Many patients visit emergency departments complaining of fever. However, it is often difficult to definitively diagnose such patients at the initial consultation. We retrospectively examined the characteristics of patients who had unexplained fever and were hospitalized, among adult patients who visited our hospital's emergency department between September 2016 and August 2017. Twenty-four patients were included in our study. 13 patients were finally diagnosed as infectious disease. The rate of positive blood cultures was 37.5%. Three patients with positive blood cultures were hospitalized after once discharged from ED. In patients with fever of unknown origin, obtaining blood cultures is important.

This study objectively assessed changes in the quality of cardiopulmonary resuscitation (CPR) performed by 4 nurses in acute care wards who had never performed CPR. Changes in the quality of CPR were assessed before and for up to 2 years after a Basic Life Support (BLS) course. The quality of chest compressions did not diminish substantially immediately after the course, and it improved 2 years later. All of the subjects attended CPR-related training after the course, and this sustained the quality of CPR. This study examined efforts and training to maintain the quality of CPR performed by nurses.

A 62 years old woman who had a sputum and cough on the day before visiting our emergency room. Her chief complaint was fever, shivering and difficulty in exercising. She was assessed septic shock because by fever, hypotension, disturbance of consciousness. A Howell-Jolly body was observed in the blood smear, and CT scan showed hypoplastic spleen. She was diagnosed as invasive pneumococcal infection caused by reduced splenic function. If Howell-Jolly body are observed in a blood smear, it suggests that spleen function is decreasing. It is supportive that searching Howell-Jolly body to prove spleen disfunction.

Leptospirosis is zoonosis caused by pathogenic bacteria called Leptospires that belong to Spirochaetales. We reported a 74 year-old man who had a sense of malaise and his body color is yellow. He had a conjunctival suffusion and muscle pain which had characteristically the calves. His blood test indicated elevated serum bilirubin, kidney impairment, or thrombopenia. We diagnosed him with Leptospirosis and started antibiotics. After starting antibiotics his blood pressure lowered by Jarisch-Herxheimer reaction, but it was getting better within 24 hours. He was discharged without any sequelae.

Patients with multiple myeloma are vulnerable to infection, although cellulitis is rare as complication of multiple myeloma. In our case of a 56-year-old man, refractory cellulitis led us to investigate immunosuppressive factors, and we found that he was suffering from multiple myeloma. As our case, unusual skin lesions suggest comorbid immunosuppressive disease such as malignancy. We need close investigation of complications in patients with atypical skin lesions.

Quick and prompt cannulation is required for Veno-Arterial Extracorporeal Membrane Oxygenation (V-A ECMO), especially ECPR cases. Because of increase number of elderly patients with arteriosclerosis, it is not uncommon to encounter complications associated with cannulation. We report two elderly cases that direct contact of the cannula tip to arterial wall at right angle due to strong arterial meandering caused complications as severe hemolysis and aortic dissection. In elderly patients, it is necessary to place cannula in the right position considering arteriosclerosis and meandering of artery.

27-year-old man with a history of epilepsy and no risks of arrhythmias was transported to the emergency department with coma. He developed convulsive seizures in the emergency department and was still in coma. His serum carbamazepine level was 56.9µg/mL so he was hospitalized due to status epilepticus and suspicion of carbamazepine intoxication. On day 4 of hospitalization, he developed ventricular fibrillation (VF) and achieved return of spontaneous circulation after cardiopulmonary resuscitation. Ictal VF was suspected due to the presence of remarkable artifacts in the electrocardiogram monitor before the onset of VF so sudden unexpected death in epilepsy was considered.

A 49-year-old woman was admitted to the emergency department due to shock, and showed hypotension and acute renal failure due to overdose of amlodipine (535 mg). The patient showed poor response to catecholamines and treatment with intravenous calcium gluconate, glucagon and lipid emulsion therapy. However, treatment with calcium chloride showed immediate increase in blood pressure. Reports suggest that calcium chloride is more effective than calcium gluconate for the treatment of calcium channel blocker poisoning. Therefore, intravenous administration of calcium chloride should be considered as an alternative treatment for patients who showed poor response to calcium gluconate.

