Chief Complaint: Lethargy… January 25, 2012

Posted by Andy Jagoda, MD in: Cardiovascular, Gastrointestinal, Hematologic/Allergic/Endocrine Emergencies, Renal and Genitourinary Emergencies , 28 comments

EMS 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?

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“Antimicrobial Therapy” … Case Conclusion January 7, 2012

Posted by Andy Jagoda, MD in: Drugs & Emergency Procedures, Infectious Disease , add a comment

The 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.