Clinical Practice and Cases in Emergency Medicine

Introduction: Prolonged emergency department (ED) wait times pose problems for both patients and ED staff. Poor patient outcomes can result in litigation that could have been prevented by faster access to care.

Case Series: We present 10 lawsuits involving patients who experienced poor outcomes allegedly due to inappropriate management in the waiting room. These cases involved allegations of violations of the Emergency Medical Treatment and Labor Act (EMTALA) or general negligence and were levied against both the physicians and hospitals involved.

Conclusion: Both common law and EMTALA’s medical screening exam requirements impose significant obligations on physicians and hospitals to proactively manage patients in the waiting room. Being familiar with these requirements may help minimize legal risks

Introduction: Urethral foreign bodies are an uncommon presentation in the emergency department (ED) and can be difficult to assess and diagnose. There are examples in the literature of ultrasound detecting urethral foreign bodies. While not standard of practice, point-of-care ultrasound (POCUS) may be a useful tool for this unique pathology.

Case Series: We describe three cases in which POCUS was used in the care of patients presenting with urethral foreign bodies. Ultrasound aided in diagnosis and helped facilitate further management.

Conclusion: While urethral foreign bodies are relatively uncommon, they can lead to significant morbidity, which makes their prompt identification and treatment important. Ultrasound provides a rapid means of evaluation that allows the patient to stay under observation by ED staff while removing exposure to radiation or contrast.

Introduction: A posterior circulation stroke at the level of the basilar artery can cause ischemia to the brainstem, cerebellum, and occipital lobes.
Posterior circulation strokes are notoriously more difficult to clinically diagnose than anterior circulation strokes, with a variety of presenting symptoms including altered mental status, dizziness, vision changes, nausea, and vomiting. Anisocoria has been reported to occur in rare cases.

Case Report: We present two cases where patients had an acute episode of altered mental status with a key exam finding of anisocoria, or unequal pupil sizes. The combination of anisocoria
and acute mental status decline are classically associated with traumatic brain injury, increased intracranial pressure, or both. In each of the two cases presented, acute basilar artery occlusion was seen on computed tomography with angiography.

Conclusion: When presented with acute decline in mental status and anisocoria, early clinicalsuspicion of an acute basilar artery occlusion is crucial in diagnosing and managing these patients
with debilitating acute posterior stroke. Time-sensitive interventions such as thrombolytics and mechanical thrombectomy can be lifesaving.

Introduction: Coronary artery disease is uncommon in adults under the age of 35, and studies show a lower incidence in women of this age group. Physicians should suspect myocardial infarction in all patients who present with cardiac arrest and a shockable rhythm.

Case Report: We report a case of a 34-year-old female who presented after return of spontaneous circulation following both pulseless electrical activity and ventricular fibrillation. The initial emergency department 12-lead electrocardiogram (ECG) demonstrated ST-segment elevation in the anterior precordial leads. The second, more notable, ECG showed a unique ischemic pattern of ventricular bigeminy with each beat containing a different morphology of injury pattern. Emergent cardiac catheterization found a 100% occlusion of the proximal left anterior descending artery.

Conclusion: Premature ventricular (or junctional) contractions can indicate ischemia when the morphology consists of excessive discordance between the QRS complex and the ST segment and T wave. This case illustrates the importance of scrutinizing each beat in every lead to increase sensitivity for ischemia.

Introduction: Wunderlich syndrome (WS) is a rare condition characterized by spontaneous, atraumatic renal hemorrhage. It often presents with non-specific symptoms and is typically diagnosed through computed tomography (CT). The most common presentation of WS includes the Lenk triad, which consists of flank pain, a palpable flank mass, and hypovolemic shock. If diagnosis and treatment are delayed, WS can rapidly progress and lead to unfavorable patient outcomes.

Case Report: A 65-year-old male presented to the emergency department with severe sudden-onset left flank pain with subsequent CT angiogram demonstrating an actively bleeding left renal hematoma. The patient was managed conservatively with supportive care. His vitals remained stable, and he did not require any surgical or vascular interventions.

