Clinical Practice and Cases in Emergency Medicine

Chest tightness and shortness of breath are relatively common reasons for presentation to the emergency department (ED), often triggering protocolized workups and dispositions. A good history, however, can reveal additional elements that may dramatically alter the differential diagnosis and management. A 70-year-old woman presented to the ED complaining of subacute chest tightness with dyspnea on exertion. This case offers a thoughtful analysis of how to integrate key findings within a patient’s history, exam, and workup in the ED. The surprising final diagnosis and case outcome are then revealed.

Introduction: Evaluating patients with acute neurologic deficits is a regular occurrence in the emergency department (ED), but some presentations warrant increased concern. This case highlights the importance of repeat evaluations and how resolution of symptoms does not rule out a more ominous underlying pathology.

Case Report: A 59-year-old male with a past medical history of coronary artery disease and Human immunodeficiency viruses (HIV) presented to a Level II trauma and comprehensive stroke center for left-sided facial droop and left- sided hemiparesis. Computed tomography of the brain including angiography and perfusion was performed revealing no hemorrhage or large vessel occlusion. Given his National Institutes of Health Stroke Scale score of 11, he received alteplase and subsequently experienced several episodes of resolution and recurrence of his symptoms while in the ED. Magnetic resonance imaging revealed an acute ischemic infarct in the right basal ganglia and insular region, which along with his clinical presentation was consistent with capsular warning syndrome.

Conclusion: Capsular warning syndrome is a rare clinical entity with an incidence ranging from1.5-5% in stroke patients. Its recognition is crucial when making decisions concerning management,
as resolution of symptoms should still garner a high level of attention given that the the increased risk of stroke with permanent neurological disability is highest within the first 48 hours. The role of
thrombolysis continues to be an area of focus as its benefit has not yet been determined but continues to be the mainstay therapy in the correct clinical setting. This is especially true in the cases of recurrent episodes post thrombolysis, which does not preclude the diagnosis of capsular warning syndrome but should heighten the need for acute management of these patients and close monitoring. This case illustrates its unique presentation and the need for increased recognition and understanding within the field of emergency medicine.

Introduction: Takotsubo cardiomyopathy is characterized by stress-induced left ventricular dysfunction. The reverse form accounts for < 25% of all cases. We present a case of reverse Takotsubo cardiomyopathy in a young, otherwise healthy, woman following illicit drug use.

Case Report: A 19-year-old female patient presented to the emergency department (ED) complainingof insomnia, left-sided chest pain, palpitations, and heightened energy levels after ingesting a significant quantity of small, rounded chocolate chips containing unidentified pills at a rave party the previous night. Her electrocardiogram revealed sinus tachycardia with ST-segment elevation in leads I and aVL. At the ED she developed respiratory distress and required oxygen supplementation. Her troponin level was 1.048 nanograms per milliliter (ng/mL) (reference range < 0.03 ng/mL), and her urine drug screen
was positive for methamphetamines. Point-of-care transthoracic echocardiography showed moderately impaired left ventricular systolic function (ejection fraction approximately 35-39%) and hypokinesia of basal and mid-left ventricular segments accompanied by hyperkinesia of the apical segments, indicative of reverse Takotsubo cardiomyopathy. The patient was admitted to the cardiac care unit and showed clinical improvement after supportive treatment. However, 30 hours after discharge she presented back to the ED with epigastric pain and was found to have left renal artery thrombosis and an occlusive thrombus at the right internal iliac artery on computed tomography angiography.

Conclusion: Amphetamine intoxication is associated with the development of reverse Takotsubo cardiomyopathy, along with multiple vascular thromboses.

Introduction: Emergency physicians can use point-of-care ultrasound (POCUS) to identify lymph nodes in certain clinical scenarios, and advanced users can determine significant information (such as concerns for malignancy or differentiating them from abscesses for incision and drainage) based on a large volume of literature and images associated with those pathologies. However, current literature does not contain a similar volume of images and cases of suppurative lymph nodes, or buboes, limiting the ability to make the diagnosis sonographically at the bedside.

