, and otomastoiditis.

Conclusion: While septic thrombophlebitis of the dural venous sinuses and internal jugular vein is typically caused by F necrophorum and usually comes from local pharyngeal spread, community-acquired MRSA is an emerging cause of this pathology.

Introduction: Purple urine bag syndrome (PUBS) is an uncommon yet visually striking condition observed in patients with long-term urinary catheters. It is associated with urinary tract infections caused by bacteria that metabolize tryptophan into indigo and indirubin pigments. Although typically benign, PUBS can signal underlying medical and social vulnerability.

Case Report: We describe a 78-year-old woman with multiple sclerosis and chronic suprapubic catheterization who presented with failure to thrive and concerns for caregiver fatigue. A striking finding on arrival was the deep purple discoloration of her urine in the Foley bag, consistent with PUBS. Additionally, she was tachycardic and had extensive, unstageable pressure ulcers. Laboratory studies revealed leukocytosis, lactic acidosis, and acute kidney injury. Imaging
suggested sacral osteomyelitis, stercoral colitis, and aspiration pneumonia. Blood cultures grew Streptococcus dysgalactiae, and she was treated empirically with broad-spectrum antibiotics. After goals-of-care discussions, she was transitioned to hospice and died shortly after discharge.

Conclusion: While purple urine bag syndrome is often benign, its presence should prompt clinicians to evaluate for serious underlying disease, particularly in debilitated or high-risk patients. It is classically associated with chronic catheterization, alkaline urine, and infections involving organisms such as Providencia stuartii, Klebsiella pneumoniae, and Proteus mirabilis. This case highlights PUBS as a visible marker of potentially severe, multisystem pathology requiring timely and comprehensive assessment. Moreover, it underscores the role of social determinants of health such as inadequate home support, caregiver strain, and fragmented post-discharge care in exacerbating clinical decline. Recognition of these factors is essential for holistic care planning in frail older adults.

Introduction: Sternutation is a physiological reflex that clears the upper respiratory tract through forceful air expulsion. Although it is typically considered benign, sternutation can generate substantial pressure and airflow that can result in barotrauma, including pneumocephalus.

Case Report: A 67-year-old female presented with shortness of breath, rhinorrhea, and a headache following sneezing. Physical exam revealed no signs of trauma or neurological deficits but did note clear rhinorrhea bilaterally. Computed tomography (CT) of the head revealed extensive extra-axial intracranial gas bilaterally, and the patient was admitted for further management. While admitted, otolaryngology was consulted and surgically corrected a right cribriform meningoencephalocele with an active cerebrospinal fluid leak. At follow-up the patient had no residual rhinorrhea symptoms or focal neurological findings.

Conclusion: One proposed mechanism of sternutation-induced pneumocephalus involves the “one-way-ball-valve” effect, whereby elevated sinus pressure during sternutation forces air through
a dural defect, trapping it within the cranial cavity. Diagnosis is typically made with non-contrast CT and treatment depends on severity, ranging from conservative oxygen therapy to urgent surgical intervention. Indications on CT, such as the Mount Fuji sign, air bubble sign, and the peaking sign, help differentiate tension pneumocephalus from less severe forms. This case adds to the growing literature on sternutation-induced pneumocephalus and highlights the importance of recognizing sternutation as a potential source for serious intracranial pathology.
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Introduction: Neurotoxic envenomation often presents with non-specific neurological symptoms and minimal local signs, which can delay appropriate diagnosis and treatment. This is the first reported case of a neurotoxic snakebite presenting with an atypical symptom of unilateral neck pain.

Case Report: A 12-year-old girl was referred to our emergency centre with neck weakness progressing to quadriplegia, attributed to a fall while playing. A diagnosis of acute flaccid paralysis secondary to cervical trauma was made and treated at the first hospital; however, she developed respiratory distress and was transferred to our centre. Clinical examination and computed tomography ruled out cervical cord injury. A diagnosis of neurotoxic envenomation was considered, given our centre’s high snakebite burden and the symptom of descending flaccid paralysis. Despite initiating antivenom and supportive treatment, the patient died. As the death was sudden and unexplained, medicolegal autopsy was done. Meticulous examination revealed a suspicious mark over the right foot. Chemical analysis on a skin sample from the site tested positive for snake venom, confirming envenomation.

Conclusion: This case highlights the diagnostic challenge posed by atypical presentations of neurotoxic snakebite, especially in the absence of a clear history. In endemic areas, flaccid paralysis should prompt clinical suspicion of snakebite. Early recognition and timely administration of antivenom are crucial to prevent fatal outcomes. This case also underscores the need for strengthening diagnostic tools and forensic confirmation to avoid missed or delayed diagnoses, which carry serious medicolegal and public health implications.

