A special thank you to Alexandra Amaducci, DO, MBA, FACEP, FACMT for 
organizing the CPC competition during PACEP’s 2026 Scientific Assembly. 
Congratulations to this year’s second place winners – Betsy Rojas, MD 
from Thomas Jefferson University Hospital for submitting the case and 
being the resident presenter, and Philip Salen, MD from St. Luke’s Health 
Network for being the attending discussant.
PMHx: Hypertension, osteoarthritis, 
hepatitis C, severe hemophilia A with 
Factor VIII inhibitors 
PSHx: bilateral knee arthroplasty
Meds: Emicizumab infusions biweekly, 
Antihemophilic factor (recombinant), 
carvedilol, gabapentin, varenicline, 
olmesartan-amlodipine-hctz, tramadol 
PRN
NKDA
Social Hx: cigarette & marijuana use 
VS: HR 116 bpm, BP 163/93 mmHg, RR 18 
bpm, Spo2 99% RA, Temp 97.7°F
PE:
General: sitting up in bed in NAD
Extremity:
• appearance: left first and fifth toes 
appear dusky; ecchymosis noted to 
lateral aspect of left foot
• mild TTP of L first and fifth toes 
• dorsalis pedis/posterior tibialis pulses: 
faint but palpable bilaterally
• strong equal pulses appreciated with 
doppler U/S
• sensation: intact
• motor: intact, full active and passive 
ROM, 5/5 strength
PACEP SCIENTIFIC ASSEMBLY 2026 CPC HIGHLIGHT
What is the Diagnosis?
Acute Foot Pain in a 54-year-old M with Hemophilia A
54-year-old male with PMHx of severe Hemophilia A presents with one week of gradually 
worsening left 1st and 5th toe pain, swelling and bruising. Patient recently cut his toenails. 
The pain is so severe that it limits his ADLs and he is unable to bear weight on L foot. 
Pt reports the pain is consistent with past episodes of hemarthrosis, however, the pain 
persists despite self-administered factor at home. Pt denies fever, chills, numbness/tingling, 
palpitations, chest pain, shortness of breath, syncope, lightheadedness.
CPC CASE 
STUDY
THE CASE
LAB
RESULT
WBC
9.7
HGB
16
HCT
45.2
PLATELETS
334
PTT
21
PT
10.6
INR
0.97
ESR
13
CRP
0.60
Urate
5.3
Na
134
K
4.1
Anion Gap
12
BUN
18
Cr
1.06
Ca
10.3
TEST
REPORT
Left foot X-ray
No fx. Normal alignment. Severe 
OA of L ankle, subtalar and first 
MTP joints noting joint space 
narrowing and osteophyte 
formation
DVT Ultrasound
No acute femoropopliteal DVT 
in LLE.
No DVT in visible portions of calf 
veins.
CT of L foot 
(non-contrast)
No acute fx. Severe OA of ankle, 
subtalar and first MTP joints
CT angiogram 
AP with run-off
Patent abdominopelvic and 
lower extremity vasculature with 
three-vessel runoff to the ankle 
bilaterally (limited evaluation due 
to streak artifact from prosthesis)
Pertinent Labs:
What test will make the diagnosis? 
What is the final diagnosis?
conclusion 
on page 18
12
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