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Adolescent Gynecologic Emergencies. What do you do? February 14, 2019

Posted by Andy Jagoda, MD in : What's Your Diagnosis , 1 comment so far

You are then called to the resuscitation room for a 17-year-old girl who was found unresponsive at home. On examination, she is ill-appearing, lethargic, has cool distal extremities, normal heart sounds, and clear lungs, and her abdomen is soft but tender in the left lower quadrant. Her vital signs are: blood pressure, 80/40 mm Hg; heart rate, 130 beats/min; respiratory rate, 25 breaths/min; and oxygen saturation, 95% on room air. What are the immediate first steps in managing this patient? What testing is needed for evaluation and management? What is the appropriate disposition?

Case Conclusion:
The 17-year-old girl presented in shock. IV access was obtained quickly for fluid resuscitation. Bedside abdominal ultrasound revealed free fluid on the suprapubic view. The following laboratory tests were sent: hCG, CBC, complete metabolic panel, type and screen, and blood culture. Her hCG resulted positive, raising concern for ectopic pregnancy. After she was resuscitated, gynecology was consulted and noted an empty uterus and free peritoneal fluid on ultrasound, in spite of a serum hCG of 10,000 mIU/mL. The patient was quickly transferred to the operating room where an ectopic pregnancy complicated by hemoperitoneum was found.

Would you have done it different? Tell us how you would have handled this case.

Life-Threatening Headache. What do you do? February 12, 2019

Posted by Andy Jagoda, MD in : What's Your Diagnosis , 2comments

A 55-year-old man with history of nonsmall cell lung cancer who is on cisplatin presents with an acute headache and lethargy for 6 hours. His vital signs are remarkable for a blood pressure of 210/120 mm Hg, heart rate of 70 beats/min, and a temperature of 36.7°C (98°F). His physical exam reveals a lethargic patient with no localizing neurologic signs and no meningismus. You order a noncontrast CT of the head and consider lowering this patient’s blood pressure, though you wonder how much and how fast it should be reduced…

Case Conclusion:
You recognize that this cancer patient’s change in mental status and severely elevated blood pressure was likely the result of PRES. You obtained a CT of the head, which revealed white-matter changes in the posterior cerebral hemispheres. Utilizing IV nicardipine, you lowered the patient’s MAP by 25% over the first hour. In addition, you temporarily discontinued his chemotherapy medication. He subsequently became more alert and responsive.

Would you have done it different? Tell us how you would have handled this case.

Skiing with no gloves. How do you handle these cold injuries? — Management of Pediatric Hypothermia January 14, 2019

Posted by Andy Jagoda, MD in : What's Your Diagnosis , add a comment

Case Recap:
A 17-year-old boy comes into your ED complaining of numbness and hardening of his fingers. He is a previously healthy foreign exchange student who is staying with a host family. The symptoms started yesterday after he went snow skiing for the first time. He says he wore gloves, but he was having a hard time holding the ski poles, so he took them off midway through the day. On examination, the fingertips on both of his hands are firm to the touch, have a dark discoloration, and are without sensation. The firmness and discoloration extend only to the distal interphalangeal joint in most of the fingers, but to the proximal interphalangeal joint in the middle finger of his left hand. The thumb on his right hand has a sizeable blister. As you step out of the room, you contemplate the next steps.

How do you classify the severity of his cold injuries? Does his thumb need debridement? Should you consult a hand surgeon and/or the burn center? What is the long-term prognosis for his injuries?

Case Conclusion:
The hands of the 17-year-old boy who did not wear gloves while skiing were placed in a warm water bath at 38°C (100.4°F) and gently rewarmed for 30 minutes. The pain did increase in his hand secondary to reperfusion, and all of his tissues softened except for his thumbs. You left his thumb blister intact, as it was not causing any restriction in movement and was filled with clear fluid. You placed aloe vera gel on all of his digits and loosely wrapped his hands in nonadhesive dressing. You gave him instructions to follow up at the burn center for continued outpatient therapy. He did not lose any digits, but the decreased sensation in his left thumb remained.

