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What’s Your Diagnosis? a 9-month-old infant gasping for air September 30, 2019

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

But before we begin, check out if you got last month’s case right, about the 11-year-old boy with acute abdominal pain. Click here to check out the answer!

Case Presentation: an 9-month-old infant gasping for air

As your shift is winding down at 4 AM, a mother brings in her 9-month-old infant, whom she describes as “gasping for air.” The baby has had a runny nose and cough for a few days as well as a low-grade fever, but now he is breathing rapidly and wheezing, with lower intercostal retractions.

The mother states that the infant has had wheezing in the past, and she asks if he might have asthma since “it runs in the family.” She also indicates that in the last 12 hours, he has not taken his usual amount of fluids.

His oxygen saturation level is 87% on room air.

You begin to think… should I treat this as reactive airway disease, asthma, or bronchiolitis? When should I give the patient albuterol, nebulized epinephrine, or oxygen? Does the infant need steroids? You also wonder whether this patient is going to tire and require assisted ventilation or whether there are any other alternatives to intubation.

Leave your solution in the comments below and review the issue to find out what was the authors’ recommendation.

Not a subscriber? You can find out the conclusion and if you got it right, next month when a new case is posted, so stay tuned!

Click to review Pediatric Emergency Medicine Practice

What’s Your Diagnosis? Nonconvulsive Status Epilepticus: Overlooked and Undertreated September 30, 2019

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

But before we begin, check out if you got last month’s case, on assistance with air travel emergencies, right. Click here to check out the answer!

Case Presentation: An 81-year-old woman presents with 1 day of behavioral changes

An 81-year-old woman presents with 1 day of behavioral changes. On examination, she is disoriented, with no focal neurologic findings and no evidence of seizure activity. Her medical history is remarkable for anxiety, arthritis, and hypertension; she has no history of stroke, trauma, or immunocompromise. Her medications include furosemide, lorazepam, and acetaminophen. After an extensive workup in the ED including ECG, CBC, CMP, UA, and
brain CT, all of which were normal, she was admitted to the floor.

You wonder: Is there something you forgot to consider in your differential diagnosis?

Leave your solution in the comments below and review the issue to find out what was the authors’ recommendation.

Not a subscriber? You can find out the conclusion and if you got it right, next month when a new case is posted, so stay tuned!

Click to review this Emergency Medicine Practice Issue

What’s Your Diagnosis? 11-year-old boy with acute abdominal pain August 29, 2019

Posted by Andy Jagoda, MD in : What's Your Diagnosis , 5comments

But before we begin, check out if you got last month’s case right, about the 8-year-old boy presenting to the ED after falling at a local playground. Click here to check out the answer!

Case Presentation: an 11-year-old boy with acute abdominal pain

An 11-year-old previously healthy boy presents to the ED on a busy Saturday evening. He has acute abdominal pain that started 18 hours ago as diffuse periumbilical abdominal pain. Within the last 3 hours or so, the pain migrated to the right lower quadrant and worsened in severity. The child says the bumps on the car ride to the hospital were painful, and hopping up and down makes the pain worse. He says it seems to be a bit better when he lies still and does not move. Oral ibuprofen has not really helped the pain. The patient has not eaten a meal all day and has vomited 3 times today. On presentation, he has a temperature of 38.3°C (101°F). He is fully immunized and does not have any upper respiratory symptoms. He has never had similar pain in the past and has no history of previous
abdominal surgeries. He has a normal genitourinary examination. He has obvious discomfort with palpation of his abdomen with maximum tenderness in the right lower quadrant. He exhibits guarding and rebound tenderness.

His mother asks you whether this could be appendicitis, and whether he will need surgery. You begin to think…

Is this appendicitis? What else could it be? How will you definitively determine the diagnosis? What laboratory evaluation and imaging tests should you order? It is now 2:00 AM. If the patient definitely has appendicitis, does he need an emergent appendectomy or can it wait?

