Vaginal Bleeding Due to Iatrogenic Uterine Perforation - A Case Report.

Uterine perforation is a rare but potentially life-threatening complication of gynecologic procedures. Serious complications include hemorrhage, infection, and injury to surrounding organ systems (eg, gastrointestinal, urological, vascular, etc.). Risk factors include advanced maternal age, prior gynecologic surgeries, and other anatomical features that impact the difficulty of accessing the uterine cavity. In this case report, we discuss a patient who presented to the emergency department (ED) with diffuse abdominal pain and vaginal bleeding that occurred after an elective dilation and curettage (D&C) for a termination of pregnancy. The diagnosis was suspected clinically and confirmed by imaging including ultrasound (US) and computed tomography (CT) of the abdomen and pelvis. The patient was managed operatively with a multidisciplinary approach including Gynecology, General Surgery, and Urology. The patient was stabilized and eventually discharged. Uterine perforation should be included in the differential for patients with a history of recent gynecologic instrumentation presenting with abdominal pain and vaginal bleeding. The stabilization of these patients requires aggressive volume resuscitation, controlling the source of bleeding, and emergent surgical consultation. Topics: Gynecology, vaginal bleeding, ultrasound, computed tomography.

A Patient with Generalized Weakness - A Case Report.

Emphysematous pyelonephritis (EPN) is a rare and life-threatening sequalae of a urinary tract infection marked by a gas-producing necrotizing infection of the renal parenchyma requiring prompt treatment. It has been found to be correlated with uncontrolled diabetes mellitus and is more common in females due to their increased susceptibility to urinary tract infections. Early recognition and treatment of EPN are essential to improve the patient's prognosis and prevent further complications. In this case we highlight a progressive case of pyelonephritis complicated by emphysematous abscess formation requiring surgical management. A 49-year-old female with a history of diabetes, hypertension, asthma, and lupus who presented to the emergency department (ED) for evaluation of generalized weakness. Lactate was elevated and urinalysis was suggestive of infection. A computed tomography (CT) scan of the abdomen and pelvis revealed a large subcapsular fluid collection with multiple gas and air-fluid levels along the right kidney, as well as another suspected fluid collection adjacent to the upper pole of the right kidney. The findings suggested complicated pyelonephritis with emphysematous abscess formation. Urology was consulted and they suggested a perinephric drain be placed by interventional radiology (IR). The patient progressed well and was ultimately discharged days later in stable condition. Despite its rarity, healthcare providers should consider infectious processes such as EPN in the differential for generalized weakness and promptly initiate appropriate diagnostic and therapeutic measures. Topics: Weakness, sepsis, urology, CT scan.

A Man with Sore Throat-A Case Report.

Supraglottic thermal burns resulting from ingestion of excessively hot food or drink can potentially lead to fatal airway obstruction due to severe edema. In this case we evaluate an adult male who presented to the emergency department (ED) with sore throat and mild voice hoarseness that began while eating hot rice soup two days prior. The patient states that after taking a bite of the hot soup, he coughed due to the heat. Shortly after, he felt a burning sensation in his throat and developed a foreign body sensation. A visual examination with video laryngoscopy of the upper airway showed no evidence of foreign bodies; however, there were suspected thermal burns near the patient's epiglottis. This case demonstrates how thermal burns can be evaluated and treated with conservative measures to reduce edema, but care takers should be aware of the severe burns leading to complete airway obstruction. Topics: Supraglottic burns, airway obstruction, laryngoscopy.

To Drain or not to Drain? Point-of-care Ultrasound to Investigate an Axillary Mass: Case Report.

INTRODUCTION: Point-of-care ultrasound (POCUS) has great sensitivity in the diagnosis of abscesses and swollen lymph nodes. Many studies outline the characteristics that distinguish abscesses from lymph nodes on POCUS. CASE REPORT: We present a case from the emergency department in which a patient presented with a potential abscess but was found to have a malignant lymph node on imaging. CONCLUSION: Point-of-care ultrasound can be used to differentiate an abscess from a swollen lymph node. Abscesses are generally anechoic or hypoechoic with septae, sediment or gas contents, and they lack internal vascularity. Benign lymph nodes are echogenic with hypoechoic cortex with hilar vascularity.

