“Chief Complaint: Lethargy” … Case Conclusion February 6, 2012
Posted by administrator in : Cardiovascular, Gastrointestinal, Hematologic/Allergic/Endocrine Emergencies, Renal and Genitourinary Emergencies , add a commentThe Conclusion Is…
The local Poison Control Center was promptly contacted and the controversies, risks, and benefits of HBO treatment were discussed. The local HBO center was contacted and because of its close proximity and because the patient had evidence of end-organ damage, the decision was made to transfer the patient for treatment. She received an aspirin for her ECG changes and was transferred with ongoing NBO therapy. The HBO treatment was provided without complication. The patient was admitted to the medical service, after which she underwent 2 additional “dives” during her hospitalization. Her 6-hour troponin I level peaked at 2.1 mg/L, and an ECG obtained at that time had returned to her baseline. Subsequent cardiac biomarkers were obtained 12 hours after presentation and were normal. She remained hemodynamically stable and free of symptoms during her hospitalization. After undergoing stress echocardiography testing on hospital day 2, which did not reveal evidence of reversible myocardial ischemia, she was discharged on hospital day 3. At a 6-week clinic follow-up appointment, she denied any symptoms and had a normal examination. However, she said she had sold her apartment and moved in with her son’s family.
Congratulations to Dr. Aziz, Dr. Garcia, Dr. Koury, Dr. Luvetz, and Dr. Stanley — this week’s winners of Emergency Medicine Practice’s “Advances In Diagnosis And Management Of Hypokalemic And Hyperkalemic Emergencies!” For an evidence-based review of the etiology, differential diagnosis, and diagnostic studies for detecting hypokalemia and hyperkalemia, read this issue.
Chief Complaint: Lethargy… January 25, 2012
Posted by administrator in : Cardiovascular, Gastrointestinal, Hematologic/Allergic/Endocrine Emergencies, Renal and Genitourinary Emergencies , 28commentsEMS brings in a 64-year-old gentleman with a chief complaint of lethargy. On arrival, the patient is bradycardic at 40 beats per minute with a normal blood pressure. You ask the nurse to immediately move the man to the resuscitation bay, obtain intravenous access, draw a rainbow of labs, and obtain an ECG. The EMS report states that they found him at home alone, unable to ambulate without assistance. The patient tells you that he has missed dialysis for the past few sessions because he did not have the energy to make it to clinic. You obtain an ECG and immediately notice concerning abnormalities.
What’s Your Next Step?
(Enter to win the latest issue of Emergency Medicine Practice, including CME, by submitting your answer to the question above. To do so, simply enter your response in the comments box. The deadline to enter is February 6th.)
“Antimicrobial Therapy” … Case Conclusion January 7, 2012
Posted by administrator in : Drugs & Emergency Procedures, Infectious Disease , add a commentThe Conclusion Is…
The 35-year-old female was young and healthy, and therefore a decision was made for outpatient management that included coverage for atypical organisms. In the ED, 500 mg of azithromycin was administered and a prescription for 4 additional days at 250-mg-per-day dosing was provided. She was given strict instructions to return if she felt more shortness of breath or worse in any way. She followed up with her primary care doctor in 3 days, feeling much better.
The 70-year old female was presumed to have a mild delirium induced by her UTI. She was given IV ciprofloxacin, and her mental status returned to normal on hospital day 2. Her urine culture grew E coli sensitive to fluoroquinolones, and she was discharged on oral ciprofloxacin on hospital day 4.
The 23-year-old with the infected forearm had the abscess incised and drained in the ED. Because there was also a surrounding cellulitis, he was given oral trimethoprim-sulfamethoxazole and instructed to return for a wound check. His arm was markedly improved by a day 3 wound check, and his wound culture was positive for CA-MRSA.
The 85-year-old from the nursing home had a CT of the abdomen and pelvis that revealed diverticulitis with no evidence of abscess or perforation. Treatment with cefepime and metronidazole was initiated, and he was admitted. The hospital discharge summary indicated that he defervesced after 4 days and was sent back to the nursing home on day 8.
Congratulations to Dr. Barone, Dr. Brown, Dr. Cohen, Dr. Nabhani, and Dr. Tampi— this week’s winners of Emergency Medicine Practice’s “Evidence-Based Guidelines For Evaluation And Antimicrobial Therapy For Common Emergency Department Infections!” For a discussion of common infectious diseases presenting to the ED and a review of the current literature and guidelines, read this issue.
Antimicrobial Therapy… December 30, 2011
Posted by administrator in : Drugs & Emergency Procedures, Infectious Disease , 22commentsAt 7:00 on a Monday morning, the day begins with a full line-up of “to be seen.” A 35-year-old female with no past medical history presents to the ED complaining of cough and shortness of breath for 2 days that is progressively worsening. On physical examination, she is febrile with an oxygen saturation of 94% on room air and decreased breath sounds at the right base. You order a chest x-ray that shows right lower lobe consolidation.
The second patient on your tracking board is a 70-year-old female with fever, nausea, and back pain for 3 days. She is accompanied by her daughter, who states her mother hasn’t been herself today and that she had a similar presentation when she had a UTI 2 years ago. She is febrile to 38.3°C (101°F), oriented x2, with left costovertebral angle tenderness. Her urine dipstick is positive for leukocyte esterase and nitrites.
In the next bed, you are evaluating a 23-year-old male who has had a painful, swollen right forearm for 2 days. He reports a subjective fever earlier in the evening, but no other systemic symptoms. He denies any past medical history and has no IV drug abuse and no history of diabetes. He is afebrile with normal vital signs. A 6-cm area of erythema, induration, and tenderness is noted on his proximal forearm with a 2-cm central fluctuant, raised area. He has full range of motion at the elbow.
Just as you sit down for a cup of coffee, the triage nurse notifies you that she just received an 85-year-old male from a nursing home that was sent in for evaluation for fever. He has a history of insulin-dependent diabetes mellitus, hypertension, and dementia. On physical examination, he is febrile, with otherwise normal vital signs. His abdomen is slightly distended, soft, but diffusely tender to palpation.
Four infectious disease cases in a row — it feels like an epidemic. In the age of emerging pathogens — and when the right antibiotic choice may be the difference between a good or bad outcome — which antibiotic(s) do you use?
(Enter to win the latest issue of Emergency Medicine Practice, including CME, by submitting your answer to the question above. To do so, simply enter your response in the comments box. The deadline to enter is January 6th.)
Welcome To “What’s Your Diagnosis?” October 26, 2011
Posted by administrator in : Uncategorized , add a commentWelcome to EB Medicine’s “What’s Your Diagnosis” blog! We created “What’s Your Diagnosis” to be a fun way for emergency clinicians to test their knowledge of challenging clinical cases. One ED patient presentation will be posted each month, with the case conclusion posted one week later including a link to a full text article on the topic. Post your guess to the diagnosis before we share the conclusion, and then see if you got it right!
