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Case Presentations and Posters - Emergency Medicine

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Clinical Pathologic Case (CPC) Competitions


Poster Presentations

london fasciitis

A Deflected Blow: The Case of an Inflated Face Mimicking Necrotizing Fasciitis

Hollis London, DO, Steven Zimmerman MD, Stephen Havasy MD

A 31 year old female developed extensive subcutaneous emphysema after blowing her nose in the setting of a recent canine bite to the face.  This  process mimicked necrotizing fasciitis.


siddhartha cvst

Cerebral Venous Sinus Thrombosis as a Cause of Headache in the Emergency Department: A Case Report

Siddhartha Al-Hashimi, DO, John Leavens, MD

A 23 year old female presented with an atraumatic headache that was different than her typical migraine.  A non-contrast CT illustrated a CVST.  This illustrates both a rare disease and contradicts CMS recommended use of CT imaging in the ED for atraumatic headaches.


patel co poison

Carbon Monoxide Intoxication Disguised as Atrial Fibrillation

Punam Patel, DO, Steven Sattler, DO

A 62 year old female presented with new AF with RVR, discovered to be induced by CO poisoning.  CO poisoning can be very difficult to diagnose outside of the typical clinical vignette.


lyncean killer ticker

The Killer Ticker

Lyncean Ung, DO, Doni Marie Rivas, DO, Steven Sattler, DO

A 50 year old male with unilateral neck swelling after placement of an AICD, found to be caused by a right IJ DVT.  IJ DVT is extremely rare, even in the setting of an AICD.


bober addisons

Addison’s Disease: A Rare Cause of Syncope

Wojciech Bober, DO, David Levy, DO, Cynthia Rosenthal, DO

A 15 year old female presented with syncope, vomiting, weakness and hyponatremia with a low cortisol, elevated rennin and adrenal cortex antibodies. Patient was found to have Addison’s disease. It exhibits what a difficult diagnosis this can be in the emergency department setting.


ault not all coins

Not All Coins Pass: Case Report of an Atypical Quarter Ingestion 

Brian Ault, DO, Rudolph Baldeo MD, Martin Winick, MD, Ronald Dvorkin, MD, David Levy, DO

A 5 year old male presented with a small bowel obstruction due to a retained quarter than he had ingested.  At laparotomy, he was found to have a duplication cyst.


fil omm headaches

Does The Use of Osteopathic Manipulative Treatments on Patient’s With Headache in the Emergency Department Result in Decreased Pain? 

Genevieve McGerald, DO, Ronald Dvorkin, MD, David Levy, DO, Jacob Bair, DO, Laura Fil, DO,  Doni Marie Segerivas, DO, Shannon Weinstein, DO, David Yens PhD

The effect of osteopathic manipulation upon headache has not been studied in the emergency department.  The purpose of this study is to compare the clinical efficacy of the use of OMT in the emergency department who present with headache as compared to sham treatment. We were unable to demonstrate that OMT is an effective treatment for headaches in the emergency department. There may be a different outcome if the study was repeated in a different clinical setting or with different techniques.


fil acetominophen

Does Patient Education in the Emergency Department Increase Patient Awareness that Acetaminophen is Contained in Percocet?  

Laura Fil MS DO, Steve Sattler DO, Ron Dvorkin MD, David Yens PhD, Mark Baginski OMS I

The study assessed if patient education in the Emergency Department (ED) can lead to increased awareness of acetaminophen in their prescription opioid-acetaminophen medication. Our study showed that most patients are able to retain educational information that is told to them for a short time, however after a 4 month period of time patients may not retain this information.


busch sneeze

The Sneeze That Broke One’s Back 

Kristie Busch, DO, David Levy, DO

A previously healthy young male who presented to the ED with back pain after sneezing. Evaluation revealed advanced stage metastatic gastric cancer with a pathologic vertebral body fracture.


hughes appendicitis

Omental Infarction Masquerading as Appendicitis in a 3 Year Old 

Heather Hughes, DO, Reethamma Daniel, MD, Genevieve McGerald, DO, Neil Kutin, MD

A 3 year old female presented to the emergency department with a 3 day history of right lower quadrant pain and a CT suggesting appendicitis. This turned out to be an omental infarction, the youngest reported case and suggest it be included in the differential diagnosis of abdominal pain in this age group.


bozek supernumerary spleen

From One Rarity to Another: A Case of a Supernumerary Ovary in a 13 Year Old Girl

Joshua Bozek DO, David Levy DO, Rudolph Baldeo MD, Martin Winick MD

A 13 year old female presented with abdominal pain that during surgery was thought to be a retroperitoneal lymphangioma. Pathology showed that this was a rare case of a supernumerary ovary, only the second case of a pediatric supernumerary ovary ever described in the literature.


prahl labial fusion

A Rare Case of Labial Fusion Resulting in Urinary Retention 

Robert Prahl, DO, Michelle Gebhard, DO, Genevieve McGerald, DO, Richard Klein, MD

An 85 year old female presented to the ED with lower abdominal pain and urinary retention.  On exam she was noted to have labial agglutination, or adhesions, as the cause of a mechanical obstruction. 