Conclusion: Wunderlich syndrome is a spontaneous renal or perinephric hemorrhage occurring in the absence of trauma; it is rarely included in the differential for patients with flank pain but can become life-threatening when not recognized.

Introduction: Fat embolism syndrome (FES) is a rare, life-threatening condition most seen in traumatic orthopedic injuries, especially long bone fractures. Classically, FES presents with
hypoxemia, neurological abnormalities, or a petechial rash; however, clinical findings can extend beyond this classic triad. Since FES is a clinical diagnosis, emergency physicians must recognize both classic and subtle presentations.

Case Report: A 22-year-old female presented as a transfer from an outside hospital for multiple long bone fractures secondary to gunshot wounds. Upon arrival, she was found to be hypoxic, despite no signs of thoracic injury on exam or initial imaging. Her presentation, laboratory findings, and repeat imaging were consistent with FES. She was given supportive care through supplemental oxygen and close monitoring. She improved with supportive care and was discharged home in stable condition.

Conclusion: Although there is no definitive treatment for fat embolism syndrome, prompt recognition of the various clinical findings associated with FES by emergency physicians can expedite
supportive care, allow prompt admission to a critical care unit, and aid with monitoring for potential deterioration.

Introduction: Compartment syndrome is an emergent condition of increased pressure within a muscle compartment.  Paraspinal is a rare location for compartment syndrome and is typically secondary to exertion, trauma, or surgery.

Case report: We present a case of paraspinal compartment syndrome in a patient who presented after fentanyl overdose.  This patient was likely exposed to Xylazine, also known as “tranq”, which may have contributed to his presentation.

Conclusion: Emergency medicine physicians must be aware of paraspinal compartment syndrome to facilitate rapid diagnosis and treatment and prevent associated morbidity and mortality.

Introduction: Acute vision loss constitutes a true medical emergency, as a delay in diagnosis and treatment may lead to permanent visual impairment. Orbital compartment syndrome is most
commonly associated with blunt trauma causing a retro-orbital hematoma and resulting compromise of the optic nerve. Orbital compartment syndrome, however, can occur in other scenarios including status post blepharoplasty.

Case Report: This is a case of a 67-year-old male who presented less than 24 hours after a bilateral upper blepharoplasty due to decreased visual acuity of his right eye. A lateral canthotomy was performed despite the absence of elevated intraocular pressures on tonometry. He regained visual acuity in his right eye shortly after the cantholysis.

Conclusion: It is vital to consider the range of entities that can cause orbital compartment syndrome, including blepharoplasty. Recognition and emergent intervention improved the visual acuity in this case.

Introduction: Orbital compartment syndrome (OCS) is a rare but high-morbidity emergency requiring prompt recognition and management.

Case Report: We present a case of a man who developed OCS from external compression of the globe while lying in a prone position. Initially obtunded and unable to provide any history, the patient exhibited anisocoria, which later progressed to severe chemosis and proptosis. Intraocular pressure reached nearly 100 millimeters of mercury, improving immediately after emergent lateral canthotomy with cantholysis. His course was complicated by ipsilateral limb compartment syndrome and
worsening renal failure requiring dialysis.

Conclusion: This case highlights the critical role emergency physicians play in the rapid diagnosis and treatment of orbital compartment syndrome.

Introduction: Thyroid storm is a rare, life-threatening emergency with a 3.6-17% mortality rate despite proper management. Elevated levels of circulating thyroid hormones can increase metabolic demand, leading to adverse effects on multiple organ systems, particularly critical cardiovascular complications such as cardiomyopathy, myocardial infarction, ventricular arrhythmias, or coronary vasospasm. Precipitating factors can include infection, surgery, or trauma, with infection being the most common. The potential for cardiovascular mortality is high. While beta blockers are key for treatment, they can potentially reduce necessary cardiac output, risking hemodynamic collapse. Traditionally, propranolol has been recommended. We report a rare case of an adolescent experiencing cardiac arrest after propranolol administration in thyroid storm and acute appendicitis.