Intrauterine pregnancy presenting with fever. What do you do? — First Trimester Pregnancy Emergencies in the ED January 12, 2019

Posted by Andy Jagoda, MD in : What's Your Diagnosis , add a comment

Case Recap:
Late in your shift, you evaluate a 26-year-old woman who has a confirmed intrauterine pregnancy at 11 weeks’ gestation and presents for fever, dysuria, and right flank pain. An ultrasound was performed in triage that showed bilateral mild hydronephrosis.

Several questions flood your mind. What do you make of that finding, which antibiotics would be safe for treatment, and can she be managed as an outpatient?

Case Conclusion:
You diagnosed your patient with pyelonephritis. Since there are not good data supporting routine outpatient management of pyelonephritis in pregnancy, you consulted her obstetrician to discuss admission. She received ceftriaxone 1 g IV, was admitted to the hospital, and recovered uneventfully. The hydronephrosis was symmetric and bilateral, which is typical during pregnancy, so no further workup for this was undertaken. She was discharged on cephalexin after sensitivities resulted.

 

Skiing with no gloves. How do you handle these cold injuries? — Management of Pediatric Hypothermia January 7, 2019

Posted by Andy Jagoda, MD in : What's Your Diagnosis , 3comments

A 17-year-old boy comes into your ED complaining of numbness and hardening of his fingers. He is a previously healthy foreign exchange student who is staying with a host family. The symptoms started yesterday after he went snow skiing for the first time. He says he wore gloves, but he was having a hard time holding the ski poles, so he took them off midway through the day. On examination, the fingertips on both of his hands are firm to the touch, have a dark discoloration, and are without sensation. The firmness and discoloration extend only to the distal interphalangeal joint in most of the fingers, but to the proximal interphalangeal joint in the middle finger of his left hand. The thumb on his right hand has a sizeable blister. As you step out of the room, you contemplate the next steps.

How do you classify the severity of his cold injuries? Does his thumb need debridement? Should you consult a hand surgeon and/or the burn center? What is the long-term prognosis for his injuries?

Come back on Jan 14th to see if you got it right!

Intrauterine pregnancy presenting with fever. What do you do? — First Trimester Pregnancy Emergencies in the ED January 5, 2019

Posted by Andy Jagoda, MD in : What's Your Diagnosis , 17comments

Late in your shift, you evaluate a 26-year-old woman who has a confirmed intrauterine pregnancy at 11 weeks’ gestation and presents for fever, dysuria, and right flank pain. An ultrasound was performed in triage that showed bilateral mild hydronephrosis.

Several questions flood your mind. What do you make of that finding, which antibiotics would be safe for treatment, and can she be managed as an outpatient?

Are you prepared? — Bioterrorism Attacks Involving Pediatric Patients Conclusion December 14, 2018

Posted by Andy Jagoda, MD in : What's Your Diagnosis , 1 comment so far

Case Recap:

Your next patient is a 2-year-old girl with a 3-day history of high fevers, body aches, fatigue, and a rash. Her vital signs are; temperature, 40.5°C (104.9°F); heart rate, 105 beats/min; and blood pressure, 100/60 mm Hg. The physical examination reveals pustular vesicles with central umbilication in the same stage of development on her face, torso, and extremities. The mother says the lesions started in the girl’s mouth 3 to 4 days ago. The patient’s past medical history is notable only for severe eczema.

What features of this suggests a potential bioterrorism threat? Does the patient require isolation? What public health notifications are needed?