Case Conclusion

You sent a CBC and CRP for the 11-year-old boy with abdominal pain and vomiting. The WBC count and CRP were both elevated. An appendix ultrasound showed a dilated, noncompressible appendix with mesenteric fat stranding and appendiceal wall hyperemia, and you diagnosed the boy with appendicitis. The on-call pediatric surgeon was contacted and asked that you start antibiotics and admit the patient for appendectomy in the morning.

Review the issue to find out more recommendations.

Not a subscriber? You can find out the conclusion and if you got it right, next month when a new case is posted, so stay tuned!

Click to review Pediatric Emergency Medicine Practice

What’s Your Diagnosis? Assisting With Air Travel Medical Emergencies August 29, 2019

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

But before we begin, check out if you got last month’s case, on assess anticoagulation status, right. Click here to check out the answer!

Case Presentation: a 53-year-old female passenger in the economy section has become “unresponsive.”

You are flying from London Heathrow Airport to New York JFK on British Airways when a flight attendant makes a request over the intercom for medical personnel to respond to an ill passenger. Among the responders is a Basic Life Support-trained EMT, a nurse intensivist, a psychiatrist, and yourself, an emergency medicine physician. The flight attendant informs you that a 53-year-old female passenger in the economy section has become “unresponsive.” Her husband says that she has a history of diabetes, hypertension, and coronary artery disease; has 2 stents; and is currently taking insulin, aspirin, clopidogrel, and metoprolol. On physical exam, she is initially diaphoretic, pale, and lethargic, but quickly regains consciousness and is able to provide some history, and she reports feeling lightheaded prior to losing consciousness. She reports ongoing general weakness and presyncope. She is bradycardic at 35 beats/min but she is alert, with no increased work of breathing. Her neurological exam is nonfocal, and she has a soft abdomen and thready peripheral pulses.

Case Conclusion

For your diabetic patient with weakness and loss of consciousness, you were able to access the AED and could see that she was bradycardic with a ventricular escape rhythm. Her husband retrieved her glucometer from her carry-on luggage, and her glucose measured at 45 mg/dL. She was able to drink some juice, and her glucose improved to 100 mg/dL and her heart rate improved to 60 beats/min, with improved mental status and peripheral pulses. She reported improving symptoms. The flight attendant connected you to the medical control officer employed by the airline, and you were able to describe the situation to her. Given the patient’s improving condition and the current location over the Atlantic Ocean, she recommended continuing to your final destination. The patient did well for the remainder of the flight, and was transported to an ED by EMS upon landing.

Review the issue to find out more recommendations.

Not a subscriber? You can find out the conclusion and if you got it right, next month when a new case is posted, so stay tuned!

Click to review this Emergency Medicine Practice Issue

How best to assess his anticoagulation status July 29, 2019

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

As you begin your shift, the first patient is a 70-year-old man brought in for a ground-level fall with isolated head injury. A review of the patient’s history reveals atrial fibrillation, and he is currently on anticoagulation with apixaban. A rapidly obtained CT scan of the head shows
a subdural hematoma.

As you resuscitate the patient, you wonder how best to assess his anticoagulation status and how best to address reversal.

What are your next steps?

Case Conclusion

Your patient on apixaban with traumatic subdural hematoma received initial resuscitation focusing on maintenance of the airway, breathing, and circulation, as appropriate for head trauma. After reviewing your hospital’s policy on DOAC reversal and local availability of specific reversal agents for this DOAC, you administered a dose of 4-factor PCC at 50 units/kg in the ED. He was admitted to the neurosurgical ICU for continued care, and a repeat CT of the head showed no interval expansion of the hemorrhage.

Review the issue to find out more recommendations.

Not a subscriber? You can find out the conclusion and if you got it right, next month when a new case is posted, so stay tuned!