Case Report: A 17-year-old female with a history of Grave disease, non-adherent to methimazole, underwent evaluation and treatment of thyroid storm and concomitant acute appendicitis. Aggressive initial treatment measures were started, including intravenous and oral propranolol. She went into cardiac arrest approximately six hours after initial medication administration, with subsequent return of spontaneous circulation achieved. The patient underwent aggressive resuscitation and multidisciplinary management. She had a prolonged course in the intensive care unit and was ultimately discharged from the hospital approximately three weeks later.

Conclusion: Beta-blocker use in the management of thyrotoxicosis can potentially cause cardiovascular collapse. We suggest consideration of shorter acting beta blockers, such as esmolol or landiolol.

Introduction: Burkitt lymphoma is a highly aggressive subtype of non-Hodgkin lymphoma with varied clinical presentation, including in some cases involvement of the intraoral cavity. Early recognition of this malignancy is critical, as it typically responds well to prompt and intensive treatment. In this case report, we present a rare manifestation of Burkitt lymphoma presenting as an oropharyngeal mass.

Case Report: An eight-year-old male presented with tonsillar swelling and new-onset oral bleeding. A month earlier, he had been seen in the emergency department (ED) for similar swelling following a streptococcal infection. At that time, a needle aspiration for suspected peritonsillar abscess yielded no drainage, and he was treated with a week of clindamycin, resulting in brief symptom improvement. He subsequently developed difficulty breathing, a muffled voice, and oral bleeding, prompting a return to the ED. On evaluation, he was afebrile, well-appearing, and in no respiratory distress. Examination revealed significant left tonsillar swelling with uvular deviation but no active bleeding. Magnetic resonance imaging demonstrated a bulky left oropharyngeal mass
with airway narrowing, raising suspicion for lymphoma. Laboratory results were unremarkable, and biopsy confirmed Burkitt lymphoma based on c-MYC positivity and the characteristic “starry sky” appearance, leading to the initiation of chemotherapy.

Discussion: Burkitt lymphoma is a high-grade lymphoma with a large tumor burden and, thus, high risk for tumor lysis syndrome. Fortunately, Burkitt lymphoma has superior survival outcomes in pediatrics with a two-year survival rate estimated to be 89% and requiring minimal cycles of chemotherapy. This case underscores the diverse presentations of Burkitt lymphoma and the importance of including it in the differential for all pediatric neck masses, regardless of demographics.

Introduction: Renal colic is a common reason for patients to present to the emergency department (ED). The most common reasons for this pain are usually renal in origin. Here we present the case of a 45-year-old woman with severe right-sided flank pain and associated hydronephrosis secondary to ureteral obstruction caused by the suction of a menstrual cup.

Case Report: A 45-year-old female presented to the ED with sudden severe right-sided flank pain. The patient endorsed nausea without vomiting, fever, chills, hematuria, or dysuria. She stated that she was currently having her menstrual period. On physical exam, the patient was in distress but had no tenderness with palpation of the flank or abdomen. A computed tomography of the kidneys, ureters, and bladder did not show renal or ureteral stones but demonstrated right-sided hydronephrosis secondary to an anatomical blockage of the ureter, which had been suctioned and involuted into a malpositioned menstrual cup. The patient removed her menstrual cup and had immediate relief of her symptoms. She was observed and remained completely asymptomatic upon reassessment two hours later.

Conclusion: Ureteral obstruction and hydronephrosis is a rare complication of menstrual cup use. As these devices become more common, emergency physicians must be aware of this complication as a cause of severe back pain in menstruating women.