Case Report: We report on a man who presented to the emergency department (ED) with a worsening inguinal mass that changed size with positioning, as well as a 20-pound weight loss occurring over the course of a month. Point-of-care ultrasound of the mass was concerning for a necrotic suppurative lymph node, which was further evaluated with cross-sectional imaging. The patient was admitted for a biopsy to rule out malignancy. He was discharged with serologies for Bartonella henselae pending, which later returned positive. The patient was then switched to azithromycin with significant improvement of his symptoms.

Conclusion: As POCUS becomes the modality of choice for rapid assessment of soft tissue masses in the ED, familiarity with less common variants of soft tissue infections such as buboes can help with medical decision-making, risk stratification, and further workup. This sonographic description of a bubo caused by a common zoonotic infection will enable clinicians to familiarize themselves with their appearance.

Introduction: Temporal lobe epilepsy is a form of focal epilepsy that originates in the temporal lobes, often presenting with a variety of symptoms including altered consciousness, automatisms, and focal seizures with or without impaired awareness. Given such a diversity of manifesting symptoms, recognizing temporal lobe epilepsy in the emergency department (ED) can be challenging. Early identification is crucial for appropriate management, including timely initiation of antiepileptic therapy and differentiation from other neurological emergencies.

Case Report: A 50-year-old male with no prior history of seizures or neurological conditions presented to the ED after experiencing unusual sensations that had begun three days earlier. The patient described an intermittent sensation of warmth rising from his pelvis to his head, accompanied by an experiential déjà vu-like feeling he described as “dream reenactment.” His episodes had become progressively more frequent, occurring approximately once every 90 minutes within the first 24 hours, with two instances of brief loss of consciousness. Diagnostic workup, including neurology consultation and an electroencephalogram in the ED, revealed a 19-second, non-motor focal seizure originating from the left anterior temporal region, consistent with temporal lobe epilepsy. Magnetic resonance imaging showed no acute structural abnormalities. The patient was diagnosed with temporal lobe epilepsy, started on lacosamide, and discharged from the ED.

Conclusion: This case underscores the importance of recognizing temporal lobe epilepsy in the ED, particularly in patients with recurrent episodes of altered consciousness or unusual sensory experiences. Prompt diagnosis and treatment are critical to preventing further seizures and improving quality of life.

Introduction: Hyperkalemic emergencies can present with weakness, paralysis, sensorimotor deficits, and potentially fatal cardiac conduction abnormalities even in the absence of an elevated serum potassium. Common antihypertensive medications, such as angiotensin-converting enzyme inhibitors or angiotensin II receptor blockers, are associated with serum potassium elevations and can exacerbate hyperkalemia, especially in patients with renal impairment.

Case Report: We report a 49-year-old patient who presented to the emergency department six hours following an intentional ingestion of potassium supplements totaling 600 milliequivalents (mEq). The patient also reported chronic use of ibuprofen and losartan 50 mg. Symptoms on presentation included weakness, chest pain, and shortness of breath. Initial labs revealed a potassium > 10 mEq/L which was beyond the upper limit of assay detection for metabolic testing. Calcium gluconate, insulin with dextrose, albuterol, sodium bicarbonate, calcium chloride, fluids, and furosemide were sequentially administered. Initial electrocardiogram (ECG) showed tachycardia, a widened QRS complex without discernible P waves, and non-specific ST-segment changes. Following treatment, a repeat ECG demonstrated decreased heart rate, normal axis, and a decreased QT interval. Creatinine at presentation was 1.67 mg per deciliter (patient’s baseline) with repeat labs revealing a potassium of 9.6 mEq/L. Definitive treatment with placement of a central venous catheter for emergent dialysis was initiated.

Conclusion: This case illustrates how a patient’s regularly prescribed medication may complicate the management of an acute overdose. Prompt identification of a patient’s medications and supplements may expedite potentially life-saving interventions in a hyperkalemic emergency.

Introduction: Dislocations of the pisiform bone are rare, and literature on this injury is sparse. The uncommon nature of this condition, as well as limited data, makes recognition and diagnosis difficult, increasing the chances these injuries may be overlooked. Missing this diagnosis can lead to pain, reduced joint function, and nerve damage.

