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.
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