Introduction: Carotid artery dissections are uncommon but critical vascular injuries. They involve a tear to the intima, the innermost layer of the arterial wall, leading to formation of a false lumen. This false lumen can disrupt blood flow, weaken the wall, and lead to thrombus or rupture of the artery. Carotid artery dissections can occur spontaneously or in the setting of trauma. Traumatic carotid artery dissections (TCAD) are rare and occasionally present with third-order Horner syndrome,
characterized by ipsilateral ptosis, miosis, and anhidrosis. The presence of subtle physical exam signs like Horner syndrome reinforces the importance of maintaining a high index of suspicion and obtaining vascular imaging in trauma-related cases. While there have been case reports of bilateral TCAD, these have been rarely reported in the literature.

Case Report: We present a case involving a 53-year-old female with no significant past medical history who presented to the emergency department after tripping and falling down a flight of stairs. Over three weeks, the patient had persistent tinnitus and right neck pain and, on the exam, was found to have right-sided miosis and ptosis. These exam findings led us to obtain a computed tomography (CT) angiogram of her neck, which revealed bilateral internal carotid artery dissections.
The patient was taken for cerebral angiography, which confirmed the diagnosis. A stent was placed in the right internal carotid artery, and the patient was started on aspirin and clopidogrel. The patient was discharged without deficits three days later.

Conclusion: Traumatic internal carotid artery dissection can occasionally result in Horner syndrome and requires CT angiography of the neck and potentially a diagnostic cerebral angiogram to diagnose. This case adds to the limited literature on bilateral TCAD, particularly with a delayed and asymmetric presentation. Horner syndrome in the setting of trauma, while subtle, can suggest a carotid artery dissection. Awareness of such rare presentations is key to early diagnosis and
treatment. Clinicians must maintain a high index of suspicion for underlying vascular injury in patients presenting with lesser mechanisms of injury.

Introduction: Foreign body airway obstruction is a high-stakes airway emergency that can rapidly become fatal without timely intervention.

Case Report: We present a case of a 65-year-old male in respiratory extremis due to aspiration of a chicken bone. Following double setup for rapid sequence intubation and cricothyrotomy, the foreign body was successfully removed using Magill forceps under video laryngoscopic guidance.

Conclusion: This case highlights the critical role of early recognition, team readiness, and familiarity with Magill forceps technique in managing foreign body airway obstruction in unstable patients

Introduction: Neuroleptic malignant syndrome (NMS) is a rare but life-threatening condition often associated with dopamine antagonist use. However, its overlap with other hyperthermic and toxidromic syndromes presents significant diagnostic challenges. We present the case of a 27-year-old man with severe hyperthermia, altered mental status, and diffuse rigidity, ultimately managed as possible NMS but with multiple differential diagnoses.

Case Report: We describe a diagnostically challenging case of a 27-year-old male with an unknown medical history presenting with altered mental status, absence of personal identification, severe hyperthermia, and positive systemic inflammatory response syndrome criteria. The patient initially presented with hyperthermia (42.1 °C), tachycardia, tachypnea, diaphoresis, agitation, and rigidity. Initial lab findings demonstrated leukocytosis, elevated creatine kinase, metabolic acidosis, and rhabdomyolysis. Computed tomography ruled out acute anatomical abnormalities, while urine toxicology returned positive for amphetamines and cocaine. The patient required sedation, rapid sequence intubation, and dantrolene administration, which rapidly resolved his rigidity and hyperthermia and stabilized his vital signs. He was admitted to the intensive care unit, where supportive care, including antipyretics, hydration, and muscle relaxants led to gradual improvement. When the patient became less altered, he admitted to a history of aripiprazole use for schizophrenia, as well as daily amphetamine and cocaine use.

Conclusion: This case underscores the importance of considering neuroleptic malignant syndrome in patients with atypical presentations, suspicion for comorbid psychiatric conditions, and substance use disorder. Timely diagnosis, discontinuation of the offending agent, and targeted therapies such as dantrolene are critical in preventing complications. We highlight the diagnostic challenges and management strategies for NMS in the context of a limited history and severe hyperthermia.

