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Multiple medical concerns to consider… September 28, 2012

Posted by Andy Jagoda, MD in : Hematologic/Allergic/Endocrine Emergencies , 8comments

An 88-year-old woman with history of moderate dementia presents via ground ambulance for irritability and increased weakness after having 2 weeks of cough and vomiting at her extended care facility. She was found febrile and confused during morning nursing rounds. Her past medical history is significant for recent cerebrovascular accident with residual left-sided weakness and chronic kidney disease. Current medications include metformin, hydrochlorothiazide, metoprolol, and aspirin. Her vital signs on arriving in the ED are blood pressure 98/63 mm Hg, pulse 95 beats per minute, respiratory rate 24 breaths per minute, oral temperature 38.3C, and oxygen saturation 95% on 2 L nasal cannula. On physical exam, she is frail and appears dehydrated, with intermittent confusion. Her pulmonary exam is remarkable for crackles at the right base with mild diffuse abdominal discomfort. Her chest x-ray shows right middle lobe pneumonia. Blood is obtained, and a serum chemistry panel shows sodium 152 mEq/L, potassium 4.0 mEq/L, chloride 108 mEq/L, bicarbonate 14 mEq/L, BUN 55 mg/dL, creatinine 1.7 mg/dL, and glucose 131 mg/dL. The nurse asks you what IV fluids you want and how fast

What’s your diagnosis? And how do you proceed?

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“4 cases, 4 head injuries…” Case Conclusion September 6, 2012

Posted by Andy Jagoda, MD in : Neurologic, Radiology, Trauma , add a comment

Your 16 year-old soccer champ had no history of loss of consciousness, and while in the ED, his symptoms resolved completely within 2 hours. Using the CDC guidelines, you determined that a CT was not indicated. You discussed this with his parents, and he was discharged home symptom-free 6 hours after his injury. You instructed him and his parents about the importance of physical and cognitive rest (based on the Zurich Guidelines) until cleared by his primary care provider.

The 38-year-old woman in the low-speed motor vehicle crash had a loss of consciousness but no symptoms or risk factors. Based on the CDC guidelines, you do not think a CT is indicated. You discussed with her the very low likelihood of a clinically important ICI, and she was discharged with head injury precautions and information about postconcussive syndrome.

The history on the 2-month old baby was inconsistent, so you suspected abuse. She had a small hematoma in the left parietal region, and you ordered a CT, which revealed a small subdural. Child Protective Services was called, and the patient was admitted to the PICU.

Your drinking buddy sobered up quickly, but you convinced him to wait for the CT you ordered based on the following CDC criteria: presumed loss of consciousness, intoxication, and physical evidence of trauma above the clavicles. His CT showed atrophy but was otherwise normal. You provided him with follow-up and clear discharge instructions, which he promptly threw in the trash on the way out. Another night in the ED…

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