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A Case Report of Subtle EKG Abnormalities in Acute Coronary Syndromes Indicative of Type One Myocardial Infarction

Paige Matijasich, BA*, Patrick Bruss, MD^, Gregory Reinhold, MD^ and Zachary Koppelmann, MD^

DOI: https://doi.org/10.21980/J8W06X Issue 8:2[mrp_rating_result]
The ECG does show multiple subtle abnormalities that in conjunction with his symptoms and risk factors are concerning for ischemia and/or occlusion of the coronary artery vessel. 1) ST depression in aVL. Although slight, the ST segment is below the TP segment or isoelectric point (blue circles). 2) Focal hyper QT waves. The T-waves in II, III, AVF V2, V3, and V4 are hyper acute, namely peaked and tall in relationship to the QRS. These are best displayed in leads II, III, and AVF where the T-waves are taller than the QRS amplitude (vertical blue lines). 3) Straightening off the ST segment. Multiple leads display a straight ST segment namely aVL, III, AVF, and V2 (red lines). Of note, the length of the straight ST segment is greater than 1/4 the amplitude of the QRS (purple lines). 4) Although subtle, these abnormalities are focal in nature.
Visual EMCardiology/Vascular
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Case Report of Herpes Zoster Ophthalmicus with Concurrent Parotitis

Serena Tally, BS*, Michelle Brown, DO* and Edmund Hsu, MD*

DOI: https://doi.org/10.21980/J8R93N Issue 8:2[mrp_rating_result]
The presence of soft tissue stranding about the parotid gland suggested an underlying inflammatory or infectious process of the parotid gland. Cellulitis was considered as a possible diagnosis as well, given the presence of soft tissue stranding in the dermis that is adjacent to the parotid gland. Fortunately, no enhancement was seen in local muscles, fascia, or bones to suggest a myositis, fasciitis, or osteomyelitis. By using the anatomy of the patient and understanding the changes that occur on CT when inflammation is present, the appropriate depth and location of infection can be made, allowing for appropriate treatment regimens.
Visual EMInfectious DiseaseOphthalmology
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A Man with Sore Throat—A Case Report

Nathan Mercado, BS*, Sawyer Schuljak, MD^, Daniel Ng, MD*^, Curtis Knight, MD*^, Allison Woodall, MD*^ and John Costumbrado, MD, MPH*^

DOI: https://doi.org/10.21980/J8MH0B Issue 8:2[mrp_rating_result]
Video laryngoscopy of the upper airway was performed two days after initial burn injury. The images obtained demonstrated laryngeal edema and inflammation near the epiglottis. The dot identifies the epiglottis and the asterix identifies the area of moderate thermal burns. Imaging also demonstrated adequate patency of airway and ruled out the need for intubation at that time.
Visual EMENTProcedures
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The Continued Rise of Syphilis: A Case Report to Aid in Identification of the Great Imitator

Nicole Finney, MPH*, Eli Soyfer, MS*, Rory Schwan, MD* and Lindsey C Spiegelman, MD, MBA*

DOI: https://doi.org/10.21980/J8R93N Issue 8:2[mrp_rating_result]
Images taken of the bilateral palmar skin lesions at our institution showed multi-centimeter, well-demarcated, friable, verrucous, crusted plaques with overlying fine yellow crust. Lesions such as these are suspicious for syphilitic gummas seen with cutaneous tertiary syphilis.
Visual EMInfectious Disease
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Telemedicine Consult for Shortness of Breath Due to Sympathetic Crashing Acute Pulmonary Edema

Derek Jacob Carver Hunt, DO*, Kevin McLendon, DO*, Carl Johns III, DO* and Daniel Crane, MD*

DOI: https://doi.org/10.21980/J8HS86 Issue 8:1[mrp_rating_result]
At the completion of the simulation and debriefing, the learner will be able to: 1) recognize the physical exam findings and presentation of SCAPE, 2) utilize imaging and laboratory results to further aid in the diagnosis of SCAPE, 3) initiate treatments necessary for the stabilization of SCAPE, 4) demonstrate the ability to assist with the stabilization and disposition of a patient via tele-medicine as determined by the critical action checklist and assessment tool below, 5) interpret the electrocardiogram (EKG) as atrial fibrillation with rapid ventricular response (AFRVR), and 6) recognize that SCAPE is the underlying cause of AFRVR and continue to treat the former. 
RespiratoryClinical Informatics, Telehealth and TechnologySimulation
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Anticholinergic Toxicity in the Emergency Department

