A Case of Green Nail Syndrome Diagnosed in the Emergency Department.

Green nail syndrome (GNS) is a rare diagnosis in which a patient presents with green-yellow, green-blue, or green-brown discoloration of a finger or toenail. It occurs due to a Pseudomonas aeruginosa infection of the nail. Pseudomonas aeruginosa produces pigments that can infuse into the underside of the nail plate, creating a color change. Here, we present the case of a 34-year-old female with a green-brown area of discoloration of her right middle finger in which the diagnosis of GNS was made. The patient used acrylic nails, which is a known risk factor. The characteristic clinical context and physical exam findings of green-yellow, green-blue, or green-brown nail discoloration are said to be sufficient to make a working diagnosis of GNS. The differential diagnosis of GNS includes a subungual hematoma, a subungual melanoma, and exogenous yellow pigment exposure. The history, physical examination, and response to treatment will help to clarify the differential. Ciprofloxacin is a commonly used empiric treatment. Laboratory testing of a nail clipping can be used in cases that do not respond to treatment. Cultures of nail clippings appear to be specific, but not sensitive, to the detection of P. aeruginosa. Our patient saw an immediate improvement within a week of treatment, with complete resolution in eight weeks. This is a typical timeframe. Knowledge of the syndrome can be helpful to reduce patient anxiety and guide effective therapy.

Emergency Department Management of Common End-of-Life and Palliative Care Symptoms: Three Cases.

The emergency department (ED) is at times the only place where patients can turn for symptom relief. Patients of all ages may turn to the ED for help with the management of end-of-life (EOL) and palliative care (PC) symptoms. Emergency medicine (EM) is a specialty that manages disease-directed treatment for a variety of acute conditions. In contrast, EOL and PC are focused on improving quality of life. Patients with serious illness, even hospice patients, present to the ED in increasing numbers for symptom management. It has become essential for emergency physicians to care for patients who are not seeking life-sustaining measures but instead need quality-of-life interventions. The development of a clear, concise review of the most common acute symptoms can provide a framework for EM physicians to adequately address the needs of patients at the EOL. Here, we discuss three cases that highlight the management of five of the most common EOL and PC presentations to the ED.

Spontaneous Iliac Arteriovenous Fistula Leading to High-Output Heart Failure and Cardiac Arrest.

We report a case of a 70-year-old male who complained to family members of the sudden onset of groin pain. He then collapsed, and emergency medical services were called. The patient arrived at the ED with a return of spontaneous circulation after cardiac arrest. The patient was diagnosed with a spontaneous iliac arteriovenous (AV) fistula secondary to aneurysmal rupture. This is a rare but potentially life-threatening condition that can result in high-output heart failure and, as described here, cardiac arrest. The differential diagnosis of groin pain is vast, but in the setting of cardiac arrest, vascular causes must be considered. Treatment is most often operative intervention, as was the case with the patient presented. It is predictable that as the population ages and invasive vascular surgeries become more common, the incidence of iliac AV fistulas will increase, resulting in more presentations of high-output heart failure or cardiac arrest in the emergency department.

Use of Handheld Bedside Ultrasound to Confirm Successful Reduction of an Anterior Shoulder Dislocation.

We present the case of a 30-year-old male with anterior shoulder dislocation in which a bedside handheld ultrasound was used after sedation and a reduction procedure to confirm successful reduction. X-ray imaging as well as bedside ultrasound was performed before and after the reduction. The bedside handheld ultrasound demonstrated findings comparable to the X-ray results. X-ray imaging is used as a standard not only in the diagnosis of a dislocated shoulder but also to ensure successful reduction and to assess for any procedure-related fractures. An advantage of immediate bedside ultrasound is that immediate recognition by ultrasound of an unsuccessful reduction can allow the reduction process to continue while the patient is sedated, thus avoiding additional independent sedation procedures. The utilization of bedside ultrasonography in this manner may allow more expeditious and safer care for patients with shoulder dislocations.

Hawthorne root (Crataegus mexicana) toxicity.