fil overdose

A Massive Overdose of Dalfampridine (Ampyra®) 

Laura Fil, DO, Steven Sattler, DO, Stephen Havasy, MD

A 34 year old male with multiple sclerosis was brought to the Emergency Department and developed seizures secondary to an overdose of Dalfampridine or 4-aminopyridine (4-AP) with a level of 530 ng/mL.  The case illustrates the highest reported level of 4-AP in an overdose.


weinstein abdominal mass

A Case of an Abdominal Mass Masquerading as Shoulder Pain 

Shannon Weinstein DO, Babak Saadatmand MD, Steven Sattler DO, David Levy DO

A 62 year old female presented to the ED with three weeks of left shoulder pain.  Evaluation in the Emergency Department revealed a large abdominal mass measuring 13cm x 15cm x 24cm in size and subsequently found to be a lymphoma. 


vitello scfe

Slipped Capital Femoral Epiphysis Detected with Ultrasonography

Sarah Vitello, DO, David Teng, MD, Genevieve McGerald, DO

An 11 year old male presented complaining of left hip pain and a bedside ultrasound revealed a physeal step-off on the left as compared to the right. Ultrasonography is a quick and effective modality for the bedside diagnosis of SCFE (Slipped Capital Femoral Epiphysis).  


dubroviskiy renal infarct

Right Renal Infarct Diagnosed with Contrast CT

Aleksandr Dubrovskiy, DO, David Levy, DO, Babak Saadatmand, MD

A 56 year old male presented with right flank pain that with a negative non-contrast CT. After the LDH was found to be elevated a follow up contrast CT was performed which showed a right renal infarct. 


chantel lemierres

Lemierre’s Syndrome:  Not Your Everyday Sore Throat

Chantel O’Shea, DO, David Levy, DO 

A 31 year old male presented to the ED with an exudative pharyngitis and thrombocytopenia, blood cultures grew Fusobacterium necrophorum. He subsequently developed Lemierre’s syndrome (internal jugular vein thrombosis) 


davis vision loss

Can’t See the Cause: A Case of Vision Loss in a Pregnant Patient

Frederick Davis, DO, Shefali Trivedi, MD, Sanford Glantz, MD

The first described case of a pregnant female with vision loss secondary to ondansetron (Zofran). Possible explanation may involve 5-HT3A subgroup receptor and ondansetron does have an antagonistic effect on this receptor. 


keehn rij thrombo

Black and Blues: A Case Report of a Spontaneous Right Internal Jugular Vein Thrombus  

Steven Keehn, DO, Jeffrey Margulies, MD, David Levy, DO, Ronald Dvorkin, MD

A 74 year old male on warfarin presented to the ED with bilateral arm hematomas and right-sided neck pain. The cause was eventually determined to be the rare occurrence of a spontaneous internal jugular vein thrombus. 


doni marie blue leg

A Sudden Cause of a Blue Leg:  May Thurner Syndrome  

Doni Marie Rivas, DO, Steven Sattler, DO, Louis Amblard, MD

A 49 year old female presented with a left leg color change while walking. She was found to have May Thurner syndrome, a rare congenital anatomic variant causing narrowing of the left common iliac vein due to compression from the right common iliac artery against the lumbar spine. 


bair fever2

Is Fever Treated More Promptly than Pain in the Pediatric Emergency Department?

Jacob Bair, DO, Ronald Dvorkin, MD, Hardik Patel, MBBS, Sanford Glantz, MD, Jeffrey Margulies, MD

Pediatric patients are treated sooner with Acetaminophen or ibuprofen when presenting with fever than those who do not have a fever.  We believe this difference is associated with prevailing concerns about fever and the phenomena of oligoanalgesia. 


busch murmers

Two Methods of Teaching Heart Murmurs: Sim Lab vs Traditional Lecture Method

Clark Homan MD, Ronald Dvorkin MD, David Levy DO, David Yens PhD, Joshua Bozek DO, Kristie Busch DO, Frederick Davis DO, Chantel O’Shea DO, Steven Keehn DO

Medical students learn to identify heart murmurs in a multitude of ways. Our objective was to evaluate the effectiveness of the standardized lecture format of teaching and that of sim-lab training in the identification of basic heart sounds and murmurs by medical students. We found that medical student’s identification of cardiac murmurs are improved with the use of audio visual lecture presentations and simulated patients.



schwartz in-service exam

The Osteopathic Emergency Medicine Resident In-Service Examination Correlated with the American Osteopathic Board of Emergency Medicine Part I Certifying Examination

Adam Schwartz DO, David Levy DO, Steven Zimmerman MD, Ronald Dvorkin MD, David Yens, PhD

We have shown a strong correlation between a resident’s percentile score on the RISE during their fourth year of residency training and first time success on the AOBEM Part 1 Certifying Examination.  This demonstrates the usefulness of the RISE for osteopathic emergency medicine residency program directors as it offers a tool by which to gauge the performance of their residents and suggests the preparedness of fourth year residents who will be taking the Part 1 Certifying Examination.