Upon accepting foreigners, medical facilities sometimes face problems such as availability of an interpreter, medical safety, religious differences, lawsuit risks, and uncollectible fees. Japan became the first country in Asia to initiate a third country resettlement program. Refugee support organizations like RHQ and ISSJ are working for refugee issues. We report a case of an uncertified and uninsured refugee troubled with a prolonged hospital stay for 70 days due to difficulty in obtaining the designated activities visa, utilizing free/Low-cost medical services, and having an interpreter. Every hospital should be prepared for cases that an uncertified refugee seeks medical assistance.

A 70 yeaes old woman who use a steroid long time presented to our emergency department with 7-days history of vomiting and diarrhea. Although fruid resuscitation and antibiotics therapy, she died dramatically in Aeromonas hydrophila infection due to sepsis was diagnosised after culture of the blood and the stool taken on admission yielded Aeromonas hydrophila. Because of this suspectibility of immunecompromised pahients, in examing and treating patients with severe sepsis we need to remember that Aeromonas hydrophila is a potential cause.

Health care workers have thought that it was difficult to care for elderly patients at home. On the other hand, the family have thought that it was possible to care them at home, because they had had some home care experiences before.However, they started to appeal for bewilderment and anxiety about home care, because the care necessity level and the amount had obviously increased than before being hospitalized. The gap between the notion of what health care workers can do and the one of family's is large. It is important that we fill the gap carefully.

A 61-year-old woman was treated as our emergency room chiefly with a consciousness disorder. It was due to methanol intoxication that passed from 24 hours to 36 hours after the passage of time. The estimated methanol blood concentration was 331.5 mg / dL. Considering the fact that metabolism from methanol to formic acid has already progressed since it had already metabolic acidosis with pH 6.713, intermittent blood purification was attempted to remove blood methanol and formic acid. After completion of hemodialysis, the pH was improved up to 7.623, but pupil dilatation occurred after 2 hours, and brain edema with remarkable psuedoSAH was found when head CT was reexamined. Compared with past cases that followed the same course, it was found that the elapsed time was long, and cases with high methanol concentration at the time of visit appeared to tend to cause cerebral edema after hemodialysis. Causes of cerebral edema may be due to re-expansion of nerve cells due to the accumulation of methanol or its metabolite in nerve cells.

A 77-year-old man with fever and pain from the right neck to the shoulder was transferred to our hospital by ambulance. He was diagnosed with acute pyelonephritis and treated with a urine stent and antibiotics. However, his neck pain did not improve. MRI of the cervicothoracic spine, ultrasound of the neck, and CT scan of the neck were performed and showed vertebral osteomyelitis and a deep cervical abscess. The abscess was drained, and the antibiotic therapy was continued for 63 days. His subsequent clinical course was uneventful, and he was discharged on day 99.

Over 24-million tourists visit Japan every year and 30% of them are uninsured. Here we report a case, 25-year-old male foreigner and came to our department for dyspnea. He was hospitalized and diagnosed with acute lymphocytic leukemia. Because he didn't want expensive treatment, we did minimum treatments to help his breathing. After discharge, the full amount for his medical bills was paid, successfully. To the tourists who are uninsured, we believe that it is important to work as a team to come up with an inclusive approach where we choose the required treatments while taking the medical expenses into account.

Paravertebral abscess is a rare disease with few case reports. Because the symptoms are nonspecific, the diagnosis is difficult. We experienced a case with paravertebral abscess which presented with ataxic gait and tilted body truck. The paravertebral muscle is composed of three muscles (i.e. the iliocostal muscle, longissimus muscle, spinal muscle) and when one side of the paravertebral muscle contracts, the body truck turns and bends to the side. We thought that the inflammation from the abscess contracts the paravertebral muscle, resulting in the ataxic gait and tilted body truck.

