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Case Conclusions — Mosquito-Borne Illness May 11, 2014

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

Recap of Case 1: A 50-year-old man presents with fever for 3 days. He is an immigrant from Nigeria, but has resided in the United States for a decade. Ten days ago, he visited his family in a rural part of his homeland. He complains of fever, chills, and vomiting. His only medication was chloroquine, which was prescribed by his primary care physician prior to his trip. You recall reading something about increased resistance to one of the antimalarial medications in certain countries, but you can’t remember the specifics. A nurse brings you an ominous-looking ECG from EMS, just as you’re attempting to recall where to look up that information…

Recap of Case 2: A 35-year-old woman presents with fever and malaise for 1 day. While taking her blood pressure, she is noted to have petechiae on the ipsilateral arm. She says she recently returned from a trip to Puerto Rico. You have heard that there is a current outbreak of dengue on the island, but you have never seen the disease before, so you need to quickly assess whether your patient has dengue and how to manage her disease…

Case Conclusions: For your 50-year-old patient from Nigeria, you checked the CDC malaria website and called the CDC malaria hotline ([855] 856-4713), and they were able to assist you in navigating the case. The patient was well appearing and did not meet any criteria for complicated malaria. In your discussions with the patient, he felt safe going home with a prescription for atovaquone/proguanil, pending the results of the thick and thin smears.

You examined the 35-year-old female patient with petechiae who recently visited Puerto Rico, and after evaluation of the WHO Clinical Criteria for suspected dengue, you were comfortable that she did not have any warning signs for dengue. You sent off the appropriate tests (dengue virus PCR and dengue IgM antibody testing). You asked her to either return to the ED or be seen by her primary care doctor in 48 hours once her fever resolved. You carefully explained why reevaluation was so crucial, given the natural history of dengue. You made sure she understood the return precautions prior to discharging her from the ED.

Thank you to everyone who participated in this month’s challenge!

Would you like to learn more about treating mosquito-borne illness in the ED? Simply click the links below:

Mosquito-Borne Illness May 6, 2014

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

Read the following cases and let us know how you would care for these two patients in the comments box below.

Case 1: A 50-year-old man presents with fever for 3 days. He is an immigrant from Nigeria, but has resided in the United States for a decade. Ten days ago, he visited his family in a rural part of his homeland. He complains of fever, chills, and vomiting. His only medication was chloroquine, which was prescribed by his primary care physician prior to his trip. You recall reading something about increased resistance to one of the antimalarial medications in certain countries, but you can’t remember the specifics. A nurse brings you an ominous-looking ECG from EMS, just as you’re attempting to recall where to look up that information…

Case 2: A 35-year-old woman presents with fever and malaise for 1 day. While taking her blood pressure, she is noted to have petechiae on the ipsilateral arm. She says she recently returned from a trip to Puerto Rico. You have heard that there is a current outbreak of dengue on the island, but you have never seen the disease before, so you need to quickly assess whether your patient has dengue and how to manage her disease…

Our answers will be posted on May 12. Thanks in advance for participating!

“Bradydysrhythmias…” Case Conclusion September 9, 2013

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

Case re-cap:

It is about 20 minutes into your shift when EMS arrives with a pleasant 80-year-old woman who has had a syncopal event. She describes standing in her home earlier today and becoming lightheaded and falling to the ground. She is now resting comfortably, and her vital signs are: blood pressure, 140/72 mm Hg; pulse rate, 74 beats/min; respiratory rate, 14 breaths/min; and oxygen saturation, 99% on room air. You have just begun to take her history when you are interrupted and called to your next patient…

You approach the bedside of a 27-year-old woman who is pale, diaphoretic, and writhing in pain. The only history you are able to obtain is that she has had mild lower abdominal pain for a few days that acutely worsened today. Initial vital signs are: blood pressure, 70/40 mm Hg; pulse rate, 58 beats/min; respiratory rate, 20 breaths/min; and oxygen saturation, 99% on room air. Your brief exam is significant for diffuse abdominal tenderness and guarding. You then hear a flurry of activity from the hallway…

Your next patient is being rushed down the hall on a stretcher. Brought in by a family member for intermittent lightheadedness and shortness of breath, this 64-year-old man is pale and diaphoretic, with depressed mental status. A quick check of his radial artery demonstrates a weak pulse with a palpable rate of approximately 40 beats/min. You quickly place him on the cardiac monitor and notice what appears to be a third-degree heart block. Initial vitals are: blood pressure, 82/40 mm Hg; pulse rate, 38 beats/ min; respiratory rate, 18 breaths/min; and oxygen saturation, 98% on room air.

These 3 cases represent some of the variable presentations of patients with bradydysrhythmias. The underlying pathology for these patients ranges from the benign to the life threatening. You approach each case in a systematic manner, knowing that prompt evaluation, recognition, and treatment can make the difference.

Case conclusion:

When you returned to complete the history on your 80-year-old female patient who had the syncopal event at home, you found that she had no prodrome before the syncopal event, although she did describe recent episodes over the past few weeks where she suddenly became very lightheaded. These episodes apparently resolved spontaneously. She appeared stable upon arrival to the ED. After being placed on cardiac telemetry in the ED, a couple of episodes with sinus arrest were recorded, and some were followed by sinus tachycardia. Based on her brief telemetry monitoring in the ED, you suspected tachy-brady syndrome, and you admitted her to the hospital for continued monitoring, cardiology consultation, and consideration of pacemaker placement.

Your 27-year-old female patient with abdominal pain, hypotension, and bradycardia had a history of lower abdominal pain and had experienced significant worsening of the pain within the last few hours. You inquired as to pregnancy, and she confirmed a recent positive pregnancy test. Her last menstrual period placed her around 8 weeks’ gestation. Her vital signs were notable for profound hypotension with paradoxical bradycardia. As intravenous access was obtained, you prepared for fluid resuscitation as well as blood transfusion. A rapid FAST exam confirmed your suspicions of hemoperitoneum. A quick call to the in-house gynecologist requested emergent surgery for this patient with a ruptured ectopic pregnancy.