JustaCough But it’s Just a Cough…Pneumomediastinum Detected on Bedside Ultrasound

Joseph Artale, DO, David Teng, MD, David Levy, DO

An 8-year-old male presented with a cough, congestion and throat pain. He had subcutaneous emphysema of his neck on exam. Using bedside sonography, hyperechoic strands with “comet tails” were visualized which are indicative of air tracking through the carotid sheath. The patient was diagnosed with a pneumomediastinum.


SurpriseAwakening A Surprising Awakening: Case Report of Post Anesthesia Guillain Barré Syndrome

Andrew Flanagan, DO, Filippo Di Carmine, MD, David Levy, DO 

A 17-year-old female developed a rapidly progressive ascending weakness leading to paralysis following general anesthesia for an appendectomy. She was diagnosed with Guillain-Barré Syndrome (GBS) and started on intravenous immunoglobulin (IVIG).  She ultimately improved with full recovery.




diagnosed appendicitis Can a diagnosed appendicitis on ultrasound reduce the need for CT scan to rule out appendicitis: A prospective study utilizing residents of a small community hospital to determine accuracy in diagnosing appendicitis following a brief training module

Andrew Flanagan, DO, Andrew Mapley, DO, Diana Kontonotas, DO, Jason Idelson, DO, Joseph Artale, DO, David Teng, MD, Ronald Dvorkin, MD, Steven Zimmerman, MD

There are over 100,000 annual cases of appendicitis in the pediatric population in the US. Many have had a CT to diagnose. The ionizing radiation from a CT scan has been estimated by some to increase the lifetime risk of cancer by approximately 1 of every 1,000 studies. We wish to demonstrate that in many cases appendicitis can be reliably diagnosed by Emergency Physicians and Residents with a bedside ultrasound examination in the ED. Feedback may be useful in training emergency medicine residents to reliably identify appendicitis with bedside ultrasound.


internal decapitation Internal Decapitation: A New Perspective

Jason D Idelson, DO, Eric F Decena, MD, Stephen M Henesch, DO, David L Levy, DO
Annually, there are approximately 12,000 new cases of spinal cord injury in the United States. Patients who survive often face devastating physical immobility and a lifetime of related health issues. We present the case of a 42-year-old male presenting after a high speed motor vehicle collision who sustained a C6/C7 spinal level internal decapitation injury.  While some may think this highlights the importance of cervical collars, there is growing evidence to support that utilizing these collars might cause increased harm through further distraction of the spine.


life threatening leak A Life-Threatening Leak: Type 1 EVAR Symptomatic Endoleak Diagnosed on Bedside Ultrasound

Diana Kontonotas, DO, Sarah Arzt, DO, Charles La Rosa ,MD, Genevieve McGerald, DO

Endovascular aneurysm repair (EVAR) has gained acceptance asan alternative to traditional open surgery for repair of abdominal aortic aneurysms (AAAs). A recognized disadvantage is the development of an endoleak; defined as persistent blood-flow outside of the graft and within the aneurysmal sac.  We present a case of a 63-year-old male with a previous endovascular repair of an AAA who presented to the ED complaining of left lower quadrant (LLQ) abdominal pain. CT scan confirmed the diagnosis of endoleak and the patient then underwent emergent operative angiography and endovascular repair of this symptomatic type 1 endoleak.




fast pitfall

A FAST Pitfall: False Positive FAST Exam Caused by Massive Hydronephrosis

Sarah Vitello, DO, Diana Kontonotas, DO, Paul Barbara, MD, David Teng, MD, Genevieve McGerald, DO

We report a case of a 21-year-old bicyclist struck by a car with massive left hydronephrosis, localized to the upper pole of the kidney, causing a false positive FAST exam. The Focused Assessment with Sonography for Trauma (FAST) exam has become the standard of care in the evaluation of a trauma patient for intrabdominal or pericardial fluid collections. In many institutions a positive FAST exam in a hemodynamically unstable patient is an indication for an immediate exploratory laparotomy in the operating room. Hemodynamically stable patients with a positive FAST exam can be further evaluated with a CT scan. The FAST exam is now being relied upon to make critical decisions in trauma patients and it is important to identify entities that cause false positive exams.



PANDAS: (Pediatric Autoimmune Neuropsychiatric Disorders Associated with Strep)

Andrew Mapley, DO, Jonathan Golden, MD, Steven Sattler, DO, Mikhail Mirer, MD

Pediatric Autoimmune Neuropsychiatric Disorders Associated with Streptococcal infections (PANDAS) can present as a variety of neuropsychiatric complaints such as obsessive-compulsive behavior or involuntary muscle movements.  First described in 1998 PANDAS is becoming an increasingly recognized diagnosis and should be understood by physicians caring for pediatric patients. We present a case of a 3-year-old male who was brought to the ED by his parents with a primary complaint of “twitching and jerking” of hands and neck.  The patient was diagnosed with PANDAS.


crabby situation A Crabby Situation: Our Limitations

Kristie Busch, DO, Robin Mackoff, DO, Steven Zimmerman, MD, Augusto Dasilva, MD

In medicine we use imaging technology every day. The technology has advanced, but has it advanced enough?  We present a case where a foreign body should have been seen on X-ray, but was only found by incision and dissection due to the clinical suspicions of a few physicians.  During deep dissection of the patient’s right hand, the tip of a crab claw was identified piercing the flexor tendon and removed.


now thats a shock Now That’s A Shock!

