What’s Your Diagnosis? A 4-year-old with fever, right leg pain, and difficulty walking November 29, 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 a 7-year-old boy after a generalized seizure lasting 2 minutes Click here to check out the answer!

Case Presentation: a 4-year-old with fever, right leg pain, and difficulty walking

A 4-year-old boy presents to the ED with intermittent fever, right leg pain, and difficulty walking the last 3 days. His parents report that the child has a history of sickle cell disease and takes folic acid and penicillin for infection prophylaxis. The patient has never had surgery. On physical examination, there is point tenderness over the right thigh and an area of overlying edema, and the boy’s vital signs are within the normal limits for his age. You order a complete blood cell count, erythrocyte sedimentation rate, C-reactive protein, blood cultures, bone culture, and plain radiography.

What special bacterial pathogen must be considered in this case? How does this affect antibiotic treatment?

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What’s Your Diagnosis? Patient With Acute Dizziness November 29, 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 Pain Management: Beyond Opioids, right. Click here to check out the answer!

Case Presentation: A previously healthy man with dizziness

The day shift signs out to you a 44-year-old previously healthy man. He is currently at CT.

His dizziness started 6 hours previously and has been present ever since. He describes unsteadiness and “feeling like I am drunk,” and has vomited 3 times. He denies headache or neck pain, weakness, or numbness. His vital signs are normal. There is some left-beating horizontal nystagmus in primary gaze and in leftward gaze. The head impulse test is normal.

The sign-out is that if his CT scan is normal, he can go home with meclizine and follow-up with his PCP in 2 days.

That sounds reasonable, but you wonder if there is something else that needs to be considered…

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What’s Your Diagnosis? a 7-year-old boy after a generalized seizure lasting 2 minutes November 1, 2019


Posted by Andy Jagoda, MD in: What's Your Diagnosis , 4 comments

But before we begin, check out if you got last month’s case right, about the 9-month-old infant gasping for air. Click here to check out the answer!

Case Presentation: a 7-year-old boy after a generalized seizure lasting 2 minutes

A 7-year-old boy is brought in by ambulance after a witnessed generalized seizure lasting 2 minutes at home. He has no history of prior seizures. Upon arrival to the ED, he appears postictal and is moving all of his extremities. His blood glucose is 110 mg/dL. His vital signs are: temperature, 36.9°C (98.5°F); heart rate, 60 beats/min; blood pressure, 110/70 mm Hg; respiratory rate, 14 breaths/min; and oxygen saturation, 98% on room air. The boy vomits while the nurse is trying to obtain IV access.

Per the mother, the boy has been receiving chemotherapy for lymphoma and was complaining of a headache earlier in the day. He has no history of intrathecal chemotherapy. The mother does not think he had any head trauma recently.

You know that the child needs brain imaging, but you are uncertain which imaging would be most useful…

Case Conclusion

You were concerned about a CNS neoplasm in the 7 year-old boy, given his history of lymphoma with new neurologic changes. You were also concerned about intracerebral bleeding and infection that could result from his recent exposure to chemotherapy. His vomiting, low heart rate, and borderline elevated blood pressure were concerning for signs of increased intracranial pressure. As the nurse obtained IV access, you determined that the boy’s mental status was not improving rapidly enough for a typical postictal course, and you were concerned about his airway, given his vomiting. You decided to intubate the boy, and you attempted to get a better neurological examination while the team was preparing for intubation. You also noted there were no signs of trauma. After successful intubation, a CT scan of the head was performed, and it showed intraparenchymal hemorrhage. While the child was on the CT table, you also obtained a CT angiogram of the head. A CBC panel showed a platelet level of 5000/mcL. You discussed the case with the neurosurgeon and hematologist, who recommended transfusing platelets to a level of > 100,000/mcL. Other neuroprotective strategies and ICP precautions were started, and the child was admitted to the ICU.

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What’s Your Diagnosis? Pain Management: Beyond Opioids November 1, 2019


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

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

Case Presentation: A 73-year-old woman in the ED after “twisting” her ankle

A 73-year-old woman with a history of peptic ulcer disease and stage 3 chronic kidney disease presents to the ED after “twisting” her ankle. She tried acetaminophen at home, but it didn’t adequately alleviate her pain. Currently, she complains of 6/10 pain at rest. She has mild swelling and tenderness at the posterior edge of her lateral malleolus. You order an ankle x-ray to evaluate for fracture and consider giving her oxycodone…

You wonder whether there is a better and safer alternative…

Case Conclusion

You concluded that your first patient likely had either an ankle sprain or a malleolar fracture, and that icing the area and immobilization was likely to improve her pain. With her comorbidities, you were concerned about using systemic NSAIDs, and you were concerned about giving her an opioid because of the association with adverse outcomes in older patients. You decided to apply ice, elevate the extremity, and order topical diclofenac. The radiograph was normal, and the patient’s pain improved with icing, immobilization with an air cast, and topical diclofenac. You discharged the patient with a prescription for topical diclofenac, a walker, and orthopedic follow-up.

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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.

Case Conclusion

You quickly determined that your patient had severe bronchiolitis, and you knew that aggressive management was required. You placed the patient on pulse oximetry because the infant had wheezed previously, and started a trial of a nebulized bronchodilator with oxygen while closely monitoring his clinical response to treatment. Your patient’s respiratory rate was still in the 70s, with minimal decreases in the work of breathing. His pulse oximetry level was 87% on room air, so you administered supplemental oxygen via HFNC. The patient started to cry without tears, and you noticed his dry mucous membranes, so you administered IV fluids. His respiratory rate was 55 breaths/min with no retractions, and he was able to take his bottle for only a brief period even after the nurse suctioned his nasal secretions. His SpO2 level remained at 90% on room air. You decided to admit the patient because his tachypnea was leading to compromised oral intake and because of his persistent hypoxia, and you kept him on the HFNC in the meantime.

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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?

Case Conclusion

The 81-year-old woman with AMS was evaluated by a neurologist on the floor. Her EEG showed irregular, rhythmic, generalized 2.0–2.5 Hz sharp-and-slow wave complexes that ceased after 10 mg of IV diazepam. Later, her husband noted that her daily lorazepam had recently been discontinued abruptly due to a change in insurance. The patient was diagnosed with NCSE. NCSE can develop in a patient with or without underlying epilepsy, and should be included in the differential of unexplained AMS, especially in the setting of chronic benzodiazepine use. A high level of suspicion is essential for early diagnosis, but urgent confirmatory EEG is required.

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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 , 5 comments

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.

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


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

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.

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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.

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


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

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.