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Patient with vaginal bleeding… July 26, 2013

Posted by Andy Jagoda, MD in : Hematologic/Allergic/Endocrine Emergencies, Renal and Genitourinary Emergencies , 14comments

Your radio goes off and a panicked paramedic reports that they are en route with a 42-year-old woman who is having profuse vaginal bleeding and appears very ill. She is pale, tachycardic, and hypotensive. She has a history of fibroids. She has been bleeding heavily for 3 days, and the bleeding has acutely increased in the past few hours. The on-call gynecologist is delivering a baby at the hospital across town, and you will have to stabilize this patient and manage her on your own for a few hours…

How would you manage this patient?

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“Lower back pain…” Case Conclusion July 8, 2013

Posted by Andy Jagoda, MD in : Musculoskeletal Emergencies, Neurologic , add a comment

Case re-cap:

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.

Case conclusion:

You wanted to be sure your 45-year-old construction worker patient had no red flag signs or symptoms, so you specifically asked him if he had any prior history of cancer and inquired into his habits (including illicit drug use) and told him that use of intravenous drugs would alter your management. Your physical exam was consistent with a radiculopathy. You inquired about bowel or bladder abnormalities, and he reported all was good on that front. You made a diagnosis of lumbar radiculopathy, and you decided to treat with NSAIDs and a muscle relaxant. You explained that no imaging or blood testing was needed and informed him that his symptoms needed to be reassessed in 4 weeks, as more than 85% of patients are better by then. He asked for extra pain medication, and you agreed to a short course of tramadol. He will follow up with his workers’ compensation clinic, and they will determine when he can return to work.

Download free risk management pitfalls for Low Back Pain.

Congratulations to Dr. Eak, Dr. Mayeri, Dr. Lock, Dr. Shahzad, and Dr. Cohen — this month’s winners get a free copy of the latest issue of Emergency Medicine Practice on this topic: An Evidence-Based Approach To The Evaluation And Treatment Of Low Back Pain In The Emergency Department. Didn’t win but want to get a complete systematic, evidence-based review on this topic? Purchase the issue today including 4 CME credits!

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