Case Conclusion — Retching Patient With Diabetes
June 15, 2014


Posted by Andy Jagoda, MD in: Hematologic/Allergic/Endocrine Emergencies , add a comment

Case Recap: You walk into a busy Monday evening shift, and one of the nurses asks you to see a patient who has been waiting for several hours. The nurse states that the 26-year-old woman is sleepy, with a heart rate of 126 beats/min. He advises you that the patient has diabetes, for which she has been medically compliant by taking her insulin. The patient stated that she had not been feeling well for a few days, after which she developed fever, nausea, and vomiting. As you enter the room, you observe the patient retching. You note her respiratory rate is 32 breaths/min, her heart rate is 124 beats/min, and that her blood pressure is 88/50 mm Hg. You start considering your differential and wonder if this presentation is due to her diabetes or if there is something else you might be missing. read more

Retching Patient With Diabetes
June 12, 2014


Posted by Andy Jagoda, MD in: Hematologic/Allergic/Endocrine Emergencies , add a comment

June’s Case: You walk into a busy Monday evening shift, and one of the nurses asks you to see a patient who has been waiting for several hours. The nurse states that the 26-year-old woman is sleepy, with a heart rate of 126 beats/min. He advises you that the patient has diabetes, for which she has been medically compliant by taking her insulin. The patient stated that she had not been feeling well for a few days, after which she developed fever, nausea, and vomiting. As you enter the room, you observe the patient retching. You note her respiratory rate is 32 breaths/min, her heart rate is 124 beats/min, and that her blood pressure is 88/50 mm Hg. You start considering your differential and wonder if this presentation is due to her diabetes or if there is something else you might be missing. read more

Case Conclusion — Cardiotoxicity
February 6, 2014


Posted by Andy Jagoda, MD in: Cardiovascular, Drugs & Emergency Procedures, Hematologic/Allergic/Endocrine Emergencies, Toxicologic and Environmental Emergencies , add a comment

You tracheally intubated the young woman who had been taking verapamil and collapsed. You then gave her atropine and calcium and started her on a norepinephrine infusion. However, despite these therapies, she remained hypotensive and bradycardic. You then administered high-dose insulin therapy (1 U/kg/h), with a 10% dextrose infusion. Her hemodynamic status began to stabilize, with resolution of her hypotension and bradycardia. She was admitted to the ICU for further management. read more

“Anemic patient….” Case Conclusion
November 7, 2013


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Case re-cap:

A 54-year-old Hispanic male presents to the ED with the complaints of fatigue and weakness. The weakness is described as generalized, and the symptoms have been present and constant for the last 2 days. The patient denies hematemesis, hematochezia, dark-colored stools, hematuria, or other evidence of bleeding. He also denies chest or abdominal pain, dyspnea, diaphoresis, fever, or chills. The patient has not seen a doctor in the last 15 years and does not think he has any medical conditions. The only medication he has been taking is over-the-counter ibuprofen, which he has been taking daily since he injured his back at work 2 weeks ago. The patient works as a construction laborer and denies past surgeries or allergies. His vital signs are: blood pressure, 110/50 mm Hg; heart rate, 127 beats/min; respirations, 22 breaths/min; and SpO2, 97% on room air. The patient is afebrile. His skin is warm and dry but, despite being dark-skinned, he appears a little pale. On eye examination, the sclerae appear to have a yellow hue. Cardiovascular examination reveals bounding pulses, a hyperdynamic precordium, and a grade II over VI soft, systolic murmur. The remainder of the examination is unremarkable, including a rectal examination, which is negative for occult blood. An ECG shows a sinus tachycardia but is otherwise normal. A basic chemistry panel is within normal limits; however, the CBC reveals a hemoglobin of 5.4 g/dL, hematocrit of 16%, WBC of 8000, and platelet count of 154,000. Based on the presenting symptoms and signs, the patient is likely to need RBC transfusions. An IV catheter is placed, and a normal saline infusion is initiated. A 500-mL bolus of normal saline reduces the heart rate to 105 beats/min. read more

Anemic patient….
November 1, 2013


Posted by Andy Jagoda, MD in: Hematologic/Allergic/Endocrine Emergencies , 18 comments