Introduction: In this report we highlight the emerging role of pediatric cardiac point-of-care ultrasound (POCUS) in rapidly diagnosing infective endocarditis, using a clinical case as illustration.

Case Report: A six-year-old girl with a known ventricular septal defect presented with worsening respiratory symptoms, fevers, abdominal pain, and decreased oral intake. Initial POCUS, performed by an emergency physician, indicated a suspicious echogenic mass in the right atrium, prompting formal echocardiography. Further imaging and cultures confirmed infective endocarditis due to methicillin-sensitive Staphylococcus aureus.

Conclusion: This case underscores the utility of pediatric cardiac POCUS as a rapid bedside diagnostic tool for infective endocarditis in emergency settings, leading to early diagnosis and management. Although POCUS cannot replace comprehensive echocardiography, its immediate availability significantly accelerates diagnosis and management initiation, particularly in pediatric patients with congenital heart conditions who are at increased risk for the condition. Ongoing training and standardized protocols will enhance its efficacy. Clinicians should recognize the strengths and limitations of POCUS, integrating it into broader diagnostic workflows for pediatric infective endocarditis.

Introduction: Drowning is a significant cause of death in Nepal, especially in rural areas. Identifying pulmonary edema is important for management of cases of non-fatal drowning, and while radiograph is the standard of care, point-of-care ultrasound (POCUS) offers a rapid, accessible alternative.

Case Report: A 40-year-old woman presented to the emergency department after non-fatal drowning with respiratory distress and hypoxia. Chest radiograph was unavailable. Point-of-care ultrasound revealed diffuse B-lines consistent with pulmonary edema. She was stabilized and transported to a hospital with intensive care-level management.

Conclusion: Point-of-care ultrasound enabled rapid identification of pulmonary edema and guided timely referral. In resource-limited settings, POCUS is a valuable tool for managing drowning victims when other diagnostics are unavailable.

Introduction: Chalk-stick fractures are transverse spinal injuries seen in patients with ankylosing spondylitis due to chronic inflammation and spinal rigidity. These fractures may result from minor trauma and are associated with potentially fatal complications. While spinal fractures in ankylosing spondylitis are well recognized, thoracic chalk-stick fractures complicated by hemothorax from vascular injury remain exceedingly rare. We present a case of an elderly male with ankylosing spondylitis who sustained a thoracic chalk-stick fracture following a ground-level fall, complicated by hemothorax and hemorrhagic shock. This case highlights a rarely reported but life-threatening complication and emphasizes the importance of early imaging and high clinical suspicion in this high-risk population—even after minor trauma.

Case Report: A 90-year-old male with known history of ankylosing spondylitis presented to the emergency department after a ground-level fall associated with syncope. He had thoracic back pain, dyspnea, and hypotension. Computed tomography revealed a thoracic vertebra 11 chalk-stick fracture with interspinous vascular injury and a large, right-sided hemothorax. The patient underwent emergent chest tube placement, blood transfusion, and vasopressor support, which initially stabilized his condition. However, his hospital course was complicated by multiple comorbidities, and he ultimately died after prolonged critical care.

Conclusion: This case illustrates the potential for catastrophic vascular complications from minor trauma in patients with ankylosing spondylitis. Thoracic chalk-stick fractures may result in life-threatening hemothorax and hemorrhagic shock. Emergency physicians should maintain a high index of suspicion and obtain early radiographic imaging to facilitate timely diagnosis and intervention in this high-risk population.

Introduction: Intracranial arterial injury is typically associated with high-energy trauma.  Early diagnosis and treatment are essential for improving patients' functional prognosis. 

Case Presentation: A 76-year-old woman complained of pulsatile tinnitus on the 15th day after her traffic accident, in which she got injured only a bruise to her face, while severe injuries to her torso. On the 17th day, ptosis, conjunctival congestion, and an ocular motility disorder developed in her right eye. Magnetic resonance angiography showed a direct high-flow shunt from the internal carotid artery to the cavernous sinus. On the 20th day, the same symptoms developed in her left eye. On the 23rd day, coil embolization to the fistula reduced symptoms in the left eye, but not the right eye.

Discussion: This complication rarely occurs in patients with head trauma. Our case indicates that this can occur even in patients without obvious head or facial trauma, and even in the subacute phase of trauma care.