Here we present the case of a patient who purchased a Hawthorne root (Crataegus mexicana) product, Raiz de Tejocote, for weight loss purposes. She presented with diffuse myalgias, dizziness and a heart rate of 52 beats per minute. At triage and at initial evaluation, the patient denied taking any medications, but on iterative questioning concerning over-the-counter, over-the-internet and herbal medications, she reported taking Hawthorne root tablets in the three days prior to the emergency department (ED) visit for the purpose of weight loss. The product was purchashed through the internet. Her plasma digoxin concentration was 0.4 ng/ml the patient's constellation of symptoms, as well as the detectable plasma digoxin concentration, were consistent with hawthorne root toxicity. Hawthorne root has intrinsic cardiac glycoside activity. In addition, Hawthorne root may cause a range of toxicity. Mild symptoms can include flu-like syndrome with significant myalgias. However, in the more severe exposures the cardiac glycoside effects can result in bradycardia and hemodynamic instability. Symptoms resolved with ED observation. The heart rate normalized. This case reinforces the importance of asking a patient about all medications, including over-the-counter, over-the-internet and herbal medications.

Celiac Artery Aneurysm: A Rare Cause of Abdominal Pain.

We present the case of a 48-year-old male who presented to the emergency department with left-sided abdominal pain of four-day duration. The pain was described as sharp in nature and was located in the left lower quadrant with radiation to the left shoulder. A computerized tomography (CT) scan of the abdomen and pelvis without contrast showed celiac artery enlargement with adjacent inflammatory stranding. There were other chronic findings secondary to prior surgery. A CT angiogram of the abdomen and pelvis was performed, which showed a 10 x 5 mm saccular pseudoaneurysm at the posterior aspect of the celiac trunk with surrounding inflammatory changes. Endovascular repair was accomplished in the operating room after the placement of the stent graft. Repeat angiogram showed successful exclusion of the aneurysm, with excellent perfusion to the arteries distal to the site of repair. The patient was successfully discharged two days later with outpatient follow-up. Celiac artery aneurysms can present to the emergency department with abdominal pain. The detection of celiac artery aneurysms may be increasing due to increased detection on CT scans. Although rare, this type of visceral artery aneurysm carries a high mortality rate if ruptured. Surgical repair may be either through an endovascular approach or through open surgical repair of the aneurysm preferably with prosthetic grafts.

The Risks of Patient Pill Splitting: A Case Report and Review.

The cutting or splitting of pills can be used by patients to create an intermediate dose or to save money in situations where a higher dose is priced at relatively the same cost as a lower dose. A number of studies of selected medications have concluded that pill splitting in general can be done without adverse effects, with the exception of enteric-coated medications and extended-release medications. Individual patients should be assessed for evidence of patient understanding, as well as the physical abilities for pill splitting. Here, we present the case of a patient whose lack of understanding and inability to organize the pill-splitting process led to poor control of her hypertension, resulting in an emergency department (ED) evaluation.

Colloid Cyst Presenting With Severe Headache and Bilateral Leg Weakness: Case Report and Review.

Colloid cysts are benign growths commonly found in the third ventricle at the foramen of Monro. They can be asymptomatic or present with a variety of symptoms, including headaches, diplopia, memory problems, psychosis, urinary incontinence, and ataxia. Obstructive hydrocephalus from a colloid cyst is caused by a blockage of cerebral spinal fluid (CSF) from the lateral ventricles at the foramen of Monro. Colloid cysts have rarely been reported to cause sudden death. Here we present the case of a 32-year-old female with a known history of a colloid cyst who presented with a headache and transient weakness in her lower extremities noted while climbing stairs.

A Case of Cocaine Toxicity From Body Stuffing.

Here, we report a case of body stuffing leading to severe cocaine toxicity. Medical management and supportive care are usually the best course of action in cases of body stuffing, as seen in our case. While surgery is rarely indicated, surgical consultation should occur early to ensure prompt intervention if obstruction or perforation occurs.

Turquoise Urine in a Man Who Had Urinary Retention.

While distressing to patients and physicians alike, urine discoloration is mostly benign. Most cases are due to food and drugs. A thorough history and physical exam generally elucidate the etiology but clinicians should have a broad knowledge of the differential diagnosis because life-threatening conditions, such as infection and poisonings, can also manifest as urine discoloration. Here, we present a case of a patient who presented with urinary retention and was found to have turquoise-colored urine, which was due to one of the patient's medications, Uribel. An appreciation of urine discoloration that is related to a benign and reversible medication can lead to stress reduction for patients and a reduction in unnecessary additional testing.

