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Lower back pain… June 24, 2013

Posted by Andy Jagoda, MD in : Musculoskeletal Emergencies, Neurologic , 10comments

A 45-year-old man presents after 7 days of pain in his lower back. He reports that it began the day after he started at a new job site. The pain initially improved with ibuprofen, but he woke up this morning with a severe exacerbation of the pain. He denies a fall or other trauma, and he states that the pain radiates from his left buttock to his left foot. He has had intermittent back pains in the past, but he never required any imaging or interventions. Employed in the construction industry, he has a history of hypertension and is going through a divorce. He is afebrile, has a benign abdominal exam, and displays an antalgic gait. He has intact patella and Achilles reflexes, and he has a positive left straight-leg raise sign and crossed straight-leg raise sign. Strength and sensation, including the perineum, are intact and symmetrical. The patient insists that he needs an MRI but you’re not convinced that’s necessary.

How would you manage this patient?

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“Pregnant asthmatic…” Case Conclusion June 7, 2013

Posted by Andy Jagoda, MD in : Airway, Infectious Disease, Respiratory Emergencies , add a comment

Case re-cap:

While establishing IV access and calling respiratory therapy for your first patient, a 24-year-old Hispanic female with a history of asthma who is 15 weeks pregnant presents with tachypnea and acute shortness of breath with audible wheezing. She has been taking albuterol and fluticasone at home with no relief of symptoms. She has a blood pressure of 110/78 mm Hg, heart rate of 110 beats/ min, respiratory rate of 40 breaths/min, and pulse oximetry of 93% on room air. Physical exam demonstrates accessory respiratory muscle usage, decreased breath sounds, and expiratory wheezing. You recognize that your patient is at risk for deteriorating, and you wonder which interventions are safest to use in pregnancy…

Case conclusion:

For the 24-year-old pregnant female with a mild asthma exacerbation, you began 3 consecutive metereddose inhaler treatments with albuterol. You also administered 16 mg of dexamethasone orally. Peak flows performed before and after the first treatment were 125 L/min (predicted 235), and auscultation revealed loud expiratory wheezing and better airflow. Peak expiratory flow rate continued to improve, and there was clearing of breath sounds and much-improved airflow. Her respiratory rate was 24 breaths/min at that time, and her heart rate was 108 beats/min. After 2 hours, her symptoms were nearly resolved; you gave her a prescription for repeat dexamethasone with a metered-dose inhaler refill and sent her home.

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