Introduction: Hyponatremia is a common and often vexing electrolyte abnormality seen in the emergency setting. The severity of a patient’s symptoms is often dictated by the acuity of hyponatremia development and degree of serum sodium deficit, with patients typically demonstrating more severe neurological symptoms in acute-onset severe hyponatremia. Patients prescribed chlorthalidone are at particular risk of developing hyponatremia, especially in the setting of a secondary insult.

Case Report: We describe two patients presenting to the emergency department with severe hyponatremia who were taking chlorthalidone. Both patients had clinical symptoms that were mild given the degree of their hyponatremia. Additionally, each patient had a secondary insult affecting their volume status that was an important contributing factor in the development of hyponatremia.

Conclusion: Thiazide diuretic use, particularly chlorthalidone, is an important consideration when evaluating patients with new-onset hyponatremia, especially in the setting of excess volume losses or increased consumption of water. These cases demonstrate how patients with severe hyponatremia can present with atypical or mild clinical symptoms and often do not demonstrate significant neurological symptoms such as seizures.

Introduction: Central retinal artery occlusion (CRAO) is a neurological and ophthalmologic emergency that presents as sudden, painless, monocular vision loss. Central retinal artery occlusioncan be classified as arteritic or non-arteritic. Most cases of non-arteritic CRAO are due to embolism, commonly from atherosclerosis of the ipsilateral carotid artery. More proximal sources of embolism are uncommon but can occur. Prompt recognition of CRAO is critical for vision preservation therapy and initiation of ischemic stroke diagnosis protocols.

Case Report: We present the case of a 66-year-old female who presented to the emergency department eight hours after sudden, painless, monocular vision loss. Her past medical history included type II diabetes, hypertension, and hyperlipidemia. She had previously undergone bilateral lens replacement for cataracts three years prior and had a history of intermittent floaters, which had been worsening over the previous six months. She denied any associated pain, headache, speech difficulty, focal weakness, and ocular trauma. Point-of-care ultrasound (POCUS) of the affected eye revealed the presence of a retrobulbar spot sign, which is associated with CRAO with a non-arteritic embolic etiology.

Conclusion: Point-of-care ultrasound is an efficient diagnostic tool for the assessment of acute, painless, monocular vision loss. The presence of a retrobulbar spot sign indicates central retinal artery occlusion, providing both diagnostic and prognostic information. Although not a definitive diagnostic tool, POCUS can expedite treatment for patients with central retinal artery occlusion, a diagnosis with a time-sensitive treatment window.

Introduction: Radial collateral ligament injuries of the thumb are rare, especially in adolescent athletes. We present a case of a 17-year-old female cheerleader who sustained a complete radial collateral ligament tear while basing during a cheerleading stunt.

Case Report: The patient presented to the emergency department with pain in the right thumb after catching a falling flyer. Examination of the first metacarpophalangeal joint of the right thumb revealed tenderness and laxity. Radiographic imaging showed no fracture. Magnetic resonance imaging confirmed a complete radial collateral ligament tear. She underwent surgical repair with full recovery.

Conclusion: This case highlights an uncommon thumb ligament injury in a non-traditional mechanism. Emergency physicians should consider radial collateral ligament tears in patients with metacarpophalangeal joint tenderness, even when radiographs are normal.

Introduction: The vasovagal reaction can lead to benign, self-limiting syncope triggered by stimuli such as pain or emotional stress. However, in rare and severe cases it may result in cardiac asystole. Previous episodes of vasovagal reactions could be a risk factor for cardiac asystole.

Case Report: We present a 39-year-old male with a previous episode of vasovagal syncope who developed an unexpected 15-second episode of asystole during venipuncture, for which we performed immediate chest compressions. Further evaluations revealed no apparent underlying cause. The patient was subsequently diagnosed with transient asystole secondary to vasovagal reaction.

Conclusion: While venipuncture is a common procedure in clinical practice, clinicians should be aware of the potential risk for cardiac asystole. Detailed medical history of previous episodes of vasovagal reactions could be helpful.

Introduction: Diclofenac sodium is a widely used medication for its analgesic and anti-inflammatory properties. Although the adverse effects of diclofenac are well described, diclofenac-associated new-onset atrial fibrillation in a young, healthy adult has not been previously reported.