Case Report: We present a case of pediatric pisiform dislocation and discuss the diagnosis and treatment in an emergency department setting.

Conclusion: Prompt diagnosis and treatment of pisiform dislocations are vital to ensure favorable outcomes.

Introduction: Foreign bodies in the external auditory canal are an uncommon presentation in emergency settings. Among adults, insects represent a frequent organic foreign body, often causing symptoms such as otalgia, tinnitus, vertigo, and anxiety. Prehospital management of such cases is rarely addressed in the medical literature, with minimal guidance available for emergency medical services (EMS) personnel. In this report we discuss their role in stabilizing patients and reducing discomfort through appropriate interventions.

Case Report: A 40-year-old male called EMS after a live insect entered his left ear, causing severe otalgia and distress. Prehospital medical personnel clinically confirmed the presence of the insect and assessed for signs of tympanic membrane perforation. A medical command physician authorized the use of 2% lidocaine to euthanize the insect, which alleviated movement-related discomfort within 20 seconds. Despite initial symptom relief, the patient experienced persistent fullness in the ear and was transported to a tertiary-care hospital. In the emergency department multiple removal attempts were made, with successful extraction using thin dressing forceps. No tympanic membrane perforation was noted, although minor trauma to the external auditory canal was present. The patient was discharged with ciprofloxacin-dexamethasone otic drops and return precautions.

Conclusion: Prehospital use of lidocaine for a live insect in the auditory canal may provide significant symptom relief while reducing the risk of further auditory canal trauma. This case underscores the importance of command-based support for EMS personnel to provide safe, evidence-based approaches for managing intra-aural insects in the field.

Introduction: Ewing sarcoma is a relatively common neoplasm occurring in pediatric patients 10-20 years of age, commonly presenting with bone fracture, fever, and pain and swelling at the site of the primary tumor. Here we present an unusual case of Ewing sarcoma in the cervical spine leading to neurological symptoms including left lower extremity hemiparesis and left upper extremity hemiplegia.

Case Report: A 19-year-old Bengali-speaking male presented to the emergency department with a three-week history of left lower extremity hemiparesis and left upper extremity hemiplegia. Due to concern for spinal cord compression, a computed tomography of the cervical spine without contrast was obtained, which revealed a lucent lesion in the left fifth cervical (C5) vertebral body. Magnetic resonance imaging of the cervical spine revealed a left cervical extradural mass present from C3-C7. The patient subsequently underwent C3-C7 laminectomy with tumor decompression and fusion one week later. Surgical pathology revealed Ewing sarcoma. Following chemotherapy two months later the patient
regained complete recovery of motor and sensory function in the left lower and left upper extremities.

Conclusion: It is important for emergency physicians to broaden their differential diagnosis when the physical examination reveals neurological deficits as exhibited in this case. A broader workup must be obtained that does not solely consist of head imaging but also includes imaging of the spine to prevent missing the diagnosis.

Introduction: Ectopic pregnancy is a serious pregnancy complication that occurs when a gestational sac implants outside the uterus, most commonly in the fallopian tubes. However, a rare form of ectopic pregnancy, the cesarean scar ectopic pregnancy, occurs within a prior cesarean section scar and is becoming more common as cesarean delivery rates continue to rise. Cesarean scar ectopic pregnancies are challenging to diagnose and pose significant risks, including rupture and hemorrhage, which can lead to maternal death.

Case Report: A 27-year-old woman presented to the emergency department with a 16-day history of abdominal pain and vaginal bleeding, initially believed to be her menstrual period. She had a history of one previous lower uterine segment cesarean section. On examination, her beta-human chorionic gonadotropin (β-hCG) levels were elevated, and transvaginal ultrasound revealed an empty uterus with a gestational sac within a cystic area of the cesarean scar. The patient was diagnosed with a cesarean scar ectopic pregnancy. Given the high rupture risk, she underwent laparoscopic surgery with dilation and curettage. Postoperative management included methotrexate, antibiotics, and analgesics. A follow-up β-hCG test showed a significant decline, confirming resolution of the ectopic pregnancy. At her two-week follow-up, the patient remained asymptomatic with no bleeding, and ultrasound confirmed no retained products of conception.