C Eric McCoy, MD, MPH* and Reid Honda, MD^ 

DOI: https://doi.org/10.21980/J8D07Z Issue 8:1[mrp_rating_result]
By the end of this simulation case, learners will be able to: 1) describe the classic clinical presentation of anticholinergic toxicity, 2) discuss common medications and substances that may lead to anticholinergic toxicity, 3) recognize the electrocardiogram (ECG) findings in anticholinergic toxicity that require specific therapy, and 4) review the management of anticholinergic toxicity.
ToxicologySimulation
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The Suicidal Patient in the Emergency Department Team-Based Learning Activity

Caroline Stoddard Astemborski, MD* and Sara Dimeo, MD, MEHP^

DOI: https://doi.org/10.21980/J8892XIssue 8:1[mrp_rating_result]
By the end of the session, participants will be able to: 1) describe risk factors for suicide; 2) summarize the emergency physician’s role in assessing patients with psychiatric emergencies; 3) assess a patient using a mental status evaluation; 4) identify the criteria for involuntary psychiatric hold placement; 5) develop a safe discharge plan for patients experiencing depression; and 6) Formulate a plan for evaluating a suicidal patient who is acutely intoxicated.
PsychiatryTeam Based Learning (TBL)
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Child Maltreatment Education: Utilizing an Escape Room Activity to Engage Learners on a Sensitive Topic

Shelley Brukman, MSN, RN*, Makenzie J Ferguson, BSN, RN*, Kimberly D Zaky, MSN, FNP-C*, Chloe Knudsen-Robbins, MM^ and Theodore W Heyming, MD†

DOI: https://doi.org/10.21980/J84H1C Issue 8:1[mrp_rating_result]
By the end of the escape room, the learner should be able to: 1) understand the national and local prevalence of child maltreatment; 2) understand the different types of child maltreatment and common associated presentations; 3) know the local EMS agency reporting requirements; 4) understand when to make base hospital contact with respect to concern for maltreatment; 5) collaborate effectively as a team.
PediatricsSmall Group LearningTrauma

Acute Chest Syndrome

Patrick Meloy, MD*, Daniel R Rutz, MD^ and Amit Bhambri, MD†

DOI: https://doi.org/10.21980/J80S8J Issue 8:1[mrp_rating_result]
At the end of this oral board session, examinees will: 1) demonstrate the ability to obtain a complete medical history; 2) demonstrate the ability to perform a detailed physical examination in a patient with respiratory distress; 3) identify a patient with respiratory distress and hypoxia and manage appropriately (administer oxygen, place patient on monitor); 4) investigate the broad differential diagnoses which include acute chest syndrome, pneumonia, acute coronary syndrome, acute congestive heart failure, acute aortic dissection and acute pulmonary embolism; 5) list the appropriate laboratory and imaging studies to differentiate acute chest syndrome from other diagnoses (complete blood count, comprehensive metabolic panel, brain natriuretic peptide (BNP), lactic acid, procalcitonin, EKG, troponin level, d-dimer, chest radiograph); 6) identify a patient with acute chest syndrome and manage appropriately (administer intravenous pain medications, administer antibiotics after obtaining blood cultures, emergent consultation with hematology) and 7) provide appropriate disposition to the intensive care unit after consultation with hematology.
Cardiology/VascularCertifying Exam Cases
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Imaging Findings of Small Bowel – Diverticulitis: A Case Report

Albert Zhou, MD*, Sarah Bella, DO*, and Amy Patwa, DO*

DOI: https://doi.org/10.21980/J8F078 Issue 8:1[mrp_rating_result]
Bedside ultrasound was performed and showed thickened bowel wall (orange marker), fat enhancement (green marker), and phlegmonous structure with central echogenicity (yellow marker). Imaging of the abdomen and pelvis with CT showed marked wall thickening and inflammatory change involving a 7.0cm segment of the distal/terminal ileum suspicious for severe ileitis with phlegmon and microabscess on the coronal image (yellow arrow). Additonally, the transverse images show a small rim-enhancing focus within this region of inflammation measuring up to 1.4cm which could represent microabscess (yellow arrow). Diagnosis of diverticulitis by ultrasound is made by identifying the following findings: colon wall thicker than 5mm, fat enhancement, evidence of abscess, visualized diverticuli, air artifacts suggesting diverticuli, and tenderness with compression of the probe.6 Diagnosis of diverticulitis by CT is made by identifying the following findings: colonic wall thickening, pericolic fat stranding, abscess formation and enhancement of the colonic wall. Often, these signs are associated with an identifiable inflamed diverticulum.7
Abdominal/GastroenterologyVisual EM