Author: Nisha Crouser, MS4 // Editor: Michael Barrie, OSU EM Attending
One of the first questions Emergency Medicine physicians have to ask themselves is “Do I think this patient is sick or not sick?” A simple question, that takes years of practice and experience to answer. Once a patient is deemed “sick” the questions to follow become more difficult, “How sick?” “What should we do next?” The following case presentation helps elucidate some of the difficulties faced in the ED when sick patients arrive and how to act on the dangerous diagnosis of septic shock.
A 58-year-old patient with several past medical problems including hypertension, hyperlipidemia, and heart disease; presents to the ED with a fever and back pain. Upon arrival the patient is a diaphoretic and ill-appearing obese female who is able to follow commands and answer a few questions. It is difficult to obtain a history from the patient and there is no family present to contribute any information. She is tachycardic and hypotensive when placed on the monitor. Given these vitals in combination with her fever, a Septic Shock alert is initiated. The ED is very busy and there is another severely ill patient that the physician is also covering. Several tests are ordered and fluids are started, there is no obvious source of infection. Over the course of the next half an hour, the internal medicine doctors lay eyes on the patient who has now become more unresponsive. As another half an hour goes by, the patient’s skin become extremely mottled and blue. Her oxygen saturation and blood pressure drop precipitously and she goes into asystole.
Author: Lilamarie Moko, MS4 // Editor: Michael Barrie, OSU EM Attending
It’s another late Thursday night in the ED and the waiting room is backed up with patients needing care. As you finish up with your seventh patient presenting with undifferentiated abdominal pain, your eyes rove the board for something new. You assign yourself to a gentleman in his 60s, a “John Doe” with left arm swelling. Hopefully his abdomen has been behaving itself…
Upon entering the patient room, you see a pleasant, comfortable appearing gentleman in his mid-60s. He’s been having left arm pain and swelling that started 6 days ago. His arm is “on fire”. He first noticed some redness in his left elbow, associated swelling, tenderness, and restriction flexion and extension of his elbow. After about a day, he noticed the redness spreading down to his left wrist, with similar swelling, tenderness, and restricted flexion and extension of both wrist and fingers. He’s had a temperature to 100F, diaphoresis and chills. Also he reports some diarrhea, and urinary frequency in the past 2 days. With some further probing, he reveals that he just returned from Florida several days ago, had no noted scrapes or wounds, and spent most of his time fishing. He works as a farmer, but hasn’t been working for the past couple weeks.
Chief Complaint: Ankle Injury–Does this patient have a fracture?
Author: David Sacolick, MS4 // Editor: Michael Barrie, OSU EM Attending
Musculoskeletal injuries are common chief complaints in both emergency medicine and primary care settings. In particular, over 5 million ankle injuries occur in the United States each year. This patient population includes both young active patients as well as elderly patients. And while ligamentous sprains are more common, fractures are also common and can have long term consequences if not appropriately treated.
When a patient presents with a chief complaint of an ankle injury, how do you answer the question: Does this patient have a fracture? Continue reading
Welcome back to another week of rapid fire case conference review here at THE OSU EM Residency Program.
Leading off is Dr. Nicholson with his patient presenting from dialysis clinic with a chief complaint of “Problem with fistula site.” A quick duplex study with basic labs reveals an occluded outflow vein and a potassium of 7.3. Understanding the arrhythmogenic potential for hyperkalemia, he obtains the following EKG:
Maya S. Iyer, MD, FAAP, Clinical Assistant Professor of Pediatrics, Nationwide Children’s Hospital, Section of Emergency Medicine
Fussy Neonate Jeopardy
This jeopardy game highlights key clinical considerations for infants who present to the emergency department with the chief complaint of fussiness. In particular, the topics highlighted in this game include: fever in the neonate, sudden infant death syndrome (SIDS), brief resolved unexplained events (BRUE) and apparent life threatening events (ALTE), non-accidental trauma (NAT) and a potpourri of other interesting clinical conditions. The questions require second order thinking. After completing this game, emergency medicine residents should be able to describe the cardinal signs and symptoms, management and possible complications of the above conditions.
Welcome back to another edition of Case Conference Review here at Academic Medicine Pearls at THE Ohio State University! Old Man Adams starts us off with a 38-year-old male with known history of alcohol abuse presenting via EMS for suspected EtOH withdrawal. On walking into the room, Dr. Adams is greeted with choice expletives and the subsequently refuses any vitals or to participate in the examination. The patient then promptly starts to seize, sending Dr. Adams down his alcoholic withdrawal seizure pathway.
Conference moderator and forever resident Dr. Zach Adams leads off this week’s case conference with a 65-year-old female diabetic presenting with the always challenging chief complaint of a “room-spinning” dizziness, otherwise classified as vertigo. She describes it as worse with position, severe, and present intermittently for the past few days. Suspicious for peripheral vertigo, Dr. Adams performs the Dix-Hallpike maneuver (Figure 1). Seconds after placing the patient in the reclined position with head turned laterally, the patient displays strong rotary nystagmus and promptly vomits on Dr. Adams’ shoes. Confirming his suspicion for benign paroxysmal peripheral vertigo, Dr. Adams then successfully performs the Epley maneuver (Figure 2) to reposition the otoliths within the semicircular canal and relieve the patient’s vertigo.