Conclusion: Cesarean scar ectopic pregnancies are a rare and life-threatening complication of pregnancy that require timely diagnosis and intervention. Early detection through transvaginal ultrasound and appropriate multidisciplinary management are critical to prevent adverse outcomes. This case highlights the importance of early recognition, classification, surgical decision-making, and standardized diagnostic protocols to improve outcomes and save lives

Introduction: We present the case of a patient with the unusual occurrence of phantom arm pain and an acute exacerbation of chronic tinnitus during an ST-segment elevation myocardial infarction (STEMI).

Case Report: A 56-year-old man was having several classic symptoms associated with acute coronary syndrome, along with perceived pain in an arm lost years earlier in a traumatic accident and a sudden worsening of his chronic tinnitus. Emergency medical services responded and diagnosed a STEMI on scene. A 100% occlusion of his right coronary artery was rapidly identified in the hospital and treated with the deployment of two drug-eluting stents. After the procedure his symptoms resolved. He was discharged without incident two days later.

Conclusion: Whereas arm pain is a well-documented presenting symptom of acute coronary syndrome, phantom limb pain and exacerbation of tinnitus have been rarely reported in the literature.

Introduction: Acute lymphoblastic leukemia (ALL) is typically a childhood disease but may present in older patients in rare occurrences. Due to its significant morbidity and mortality, early diagnosis is crucial. The symptoms of ALL may be non-specific, making the initial diagnosis difficult leading to delayed treatment.

Case Report: We present the case of a 34-year-old, healthy male runner presenting to the emergency department with a common complaint of bilateral knee pain, who was ultimately diagnosed with ALL with signs of tumor lysis syndrome leading to premature death.

Conclusion: We discuss the presenting symptoms of acute lymphoblastic leukemia, which may include joint or knee pain as well as leukemic arthritis. We further discuss the importance of clinicians maintaining a high level of suspicion for the “bounce-back” patient and avoiding taking cognitive shortcuts.

Introduction: Acute hypercapnic respiratory failure secondary to foreign body aspiration is a rare but severe complication seen in pediatric patients. Foreign body aspiration is one of the leading causes of death in children and requires prompt intervention and stabilization when definitive bronchoscopy is not readily available.

Case Report: We describe the case of a 16-month-old male who developed acute hypercapnic respiratory failure following the aspiration of a foreign body. On presentation to the emergency department, the child was in respiratory distress, appeared cyanotic, and had severely impaired oxygenation, all indicating respiratory failure. Initial management involved stabilization, advanced airway management, and ventilatory adjustments. Efficient communication with multiple specialists
coordinated the appropriate transfer of the patient to a tertiary pediatric facility for bronchoscopy and ultimate successful foreign body removal without complications.

Conclusion: The report highlights challenges in the management of pediatric foreign body aspiration leading to severe hypercapnia, the importance of interdisciplinary coordination, and the management techniques used to stabilize the patient for safe transfer to a tertiary care center.

Introduction: Aortic dissection is a rare but life-threatening condition with a high mortality rate if diagnosis is delayed. Aortic dissection classically presents with sudden-onset, sharp pain in the chest or back. However, atypical presentations can also occur, which could lead to a delay in diagnosis.

Case Report: A patient initially presented to the emergency department (ED) with left testicular pain ongoing for several hours. On examination, he had tenderness in the left lower quadrant abdomen and left testicle. A testicular ultrasound revealed decreased blood flow to the left testicle, raising concern for testicular torsion. The patient was taken to the operating room, where no torsion was found, and he was subsequently discharged home. Several days later, the patient returned to the ED with worsening pain radiating to the back. A computed tomography revealed an acute type A aortic dissection extending to the iliac arteries. He was transferred for surgical repair and discharged 12 days later.

Conclusion: While acute aortic dissection (AAD) typically presents with chest or back pain, atypical presentations can occur. When initial findings do not fully explain a patient’s symptoms, AAD should remain on the differential. This case highlights an uncommon presentation of AAD initially mimicking a testicular torsion.

