Rash and Fever in a Returned Traveler.

Case Presentation: A 21-year-old, otherwise healthy female presented to the emergency department with fever among other nonspecific symptoms after recently returning from Ghana. On physical exam, she had a characteristic upper extremity rash, and a tourniquet test revealed numerous petechiae. The diagnosis of dengue was suspected and subsequently confirmed. Discussion: Dengue is one of many viral illnesses that should be considered in returning travelers presenting with fever and other nonspecific symptoms. Emergency physicians must keep a broad differential when evaluating fever in returned travelers and prioritize history and physical exam findings to help narrow the diagnosis and provide appropriate management and supportive care while awaiting further confirmatory testing.

Rapid Cycle Deliberate Practice Training for Simulated Cardiopulmonary Resuscitation in Resident Education.

Background: Simulation-based medical education has been used in medical training for decades. Rapid cycle deliberate practice (RCDP) is a novel simulation strategy that uses iterative practice and feedback to achieve skill mastery. To date, there has been minimal evaluation of RCDP vs standard immersive simulation (IS) for the teaching of cardiopulmonary resuscitation to graduate medical education (GME) learners. Our primary objective was to compare the time to performance of Advanced Cardiac Life Support (ACLS) actions between trainees who completed RCDP vs IS. Methods: This study was a prospective, randomized, controlled curriculum evaluation. A total of 55 postgraduate year-1 internal medicine and emergency medicine residents participated in the study. Residents were randomized to instruction by RCDP (28) or IS (27). Stress and ability were self-assessed before and after training using an anonymous survey that incorporated five-point Likert-type questions. We measured and compared times to initiate critical ACLS actions between the two groups during a subsequent IS. Results: Prior learner experience between RCDP and IS groups was similar. Times to completion of the first pulse check, chest compression initiation, backboard placement, pad placement, initial rhythm analysis, first defibrillation, epinephrine administration, and antiarrhythmic administration were similar between RCDP and IS groups. However, RCDP groups took less time to complete the pulse check between compression cycles (6.2 vs 14.2 seconds, P = 0.01). Following training, learners in the RCDP and IS groups scored their ability to lead and their levels of anticipated stress similarly (3.43 vs 3.30, (P = 0.77), 2.43 vs. 2.41, P = 0.98, respectively). However, RCDP groups rated their ability to participate in resuscitation more highly (4.50 vs 3.96, P = 0.01). The RCDP groups also reported their realized stress of participating in the event as lower than that of the IS groups (2.36 vs 2.85, P = 0.01). Conclusion: Rapid cycle deliberate practice learners demonstrated a shorter pulse check duration, reported lower stress levels associated with their experience, and rated their ability to participate in ACLS care more highly than their IS-trained peers. Our results support further investigation of RCDP in other simulation settings.

Massive Hiatal Hernia With Acute Gastric Volvulus Masked as a Suspected Food Poisoning: A Case Report.

We describe the case of a 69-year-old female who thought she had "food poisoning", which prompted her visit to the Emergency Department for evaluation of her vomiting and abdominal discomfort. Contrasted computed tomography imaging with contrast of the abdomen subsequently revealed the diagnosis of gastric volvulus, and the patient was promptly taken for surgical intervention. Gastric volvulus is rare and presents with a nonspecific history, exam, and laboratory findings. In the acute care setting, it is important to maintain a high clinical suspicion for this diagnosis, as timely imaging and intervention are crucial to decreasing patient morbidity and mortality.

Female with Atraumatic Abdominal Bruising.

CASE PRESENTATION: We describe the case of a 38-year-old female patient with a history of lupus presenting with atraumatic abdominal pain and ecchymosis. The ultimate diagnosis of abdominal lupus erythematous panniculitis was determined based on physical exam and imaging findings. DISCUSSION: Lupus erythematous panniculitis is a rare diagnosis, but consideration is important as early recognition and treatment is important to reduce pain and lessen the possibility of irreversible disfigurement and unnecessary costs to affected patients.

A Woman with Abdominal Pain After Lap-belt Trauma.

Case presentation: A 24-year-old female presented to the emergency department with diffuse abdominal pain after involvement as a restrained driver in a motor vehicle collision (MVC). Computed tomography of the abdomen revealed a traumatic abdominal wall hernia due to rectus wall rupture with complete bowel herniation. Discussion: A traumatic abdominal wall hernia is a rare complication of blunt abdominal trauma that is typically associated with injury from a motorcycle handlebar but is more commonly seen after a MVC. It is important to consider this diagnosis when evaluating patients with abdominal pain after blunt abdominal trauma from either of these mechanisms.

Point-of-care ultrasound diagnosis of flexor tenosynovitis caused by an unusual pathogen.

Skin and soft tissue infections are commonly encountered in the emergency department and are typically caused by common gram-positive bacteria. In the immunocompromised patient, however, infections from unusual pathogens should also be considered. We describe the case of a 66-year-old male with a history of renal transplant who was diagnosed with flexor tenosynovitis by point-of-care ultrasound. Although initial wound cultures were negative, subsequent microbiological testing led to the underlying cause, a nontuberculous mycobacterial infection.