Frederick Davis, DO, Steven Sattler, DO, Genevieve McGerald, DO, Michael Gray, MD

Toxic shock syndrome (TSS) is a shock syndrome caused by the inflammatory response to toxins produced by various bacteria, most commonly streptococcus and staphylococcus species. We present a case of a 35-year-old male presented to the emergency department for fever and difficulty with concentration and conversation.  The patient developed TSS and an infected shoulder bursitis was identified as the initial site of Staphylococcal infection.


group A strep

GBS:  Making the Connection


Chantel O’Shea DO, David Levy DO, Sara Arzt DO, Sandra Deniz, MD


We present a case report of a 34-year-old female who presented to the ED with lower abdominal pain and vaginal discharge.  She was diagnosed with Group A streptococcus (GAS) peritonitis from an ascending infection of her genitourinary tract. Her husband had a GAS pharyngitis and was identified as the initial reservoir.



zebra Sometimes You Don’t Have to Look for a Zebra in the Forest: A Case Report of a Celiac Artery Thrombosis, Splenic Infarct, and Pulmonary Embolism

Steven Keehn DO, Robin Mackoff DO, David Levy DO, Lawrence Womack MD, Manal Hegazy MD

We report a case of a patient who presented to the ED with abdominal pain. The cause was eventually determined to be the rare occurrence of a celiac artery thrombosis leading to splenic infarction.  The patient concurrently developed a pulmonary embolism. The patient had no risk factors for these diagnoses or hypercoagulable disorders.



punch in the face A Punch in the Face: The Case of a Rapidly Expanding Odontogenic Cyst

Jacob Bair DO, Eric Decena MD, Stephen M Henesch DO, Rachel Ruotolo MD, Sarah Miller PA,  John Mathew, DO

Odontogenic cysts develop within the normal dental follicle that surrounds an unerupted tooth.  These cysts can grow very large and can move teeth, but more commonly are relatively small.  We describe a young male who presented to the ED with the complaint of right facial swelling of two months that was determined to be a large odontogenic cyst.




dying to lose weight Dying to Lose Weight: A Case of a Myocardial Infarction in a Patient Taking an Over-the-Counter Weight Loss Supplement

Laura Fil DO, Eric Decena MD, Rikesh Patel MD, David Levy DO

We present a case of a young male who presented to the ED with an acute myocardial infarction.  We believe that an over-the-counter weight loss supplement contributed to his acute event secondary to an undeclared ingredient in the product. The ingredients of the drug listed on the bottle were all natural ingredients.  However, it was discovered that “Solo Slim” had been taken off the market by the FDA because of an undeclared ingredient named didesmethyl sibutramine.   There have been no other reported cases of this nature.


fatal drip Fatal Drip:  A case of sinusitis causing ascending meningitis

Doni Marie Rivas DO, Genevieve McGerald DO, Patrick Reid MD, Jason Winslow MD, Loretta Rispoli NP

Cerebrospinal fluid leak is a serious condition that can occur secondary to either traumatic or atraumatic causes.  Detection of the defect causing the leak is imperative to avoid serious life-threatening complications. We present a case of a 48-year-old female with an idiopathic left superior ethmoid cell defect which allowed CSF leakage through the ethmoid sinuses as demonstrated on MRI.


multiple medications Is the Use of Multiple Medications an Independent Predictor of Length of Stay and Probability of Admission?

Shannon Weinstein, DO, Ronald Dvorkin, MD, David Levy, DO, David Yens, PhD

It is required that all patients presenting to the ED be asked to provide their current medications and that this list be updated or reconciled when the patient is discharged.  Our study concluded that the number of medications a patient reported at arrival is a predictor of length of stay and probability of admission, and may be useful in constructing models of ED throughput.




The Institution of a Requirement for Osteopathic Manipulative Therapy in an Emergency Medicine Residency Training Program and its Effect on Emergency Department Operations

Andrew Mapley, DO, David Levy, DO, Ronald Dvorkin, MD, Curt Cicotte, RN, David Yens, PhD

While Osteopathic Manipulative Treatments (OMT) have been used successfully in the ED and have been acknowledged as safe and effective modalities, they remain underutilized.  Prior publications have listed “lack of time” as the primary reason for underutilization of OMT.  We have demonstrated that OMT can be successfully practiced in a busy academic community hospital as part of an Emergency Medicine Residency program. Descriptive statistics for the eleven most common diagnoses where OMT was used are presented. OMT has a small but significant effect on the LOS of patients presenting to the ED for common musculoskeletal complaints.


Systolic Blood Pressure

A Novel Method to Measure Systolic Blood Pressure Using Color Flow Doppler

Adam Schwartz, DO, Ronald Dvorkin, MD,  Chris Hill, DO, Tom Hubmer, DO, Beth Hayes, DO, Golru Ghaffari, DO, Eric Decena, MD, David Yens, PhD

Study evaluating the use of ultrasound color flow Doppler as an alternative to traditional methods of determining blood pressure.