A case of spinal epidural lipomatosis presenting as a stroke mimic.

Here we present the case of a patient with right upper extremity and right lower extremity weakness of a three-day duration, which triggered a stroke evaluation. Ultimately, the diagnosis of spinal epidural lipomatosis (SEL) was made. Non-stroke diagnoses that present with stroke-like symptoms are referred to in the medical literature as stroke mimics. Such cases present with neurological deficits that imitate acute ischemic stroke. The frequency of such presentations occurs in up to 30% of initially suspected stroke. This case illustrates that SEL can present as a stroke mimic. To our knowledge, this is the first description of a presentation in the medical literature of SEL as a stroke mimic.

A curious case of a blue finger.

ABSTRACT: This article describes an unusual presentation of a blue finger in a middle-aged woman with no significant past medical history. The patient was diagnosed with Achenbach syndrome, a rare condition that is generally considered transient and benign. The underlying pathophysiology of this condition is unclear, but may be related to transient subcutaneous ecchymosis, possibly from microtrauma. If the condition recurs, a workup can include laboratory tests for autoimmune diseases such as rheumatoid arthritis. Clinician awareness of this presentation may reduce patient anxiety and unnecessary testing.

Palliative and end-of-life care in the emergency department.

With current medical advances, the human population continues to age. This presents healthcare practitioners with the increasing complexity of providing care to elderly patients with multifactorial medical and personal needs. This is a particular challenge in the emergency department, where patients often present for care in the last months of their lives. Early identification of palliative care needs and initiation of comfort care can drastically improve patient care and quality of life. Although emergency physicians agree that palliative care is an important area of knowledge, there is a gap in palliative care training in emergency medicine residencies. It is increasingly important for emergency medicine providers to have the resources and training to provide palliative care and to understand end-of-life issues.

A Bitter Experience-A Bitter Apple (Citrullus colocynthis) Ingestion in a Child.

Here we present the case of a 4-year-old child who presented to the emergency department (ED) with bloody diarrhea. The causative agent was confirmed to be Citrullus colocynthis (bitter apple), which had been given to the patient by his grandmother for constipation. Hemorrhagic colitis can be induced by Citrullus colocynthis. Treatment is essentially support. Hypoglycemia and transaminitis have been associated with Citrullus colocynthis ingestion. The case highlights that pediatric patients can be inadvertently exposed to herbal medications that can cause harm. It also highlights that certain herbal medications with toxic potential, such as Citrullus, can be seen in emergency departments that are geographically quite distant from the most common origins of the plant. To our knowledge, this is the first American pediatric case report of bitter apple induced hemorrhagic colitis.

Aspergilloma Superimposed Infection on Lymphoid Interstitial Pneumonia.

We describe a case of a 27-year-old female without any prior underlying immunodeficiency syndromes who presented with hemoptysis secondary to subacute invasive pulmonary aspergillosis and subsequently diagnosed with lymphoid interstitial pneumonia (LIP). CT chest demonstrated bilateral interstitial disease with patchy opacities and multiple large cysts and bullae. Diagnosis was confirmed histologically after surgical lung resection of the mycetoma containing cavitation. Therefore, LIP should be suspected in patients presenting with opportunistic infections in the setting of cystic lung disease.

Intussusception in an infant with two non-diagnostic abdominal ultrasound studies / 世界急诊医学杂志（英文）

@#Intussusception is the invagination of one portion of the intestines into another, and is the most common form of intestinal obstruction in infants.[1] The vast majority of cases of intussusception are idiopathic, and are thought to be due to hyperplasia of the lymphoid tissue in the Peyer 's patches of the terminal ileum. The clinical diagnosis of intussusception may be difficult to make as it may be masked by its propensity to occur in the context of viral gastroenteritis. The diagnosis of intussusception can be made wi th sonography, plain abdominal radiographs or contrast enema. Ultrasonography has been found to have a negative predictive value of 100%. However, we report a case of a full term 7-month-old male with no significant medical history who presented to the emergency department with fever, decreased PO intake, decreased urine output, and vomiting for three days, that was subsequently diagnosed with a small bowel obstruction secondary to intussusception without sonographic evidence of intussusception on two ultrasound studies.