Troubling headache…. May 30, 2012

Posted by Andy Jagoda, MD in: Neurologic, Radiology , 28 comments

Your first patient of the day is a 46-year-old female with a history of migraine headaches who presents with a severe, constant pain that started suddenly while running. She admits this “feels different than my normal headaches.” On examination, she appears ill and is vomiting. Her neurologic examination demonstrates mild neck stiffness. She asks for a refill of her sumatriptan, which “always works for my headaches.” While she has a known primary headache disorder, the features of her headache are concerning.

What do you do next?

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“Afebrile patient with a swollen knee…” Case Conclusion May 7, 2012

Posted by Andy Jagoda, MD in: Uncategorized , add a comment

The Conclusion Is…

You remembered from your evidence-based review of the literature that there is no serum blood test that can adequately rule out septic arthritis, so the patient’s history and exam warranted arthrocentesis. After laying the patient flat and partially flexing the knee with a pillow, you guided the needle medially under the patella and you aspirated watery, but cloudy, material. A point-of-care sLactate came back quickly at 15 mmol/L, and removed any ambiguity — this was a septic joint. While synovial culture and Gram stain (and blood cultures) were sent, along with sWBC and pre-op labs, you initiated IV antibiotics — vancomycin and ceftriaxone. Then you called up the orthopedist and asked him to prepare the OR.

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