Introduction: Cold agglutinin hemolytic anemia is a rare but serious complication of infections, including Mycoplasma pneumoniae. This case highlights the importance of considering infectious causes in patients with unexplained hemolysis. 

Case Report: A 62-year-old previously healthy male developed jaundice, dyspnea, and fatigue three weeks after returning from South America. Labs showed hemolysis with agglutination, a positive direct Coombs test, and elevated cold agglutinin titers. M. pneumoniae was identified via PCR (polymerase chain reaction), confirming the diagnosis. He required uncrossmatched blood transfusion and was treated with doxycycline, with clinical improvement over four days.

Conclusion: This case underscores the need for emergency physicians to recognize M. pneumoniae-induced hemolysis in returning travelers. Early diagnosis, targeted testing, and awareness of macrolide resistance are critical for timely intervention and improved outcomes. 

Introduction: Paralysis from hypokalemia commonly presents with generalized weakness; however, in rare cases it may present with unilateral or focal symptoms. Unilateral paralysis in hypokalemia is particularly challenging due to its mimicry of central nervous system (CNS) disorders such as ischemic stroke. Patients often undergo extensive and costly neuroimaging before a metabolic etiology is recognized.

Case Report: A 19-year-old male presented to the emergency department reporting an abrupt onset of inability to hold things in his right hand. He denied any precipitating factors but did note that he was fasting for the Muslim holy month of Ramadan. On exam, the patient was seen to have absent grip strength in the right hand. The patient’s metabolic panel showed hypokalemia with a potassium of 2.4 millimoles per liter (mmol/L) (reference range: 3.5 to 5.2 mmol/L). Following neurology consultation, we determined that the patient’s focal weakness was secondary to hypokalemia, possibly triggered by his fasting. The patient was given potassium chloride 120 milliequivalents by mouth, and repeat potassium had increased to 3.2 mmol/L. The patient was re-evaluated and reported that his symptoms had completely resolved.

Conclusion: Cases of focal weakness due to hypokalemia can occur. Primary CNS causes should be ruled out prior to making the diagnosis. Treatment should be focused on potassium repletion
and avoidance of triggers. If hypokalemic periodic paralysis is a concern, neurology follow-up should be arranged for definitive diagnosis with electromyography

Introduction: Idiopathic intracranial hypertension is a disorder typically affecting females with common complaints of headaches and visual disturbances. Diagnostic criteria have been described with clinical findings, high opening pressures in lumbar punctures, and magnetic resonance imaging (MRI) findings.

Case Report: A 36-year-old female presented with double vision and headaches. Point-of-care ultrasound demonstrated tortuosity of the optic nerve, a finding previously described in MRI studies, which may serve as an additional marker for ideopathic intracranial hypertension.

Conclusion:This case highlights the potential of point-of-care ultrasound to detect tortuous optic nerves, which may help in the early diagnosis of ideopathic intracranial hypertension, facilitating more timely and effective management.

Introduction: Chlorine and chloramine gases are pulmonary irritants that can cause pulmonary edema and acute respiratory distress syndrome (ARDS). We present two cases that show effective treatment with noninvasive positive pressure ventilation (NIPPV).

Case Reports: Case 1. A 9-year-old male developed chloramine pneumonitis and ARDS with hypoxia to 78% on room air after urinating in a bucket of sodium hypochlorite. He was placed on
NIPPV with improvement in symptoms and discharged on day four. Case 2. A 58-year-old male developed chlorine gas pneumonitis with hypoxia to 85% on room air. Point-of-care ultrasound of this patient demonstrated greater than three B-lines in bilateral lower lung fields, which resolved after initiating NIPPV. He ultimately left against medical advice.

Conclusion: Noninvasive positive pressure ventilation can be an effective treatment modality for severe lung injury secondary to chlorine or chloramine exposure.

