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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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How geriatric physiology impacts clinical care April 30, 2019

Posted by Robin Wilkinson in : Uncategorized , add a comment

Just as “children are not little adults,” the physiologic and behavioral differences of the elderly demand that emergency clinicians manage illness in the elderly differently than we do in younger adults. In fact, two central medical principles used for children can be applied to the elderly: Patients are more vulnerable, and symptoms are much less specific.

There are unique issues involved in assessment and treatment of the elderly. Sir William Osler said, “In the old and debilitated, a knowledge that the onset of pneumonia is insidious and that the symptoms are ill-defined and latent should place the practitioner on his guard and make him very careful.” Osler’s statement holds true not only for pneumonia but also for nearly all diseases in the elderly.

“Textbook” symptoms are the exception rather than the rule in many cases with elderly patients. A behavioral change may be the only hint of an underlying infection. At least 75% of all episodes of functional decline in nursing home patients are due to infection. It is a common mistake to assume that a confused 80-year-old is “just suffering from dementia,” when in fact he or she may be a normally intact and independent person with acute delirium secondary to a UTI. Ask family members or caretakers about recent falls, anorexia, decreased activity, new incontinence, or confusion. (See table below.) These may be the only clues to a serious illness.

This information can help define the patient’s baseline functional and mental status. Five minutes on the telephone with the primary care provider or the patient’s daughter may prompt life-saving antibiotics instead of an inappropriate prescription for Haldol.

Enhance your assessment skills and management practices in elderly patients with the geriatric sessions at the 18th Annual Clinical Decision Making in Emergency Medicine conference in Ponte Vedra, FL – June 26-29, 2019. http://www.clinicaldecisionmaking.com

A 2-year-old girl with upper respiratory infection symptoms — Brain Teaser. Do you know the answer? April 18, 2019

Posted by Andy Jagoda, MD in : Brain Tease , 1 comment so far

Test your knowledge and see how much you know about diagnosing and managing pediatric community-acquired pneumonia.


Did you get it right? Click here to find out!

The correct answer: B.

Earn CME for this topic by purchasing this issue.

Trauma Awareness Month Is Almost Here – Test Your Knowledge with Genitourinary Trauma Question April 18, 2019

Posted by Andy Jagoda, MD in : Brain Tease , add a comment

A patient suffering blunt abdominal trauma complains of suprapubic pain and has gross hematuria. Initial CT of the abdomen and pelvis with IV contrast is normal. Do yo know the answer?

For trauma patients in the ED, life- and limb-threatening injuries take priority, but renal and genitourinary injury can have long-term consequences for patients, including chronic kidney disease, erectile dysfunction, incontinence, and other serious problems.


Did you get it right? Click here to find out!

The correct answer: A.

Check out the issue on Emergency Management of Renal and Genitourinary Trauma: Best Practices Update to brush up on the subject.Plus earn CME for this topic by purchasing this issue. 

Clinical Pathway for Management of Sexually Transmitted Diseases in the Emergency Department April 15, 2019

Posted by Andy Jagoda, MD in : Feature Update , add a comment

Sexually transmitted disease can cause severe outcomes for patients, their partners, and their unborn babies, and swift and accurate diagnosis and treatment is essential to reduce morbidity and minimize the potential public health risks.

Sexually transmitted diseases are a growing threat to public health, but are often underrecognized, due to the often nonspecific (or absent) signs and symptoms, the myriad diseases, and the possibility of co-infection. Emergency clinicians play a critical role in improving healthcare outcomes for both patients and their partners. Optimizing the history and physical examination, ordering appropriate testing, and prescribing antimicrobial therapies, when required, will improve outcomes for men, women, and pregnant women and their babies.

This clinical pathway will help you improve care in the management of patients with sexually transmitted diseases. Download now.

Clinical Pathway for Management of Sexually Transmitted Diseases in the Emergency Department

Clinical Pathway for Management of Pediatric Patients With Community-Acquired Pneumonia April 15, 2019

Posted by Andy Jagoda, MD in : Feature Update , add a comment

A significant challenge in the management of pediatric community-acquired pneumonia is identifying children who are more likely to have bacterial pneumonia and will benefit from antibiotic therapy while avoiding unnecessary testing and treatment in children who have viral pneumonia.