Inferior STEMI Electrocardiogram in a Young Postpartum Female with Sickle Cell Trait with Chest Pain - A Case Report.

This is a case of a 35-year-old postpartum female presenting to the emergency department (ED) with acute onset chest pain and dyspnea with initial concern for acute ST-segment elevation myocardial infarct (STEMI). Her electrocardiogram (ECG) showed ST segment elevations in the lateral leads and inferior leads with depressions in the high lateral and septal leads. Given her post-partum status, spontaneous coronary artery dissection (SCAD) was part of the differential as well as other emergent processes. Upon cardiac catheterization, the patient was found to have 50% vasospasm in the left circumflex coronary artery. Her post-catheterization echocardiogram showed a normal ejection fraction (EF) without regional wall abnormalities. This is an interesting case of chest pain in a younger patient, without typical acute coronary syndrome (ACS) risk factors, presenting with a concerning ECG likely due to coronary vasospasm. We will discuss other atypical causes of STEMI patterns that should be considered in the differential and management of such patients. Topics: Sickle cell trait, STEMI, postpartum, vasospasm, ECG, cardiology.

High-Pressure Injection Injury to the Hand - A Case Report.

High-pressure injection injuries to the hand can be surgical emergencies. The injected material and subsequent edema increase the risk for infection, ischemia, compartment syndrome, and limb loss. This is a case report of a 53-year-old male who presented to the emergency department with a superficial two-centimeter laceration to the dorsum of his left hand. He had no obvious signs of infection and the surrounding structures were neurovascularly intact. The patient had been using a gas-powered pressure washer when he sustained the injury to his hand. Physical exam revealed marked crepitus throughout the left hand extending up to the mid forearm. Radiographs of the left hand and left forearm demonstrated extensive subcutaneous emphysema. Hand surgery was emergently consulted and recommended admission for serial exams and antibiotics. This case illustrates a key point: despite initially benign presentations, high-pressure injection injuries should be approached as emergent processes that can be easily overlooked if the proper history and appropriate diagnostic measures are not executed. Topics: Hand, orthopedics, x-ray, high-pressure injection injury.

Post-Coital Sudden Cardiac Arrest Due to Non-Traumatic Subarachnoid Hemorrhage-A Case Report.

Emergency medicine (EM) learners are taught to approach cardiac arrest algorithmically using Advanced Cardiac Life Support (ACLS) with particular emphasis on treatment. However, when treating patients in cardiac arrest it is important to maintain a broad differential of possible non-cardiac etiologies of the presenting symptoms. A patient presented to the emergency department (ED) as a post-coital cardiac arrest with prehospital return of spontaneous circulation (ROSC). Electrocardiogram (ECG) suggested a possible coronary artery occlusion. Given the circumstances of the arrest, computed tomography (CT) of the head was performed which demonstrated a large subarachnoid hemorrhage (SAH). Emergent percutaneous coronary intervention (PCI) was deferred due to the alternative explanation for the ECG changes and the patient's instability. Her condition declined, and soon after the patient expired. Patients with sudden cardiac arrest (SCA) due to SAH are unlikely to benefit from PCI, hindering a more appropriate workup and treatment.1 When faced with patients presenting with SCA and relevant risk factors, it is important to avoid anchoring bias and consider that the ischemic changes on ECG may not be due to primary cardiac causes. Topics: Subarachnoid hemorrhage, sudden cardiac arrest, pulseless electrical activity, ECG, CT.

Digital Nerve Block for the Reduction of a Proximal Phalanx Fracture of the Foot - a Case Report.