Introduction: Determining a mother’s Rhesus (Rh) antigen status is a critical component of prenatal care, guiding the administration of Rh immunoglobulin (Rh Ig) to prevent Rh alloimmunization, a condition that can lead to hemolytic disease of the newborn (HDN). HDN is a blood disorder where the blood types of a mother and fetus are incompatible and causes hemolysis of the fetus’ erythrocytes, a major cause of fetal death. Rh Ig is commonly administered to Rh-negative (Rh-) women as a prophylactic measure. However, categorizing a patient’s Rh status is not always straightforward as individuals can exhibit “weakly Rh+” or “formerly Rh+” phenotypes, complicating clinical management.

Case Report: This is a case of a 28-year-old Gravida three Para two (G3P2) woman whose Rh status has varied across multiple pregnancies, who presented to the emergency department with an active miscarriage requesting a dose of Rh Ig.  Her blood typing indicated O+ status, which conflicted with her previous history of being O-.

Conclusion: Most women in the United States are Rh-positive (Rh+), which eliminates the need for Rh Ig during pregnancy. Nevertheless, there are approximately 550,000 women annually who are categorized as Rh-, and 16,700 of these cases may represent weak Rh positivity. Identifying weakly Rh+ individuals holds potential to reallocate scarce Rh Ig resources to those who require them. This report explores the clinical implications of weak Rh positivity, emphasizing maternal-fetal health considerations and the nuanced approach required to manage such cases effectively in the emergency department.  

Introduction: Dysarthria-clumsy hand syndrome (DCHS) is a rare finding reported in lacunar strokes. Lesions in various anatomic locations have been reported. While the association of DCHS
with a caudate nucleus lesion has been documented, such reports remain infrequent.

Case Report: In this case we present a 52-year-old male who presented with DCHS following a stroke affecting the caudate nucleus. Neurological examination revealed left-sided motor deficits.
Magnetic resonance imaging confirmed an isolated infarct in the right caudate nucleus.

Conclusion: This case report describes a patient with dysarthria-clumsy hand syndrome, due to a lesion in the caudate nucleus and the internal capsule

Introduction: Extracorporeal membrane oxygenation (ECMO) is a life-saving intervention that has become more prevalent in the emergency department (ED) for patients with potentially reversible cardiac or pulmonary failure.

Case Report: We report a case of a young male patient who presented in septic shock and ultimately suffered a cardiac arrest in the ED. Extracorporeal membrane oxygenation was initiated after multiple rounds of cardiopulmonary resuscitation proved futile. Transthoracic echocardiography (TTE) was employed in the ED to guide ECMO cannulation, and the patient was able to make a full recovery after a one-month admission in the intensive care unit.

Conclusion: Transesophageal echocardiography and fluoroscopy are often favored over TTE for ECMO cannulation due to greater resolution of the former modalities.Transesophageal echocardiography is invasive, less accessible, and requires greater expertise. Fluoroscopy requires patients to be moved to a catheterization suite and comes with a risk of extra radiation and contrast-induced nephropathy. While the concept of TTE-guided ECMO cannulation is not especially novel, few case reports exist on its emergent deployment in the ED. Here, we discuss a unique case in which TTE proved effective for timely ECMO deployment for a critically ill ED patient.

Introduction: Ruptured aneurysms are associated with significant mortality limiting a patient’s chances of survival, making early and accurate diagnoses crucial. A commonly overlooked cause
is the hepatic artery aneurysm, where most patients exhibit no distinct symptoms and detection typically occurs only after the aneurysm has ruptured. Hepatic artery aneurysms are linked with high rupturing rates resulting in substantial mortality when compared to other splanchnic artery aneurysms. Enhancing recognition and consideration of splanchnic artery aneurysms, including hepatic artery aneurysms, will increase a patient’s odds of a successful recovery. The following case report illustrates the critical nature of these cases and highlights how important early diagnosis and aggressive intervention are to prevent death once rupture of the hepatic artery
aneurysm has occurred.