Case Report: A 22-year-old man with severe pain following an ankle injury used diclofenac sodium at a dose of 50 mg orally three times daily for one week. At the end of the week, he presented to the emergency department (ED) complaining of palpitations for a few hours. The patient had no past medical history. His physical examination revealed no pathologic signs except for tachycardia and an irregularly irregular pulse rate. An electrocardiogram showed an irregularly irregular rhythm with a ventricular rate of 128 beats per minute (bpm) (rapid ventricular response) and absent P waves, consistent with atrial fibrillation. The patient was monitored in the ED, and a standard regimen of intravenous amiodarone was initiated for rate control. Approximately three hours after initiation, sinus rhythm returned and his heart rate stabilized at 60 bpm.

Conclusion: This case report describes a possible association between diclofenac use and new-onset atrial fibrillation in a young, previously healthy individual. The findings highlight the need for awareness of the potential arrhythmogenic effects of diclofenac and underscore the importance of taking a careful drug history in patients presenting with unexplained atrial fibrillation.

Introduction: Dense deposit disease, also known as C3 glomerulopathy, is a rare renal disorder caused by abnormal complement deposition in the glomerular basement membrane. Patients often require long-term immunosuppressive therapy and, in some cases, complement inhibitors such as ravulizumab. While effective at limiting renal damage, complement blockade significantly increases susceptibility to invasive infections from encapsulated bacteria, particularly Neisseria meningitidis. Despite immunization and antimicrobial prophylaxis, these patients remain incompletely protected. We describe a case of meningococcemia in a fully vaccinated adolescent with dense deposit disease on ravulizumab therapy.

Case Report: A 17-year-old male with a history of dense deposit disease on mycophenolate mofetil and ravulizumab presented to the pediatric emergency department with fever, vomiting, altered mental status, and a rapidly evolving  etechial-purpuric rash. He was fully immunized with both meningococcal conjugate and serogroup B vaccines. Initial evaluation revealed fever, hypotension, and altered level of consciousness. Laboratory studies showed leukocytosis, elevated inflammatory markers, and blood cultures subsequently confirmed N. meningitidis. Empiric ceftriaxone and vancomycin were initiated, later narrowed to ceftriaxone. Supportive management included intravenous (IV) fluids, vasopressors, IV immunoglobulin, and dexamethasone. The patient demonstrated rapid improvement, with resolution of hemodynamic instability and normalization of kidney function. He was discharged on hospital day eight with prophylactic penicillin and close outpatient follow-up.

Conclusion: This case underscores the risk associated with complement inhibition, even in fully vaccinated individuals. Clinicians must maintain high vigilance for meningococcal disease in immunocompromised patients and initiate early aggressive therapy to optimize outcomes.

Introduction: Reversible cerebral vasoconstriction syndrome is a recently defined disease entity classically presenting with recurrent thunderclap headache. The pathology involves triggered cerebral arterial vasoconstriction, which can lead to complications including seizure, ischemic stroke, and intracranial hemorrhage. Diagnosis requires angiography, and treatment consists of vasodilatory therapy.

Case Report: We describe a case of reversible cerebral vasoconstriction syndrome following glucocorticoid burst therapy in a patient on multiple vasoactive medications, suggesting the possibility of compounding risk factors and triggers. As is common with this syndrome, the patient in our case required multiple hospital visits for diagnosis but ultimately experienced a positive outcome upon treatment.

Conclusion: The presentation of reversible cerebral vasoconstriction syndrome can vary. Diagnosis requires a high degree of suspicion in patients with potential triggers to ensure early treatment and avoidance of poor outcomes.

Introduction: Metformin, a first-line type two diabetes medication, is generally considered safe and effective. However, it is rarely associated with life-threatening lactic acidosis. This generally presents in patients with gastrointestinal upset as a primary complaint. It is most common in patients with underlying chronic kidney disease. Prevention of associated mortality requires early diagnosis and intervention with fluids, bicarbonate, vasopressors, and hemodialysis.

Case Report: This is a notable presentation of metformin toxicity, as the 68-year-old male patient presented with an atypical chief complaint of dyspnea and no history of kidney disease. Physical exam was notable for tachypnea and clear breath sounds. Labs revealed anion gap metabolic acidosis from an accumulation of lactic acid and acute renal failure. Other causes of lactic acid metabolic acidosis were considered and ruled out. Nephrology was consulted and pharmacological therapies started as the patient transitioned to the intensive care unit for emergent hemodialysis. He eventually regained renal function and was discharged. His metformin level returned several weeks later significantly elevated.

Conclusion: Emergency physicians should maintain metformin toxicity on the differential for patients on metformin presenting with dyspnea and anion gap metabolic acidosis with elevated serum lactic acid concentrations. Other sources of lactic acidosis should be ruled out, and corrective therapies, including renal replacement therapies, should be started immediately. Additionally, it is essential to determine a patient’s kidney function before being prescribed metformin and to have the patient serially monitored as an outpatient.

