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Which empiric antibiotics to use? — Pediatric Bacterial Meningitis November 7, 2018

Posted by Andy Jagoda, MD in : What's Your Diagnosis , 8comments
A 4-month-old boy presents with a history of cough, pallor, fever to 38.9°C (102°F), and decreased feeding on the morning of presentation. The infant drank 6 ounces about 4 hours before arrival, but would not feed at presentation. The boy’s parents state he did not vomit or have diarrhea. His past medical history is notable for cesarean delivery at 36 weeks’ gestation. There was prolonged rupture of membranes and he was hospitalized for 3 days after delivery. The boy’s parents report no prior illnesses, and his immunizations are up-to-date. On physical examination, the boy’s vital signs are: temperature, 38.9°C (99.6°F); heart rate, 158 beats/min; respiratory rate, 50 breaths/min; and oxygen saturation, 98% on room air. The boy is arousable but sleepy and does not fix and follow. His fontanel is flat. His HEENT examination is notable for nasal congestion with mucus secretions. The boy’s cardiopulmonary and abdominal examinations are unremarkable. The boy’s capillary refill is < 2 seconds, but his muscle tone is decreased. He is fussy during the examination. 
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Is this merely an upper respiratory infection or should meningitis be considered? What are common clinical features of meningitis in this age group? What further management is indicated? Which empiric antibiotics—if any—are indicated at this time?
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Fever, chills, and abdominal pain — Brain Teaser. Do you know the answer? October 24, 2018

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

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

The correct answer: C.

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Treatment Pathway for Initial Management of Patients with Sepsis October 17, 2018

Posted by Andy Jagoda, MD in : Feature Update , 3comments
Sepsis is a common and life-threatening condition that requires early recognition and swift initial management. Diagnosis and treatment of sepsis and septic shock are fundamental for emergency clinicians, and include knowledge of clinical and laboratory indicators of subtle and overt organ dysfunction, infection source control, and protocols for prompt identification of the early signs of septic shock.
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This clinical pathway will help you improve care in the initial management of patients with sepsis. Download now.
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To Discharge Or Not — Sepsis In The ED Conclusion October 12, 2018

Posted by Andy Jagoda, MD in : What's Your Diagnosis , 1 comment so far
Case Recap: 
A 45-year-old man with hypertension and prostate cancer in remission presents complaining of 3 days of burning with urination, fevers, and chills. His vital signs are: heart rate, 110 beats/min; respiratory rate, 20 breaths/ min; blood pressure, 130/90 mm Hg; SpO2, 98% on room air; and temperature, 38.4°C (101.2°F). He is alert and fully oriented. His physical exam reveals mild suprapubic tenderness without rebound or guarding and bilateral costovertebral angle tenderness. Lab findings include a WBC count of 18,000 with 5% bands, a creatinine of 1.5 mg/dL, a platelet count of 130 x 103/mm3, 80 WBCs on urinalysis with positive nitrite and leukocyte esterase, and a serum lactate of 1.2 mmol/L. After receiving ibuprofen and a fluid bolus, the patient feels better and states, “I need to go get my dog!” The nurse asks you if she can remove the IV for the patient to be discharged, which sounds reasonable, but something worries you…
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Case Conclusion:
The 45-year-old man with the urinary tract infection had a SOFA score of 2 and met the Sepsis-3 definition of sepsis, due to pyelonephritis. The patient was convinced to stay in the hospital, had 2 sets of blood cultures drawn, 30 mL/kg of IV fluids administered, and a dose of ceftriaxone 2 grams IV administered. His vital signs remained stable, and the patient was admitted to a monitored hospital bed. He was discharged 2 days later to continue oral antibiotics.
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Congratulations to Rachael Kinuthia, Micelle Jo Haydel, Annie Nunley PA-C, Dennis Allin, and Walter L Novey — this month’s winners of the Emergency Medicine Practice Audio Series Vol IV
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To Discharge Or Not — Sepsis In The ED October 5, 2018

Posted by Andy Jagoda, MD in : What's Your Diagnosis , 30comments
A 45-year-old man with hypertension and prostate cancer in remission presents complaining of 3 days of burning with urination, fevers, and chills. His vital signs are: heart rate, 110 beats/min; respiratory rate, 20 breaths/ min; blood pressure, 130/90 mm Hg; SpO2, 98% on room air; and temperature, 38.4°C (101.2°F). He is alert and fully oriented. His physical exam reveals mild suprapubic tenderness without rebound or guarding and bilateral costovertebral angle tenderness. Lab findings include a WBC count of 18,000 with 5% bands, a creatinine of 1.5 mg/dL, a platelet count of 130 x 103/mm3, 80 WBCs on urinalysis with positive nitrite and leukocyte esterase, and a serum lactate of 1.2 mmol/L. After receiving ibuprofen and a fluid bolus, the patient feels better and states, “I need to go get my dog!” The nurse asks you if she can remove the IV for the patient to be discharged, which sounds reasonable, but something worries you…
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What do you do next?
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Enter to win a free copy of Emergency Medicine Practice Audio Vol IV, the latest in our audio series collection, by submitting your answer to the question above. To do so, simply enter your response in the comments box. A valid email address is required to enter. The deadline to enter is October 11, 2018.
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