Pumped up! A Case Report of Subclavian DVT in a Weight Lifter

Joseph Artale DO, Jonathan Golden MD, Cynthia Rosenthal DO, David Levy DO

A 17-year-old weight lifter presented with left arm swelling. His work-up in the ED was negative for DVT, however, an MRI performed that same day did reveal a subclavian thrombosis.  Following clot lysis by interventional radiology, an angiogram revealed persistent luminal narrowing which was secondary to a hypertrophied scalene muscle.


hubmer presentation

An Investigation of the use of Scribes in an Emergency Department Fast Track and its Effect on Efficiency

Thomas Hubmer, DO, Ronald Dvorkin, MD, Sanford Glantz, MD

Scribes provide assistance with documentation and ordering to the emergency department physician.  The study seeks to quantify the hypothesis that having a scribe as part of the team will allow the physician to see more patients during a shift while decreasing waiting times for patients.


Hill Presentation

How Effective Is The Medical Reconciliation Process in Patients Discharged from the 
Emergency Department?

Christopher Hill, DO, Adhi Sharma, MD, Ronald Dvorkin, MD, Veronica Tucker, OMS III, Jeffrey Margulies, MD

EDs are expected to compile a list of patient medications, reconcile them and pass them along to the next provider. This study showed that there are frequent discrepancies in the medication information that patients provide and that requiribg the ED to reconcile medication information and pass it on to the next provider can be a source of treatment errors in the outpatient setting.


Flanigan Presentation

The Mid-Track System-Flexibly Allocating Resources And Space For A Specific Underserved Population-Comparison Of Walkout Rates For Gynecological and Obstetrical Problems Before and After The Institution Of The New System

Andrew Flanagan, DO, Adhi Sharma, MD, Ronald Dvorkin, MD, Sanford Glantz, MD, David Levy, DO, Eileen Swailes, RN

Many patients with gynecological or obstetrical complaints are classified in a non-emergent tier.  Patients in this tier frequently experience longer wait times to be seen and subsequently leave without being seen (LWBS). The institution of the Mid-Track system reduces the LWBS rate while simultaneously decreasing the LOS in a busy ED with limited space.



A Pressing Headache 

Joshua Bozek, DO, Steven Zimmerman, MD, Andrew Rogove, MD, PhD, Elliott Eisenberger, MD

Posterior reverisble encephalopathy syndrome (PRES) is a diagnosis that can be made in the ED by the astute clinician. Knowing to look for headache, vision changes, altered mental statusa and seizures in a patient with hypertension could help you save brain cells and even a life by simply treating the blood pressure.


busch presentation

Tb or Not To Be: Pott Disease

Kristie Busch, DO, Halina Borowski, MD, David Levy, DO, Stephen Henesch, DO

A 4-year-old who presented with three days of non-traumatic back pain.  The final diagnosis was Pott disease, also known as tuberculous spondylitis. This case is unusual because of the age of the patient and the short duration of symptoms.


Hayes Presentation

Hypoplasia of the Anguli Oris in an Infant: An ED Case Presentation

Beth Hayes, DO, Ira Eckstein, DO, Mikhail Mirer, MD, Sanford Glantz, MD

A 32-day-old male was brought into the ED for evaluation of a right sided facial droop present for the preceding two weeks.  The droop was obvious when the patient cried and was associated with drooling from the right side of his mouth when eating.  His diagnosis was congenital asymmetric crying facies (ACF), a congenital defect secondary to hypoplasia or absence levator anguli oris muscle. The condition may spontaneously resolve in the first year of life but may linger and become less noticeable into childhood.



Spontaneous Rupture of a Renal Angiomyolipoma: Report of a Case

Steven Keehn, DO, Genevieve McGerald, DO, Manish Sharma, MD, David Levy, DO

Renal angiomyolipomas are benign tumors that contain vascular, smooth muscle, and fatty elements.  There are two broad categories of such tumors:  isolate and those associated with tuberous sclerosis.  The majority of cases of angiomyolipomas are asymptomatic; complications include retroperitoneal or intratumoral hemorrhage.



A Rare Cause for Alarm

Frederick Davis, DO, Steven Havasy, MD, David Levy, DO

A 45-year-old female presented to the emergency department with a sore throat whose etiology was determined to be a tongue abscess.  An abscess of the tongue is a very rare condition.  Over the last 30 years, only 50 cases of global abscess have been reported in the English literature.



Adrenal Colic

Golru Ghaffari, DO, Eric Decena, MD

An elderly patient presented to the ED with symptoms of billiary colic and was found to have a symptomatic adrenal hemorrage.



It's Not a Tumor: A Rare Entity

Jason Idelson, DO, Evgeniy Moshkovich, MD, David Levy, DO

This is a case of a 72-year-old female who presented with two weeks of increasing swelling to her anterior forehead.  Work-up revealed a Pott's puffy tumor which is a rare entity in developed countries secondary to widespread availability and use of antibotics.  When it does occur it is described as a disease affecting the pediatric population.



Back Pain That Will Take Your Breath Away

Steven Keehn, DO, David Levy, DO, Steven Zimmerman, MD, Lenny Weinstein, MD

This is a case of a patient who presented to the emergency department with back pain.  The cause was eventually determined to be a rare bacterial infection with pulmonary and systemic nocardiosis.