Case Report: A 57-year-old female presented to the emergency department brought in by helicopter for generalized chest and abdominal pain. A computed tomography angiography of the chest, abdomen, and pelvis was performed and revealed a saccular aneurysm exhibiting multiple lobes in the left hepatic artery accompanied by hemoperitoneum confirming a spontaneous rupture. As a result of the ruptured aneurysm, it was decided an immediate coil embolization was necessary. Ultimately the patient underwent a successful coil embolization and was transferred to a facility with hepatobiliary and transplant surgery capabilities. She remained stable, was extubated the following day, and did not require any additional surgeries.

Conclusion: By encompassing hepatic and associated splanchnic artery aneurysms in the diagnosis of patients with abdominal pain and signs of hemodynamic instability, physicians can improve early identification, facilitating early endovascular repair and improved patient outcomes. It is a rare diagnosis that can present with a wide range of symptoms. Currently, endovascular approaches for ruptured hepatic artery aneurysms are preferred over open surgery.

Introduction: Ogilvie syndrome is described as the dilation of the colon without a clear mechanical obstruction. One predisposing factor to Ogilvie syndrome is hypothyroidism. The hypothyroid state can cause decreased gastrointestinal motility; however, hypothyroidism resulting in Ogilvie syndrome is a rare complication and is referred to as myxedema ileus. A review of literature shows limited reports of this specific process and none in the emergency medicine literature.

Case Report: A 54-year-old woman with a history of hypothyroidism presented to the emergency department with three days of fatigue, generalized weakness, chills, diarrhea, and shortness of breath without chest pain or cough. Lab work showed high levels of ultra thyroid-stimulating hormone and decreased thyroid hormone levels. A computed tomography angiography of the chest, abdomen and pelvis showed multiple dilated loops of large bowel. Ultimately, she was diagnosed with pseudo-obstruction (Ogilvie syndrome) secondary to myxedema ileus.

Conclusion: Ogilvie syndrome in the setting of myxedema ileus is a serious complication that may occur in patients who are in a severe hypothyroid state. It is important for emergency physicians to consider hypothyroidism as a potential cause of intestinal pseudo-obstruction.

Introduction: Subclavian artery pseudoaneurysms are a rare complication of blunt thoracic trauma with high mortality and incidence of long-term disability.

Case Report: We describe a 49-year-old female who suffered a midshaft clavicle fracture after a motorcycle collision who presented five weeks later with right arm weakness, paresthesias, and persistent clavicle pain and swelling. She was diagnosed with a subclavian artery pseudoaneurysm on point-of-care ultrasound performed in the emergency department, which was confirmed with computed tomography angiography. She underwent endovascular stenting but continued to suffer from long-term neurologic deficits related to her condition.

Conclusion: This case underscores that the diagnosis of subclavian artery pseudoaneurysm requires a high index of suspicion. In addition, the case also highlights the utility of point-of-care ultrasound as a modality that can assist in arriving at the diagnosis.

Introduction: This case is unique in that it documents isolated, painless vaginal bleeding as the sole presenting symptom of a Stanford type A aortic dissection (STAAD), a presentation not
previously reported. It adds to the literature by expanding the spectrum of atypical aortic dissection presentations and underscores the need to consider this diagnosis in elderly patients with vascular risk factors, even when they present with non-classical symptoms such as unexplained bleeding.

Case Report: We present a novel case of STAAD in a 72-year-old woman with a history of hypertension, dyslipidaemia, prior hysterectomy, and cholecystectomy. Her primary complaint was a
single, transient episode of painless vaginal bleeding. Notable clinical findings included a diminished right radial pulse, a significant inter-arm blood pressure discrepancy, and unremarkable systemic and vaginal examinations. Given these findings, further evaluation was pursued. Computed tomography aortography revealed a STAAD extending from the aortic arch to the bifurcation, involving the left internal iliac artery and a vaginal arterial branch. The patient underwent emergent surgical repair and was discharged in good condition on hospital day 11. At her most recent follow-up, three years post- event, she remained clinically stable with no recurrence.