Meanwhile, your 64 year-old patient with bradycardia was noted to be pale, diaphoretic, and altered. Initial ECG analysis demonstrated third-degree heart block. You quickly secured IV access and gave him IV atropine, but he had minimal-to-no response in the conduction block. You initiated transcutaneous pacing, capture was demonstrated, and you noted marked improvement of his distal perfusion and mental status. Because of the discomfort associated with transcutaneous pacing, you obtained central venous access and transitioned the patient to a transvenous pacer. From his health records, you learned that he had long-standing bundle branch block from dilated cardiomyopathy. With the transvenous pacer, he appeared to be doing much better, and he was admitted to the cardiac critical care unit with a plan to place a permanent pacer/ AICD soon.

Download free risk management pitfalls for Bradydysrhythmias In The Emergency Department.

Congratulations to Jesus Llabres, Uttam Bhatta, Nga Collard, Giovanni Moschini, and John Ventura — this month’s winners get a free copy of the latest issue of Emergency Medicine Practice on this topic: Evaluation And Management Of Bradydysrhythmias 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!

“Pregnant asthmatic…” Case Conclusion June 7, 2013

Posted by Andy Jagoda, MD in : Airway, Infectious Disease, Respiratory Emergencies , 1 comment so far

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.

Download free risk management pitfalls for Asthma Management In The Emergency Department.

Congratulations to Dr. Masa, Dr. Samuels, Dr. Woodard Jr., Dr. Flynn, and Dr. Murphy — this month’s winners get a free copy of the latest issue of Emergency Medicine Practice on this topic: Management Of Acute Asthma 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!

“Antimicrobial Therapy” … Case Conclusion January 7, 2012

Posted by Andy Jagoda, MD in : Drugs & Emergency Procedures, Infectious Disease , add a comment

The Conclusion Is…

The 35-year-old female was young and healthy, and therefore a decision was made for outpatient management that included coverage for atypical organisms. In the ED, 500 mg of azithromycin was administered and a prescription for 4 additional days at 250-mg-per-day dosing was provided. She was given strict instructions to return if she felt more shortness of breath or worse in any way. She followed up with her primary care doctor in 3 days, feeling much better.

The 70-year old female was presumed to have a mild delirium induced by her UTI. She was given IV ciprofloxacin, and her mental status returned to normal on hospital day 2. Her urine culture grew E coli sensitive to fluoroquinolones, and she was discharged on oral ciprofloxacin on hospital day 4.

The 23-year-old with the infected forearm had the abscess incised and drained in the ED. Because there was also a surrounding cellulitis, he was given oral trimethoprim-sulfamethoxazole and instructed to return for a wound check. His arm was markedly improved by a day 3 wound check, and his wound culture was positive for CA-MRSA.

The 85-year-old from the nursing home had a CT of the abdomen and pelvis that revealed diverticulitis with no evidence of abscess or perforation. Treatment with cefepime and metronidazole was initiated, and he was admitted. The hospital discharge summary indicated that he defervesced after 4 days and was sent back to the nursing home on day 8.

Congratulations to Dr. Barone, Dr. Brown, Dr. Cohen, Dr. Nabhani, and Dr. Tampi— this week’s winners of Emergency Medicine Practice’s “Evidence-Based Guidelines For Evaluation And Antimicrobial Therapy For Common Emergency Department Infections!” For a discussion of common infectious diseases presenting to the ED and a review of the current literature and guidelines, read this issue.

Antimicrobial Therapy… December 30, 2011

Posted by Andy Jagoda, MD in : Drugs & Emergency Procedures, Infectious Disease , 25comments

At 7:00 on a Monday morning, the day begins with a full line-up of “to be seen.” A 35-year-old female with no past medical history presents to the ED complaining of cough and shortness of breath for 2 days that is progressively worsening. On physical examination, she is febrile with an oxygen saturation of 94% on room air and decreased breath sounds at the right base. You order a chest x-ray that shows right lower lobe consolidation.

The second patient on your tracking board is a 70-year-old female with fever, nausea, and back pain for 3 days. She is accompanied by her daughter, who states her mother hasn’t been herself today and that she had a similar presentation when she had a UTI 2 years ago. She is febrile to 38.3°C (101°F), oriented x2, with left costovertebral angle tenderness. Her urine dipstick is positive for leukocyte esterase and nitrites.

In the next bed, you are evaluating a 23-year-old male who has had a painful, swollen right forearm for 2 days. He reports a subjective fever earlier in the evening, but no other systemic symptoms. He denies any past medical history and has no IV drug abuse and no history of diabetes. He is afebrile with normal vital signs. A 6-cm area of erythema, induration, and tenderness is noted on his proximal forearm with a 2-cm central fluctuant, raised area. He has full range of motion at the elbow.

Just as you sit down for a cup of coffee, the triage nurse notifies you that she just received an 85-year-old male from a nursing home that was sent in for evaluation for fever. He has a history of insulin-dependent diabetes mellitus, hypertension, and dementia. On physical examination, he is febrile, with otherwise normal vital signs. His abdomen is slightly distended, soft, but diffusely tender to palpation.

Four infectious disease cases in a row — it feels like an epidemic. In the age of emerging pathogens — and when the right antibiotic choice may be the difference between a good or bad outcome — which antibiotic(s) do you use?

(Enter to win the latest issue of Emergency Medicine Practice, including CME, by submitting your answer to the question above. To do so, simply enter your response in the comments box. The deadline to enter is January 6th.)

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