NMS - From Back Pain to a Hot Mess

Chantel O'Shea, DO, David Levy, DO

A 59-year-old female presented to the ED after being found on the floor.  The patient slowly began to develop fever and rigidity at which time it was revealed that she had overdosed on a concert of medications which may cause Neuroleptic malignant syndrome (NMS).  NMS has become a rare entity secondary in part to the more frequent use of newer and safer antipsychotic medications. This patient's presentation was atypical in that the onset of symptoms was significantly delayed.



Oh No...A PFO

Andrew Flanagan, DO, Stephanie Lovell-Rose, MD, David Levy, DO

This is a case of a young female with multiple syncopal episodes.  Her work-up revealed a patent foramen ovale which is thought to have played a role with microemboli in causing her symptoms.



Ovarian Hyperstimulation Syndrome

Beth Hayes, DO, Stephanie Lovell, MD, Ronald Dvorkin, MD, Sanford Glantz, MD, David Levy, DO

A case of ovarian hyperstimulation syndrome (OHHS), which is an iatrogenic complication of assisted reproduction was reviewed.  Though rarely life-threatening, this case demonstrates a severe case with potential for death.



A Comparison of Three Ways to Measure Blood Pressure: By a Novel Ultrasound Color Flow Doppler Method, by a Traditional Audible Doppler Method and by the Traditional Auscultatory Method

Christopher Hill, DO, Beth Hayes, DO, Golru Ghaffari, DO, Thomas Hubmer, DO, Eric Decena, MD, Ronald Dvorkin, MD

Study evaluating the use of ultrasound color flow Doppler as an alternative to traditional methods of determining blood pressure.



Are Noise Levels Associated with Vital Signs of the Emergency Department Staff?  A Pilot Study

Genevieve McGerald, DO, Michael Kelly, DO, Travis Mellon, DO, Emilissa Domingo, DO, Veronica Herman, OMS2, Ronald Dvorkin, MD, Sayed Khwaja, DO, David Levy, DO

It is well established that noisy environments adversely affect blood pressure.  This prospective cross sectional trial evaluated sound pressure levels (SPLs) with blood pressure readings of the staff of a busy community emergency department. Pilot data demonstated that there may be an association between increasing noise levels and systolic, diastolic pressure and heart rate.



A Rare Case of Flank Pain and Hematuria

Andrew Mapley, DO, Shan Ahmed, DO

This was a case of a 53-year-old male presented to the emergency department with typical ureteral colic symptoms and was found to have adrenal myelolipomas.



Myocardial Infarction vs. Pericarditis: A Burning Question

Joseph Artale, DO, Jason Winslow, MD, Larry Altschul, MD, Paul Lee, MD, David Levy, DO

This was a case of a 40-year-old female with history of systemic lupus presented with chest pain for a day and a half.  An abnormal EKG prompted a bedside echocardiogram, revealing small pericardial effucsion.  The decision was made to perfom cardiac cath which demonstrated an acute spontaneous cornary artery dissection (SCAD).



A Breathtaking Ingestion

Diana Kontonotas, DO; Stephanie Lovell-Rose, MD; David Levy, DO

This is a case of a 60-year-old male who presented with dyspnea and paresthesias of his feet.  History revealed an accidental ingestion of a product containing isobutyl nitrite leading to significant ethemoglobinemia.



Isolated Fallopian Tube Torsion - An Unfortunate Turn of Events

Thomas Hubmer, DO, Mark Pillitteri, DO, Jason Winslow, MD, Sanford Glantz, MD

This was a case of a 25-year-old female with sharp cramping RLQ pain.  Exploratory laparoscopy was performed for possible drainage of what appeared to be a cyst.  However, the cause of her symptoms was clear in the OR where she was noted to have sustained severe isolated right sided fallopian tube torsion.



Above the Tentorium

Jason Idelson, DO, Ira Eckstein, DO, David Levy, DO

A 14-year-old female presented with worsening nausea, vomiting, headache and mild photophobia.  Her physical exam became significant for an increasing number of cutaneous hematomas on the posterior legs, buttocks and back.  She was found to have bilateral supratentorial subdural hematomas.  A final diagnosis of lupus anticoagulant hypoprothrombinemia syndrome made.



Pericardial Tamponade Presenting as a Transient Ischemic Attack

Christopher Hill, DO, Michael Gewirtz, MD, Steven Zimmerman, MD

A 51-year-old male was evaluated for symptoms of a transient ischemic attack.  He was diagnosed with a large pericardial effusion with pericardial tamponade.  Tamponade rarely presents with neurologic symptoms, however hypotension secondary to the tamponade likely account for the symptoms of TIA that this patient exhibited.



Superior Mesenteric Artery Dissection: A Rare Cause of Abdominal Pain

Genevieve McGerald, DO; David Levy, DO, FACEP, FACOEP

A 46-year-old male presented with intermittent severe epigastric pain.  The rare diagnosis of a spontaneous dissection of the superior mesenteric artery (SMA) without associated aortic dissection was made.  As of March 2008, there were 71 case reports in the literature of isolated SMA dissection.