Introduction: Milk-alkali syndrome is characterized by the triad of hypercalcemia, metabolic alkalosis, and acute kidney injury resulting from excessive intake of calcium and absorbable alkali. Despite falling out of prominence with the advent of modern ulcer treatments, milk-alkali syndrome has experienced a resurgence with the widespread availability of over-the-counter calcium preparations, which now account for up to 10% of hypercalcemia cases.

Case Report: A 60-year-old man with multiple comorbidities presented to the emergency department with altered mental status after his scheduled kyphoplasty was canceled due to concerning neurological findings. Laboratory evaluation revealed severe hypercalcemia, marked metabolic alkalosis, and acute kidney injury. Further history revealed excessive antacid consumption for heartburn. The patient was diagnosed with milk-alkali syndrome, treated with intravenous fluids and calcitonin, and discharged home after 48 hours with complete resolution of signs and symptoms.

Conclusion: Milk-alkali syndrome represents an increasingly recognized cause of severe hypercalcemia in the emergency setting. This case demonstrates the importance of thorough medication history, early recognition of the classic triad, and prompt initiation of conservative management. With the growing use of calcium-based, over-the-counter preparations, emergency physicians must maintain vigilance for this potentially serious but readily treatable condition.

Introduction: Cardiac arrest remains a major global cause of mortality, with both structural and non-structural cardiac abnormalities implicated. While ischemic heart disease is a common etiology, rare conditions such as papillary fibroelastoma can also result in life-threatening events through embolization or coronary obstruction. Timely recognition and advanced cardiac imaging, particularly transesophageal echocardiography, are essential in such atypical presentations.

Case Report: A 61-year-old female with a history of ischemic heart disease presented to the emergency department following an out-of-hospital cardiac arrest. Initial electrocardiogram (ECG) demonstrated anterior ST-elevation myocardial infarction, which resolved on repeat ECG, prompting reconsideration of the underlying cause. The patient achieved return of spontaneous circulation twice and eventually self-extubated. Further investigation, including cardiac imaging, revealed a mobile mass on the aortic valve intermittently obstructing the left main coronary artery. The mass was surgically resected and histologically confirmed as a papillary fibroelastoma. The patient recovered fully with no neurological or cardiac complications.

Conclusion: This case highlights the importance of maintaining a broad differential diagnosis in patients presenting with cardiac arrest, especially when ischemic changes are transient or unexplained. Although benign, papillary fibroelastoma can lead to sudden death due to embolization or coronary obstruction. Emergency physicians should be aware of such rare but treatable causes and consider early use of advanced cardiac imaging when standard presentations do not align with the clinical picture.

Introduction: Patients with psychiatric concerns often present to an emergency department (ED) for medical evaluation prior to inpatient psychiatry placement. One diagnosis to consider prior to disposition is autoimmune encephalitis (AIE). This report describes a pediatric patient who presented with psychiatric symptoms that required inpatient admission and workup to diagnose a rare form of AIE.

Case Report: A 16-year-old female with no known past medical history presented as a transfer from an outside hospital for medical evaluation of two days of auditory and visual hallucinations. Initial labs and imaging were unremarkable. Due to the acuity of her symptoms and abnormal vital signs, she was admitted to the hospital for further medical workup. After almost three weeks inpatient and multiple specialist consultations, she was diagnosed with anti-heavy chain neuronal intermediate filament AIE. The next month of admission included treatment with immunomodulators, antibiotics for associated infections, and malignancy evaluation. Symptoms resolved, and the patient was discharged. The patient remained asymptomatic on immunotherapies, and without psychiatric medications, the following year.

Conclusion: During evaluation of psychiatric concerns in the ED, it is essential to consider organic causes of behavioral changes, which can be difficult to discern. Autoimmune encephalitis can be subtle. Features such as autonomic dysregulation, acute or subacute symptom onset, recent infection, autoimmune or malignancy history, cognitive deficits, or focal neurologic findings should raise clinical suspicion. For patients with psychiatric symptoms, the role of an emergency physician is not to diagnose autoimmune encephalitis, but to recognize nuances in patient presentations to best direct proper workup, treatment, and disposition.

