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
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.
Authors: Patrick Mescher, OSU MS4 // Michael Barrie, MD OSUEM
Standing in the physician’s office of a local Emergency Department I heard the familiar clunk of a chart being dropped into the metal bin. I walked over and picked up the chart and read “Chief Complaint: Chest Pain,” thinking to myself how this was the fifth “chest pain” I’ve seen this shift. After diagnosing GERD, costrocondritis, and pneumonia with previous patients, I felt comfortable evaluating this chief complaint so I went calmly to the patient’s room. But as I walked to the bedside I found a visibly uncomfortable patient, profusely perspiring. He told me he was having crushing chest pain. I was immediately concerned this may be the real deal STEMI.
Author: Hiro Miyagi OSU MS4 // Editor: Michael Barrie OSU EM Attending
Medical Student Corner – When do kidney stone patients need immediate intervention?
A 51yo female presents with an acute episode of severe right sided back pain with nausea and vomiting. Patient has a past medical history of HTN and chronic back pain. The pain is intermittent, described as sharp and stabbing 10/10 pain. She has not been able to tolerate any liquids since the onset of pain. The patient denies fevers or chills, with no recent infections or illnesses. No dysuria, but with mild urinary frequency. She has a past surgical history of appendectomy 30 years ago.
Dr. Kaide’s Airway “tip of the month”
There was this hypothetical patient…who was being intubated. As soon as the patient was paralyzed dark blood came pouring out into the mouth from an upper GI bleed. The resident immediately suctioned a continuous flow of blood from the airway. She could not see any airway structures because of the bleeding. Now what?