Providing efficient, and patient-centered care is the goal for managing patients in the emergency department (ED). In this case report, we will discuss how performing a digital nerve block was critical in providing analgesia and facilitating the reduction of a proximal phalanx fracture in a timely fashion for a pediatric patient that presented to the ED with a complaint of right toe pain after stubbing her toe. Radiographs showed evidence of an acute, displaced fracture of the 4th phalanx of the right foot. Utilizing the two-sided web space block, the patient was able to tolerate reduction and splinting with buddy taping without complications. The patient remained neurovascularly intact prior to and after the procedure. This case report demonstrates how a digital nerve block can be a safe, effective intervention that can improve ED throughput. The patient's condition improved throughout her ED course, and she was discharged in stable condition. Topics: Trauma, fracture, x-ray, digital nerve block.

Implementation of a hepatitis A/B vaccination program using an accelerated schedule among high-risk inmates, Los Angeles County Jail, 2007-2010.

BACKGROUND: The Centers for Disease Control and Prevention recommend vaccination for men who have sex with men (MSM) and injection drug users against hepatitis A and B. This study is the first report of a hepatitis vaccination program in a United States jail with a combined vaccine using an accelerated schedule. Los Angeles County has the largest jail system in the nation and Men's Central Jail (MCJ) is the largest facility within that system. MCJ includes a unit for self-identified MSM, where approximately 2700 inmates are housed per year. METHODS AND FINDINGS: Starting in August 2007, a combined hepatitis A and B vaccine was offered to all inmates housed in this special unit. Using an accelerated schedule (0-, 7-, 21-30 days, 12-month booster), a total of 3931 doses were administered to 1633 inmates as of June 2010. Of those, 77% received 2 doses, 58% received 3 doses, and 11% received the booster dose. Inmates who screened positive for a sexually transmitted infection in this unit were 1.3 times more likely to be vaccinated (95% CI 1.2-1.4) compared to others in the same housing unit who screened negative. CONCLUSIONS: Hepatitis vaccination initiatives can be successfully implemented in an urban jail among an extremely high-risk population using the accelerated, combined hepatitis A/B vaccine. Ours may be a useful model for other programs to vaccinate incarcerated populations.

Agarose gel electrophoresis for the separation of DNA fragments.

Agarose gel electrophoresis is the most effective way of separating DNA fragments of varying sizes ranging from 100 bp to 25 kb(1). Agarose is isolated from the seaweed genera Gelidium and Gracilaria, and consists of repeated agarobiose (L- and D-galactose) subunits(2). During gelation, agarose polymers associate non-covalently and form a network of bundles whose pore sizes determine a gel's molecular sieving properties. The use of agarose gel electrophoresis revolutionized the separation of DNA. Prior to the adoption of agarose gels, DNA was primarily separated using sucrose density gradient centrifugation, which only provided an approximation of size. To separate DNA using agarose gel electrophoresis, the DNA is loaded into pre-cast wells in the gel and a current applied. The phosphate backbone of the DNA (and RNA) molecule is negatively charged, therefore when placed in an electric field, DNA fragments will migrate to the positively charged anode. Because DNA has a uniform mass/charge ratio, DNA molecules are separated by size within an agarose gel in a pattern such that the distance traveled is inversely proportional to the log of its molecular weight(3). The leading model for DNA movement through an agarose gel is "biased reptation", whereby the leading edge moves forward and pulls the rest of the molecule along(4). The rate of migration of a DNA molecule through a gel is determined by the following: 1) size of DNA molecule; 2) agarose concentration; 3) DNA conformation(5); 4) voltage applied, 5) presence of ethidium bromide, 6) type of agarose and 7) electrophoresis buffer. After separation, the DNA molecules can be visualized under uv light after staining with an appropriate dye. By following this protocol, students should be able to: Understand the mechanism by which DNA fragments are separated within a gel matrix Understand how conformation of the DNA molecule will determine its mobility through a gel matrix Identify an agarose solution of appropriate concentration for their needs Prepare an agarose gel for electrophoresis of DNA samples Set up the gel electrophoresis apparatus and power supply Select an appropriate voltage for the separation of DNA fragments Understand the mechanism by which ethidium bromide allows for the visualization of DNA bands Determine the sizes of separated DNA fragments.