Click to review this Emergency Medicine Practice Issue

How Do You Manage Bariatric Surgery Complications? July 11, 2019

Posted by Robin Wilkinson in : What's Your Diagnosis , 2comments

Case Recap:
You are called to the bedside of patient who presents for nausea and vomiting. He is a 38-year-old man who is 2 weeks out from the placement of a laparoscopic adjustable gastric band. He reports that he had an acute onset of nausea and vomiting this evening. He is actively vomiting on presentation and complains of diffuse abdominal pain, but is hemodynamically stable. While attempting to contact his surgeon, you wonder what the best imaging modality is to make the diagnosis. What would you do?

Case Conclusion:
You returned to your patient, in whom you had a concern for a slipped gastric band. You considered obtaining either an upper GI series or CT scan with oral and IV contrast; after speaking to his surgeon, you decided on an upper GI series, as the patient was now more stable. The patient was admitted to the surgery service; on follow-up, you learned that the balloon was subsequently deflated/repositioned, and the patient was discharged home in stable condition.

68-year-old woman presents with severe abdominal pain May 31, 2019

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

Case Recap:
As you begin your shift, a 68-year-old woman presents with severe abdominal pain. She requires 4 mg of morphine before you can even talk to her. Surprisingly, her abdomen is soft, and not particularly tender. She is tachycardic to the 120s, and her pulse feels irregular. Her blood pressure is 100/50 mm Hg. It seems strange that her pain is so incongruent with her exam, and you wonder: What is the best imaging study to help clarify things?

Case Conclusion:
You recognized that she needed pain control and fluids along with a full sepsis workup, including lactate, ECG, CT abdominal angiography, and an almost-certain surgical consult. Her ECG showed atrial fibrillation, and the CT angio confirmed the diagnosis. She was emergently taken to the OR, where a dead bowel segment was resected and she had a surprisingly good recovery, thanks to your rapid mobilization of specialty care.

Did you get it right?

Brush up on most recent best practices in evaluating patients with abdominal pain in the ED with our 20th anniversary Emergency Medicine Practice issue, Assessing Abdominal Pain in Adults: A Rational, Cost-Effective, and Evidence-Based Strategy.

P.S. Emergency Medicine Practice celebrates its 20th anniversary this month! Click here to check out our story, our plans and our great anniversary sale!

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A 3-year-old girl with a known peanut allergy May 31, 2019

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

Case Recap:
A 3-year-old girl with a known peanut allergy arrives to your ED via EMS. The girl was given a cookie by a classmate and immediately developed a generalized urticarial rash. EMS personnel gave her 12.5 mg of oral diphenhydramine and transported her to the ED. On examination, the patient has a heart rate of 160 beats/min with normal oxygenation and perfusion. She has bilateral periorbital swelling, without respiratory distress, wheezing, vomiting, or diarrhea. The accompanying daycare teacher tells you that the girl has previously been admitted to the intensive care unit for anaphylaxis.

You call the girl’s parents for more information and wonder what to do in the meantime. Is diphenhydramine sufficient treatment for this patient? Are corticosteroids indicated? Is this just an allergic reaction or could it be an anaphylactic reaction? What are the criteria for diagnosis of anaphylaxis? What are the indications for administering epinephrine in patients with anaphylaxis?

Case Conclusion:
The parents of the 3-year-old girl stated that the girl’s previous anaphylactic reaction began with urticaria and facial swelling that progressed, resulting in a critical care admission for airway compromise due to angioedema. You administered epinephrine 0.01 mg/kg IM for suspected anaphylaxis and observed the patient in the ED for 4 hours. The girl had complete resolution of the facial swelling and urticarial rash. You reviewed the signs and symptoms of anaphylaxis with the parents, discussed allergen avoidance, and demonstrated appropriate use of an epinephrine autoinjector. You discharged the patient with a prescription for 2 epinephrine autoinjectors and an anaphylaxis action plan.

Did you get it right?

Brush up on most recent best practices in evaluating and treating pediatric patients with anaphylaxis in the ED with the latest issue of Pediatric Emergency Medicine Practice issue, Anaphylaxis in Pediatric Patients: Early Recognition and Treatment Are Critical for Best Outcomes.

