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Clinical Pathway for Emergency Department Management of Subarachnoid Hemorrhage February 17, 2019

Posted by Andy Jagoda, MD in : Feature Update , 1 comment so far

Headache is the fourth most common reason for emergency department encounters, accounting for 3% of all visits in the United States. Though troublesome, 90% are relatively benign primary headaches –migraine, tension, and cluster headaches. The other 10% are secondary headaches, caused by separate underlying processes, with vascular, infectious, or traumatic etiologies, and they are potentially life-threatening.

This clinical pathway will help you improve care in the management of patients with subarachnoid hemorrhage. Download now.


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.

Using chemoprophylaxis in a child aged 1 year — Brain Teaser. Do you know the answer? December 24, 2018

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

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


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

The correct answer: A.

Earn CME for this topic by purchasing this issue. 

 

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.

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: 03-18-2019
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