Case Conclusion:

The 2-year-old girl with a history of high fevers, body aches, fatigue, and rash concerned you because you remembered a rash like this from textbooks, though you had never seen a rash like this before in person. An older nurse called you from triage and said, “I’ve placed her in a negative pressure room. I think this is smallpox—I remember the pictures from when I was little.” You recalled the CDC diagnostic guidelines for smallpox and noted that the patient had (1) febrile prodrome > 38.3°C (101°F), (2) classic appearing smallpox lesions, and (3) lesions in the same stage of development. Thus, the patient met the high-risk criteria. You initiated airborne and contact precautions and alerted the infection control team and dermatology. They agreed with your risk analysis and the local health department was called. The smallpox response team was dispatched to your facility to collect lab specimens. You were fortunate that 2 of the clinicians on staff received the smallpox vaccine when they were younger because of prior military deployments. They volunteered to care for the patient using appropriate PPE in coordination with the infection control team. You later found out that the patient was the daughter of a military parent who was recently deployed for a high-risk mission requiring vaccination for smallpox. The child likely had a case of contact vaccinia.

What influenza testing do you choose? — Influenza in the ED Conclusion December 12, 2018

Posted by Andy Jagoda, MD in : What's Your Diagnosis , add a comment

Case Recap:

Your patient is a 32-year-old man with the following chief complaints: cough and fever. His maximum temperature over the past 5 days was 40˚C (103.9°F). He has been taking over-the-counter cold remedies without relief, and today he is markedly short of breath. The patient has no regular primary care provider and has no significant past medical history. His initial vital signs are: temperature 39.2˚C (102.5°F); heart rate, 118 beats/min; respiratory rate, 28 breaths/min; blood pressure, 134/78 mm Hg; and oxygen saturation, 88% on room air. On examination, he appears uncomfortable, with notable tachypnea. The oropharynx is clear and the neck supple. Crackles are noted in the right lower lung field, without any wheezing. The abdomen is soft and nontender. The patient is given oxygen via face mask, with an improvement in saturation to 100%. Chest x-ray reveals a right lower lobar pneumonia with a small pleural effusion. You start IV antibiotics and request an inpatient bed, as he is hypoxic with his pneumonia. 

You wonder whether influenza testing is indicated, and if so, what type of test to do?

Case Conclusion:

Delving further into the CDC website, you find that the false-negative rate with rapid antigen testing for influenza can be significant, especially when disease prevalence is high, as it is in your region. Based on this information, you decide to start your more seriously ill 32-year-old patient on oseltamivir 75 mg twice a day for 5 days despite the initially negative result reported by the hospital laboratory.

Are you prepared? — Bioterrorism Attacks Involving Pediatric Patients December 7, 2018

Posted by Andy Jagoda, MD in : What's Your Diagnosis , 7comments

Your next patient is a 2-year-old girl with a 3-day history of high fevers, body aches, fatigue, and a rash. Her vital signs are; temperature, 40.5°C (104.9°F); heart rate, 105 beats/min; and blood pressure, 100/60 mm Hg. The physical examination reveals pustular vesicles with central umbilication in the same stage of development on her face, torso, and extremities. The mother says the lesions started in the girl’s mouth 3 to 4 days ago. The patient’s past medical history is notable only for severe eczema.

What features of this suggests a potential bioterrorism threat? Does the patient require isolation? What public health notifications are needed?

What influenza testing do you choose? — Influenza in the ED December 5, 2018

Posted by Andy Jagoda, MD in : What's Your Diagnosis , 15comments

Your patient is a 32-year-old man with the following chief complaints: cough and fever. His maximum temperature over the past 5 days was 40˚C (103.9°F). He has been taking over-the-counter cold remedies without relief, and today he is markedly short of breath. The patient has no regular primary care provider and has no significant past medical history. His initial vital signs are: temperature 39.2˚C (102.5°F); heart rate, 118 beats/min; respiratory rate, 28 breaths/min; blood pressure, 134/78 mm Hg; and oxygen saturation, 88% on room air. On examination, he appears uncomfortable, with notable tachypnea. The oropharynx is clear and the neck supple. Crackles are noted in the right lower lung field, without any wheezing. The abdomen is soft and nontender. The patient is given oxygen via face mask, with an improvement in saturation to 100%. Chest x-ray reveals a right lower lobar pneumonia with a small pleural effusion. You start IV antibiotics and request an inpatient bed, as he is hypoxic with his pneumonia. 

You wonder whether influenza testing is indicated, and if so, what type of test to do?

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Last Modified: 02-19-2019
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