Introduction: Spontaneous splenic vein rupture is a rare condition associated with a high risk of mortality. Only a few cases have been documented, all of which have been linked to underlying predisposing conditions. In this case, however, we present a previously healthy patient with no identifiable risk factors.

Case Report: A 64-year-old male presented to the emergency department with acute-onset abdominal pain and nausea. Physical exam revealed a rigid abdomen with diffuse tenderness and guarding. Serial labs revealed a progressively decreasing hemoglobin and red blood cell count. Computed tomography demonstrated a ruptured splenic vein with a large volume of retroperitoneal hemorrhage. Laparotomy identified a large retroperitoneal hematoma with hemoperitoneum, and embolization was performed by interventional radiology. The patient recovered after one week in the surgical intensive care unit and was subsequently discharged home with no complications to date.

Conclusion: This case underscores the importance of maintaining a high clinical suspicion in patients with acute, unexplained abdominal pain, and emphasizes the crucial role of emergency physicians in the timely recognition and management of such conditions. Given the scarcity of existing literature, this case provides valuable insight into the presentation and management of spontaneous splenic vein rupture in previously healthy individuals, thereby enhancing clinical awareness of this rare and life-threatening condition.

Introduction: Antimuscarinic toxicity, which can cause delirium and unsafe behavior, may result from an adverse effect of prescribed medications or from non-medical substance use. Physostigmine shortages have prompted use of transdermal rivastigmine for management of antimuscarinic toxicity; however, symptom control is equivocal at standard dosing.

Case Report: A patient with antimuscarinic toxicity was treated with physostigmine and transitioned to 26.6 milligrams/24 hours transdermal rivastigmine for sustained symptom control. He experienced no adverse effects and tolerated floor admission.

Discussion: There is mechanistic plausibility supporting safe, sustained control of antimuscarinic toxicity with high-dose transdermal rivastigmine. Central distribution is more rapid than serum distribution and higher doses correlate with a shorter time to peak concentration.

Introduction: Pectus excavatum (PEX) is the most common congenital chest wall deformity, characterized by posterior depression of the sternum and lower costal margin. While often asymptomatic, severe PEX can lead to compression of the heart and great vessels, potentially causing right ventricular dysfunction, syncope, and other cardiovascular symptoms. Syncope due to right ventricle compression in PEX is rare but can significantly impact quality of life and may require surgical intervention.

Case Report: An 18-year-old female presented to the emergency department after an unwitnessed syncopal episode. The patient reported feeling lightheaded while showering, followed by collapse and brief loss of consciousness. Diagnostic testing revealed normal neurological and metabolic parameters including point-of-care glucose, electrocardiogram, serum troponin, electrolytes, and head computed tomography. Chest imaging showed severe PEX with concerns of right ventricular compression. Transthoracic echocardiography demonstrated normal cardiac function, and exercise stress testing showed no ischemic changes. Additional laboratory studies revealed iron deficiency anemia.

Conclusion: This case underscores the potential for PEX to cause distorted cardiac morphology, including right ventricular compression, which can lead to syncope in severe cases. The absence of cardiac ischemia, arrhythmias, or metabolic derangement suggests postural changes compounded by undiagnosed anemia and underlying PEX as the most likely cause of this patient’s syncope. Given the patient’s symptoms and anatomical findings, referral for surgical evaluation was made to discuss definitive management options. This case highlights the importance of considering structural chest wall abnormalities in the differential diagnosis of syncopal events, particularly when standard causes are excluded.

Introduction: Sternoclavicular joint injuries are rare and potentially life-threatening injuries due to their proximity to vital mediastinal structures. In adolescents, skeletal immaturity can add complexity to the injury due to potential involvement of the physis. A physeal fracture with displacement can appear as a dislocation on imaging, also known as pseudo-dislocation. Additionally, this anatomic area is difficult to visualize with plain radiographs, which can result in misdiagnosis and delayed treatment.

Case Report: We present a case of a 15-year-old male athlete who presented to the emergency department with severe right clavicular pain four hours after sustaining a football injury. Plain radiographs obtained at an outside facility as well as repeat plain radiographs at our facility showed no evidence of fracture or dislocation. The patient’s degree of pain and physical exam findings prompted further imaging with computed tomography (CT), ultimately revealing a physeal fracture of the medial right clavicle with posterior and superior displacement.