A 54-year-old Hispanic male presents to the ED with the complaints of fatigue and weakness. The weakness is described as generalized, and the symptoms have been present and constant for the last 2 days. The patient denies hematemesis, hematochezia, dark-colored stools, hematuria, or other evidence of bleeding. He also denies chest or abdominal pain, dyspnea, diaphoresis, fever, or chills. The patient has not seen a doctor in the last 15 years and does not think he has any medical conditions. The only medication he has been taking is over-the-counter ibuprofen, which he has been taking daily since he injured his back at work 2 weeks ago. The patient works as a construction laborer and denies past surgeries or allergies. His vital signs are: blood pressure, 110/50 mm Hg; heart rate, 127 beats/min; respirations, 22 breaths/min; and SpO2, 97% on room air. The patient is afebrile. His skin is warm and dry but, despite being dark-skinned, he appears a little pale. On eye examination, the sclerae appear to have a yellow hue. Cardiovascular examination reveals bounding pulses, a hyperdynamic precordium, and a grade II over VI soft, systolic murmur. The remainder of the examination is unremarkable, including a rectal examination, which is negative for occult blood. An ECG shows a sinus tachycardia but is otherwise normal. A basic chemistry panel is within normal limits; however, the CBC reveals a hemoglobin of 5.4 g/dL, hematocrit of 16%, WBC of 8000, and platelet count of 154,000. Based on the presenting symptoms and signs, the patient is likely to need RBC transfusions. An IV catheter is placed, and a normal saline infusion is initiated. A 500-mL bolus of normal saline reduces the heart rate to 105 beats/min. read more

“Novel Oral Anticoagulant Agents…” Case Conclusion
October 7, 2013


Posted by Andy Jagoda, MD in: Hematologic/Allergic/Endocrine Emergencies, Trauma , add a comment

Case re-cap:

Your first patient of the evening is a 78-year-old woman who had a witnessed mechanical fall at home approximately 3 hours prior to arrival. She reports a mild frontal headache, and her family reports that she is “just not acting right.” She takes dabigatran for stroke prophylaxis, given her nonvalvular atrial fibrillation. She is neurologically intact on your examination and is oriented to person, place, and time. The CT of her head, however, shows a 5-mm intraparenchymal hemorrhage. Her PTT is 64 seconds, and her INR is 1.5. You wonder about the relevance of her coagulation studies, what the risk of deterioration is, and whether there is anything available to reverse her anticoagulation. read more

Novel Oral Anticoagulant Agents…
September 30, 2013


Posted by Andy Jagoda, MD in: Hematologic/Allergic/Endocrine Emergencies, Trauma , 1 comment so far

Your first patient of the evening is a 78-year-old woman who had a witnessed mechanical fall at home approximately 3 hours prior to arrival. She reports a mild frontal headache, and her family reports that she is “just not acting right.” She takes dabigatran for stroke prophylaxis, given her nonvalvular atrial fibrillation. She is neurologically intact on your examination and is oriented to person, place, and time. The CT of her head, however, shows a 5-mm intraparenchymal hemorrhage. Her PTT is 64 seconds, and her INR is 1.5. You wonder about the relevance of her coagulation studies, what the risk of deterioration is, and whether there is anything available to reverse her anticoagulation. read more

“Patient with vaginal bleeding…” Case Conclusion
August 7, 2013


Posted by Andy Jagoda, MD in: Hematologic/Allergic/Endocrine Emergencies, Renal and Genitourinary Emergencies , add a comment

Case re-cap:

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… read more

Patient with vaginal bleeding…
July 26, 2013


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

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… read more

“Multiple medical concerns to consider…” Case Conclusion
October 4, 2012


Posted by Andy Jagoda, MD in: Hematologic/Allergic/Endocrine Emergencies , add a comment

Your elderly patient had multiple medical concerns that required emergent evaluation. You diagnosed her with severe hypernatremia, likely secondary to her underlying disease processes, combined with a lack of access to free water. In addition to her pneumonia, she had been having gastrointestinal losses from vomiting, along with her known underlying renal insufficiency. On arrival, she was hypotensive and febrile. You immediately established 2 large-bore IVs, placed her on 2 L oxygen via nasal cannula, and obtained a finger-stick blood glucose. You began her management by correcting her hypoperfusion and hypovolemia with a 500- mL NS bolus followed by a second 500-mL NS bolus for her persistent hypotension after the pulmonary exam and confirmation of her past medical history. You then began treatment of the underlying causes of her hypernatremia with antipyretics, antiemetics, and antibiotics for her fever, vomiting, and pneumonia, respectively. After 2 NS boluses, her vital signs normalized, and slow correction of hypernatremia was initiated with 1/2NS at 100 mL/h over 48 hours as an inpatient. read more