Worldwide, pneumonia is the most common cause of death in children aged < 5 years. Distinguishing viral from bacterial causes of pneumonia is paramount to providing effective treatment but remains a significant challenge. For patients who can be managed with outpatient treatment, the utility of laboratory tests and radiographic studies, as well as the need for empiric antibiotics, remains questionable.

Clinical Pathway for Management of Pediatric Patients With Community-Acquired Pneumonia

This clinical pathway will help you improve care in the management of pediatric patients with community-acquired pneumonia. Click here to download yours today.

Do you need to do anything regarding the missing fragment? — ED Management of Dental Trauma in Pediatric Patients April 11, 2019

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

Case Recap:
Your first patient of the day is a 2-year-old girl who tripped and fell while walking, hitting her mouth on the concrete sidewalk. On your examination, her left central incisor tooth appears to be fractured, with a yellow dot visible inside the tooth. The tooth is nontender and nonmobile. The parents don’t have the other part of the tooth and think it fell onto the street. You start to consider: How do you determine what kind of fracture this is and how serious it is? How does management differ between primary teeth versus permanent teeth, and how can you tell if this is a primary tooth or a permanent tooth? Do you need to do anything regarding the missing fragment?

Case Conclusion:
After seeing the 2-year-old girl with the chipped tooth, you realized that, given her age, this was likely primary dentition, which you confirmed with the parents. You could also tell on examination that the upper right central incisor was more of a milky-white color with a smooth edge, which is also consistent with primary dentition. You decided that the management priorities were to prevent further harm to the developing permanent dentition and to confirm that the tooth fragment was truly lost. You were unable to detect any retained foreign bodies on your physical examination, but you decided to obtain radiographic images to confirm. On facial radiography, there appeared to be a small foreign body inside her right upper lip. You repeated your physical examination and were able to extract the small tooth fragment. The girl’s left central incisor appeared to be an uncomplicated crown fracture. The girl was able to drink without difficulty. You did not have dental panoramic radiography available at your institution, so you instructed the parents to follow up with the girl’s dentist for assessment of her permanent dentition. You recommended a soft diet and to clean the tooth with chlorhexidine until the patient was able to see the dentist.

Did you get it right?

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Should you give antivenom again? — ED Management of North American Snake Envenomations April 11, 2019

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

Case Recap:
A 26-year-old man arrives to the ED via private vehicle with his arm in a makeshift sling. He reports that his pet rattlesnake bit him on his right index finger about 45 minutes ago. His hand and wrist are swollen. He reports that he has no past medical history besides his 3 previous visits for snakebites. He reports having a “reaction” to the snakebite antidote during his last visit. You wonder whether the patient is immune . . . or should you give antivenom again?

Case Conclusion:
The 26-year-old man with 3 prior rattlesnake bites was at risk for significant morbidity related to this fourth snakebite, including impaired use of his dominant hand. Additionally, his initial lab values showed a developing coagulopathy. You decided to administer 6 vials of antivenom, but you ordered pretreatment with IV corticosteroids and antihistamines. You moved the patient to your resuscitation area for administration of antivenom and admitted him to the ICU for continued monitoring; fortunately, there were no side effects with the initial dose of antivenom.

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A 6-year-old girl with a history of sickle cell disease presents with leg pain — Brain Teaser. Do you know the answer? March 23, 2019

Posted by Andy Jagoda, MD in : Brain Tease , add a comment

Test your knowledge and see how much you know about treating and managing pediatric hypertension and hypertensive emergencies.


Did you get it right? Click here to find out!

The correct answer: D.

Earn CME for this topic by purchasing this issue. 

A 68-year-old man with past medical history of atrial fibrillation on warfarin presents to the ED after motor vehicle crash — Brain Teaser. Do you know the answer? March 23, 2019

Posted by Andy Jagoda, MD in : Brain Tease , add a comment

Test your knowledge and see how much you know about treating and managing blunt cardiac injury in the ED.


Did you get it right? Click here to find out!

The correct answer: C.

Earn CME for this topic by purchasing this issue. 

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Last Modified: 06-24-2019
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