Background : We encountered a case of mycoplasma pneumonia (MP) that relapsed and increased in severity after providing standard treatment. Case : A 75-year-old man was admitted to hospital for MP. He was administered standard antibiotic therapy and was discharged home. However, he was readmitted 4 days later in the recurrence of MP. Discussion : Retrospective evaluation revealed several factors that might have induced the relapse. Conclusion : It may be necessary to reconsider the standard treatment for severe MP.

【Background】The proportion of disease which is involved in the onset of esophageal obstruction by bolus is 60-80% in the West.【Objective】To reveal the involvement of disease in patients with esophageal obstruction by bolus . 【Method】We investigated 25 cases in which bolus was obstructing the esophagus in the esophagogastroduodenoscopy test in 10 years retrospectively.【Results】The proportion of diseases which is involved in the onset of esophageal obstruction by bolus was 60%. Some of these could be medically intervened. 【Discussion】There are causative diseases that could be medically intervened in patients with esophageal obstruction by bolus.

We made a CT room in the Emergency room from the autumn of 2014. Therefore, we came to be able to perform CT photography safely and early. We consider of the patients who came to ER without CT and the patients who came to ER with CT. As a result, we came to have a short time that CT photography after patients came to the hospital for five minutes. We came to have a short time that a diagnosis took for 12 minutes. Particularly, the time that a diagnosis took became short in the patients of the high energy injury.

This studies is an analysis of psychological factors in incident of Emergency Medical Service. An object cases on this studies were the related cases of EMS in Incident Database of Fire and Disaster Management Agency Japan. As a result, it was found that lack of crisis perception and attention lead to incidents at a frequency almost twice as much as the impatience situation. It is important to clarify the direct factors and the behind factors by examining the circumstances that are likely to cause lack of crisis perception and attention according to the actions and time series of EMS crew.

We examined cases in which operation was performed in the intensive care unit (ICU) in 2 years from April 2015 to March 2017. The aim of this study was to clarify the status and issues about operation at ICU. A total of 6 patients (1 case in the chest, 5 cases in the abdomen) underwent 10 surgical procedures. There were ranged cases from relatively simple operations such as observation and closed abdominal to complicated such as intestinal and pancreatic resection. Although the shortage of staff was a problem, if the operation could not be performed in the operation room, it is necessary to perform an operation at ICU.

It is conceivable that acute aortic dissection (AAD) with disorder of consciousness is a poor prognosis. We surveyed retrospectively 13 patients that were diagnosed type A AAD combined with disorder of consciousness and performed surgery in our hospital. Their age was 72±8 years old and 30.8% were male. Many cases were complicated with cardiac tamponade and cerebral malperfusion as associated feature. In mortality, AAD combined with severe disorder of consciousness and progressive deterioration were 30.2% and 46.2%, respectively.

Background : It is rare to encounter acute cholecystitis in which Staphylococcus aureus is the causative agent.　Case : An 82-year-old woman was transferred to our Emergency Center because of altered consciousness and shock. Abdominal computed tomography revealed enlargement and thickening of the wall of the gallbladder. Percutaneous biliary drainage performed and her general condition improved. Both blood and bile cultures were positive for Methicillin-susceptible Staphylococcus aureus (MSSA). 　Discussion and Conclusion : S. aureus as the causative bacterium in acute cholecystitis is extremely rare, but still a possibility.

The patient was a 62-year-old man. He fainted five days after a urachal tumor resection. A detailed examination revealed that he had experienced an obstructive shock due to pulmonary thromboembolism. It led to a cardiopulmonary arrest. An external cardioassist was established, and the patient was moved to the intensive care unit for general care. The external cardioassist was removed, and upon completing thermoregulation, the patient had control over his neck and above, but was unable to move his limbs, and was in the state of quadriplegia. At this point, magnetic resonance imaging confirmed ischemic changes from C5 to C7.