Introduction: Foreign body-induced pancreatitis is rare and diagnostically challenging, often presenting with non-specific symptoms and no clear history, unlike typical causes.

Case Report: A 70-year-old man presented with vomiting and abdominal tenderness. Imaging revealed a 4-cm sharp foreign body near the pancreatic head causing inflammation. Endoscopy and endoscopic ultrasound failed to locate the object. Surgical exploration with intraoperative ultrasound identified and removed the foreign body at the pylorus-duodenal junction. The patient recovered without complications.

Conclusion: Early diagnosis, multimodal imaging, and surgical collaboration are essential for optimal management of foreign body-induced pancreatitis.

Case Presentation: A 52-year-old man involved in a high-speed car crash presented with hypotension, abdominal and back pain, and seatbelt bruising. Imaging revealed a mesenteric bucket-handle injury with active bleeding. He received resuscitation and was taken emergently to the operating room for a sigmoid colectomy with primary anastomosis.

Discussion: In patients with blunt abdominal trauma, 1-6% are diagnosed with mesenteric or hollow visceral injuries; the bucket handle injury is a subtype of these injuries. These injuries often present subtly and may be missed on initial evaluation, particularly when the extended focused assessment with sonography for trauma is negative. Unexplained hemodynamic instability should prompt further investigation, as delayed diagnosis can lead to bowel ischemia or infarction. Early recognition and surgical intervention are critical to reducing morbidity and mortality in these patients.

Case Presentation: A 64-year-old Black female presented to the emergency department following a new-onset tonic-clonic seizure. The patient had been given 2 milligrams of lorazepam by emergency medical services with cessation of seizure activity. On physical exam she was lethargic and had clear discharge from the right nare. Computed tomography of the brain initially demonstrated findings consistent with sinusitis versus ethmoidal mass. Magnetic resonance imaging of the brain demonstrated a right frontal ethmoidal encephalocele.

Discussion: Basal encephaloceles occur due to a defect in the skull base. Location of the defect and extracranial herniation of brain tissue can cause neurologic sequelae. This case illustrates the importance of maintaining a broad differential diagnosis and for emergency physicians to obtain imaging when evaluating seizures and/or chronic rhinorrhea in adults.

Case Presentation: A 20-year-old female with no past medical history presented to the emergency department (ED) after an episode of exertional syncope. Physical examination, vital signs, and electrocardiogram were unremarkable. Point-of-care ultrasound revealed abnormal invaginations in the interventricular septum. Laboratory evaluation was significant for markedly elevated troponin concerning for cardiac arrest. She was admitted to cardiology with suspicion for genetic cardiomyopathy. The patient underwent placement of an implantable cardioverter defibrillator after cardiac magnetic resonance imaging redemonstrated the septal invaginations known as myocardial crypts. Genetic studies later revealed sarcomere gene mutations associated with hypertrophic cardiomyopathy.

Discussion: Myocardial crypts, which are invaginations within the myocardium, are considered early morphological markers for hypertrophic cardiomyopathy and may precede the development of overt hypertrophy. The presence of myocardial crypts and syncope is highly concerning for evolving hypertrophic cardiomyopathy. In this case, identifying myocardial crypts on ED point-of-care ultrasound, in conjunction with clinical context, facilitated further confirmatory diagnostics and timely intervention with placement of an implantable cardioverter defibrillator.
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Case Presentation: An 88-year-old man was brought to our emergency department due to altered mental status and hemodynamic shock due to a urinary tract infection. Computed tomography showed an incarcerated ureter in the Petit triangle. Urology was consulted, and the hernia was reduced back into the retroperitoneal cavity.

Discussion: Petit hernia is rare; moreover, there is no literature to our knowledge discussing the ureter as the herniated structure. Interventional radiology can be considered as a reductive option.

Case Presentation: We present the case of a 53-year-old female with darting eye movements and difficulty walking who was found to have opsoclonus-myoclonus syndrome only after multiple presentations to emergency departments over five days.

Discussion: Adult-onset opsoclonus-myoclonus syndrome is a rare central nervous system disease typically associated with paraneoplastic or idiopathic etiologies. With non-specific symptom presentation, this condition is commonly misdiagnosed in adults, leading to diagnostic delays and long-term motor and cognitive sequelae.

Manuscript: A Case Report of Delayed, Severe, Paroxysmal Muscle Cramping after Chilean Rose Tarantula (Grammostola rosea) Envenomation