Introduction: Acute pain crises are a common emergency department presentation in patients with sickle cell disease. Pain management typically relies on multimodal analgesia, with opioids often playing a central role. We propose incorporating regional anesthesia techniques into the pain management regimen. Case Report: We present a case of a young patient with sickle cell disease experiencing an acute pain crisis with severe knee pain. A genicular nerve block was performed, resulting in significant pain reduction in the affected knee. Conclusion: Regional anesthesia, including isolated nerve blocks, may be safe and effective as part of a multimodal pain approach for patients suffering from acute pain crises due to sickle cell disease. This may help reduce the need for opioid or other sedating pain medications, as well as the inherent risks associated with increasing doses, such as respiratory depression.
Introduction: Retrocaval ureter (RCU) is a rare congenital anomaly resulting from abnormal development of the inferior vena cava, leading to ureteral obstruction and hydronephrosis. Patients often present with nonspecific symptoms, making diagnosis challenging. Point-of-care ultrasound (POCUS) is frequently used in the emergency department (ED) to evaluate abdominal pain and may identify clinically important abnormalities requiring further investigation. Case Report: A 30-year-old woman presented to the ED with a two-day history of nonspecific abdominal pain. Physical examination was notable only for mild epigastric tenderness. Abdominal POCUS performed by the emergency physician demonstrated moderate right-sided hydronephrosis. The patient had no urinary symptoms and normal renal function. Follow-up renal ultrasound confirmed hydronephrosis and proximal hydroureter without nephrolithiasis. Contrast-enhanced computed tomography subsequently revealed a RCU with the characteristic fish-hook configuration. Renography demonstrated preserved renal function with delayed drainage secondary to ureteral obstruction. The patient underwent surgical correction with ureteral reconstruction and stent placement. Conclusion: This case highlights the value of POCUS in the evaluation of patients with nonspecific abdominal pain. Detection of hydronephrosis prompted further diagnostic evaluation and led to the diagnosis of a rare congenital urologic anomaly requiring surgical intervention. Emergency physicians should consider further investigation when hydronephrosis is identified on POCUS, even in the absence of urinary symptoms.
When a patient with acute blindness presents to the emergency department (ED), the evaluation typically suggests one of the “can’t miss” diagnoses ingrained in emergency physicians during training. How does the differential change when the patient’s presentation does not neatly reveal an expected pathology? A 59-year-old woman presented to the ED with acute binocular blindness in the setting of three days of a flu-like illness. This case offers a practical approach to opening the lens on the presentation of acute blindness.
Introduction: Urticarial rash is a common condition but can present atypically, making it difficult to clinically diagnose. Thorough assessment with awareness and exclusion of differentials is crucial for definitive treatment. Case Report: This is a case of a 23-year-old woman who presented with signs and symptoms suggestive of streptococcal pharyngitis and was treated with clarithromycin by primary care. Two weeks later, the patient was referred to the emergency department for malaise and an acute, rapidly progressing pruritic rash. Further evaluation revealed an Epstein-Barr virus (EBV) infection. Conclusion: This case highlights the differential diagnoses and diagnostic reasoning required for a patient with a rash and concurrent respiratory symptoms. Differential considerations include viral exanthem, delayed drug-induced reaction, EBV-associated antibiotic rash, scarlet fever, and urticarial vasculitis. Early identification of atypical urticarial lesions and the exclusion of clinical mimics are vital to guide appropriate therapy and optimize patient outcomes.
Introduction: Hemophilia A is an X-linked recessive bleeding disorder characterized by deficiency of factor VIII. The clinical features of this disease are hemorrhage and can be life-threatening when major organ systems are involved. Case Report: We report the case of a 13-year-old boy with severe hemophilia A and factor VIII inhibitors who presented with fever and septic arthritis, later developing refractory shock with tachyarrhythmia. Despite initial suspicion of sepsis-related myocarditis, point-of-care ultrasound (POCUS) revealed massive hemorrhagic pericardial effusion with tamponade physiology. Recombinant factor VIIa was transfused as hemostatic rescue therapy; the patient was subsequently started on fresh frozen plasma and emicizumab. Ultrasound-guided pericardiocentesis resulted in rapid hemodynamic recovery. Conclusion: This case highlights the importance of considering obstructive shock in unstable hemophilia patients and demonstrates that timely POCUS-based diagnosis and factor-supported pericardiocentesis can be lifesaving.