Are Emergency Physcians Aware of Ionizing Radiation Doses and Risks from Commonly Ordered Studies?

Emilissa Domingo, DO, Pradnya Velankar, MBBS, Ronald Dvorkin, MD, Sayed Khwaja, DO, Stephanie Lovell-Rose, MD, David Levy, DO

A study to survey emergency physician's awareness of the ionizing radiation they commonly expose their patients to.  Emergency Medicine training programs in the United States may not be effectively conveying the risks of ionizing radiation of commonly ordered ED studies to their students and residents.



Syncope...Dissecting the Causes

Golru Ghaffari, DO, Thomas Hall, MD, Eric Decena, MD

A 56-year-old male presented tot he ED after a syncopal episode complaining of neck pain.  He was diagnosed with a cerebellar stroke and cervical spine fracture which prompted an MRI of the neck.  This provided the diagnosis of vertebral artery dissection.



Epidural Abscess - No Room For Mistakes

Beth Hayes, DO, Jeffrey Margulies, MD, Sanford Glantz, MD, David Levy, DO

A 49-year-old male with a history of diabetes and chronic left thigh cellulitis presented with altered mental status, confusion, lethargy, headache, nausea and generalized weakness.  Work up revealed an epidural abscess.



When Sinuses Drain to the Brain...

Andrew Flanagan, DO, David Levy, DO, Eric Decena, MD

A 19-year-old male presented to the ED with altered mental status.  He had recently been treated for sinusitis.  He was diagnosed with a subdural empyema requiring an emergent craniotomy.



Duodenal Hematoma of Pancreatic Origin

Michael Sabatino, DO, Jeffrey Margulies, MD, David Levy, DO

A 36-year-old alcoholic with recurrent pancreatitis was found to have an expanding duodenal hematoma, the etiology of which was from pancreatic enzyme erosion through duodenal blood vessel.



Are Prescribing Patterns for Treatment of Pain Different by Physician Assistants With and Without DEA Registration?

Michael Sabatino, DO; Ronald Dvorkin, MD; David Levy, DO; Sanford Glantz, MD; Adhi Sharma, MD

We hypothesize that if a PA lacks a DEA registration they will write fewer prescriptions for controlled substances in their treatment of painful conditions.  We found that there is a strong association between the prescriptions patients receive for certain painful conditions and whether the treating PA has a DEA registration.



Takotsubo Cardiomyopathy - A Deadly Catch

Emilissa Domingo, DO, Amy Lazarides, MD, David Levy, DO

A patient presenting with clinical and laboratory findings of myocardial infarction was found to have clean coronaries and subsequently diagnosed with a stress-induced cardiomyopathy.



Pneumocephaly Secondary to Nasal Packing Insertion

Golru Ghaffari, DO, Sandra Picone, MD, David Levy, DO

A patient presented with altered mental status following the placement of nasal packings for spontaneous epistaxis.  The patient had pneumocephally secondary to fracture of the cribform plate and subsequently required surgical repair.



Rare Case of Blue Baby

Christopher Hill, DO, Urszula Rakowska, MD, David Levy, DO, Ronald Dvorkin, MD

A 15-week-old following an episode where he had become cyanotic and unresponsive was found to have a large mediastinal teratoma causing bronchopulmonary compression.



A Bitter Pill to Swallow - An Unusual Case of Dysphagia

Thomas Hubmer, DO, Mustafa Khwaja, DO, Ronald Dvorkin, MD

A patient presented with an esophageal obstruction that was determined to be a Metamucil capsule.



Lethal Sciatica

Michael Kelly, DO, Michelle Gebhard, DO, Sanford Glantz, MD, David Levy, DO

A patient presented with progressively worsening buttock pain which was diagnosed as a myonecrosis infection.  Despite aggressive treatment, he rapidly developed septic shock, renal failure and eventually died.



Removing a Barrier to Prescribing Schedule II Opiods and Benzodiazepines is Associated with a Change in Prescribing Patterns

Genevieve McGerald, DO, Ronald Dvorkin, MD, David Levy, DO, Stephanie LOvell, MD, Adhi Sharma, MD

Our objective was to examine whether a less complicated prescription writing process is associated with a change in prescribing patterns of controlled substances in the emergency department.  We found that patients were much more likely to receive a prescription for a Schedule II opiod or a benzodiazepine after a more streamlined computer generated prescription writing process was introduced in our emergency department.



Do Physician Assistants Administer and Prescribe Pain Medications Differently to Black Patients?

Mellon TJ, Dvorkin R, Lovell S, Levy D, Sharma A

Numerous studies demonstrate physicians in emergency departments and other settings prescribe analgesics differently based on race.  Analysis of controlled analgesics administered in the ED and prescribed at discharge revealed significant differences with blacks being administered and prescribed less controlled analgesics for similar conditions.



Case Report: A Puff of Smoke and the Grave Moyamoya Disease Presenting During Acute Thyrotoxic State of Graves Disease

Travis Mellon, DO, Sarita Duchatalier, MD, Stephanie Lovell, MD



The Uncommon Abdominal Pain

Shan Ahmed, DO, MS, Michelle Gebhard, DO, Emilissa Domingo, DO

A case of a pregnant woman who presented with abdominal pain.  Her final diagnosis was necrotic bowel secondary to a clotting disorder.