Conclusion: Sternoclavicular joint injuries in skeletally immature patients are complex and require immediate diagnosis and intervention. Plain radiographs are often unreliable in recognizing these injuries and, in our case, the physeal fracture with displacement was not radiographically apparent on two separate occasions. Advanced imaging with CT revealed the diagnosis, highlighting the importance of a detailed physical exam and for physicians to maintain a high index of clinical
suspicion when evaluating adolescents with high-impact trauma, even in the setting of negative plain radiographs.

Introduction: Carotidynia is a rare, often under-diagnosed condition characterized by idiopathic inflammation around the carotid artery, presenting with unilateral neck pain that typically resolves within two weeks.

Case Report: A 32-year-old male presented with intermittent right anterior neck pain for two years, with no other associated symptoms. Computed tomography revealed carotid perivascular inflammation, consistent with carotidynia.

Conclusion: Although self-limited, carotidynia should be considered in patients with unexplained neck pain, as its recognition is crucial to differentiate it from more serious conditions and to avoid mismanagement or unnecessary interventions.

Introduction: Semaglutide, a glucagon-like peptide-1 receptor agonist, has gained increasing popularity for managing both type 2 diabetes mellitus and obesity. However, as its use increases, new adverse events are emerging. This case report presents a 70-year-old patient who developed pleural and pericardial effusions likely related to semaglutide use.

Case Report: Four weeks after being prescribed semaglutide, a 70-year-old woman presented to the emergency department (ED) with shortness of breath. Diagnostic testing in the ED and hospital revealed that she had both pericardial and exudative pleural effusions, along with a positive anti-nuclear antibody and elevated inflammatory markers. Her signs and symptoms improved with steroid administration, and no other etiology was identified.

Conclusion: The patient was diagnosed with drug-induced lupus, likely triggered by semaglutide. This case underscores the importance of recognizing and investigating uncommon drug-related complications. With the growing use of semaglutide, clinicians must remain vigilant for rare adverse effects such as pleural effusions to ensure prompt diagnosis and treatment.

Introduction: Guillain-Barré syndrome (GBS) can manifest with progressive paralysis, requiring careful monitoring and treatment with steroids or IVIG. While this disease can be devastating and require ICU level of care, there are few incidences of GBS relapses.

Case Report:  A 67-year-old man with a past medical history of Miller Fisher Syndrome (MFS) variant Guillain-Barre Syndrome (GBS), with complete recovery presenting to the emergency department (ED) with ataxia, ophthalmoplegia, dysphonia, and ambulatory dysfunction. The patient noticed his neurologic symptoms after waking up and presented to the ED with physical examination positive for difficulty with upward gaze, mild right lower facial droop, dysmetria with left finger to nose testing, and unsteady gait.  A lumbar puncture (LP) revealed albuminocytologic dissociation and he was diagnosed with recurrent MFS. The patient completed a five-day course of intravenous immunoglobulin with marked improvement of his symptoms. Unfortunately, the patient continued to have ambulatory difficulty, requiring inpatient rehabilitation with residual deficits including ophthalmoplegia and mild dysphonia.

Conclusion: MFS is an uncommon variant of GBS with atypical neurologic findings that can lead to respiratory distress that requires high levels of suspicion and diagnostic evaluation.  This disease process can recur in a patient’s lifetime, contrary to traditional medical literature. 

Case Presentation: A healthy 32-year-old man presented to the emergency department with bilateral knee pain after landing from a jump. He was unable to extend his knees and had pain to palpation superior to the patella. Bilateral quadriceps tendon rupture was confirmed using point-of-care ultrasound, and the patient underwent operative repair the next day.

Discussion: Bilateral quadriceps tendon rupture is exceedingly rare, which often leads to misdiagnosis. Magnetic resonance imaging is the gold standard diagnostic imaging study but has multiple disadvantages, especially in emergency settings. Point-of-care ultrasound is an excellent tool to screen for this injury and prevent morbidity from delay in surgical repair.

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