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Cancer is not infrequently detected in the Emergency Department (ED) and is sometimes even an incidental finding on imaging. Since the ED is designed to identify and treat acutely ill patients, the time providers can spend with patients and the depth of investigation into patient conditions is limited. However, Emergency Medicine physicians must ensure the appropriate follow-up for patients with presumptive diagnosis of cancer to ensure timely confirmatory testing, prompt treatment, and accurate prognosis. A 26-year-old woman presented to the ED for evaluation of abdominal pain and urinary complaints and was ultimately found to have a 36cm ovarian mass that was suspicious for neoplasm. The mass caused obstruction of urinary outflow leading the patient to develop a urinary tract infection. Emergency Medicine physicians are faced with the challenge of having limited time and short-lived doctor-patient relationships. In cases of suspicious findings, balancing the urgency of follow-up without causing undue harm from heightened anxiety for patients is essential. It is important to discuss findings that may be concerning for cancer with both clear verbal and written communication. Employ strategies such as direct communication with primary care physicians and outpatient specialists via phone consultation and electronic medical record messaging, as well as providing clear discharge instructions in-person and in-writing to the patient including whom to call and the time frame for follow-up., Competing Interests: The authors have declared that no competing interests exist., (Copyright © 2022, Ekpo et al.)

Objectives: Opioid overdoses have become a significant problem across the United States resulting in respiratory depression and risk of death. Basic Life Support (BLS) first responders have had the option to treat respiratory depression using a bag-valve-mask device, however naloxone, an opioid antagonist, has been shown to quickly restore normal respiration. Since the introduction of naloxone and recent mandates across many states for BLS personnel to carry and administer naloxone, investigation into the adherence of naloxone use standing protocols is warranted., Methods: This preliminary study examined 100 initial cases of BLS first responder administration of naloxone for appropriate indications and protocol adherence., Results: This study found that n=22/100 naloxone administrations were inappropriate, often given to patients who were not suffering from respiratory depression (n=11/22). Positive pressure ventilation (PPV) was not administered prior to naloxone in n=56/100 cases, of which n=42/100 had an inadequate respiratory effort documented. For patients with a known history of substance use disorder, there was a significant increase in administration of naloxone prior to PPV (60%; n=33/55) compared to patients without a known history (30%; n=9/30)., Conclusion: Overall these preliminary data suggest that during BLS naloxone administration, the majority of cases did not follow at least one component of the standard protocol for patients with respiratory depression. This study suggests that further education and more research are needed to better understand the decision-making processes of prehospital providers to ensure adherence to standard protocols., Competing Interests: The authors have declared that no competing interests exist., (Copyright © 2021, Mastenbrook et al.)

Brainstem infarction typically presents with vague symptoms, including headache, nausea, vomiting, and vertigo. Rarely do patients present with complete unilateral facial paralysis, mimicking Bell's palsy. Here we report the case of a 40-year-old woman who presented to the emergency department with intractable nausea, vomiting, and vertigo upon waking along with left-sided upper and lower extremity numbness and right-sided facial paralysis. Her atypical presentation of unilateral facial nerve paralysis in the context of nausea, vomiting, and vertigo prompted neurological studies, which were significant for a small punctate infarct in the pons involving the right facial colliculus. ​History, physical examination, and clinical suspicion are important to prevent anchoring bias. Physicians rely on history and physical examination to help distinguish true Bell's palsy from other causes of facial nerve paralysis. Stroke and other clinically emergent etiologies should be considered high on the differential diagnosis when patients have neurological signs and symptoms in addition to facial nerve palsy., Competing Interests: The authors have declared that no competing interests exist., (Copyright © 2020, Burson et al.)

Acute changes in electrolyte levels can result in severe physiologic complications. Rapid treatment of abnormally elevated potassium levels is essential due to the increased risk of potentially fatal cardiac arrhythmias. However, there are a number of circumstances that can lead to falsely elevated serum potassium levels, including fist clenching during phlebotomy and hemolysis of hematocytes during laboratory processing. Here we present a case of an elderly woman with chronic lymphocytic leukemia who presented with lower left quadrant pain and hematochezia. Laboratory tests revealed an elevated serum potassium level (7.5 mmol/L) on initial testing, in the absence of hyperkalemia symptoms, EKG changes, and hemolysis of the blood specimen. Abdominal CT revealed inflammatory changes consistent with diverticulitis. She was treated with intravenous calcium, insulin, glucose, and bicarbonate for her hyperkalemia and admitted for treatment for diverticulitis. A subsequent serum potassium level (3.9 mmol/L) and discussion with the hospitalist suggested a diagnosis of leukolysis-induced pseudohyperkalemia, and further treatment of hyperkalemia was halted. This case serves to remind current and future physicians about the importance of maintaining clinical suspicion and clarifying unexpected laboratory readings when the clinical picture and results do not completely align., Competing Interests: The authors have declared that no competing interests exist., (Copyright © 2020, Dewey et al.)

Medical laboratory tests are becoming more reliable with increased specificity and sensitivity, leading to their use as definitive diagnostic tests for many medical conditions. Enzyme-linked immunosorbent assay (ELISA) tests are convenient, sensitive, and standardly used for rapid detection and quantification of antigens or patient antibodies against specific antigens. However, based upon the specificity and sensitivity of an ELISA test, the results may not be definitive for a specific disease but merely suggestive, due to potential cross-reactivity of antigens and antibodies. Here, we present a case of a 15-year-old male who presented with fever, nausea, and right upper quadrant pain. Computed tomography scan showed an 18-cm liver mass with cystic features. Biopsy results confirmed a diagnosis of undifferentiated embryonal sarcoma of the liver; however, the clinical picture was complicated by positive ELISA results for Echinococcus, Entamoeba histolytica, and histoplasmosis. Due to the absence of travel and positive ELISA result for three different infectious agents, we hypothesize that tumor molecular mimicry might have led to false-positive ELISA results in the absence of infection in this case, demonstrating a limitation of ELISA serology. Critical appraisal of all possible evidence to ensure alignment when assigning the final diagnosis is essential for optimal patient outcomes., Competing Interests: The authors have declared that no competing interests exist., (Copyright © 2020, Letherer et al.)