Conclusion: Isolated painless vaginal bleeding, although uncommon, may indicate life-threatening pathology. Subtle signs, such as inter-arm blood pressure discrepancy, can offer critical
diagnostic clues, underscoring the importance of comprehensive evaluation in atypical emergency presentations.

Introduction: Discovery of pearl-like, radiopaque foreign bodies is not widely documented in the literature. In this report, we describe an unusual radiological finding of bubble tea pearls (small,
chewy spheres derived from cassava starch) on computed tomography (CT) from an increasingly popular drink among adolescents.

Case Report: An 11-year-old female presented to the emergency department with severe abdominal pain. Physical examination revealed generalized abdominal tenderness, with increased pain in the right lower quadrant. The patient’s history was concerning for acute appendicitis. Laboratory results were unremarkable, and ultrasound was inconclusive for suspected appendicitis. A contrast-enhanced CT of the abdomen found several ingested radiopaque densities within the stomach. Further toxicology testing was negative or within normal limits. It was later found that the patient had consumed bubble tea earlier in the day. The patient was admitted for monitoring, and symptoms resolved spontaneously the following morning.

Conclusion: When pearl-like, radiopaque densities are found in the abdomen, bubble tea could be considered as a possible etiology to prevent unnecessary workup and exposure to radiation for pediatric patients.

Introduction: Patients with symptoms suggestive of acute coronary syndromes account for up to 10% of emergency department (ED) visits, and of those visits 2% are diagnosed with takotsubo syndrome. Takotsubo syndrome associated with left ventricular outflow tract (LVOT) obstruction is an important but uncommon cause of chest pain and syncope in patients presenting with ST- segment elevations. Although rare, this variant is associated with worse clinical outcomes. Early recognition of LVOT obstruction in these patients is important to help guide proper management.

Case Report: We report a case of a 66-year-old female presenting to the ED after a syncopal episode with ST-segment elevations on the electrocardiogram. Point-of-care ultrasound revealed apical hypokinesis, thickened basal septum with LVOT obstruction and systolic anterior motion.

Conclusion: Point-of-care ultrasound can help quickly diagnose takotsubo cardiomyopathy and its complications, providing guidance to accurate management.

Case Presentation: An otherwise healthy, 30-year-old female was referred to the emergency department by a local optometrist after having flashers and blurry vision for two weeks. Point-of-
care ultrasound revealed partial retinal detachment with underlying mass, and dilated fundoscopic examination suggested hyperpigmented lesions. Ophthalmology was consulted, and the diagnosis of amelanotic choroidal melanoma was confirmed.

Discussion: Choroidal melanoma is the most common primary malignant tumor in the eye, but its diagnosis is often delayed due to non-specific symptoms. Early identification is crucial given
relatively high rates of metastasis. This case highlights how a tentative diagnosis, made using point-of-care ultrasound and funduscopic examination, can drive timely referral to ophthalmology.

Case Presentation: A 62-year-old man was brought into the emergency department by ambulance with right hip pain and deformity following a suspected hip dislocation. A plain film radiograph confirmed the diagnosis. He was sedated for closed reduction at the bedside. Despite apparently successful reduction, his case was complicated by persistent intraprosthetic dislocation of a polyurethane liner component of his prosthetic joint articulation. Computed tomography confirmed displacement of the liner, which required operative intervention.

Discussion: Intraprosthetic dislocation is a complication specific to dual-mobility hip prosthetics, characterized by displacement of the polyurethane liner unique to this type of device. This liner was designed to offer some benefits over other types of hip prosthetics, including improved biomechanics and lower risk of dislocation. The liner can become dislodged during a hip dislocation and remain displaced despite successful reduction of the metallic prosthetic components. Due to its radiolucency, diagnosis can be challenging on plain radiographs, often requiring advanced imaging. This case highlights the importance of recognizing this potential complication in patients with dual-mobility prostheses.

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