Priapism - An Unusual Cause

Michael Kelly, DO, David Levy, DO, Natela Leviashvili, MD

Low-flow state priapism with the only discernable etiology being that of marijuana use.



Can Patients Be Passively Educated in the Emergency Department Waiting Area?

Shan Ahmed, DO, Leo Huynh, DO, Mamachen Cherian, DO, Justin Greene, DO, Tamer Salib, DO, Kellee Reed, DO, Ronald Dvorkin, MD, David Levy, DO

The time spent by patients in the Emergency Department waiting area has not been traditionally thought of as an opportunity for influencing patient knowlege.  The nature of the encounter may serve to heighten a patient's awareness and may constitute a unique opportunity for patient education.



Adult Onset of a Childhood Rash - Henoch-Schonlein Purpura

Michael Kelly, DO, David Degenhardt, DO, David Levy, DO

A 35-year-old male presented with a rash of an initially unknown cause.  With considerable work-up, a definitive diagnosis was made.



A Brush with Death

Michael Sabatino, DO, Sayed Mustafah Khwaja, DO, Sandra Picone, MD

A man, while brushing his teeth, walked into a door causing an injury to his posterior pharynx.  He subsequently developed mediasitinitis.



Just Another Stone?

Justin Greene, DO, Eric Decena, MD, David Levy, DO

A patient presented with flank pain and the typical features of renal colic.  A non-contrast CT was normal.  A CT was repeated with IV contrast which revealed renal infarction.



Eisenmenger's Syndrome

Justin Greene, DO, David Degenhardt, DO, David Levy, DO

A post-partum patient with pulmonary edema, hypoxemia and right ventricular dysfunction who beat the odds of an almost 40% maternal death rate and had the unusual presentation in her fourth decade.



Just Another Rash? 

Leo Huynh, DO, Rajesh Gupta, MD, Michael K. Miller, MD, David Levy, DO

A patient presented to the ED with rash that was eventually diagnosed as Hansen's disease, or Leprosy.



Failure to Thrive

Mamachen Cherian, DO, Ira Eckstein, DO, David Levy, DO

Williams Syndrome was diagnosed in a 17-day-old who presented with failure to thrive.



A Case of Pelvic Pain and Deep Venous Thrombosis

Shan Ahmed, DO, Michelle Gebhard, DO

A Woman who presented with pelvic pain that was eventually diagnosed as an ilio-femoral DVT.



An Atypical Presentation of Coital Headache

Tamer Saliv, DO, David Levy, DO

A female patient had a recurrent complaint of the worse headache of her life during intercourse.  The etiology was nitroglycerin paste that her partner was using as a lubricant.



Atypical Presentation of Aortic Dissection Secondary to Gunshot Wound

Emilissa Domingo, DO, David Levy, DO, Sarah Iosovich, DO

A 21 year old was shot in the back.  On review of the CT on ED rounds the aortic dissection secondary to the cavitary forces of the bullet passing through his chest was discovered.


AcuteIncarceratedHernia AAA Presenting as Acute Incarcerated Inguinal Hernia

Justin Greene, DO, David Levy, DO

Two patients presented with incarcerated inguinal hernias.  In each case, the pressure of an expanding abdominal aortic aneurysm incarcerated the hernia.



Clinical Pathologic Case (CPC) Competitions

ACOEP National Convention: 2011
Faculty Discussant: Steven Sattler, DO
Cutaneous and Ureteric schistosomiasis with Obstructive Uropathy 

Resident Presenter: Doni Marie Rivas, DO
May-Thurner Syndrome

ACOEP National Convention: 2009
Faculty Discussant: Genevieve McGerald, DO
Anticholinergic Toxicity from Datura stramonium (Jimson Weed) Ingestion

Resident Presenter: Joshua Bozek, DO
Posterior Reversible Encephalopathy Syndrome (PRES)

ACOEP National Convention: 2008
Faculty Discussant: Sanford Glantz, MD
Necrotizing Fasciitis

Resident Presenter: Michael Kelly, DO
Delayed Onset Heparin Induced Thrombocytopenia Presenting as White Clot Syndrome

ACOEP National Convention: 2007
Faculty Discussant: David Levy, DO
1st Place Winner
A Left Artial Myxoma as part of Carney Syndrome

Resident Presenter: Michael Sabatino, DO
2nd Place Winner
A Case of Babesiosis

ACOEP National Convention: 2006
Faculty Discussant: David Levy, DO
2nd Place Winner
A Case of Acute Afrin Toxicity

Resident Presenter: Travis Mellon, DO
1st Place Winner
Moya Moya (A Puff of Smoke and the Grave Moyamoya Disease Presenting During Acute Thyrotoxic State of Graves Disease)

ACOEP National Convention: 2005
Faculty Discussant: Elaine Diaz, DO
Ahh The Toothache...A Case of Ludwig's Angina

Resident Presenter: Kellee Reed, DO
A Case of PANDAS - Pediatric Autoimmune Neuropsychiatric Disorders Associated with Streptococcal Infection

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