A 29-year-old male presented to our emergency department with complaint of abdominal pain after allegedly ingesting a 4-gram packet of heroin in an attempt to evade detection. Initial evaluation including computed tomography (CT) of the abdomen/pelvis with intravenous and oral contrast, as well as laboratory workup was negative and the patient was discharged. The patient returned 3 days later with complaint of “I feel high” and severe constipation, and demonstrated an opiate toxidrome requiring naloxone with improvement of symptoms. A repeat CT of the abdomen/pelvis, this time without contrast revealed a 2.1 × 1.8 cm foreign body in the gastric antrum. The patient was promptly taken to endoscopy with surgical backup. Foreign body removal included multiple plastic bags encasing heroin, which had sustained a small leak causing a gastric outlet obstruction as well as a slow opiate toxidrome. The foreign body was removed and the patient was observed and discharged with a favorable outcome.

A 67-year-old female presented to the emergency department with acute-onset severe left flank pain as well as nausea and vomiting. Physical examination was notable for left-sided abdominal, flank tenderness, and costovertebral angle tenderness. Laboratory workup revealed an elevated lactate of 9.2 mmol/L and elevated serum creatinine of 1.14 mg/dL, with an estimated glomerular filtration rate of 53 mL/minute/1.73m 2 . Urinalysis showed moderate leukocyte esterase with microscopy showing 12 white blood cells and three red blood cells per high-power field. CT of the abdomen and pelvis with intravenous contrast was notable for moderate amounts of left-sided perinephric and periureteric fluid without the presence of an obstructing calculus. Due to the amount of perinephric and periureteric fluid without associated nephrolithiasis, the differential diagnosis was broadened to include spontaneous ureter rupture as well as concern for malignancy. A delayed post-contrast CT scan of the abdomen and pelvis was obtained, which confirmed a spontaneous proximal and mid-ureter rupture. Spontaneous ureter rupture is a rare disease process with significant morbidity and mortality. It often poses a diagnostic dilemma due to a lack of clinical awareness and varied presentation. Diagnosis rests upon obtaining delayed post-contrast CT of the abdomen and pelvis. Currently, there are no standardized treatment guidelines, although most experts utilize minimally invasive endourological approaches in their treatment plans.

A 59-year-old otherwise healthy man presented with an upper respiratory illness of four weeks' duration.His initial presentation to his primary care physician one month prior included a nonproductive cough and lowgrade fever, which lasted approximately two weeks until his internist ordered a chest x-ray. That showed a 3 cm well circumscribed right lower lobe lesion, and was followed by a contrast enhanced chest CT. The chest CT was concerning for pulmonary neoplasm, and he received an interventional radiology-guided biopsy of the lesion.Results were still pending at the time of ED presentation.The patient's primary care physician had prescribed a seven-day course of Levaquin for presumed communityacquired pneumonia (CAP) before he presented to the ED. The patient's fever remained elevated after day three, and he began to worsen, at which point he was switched to clindamycin.The patient had had a prior total thyroidectomy for thyroid carcinoma as well as previously being diagnosed with hyperlipidemia and benign prostatic hypertrophy.His medications include Synthroid, Avodart, Lipitor, and clindamycin. Social history was negative for tobacco or alcohol. He was currently training for the Ironman competition and was an avid runner and CrossFit member.He had traveled to Jamaica three months earlier and to Loredo, TX, two weeks prior to his ED visit.His initial vitals at presentation were blood pressure of 112/84 mm Hg, heart rate of 65 bpm, respiratory rate of 18 bpm, temperature of 98.9°F, and pulse oximetry of 98% on room air. He complained of persistent fevers ranging from 101°F to 103°F, maculopapular rash, severe headaches, and memory loss with intermittent confusion. The rash had become more noticeable over the previous two days and appeared as an erythematous maculopapular rash that blanched on the torso. No blistering or sloughing was present. His headaches were global in nature and had been present throughout the course of the illness, but seemed to be worsening daily. His wife also described some intermittent confusion and shortterm memory loss over the prior two days of which the patient himself was unaware.Lab work demonstrated a mild leukocytosis of 13.4. A chest x-ray revealed that the right lower lobe pulmonary nodule had grown significantly from the previous study.A CT of the brain found a large area of hypoattenuation with sulcal effacement in the occipital and temporal regions with edema and a 4 mm left-to-right shift. The patient was promptly admitted and started on Bactrim, imipenem, and Decadron.We were concerned for opportunistic bacterial versus fungal infection, specifically nocardiosis, because of the patient's pulmonary, cutaneous, and CNS manifesta-

A 12-year-old female with primary amenorrhea presented to the emergency department with episodic low back pain, suprapubic discomfort, and acute urinary retention. A protruding purple mass was noted at the vaginal introitus consistent with an imperforate hymen. Point-of-care bedside transabdominal ultrasonography revealed a distended uterus containing hypoechoic material. The patient underwent formal pelvic ultrasonography, which revealed a markedly enlarged uterus containing a large number of blood products, thinned myometrium, and a distended vaginal canal consistent with hematometrocolpos secondary to imperforate hymen. Imperforate hymen is a rare congenital anomaly of the female urogenital tract, in which the hymen obstructs the vaginal opening causing a vaginal outlet obstruction. Vaginal outlet obstruction secondary to imperforate hymen may lead to retrograde menstruation with a collection of blood within the uterus and vagina, which is termed hematometrocolpos. Treatment is based on identifying and treating the underlying imperforate hymen with surgical approaches. The growing use of bedside ultrasonography allows the clinician to rapidly and accurately diagnose hematometrocolpos. The use of point-of-care bedside ultrasonography can serve as an essential tool as delayed diagnosis and treatment of this rare condition are associated with significant morbidity and lifelong infertility.

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