P.S. Emergency Medicine Practice celebrates its 20th anniversary this month! Click here to check out our story, our plans and our great anniversary sale!

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It is Trauma Awareness Month! Can you solve the trauma case below? May 10, 2019

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

Do you need to do anything regarding the missing fragment? — ED Management of Dental Trauma in Pediatric Patients

Case Recap:
You are then asked to see a 15-year-old adolescent boy who has come in with a tooth avulsion. He was at basketball practice when another player accidentally elbowed him in the mouth. He did not lose consciousness and has pain only in his mouth. He was immediately brought to your ED, which is about 15 minutes away from where the accident happened. His coach arrives with the boy’s tooth in a container of milk. On physical examination, the patient has lost his right lateral incisor and a clot remains where his tooth had been. How much time do you have to replace the tooth to have the best success of replantation? What do you need to consider while handling, storing, and cleaning the tooth?

Case Conclusion:
For the 15-year-old boy, you decided to replace the tooth as soon as possible. The patient had no other medical problems. You used Yankauer suction and light irrigation to remove the clot from the socket. You held the tooth by the crown, briefly rinsed it off, and used firm, gentle pressure to reinsert the tooth without any difficulty. You had Coe PakTM paste available at your facility, and you created a temporary splint to secure the tooth. You instructed the mother to follow up with the dentist tomorrow and to provide only a soft diet until then. You told the coach and the boy’s mom that, in the future, they should attempt to reimplant the tooth at the time of the accident and instructed them on the steps involved.

Did you get it right?

Click here to review the issue, Emergency Department Management of Dental Trauma: Recommendations for Improved Outcomes in Pediatric Patients (Trauma CME and Pharmacology CME).

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It is Stroke Awareness Month! Can you solve the stroke case below? May 10, 2019

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

Was it a “mini stroke”? — ED Management of Transient Ischemic Attack

Case Recap:
A 59-year-old obese woman presents to your community hospital ED after experiencing a distinct episode in which her left hand felt “clumsy,” along with a left facial droop and left-sided numbness. She denies experiencing frank weakness and states that the symptoms resolved in less than 10 minutes. She mentions that she experienced a similar episode 2 weeks prior, and is concerned because both her parents and an older sibling experienced disabling ischemic strokes. Her vital signs and point-of-care glucose were normal, and her ECG showed sinus rhythm. Her physical examination, including a detailed neurologic examination, was largely unrevealing, with no facial asymmetry, unilateral weakness, sensory loss, or dysmetria appreciated. A noncontrast cranial CT scan of the brain was remarkable only for nonspecific subcortical and periventricular white matter changes without evidence of acute or old infarction, mass, or hemorrhage. Although she is relieved to learn that she has not had a stroke, she is concerned that this may be a precursor of a more serious event. She does not have a primary care physician and states that she has not seen a physician in several years. She asks whether this was a “mini stroke” and, if yes, what the chances are that she will have a stroke in the future?

Case Conclusion:
The 59-year-old obese patient’s detailed description of abrupt, negative symptoms appropriately raised your concern for a right anterior circulation TIA. You calculated her ABCD2 score as a 2, correctly counting her reported facial droop and unilateral weakness. Knowing recent risk stratification data, you counseled her that her 7-day stroke risk was very low; however, you also remembered that the periventricular white matter hypointensities on CT may be indicative of underlying small-vessel cerebrovascular disease, and her report of multiple recent episodes raised your concern. Since your observation unit was at capacity, you insisted on hospital admission. As an inpatient, she underwent MRI/MRA, revealing extensive small-vessel disease and multiple lacunar infarctions of varying ages. She was seen by a neurologist, started on antiplatelet therapy, and counseled on diet and exercise strategies. She remained stroke-free at a 3-month follow-up appointment.

Did you get it right?

Brush up on most recent stroke care best practices and earn 8 stroke CME with this great online resource, Emergency Stroke Care: Advances And Controversies, Volume II.

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Last Modified: 10-20-2019
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