What's Your Diagnosis?

“Antimicrobial Therapy” … Case Conclusion has been posted

ebmedicine — Mon, 09 Jan 2012 15:23:21 +0000

The latest What’s Your Diagnosis challenge conclusion, titled “Antimicrobial Therapy … Case Conclusion,” has been posted on our new location; check it out here.

Antimicrobial Therapy…

ebmedicine — Sun, 01 Jan 2012 15:20:09 +0000

The latest What’s Your Diagnosis challenge, titled “Antimicrobial Therapy,” has been posted on our new location; check it out here.

“Gunshot Wound” … Case Conclusion

ebmedicine — Tue, 06 Dec 2011 17:52:24 +0000

The Conclusion Is…

The patient was taken to the operating room immediately. On visual inspection during thoracotomy, he was found to have a diaphragmatic injury. He required a left-lower-lobe resection but did not have any other intra-abdominal injuries, and he recovered slowly over several weeks.

Congratulations to Dr. Arellano, Dr. Arosemena, Dr. Saltzberg, Dr. Soliman, and Dr. Tsukerman — this week’s winners of Emergency Medicine Practice’s “Ballistic Injuries In The Emergency Department!” For a discussion of the emergency department (ED) management of gunshot wounds to the head, neck, thorax, abdomen, and extremities, read this issue.

Gunshot Wound…

ebmedicine — Mon, 21 Nov 2011 15:48:35 +0000

A 25-year-old man presents to the ED via ambulance after sustaining a single gunshot wound to the upper abdomen. There is no apparent exit wound. He is awake, in obvious pain and distress, with labored spontaneous breathing. He was reportedly shot with a handgun at close range, and there was significant blood loss at the scene. He has decreased breath sounds on the left side and a mildly tender abdomen with a small wound over the left anterior lower chest. A FAST examination shows no free fluid in the abdomen and no pericardial effusion. A left-sided chest tube is placed, with 200 mL of blood out immediately, and subsequent chest x-ray shows a right hemothorax with a bullet lodged in the left lower lobe.

Are additional tests needed before this patient arrives for surgery? What is this patient’s likely outcome?

(Enter to win the latest issue of Emergency Medicine Practice, including CME, by submitting your answers to the questions above. To do so, simply enter your response in the comments box. The deadline to enter is December 6th.)

“Trauma Patient” … Case Conclusion

ebmedicine — Mon, 07 Nov 2011 13:58:31 +0000

The Conclusion Is…

This patient was in hemorrhagic shock with hemoperitoneum. The MTP was activated, and the patient was given a dose of TXA. Surgical consultation was delayed by a prior patient. Blood products were brought to the bedside, and crystalloid administration was strictly limited. The patient’s blood pressure remained steady around 80/50 mm Hg, and he continued to be alert, with good peripheral pulses. Initial labs came back and showed a normal hemoglobin, but elevated PT. Two units of PRBCs and 2 units of FFP were transfused through a fluid warmer. These brought the patient’s blood pressure up to 100/60 mm Hg and heart rate down to 100 beats per minute. The patient remained stable until surgical consultation arrived. Because of his demonstrated stability, he underwent a CT scan, which showed a grade 3 liver injury with a blush. He was taken to the angiography suite and his liver injury was embolized. The patient was monitored in the ICU and did well, never requiring an operation. He was discharged home after 1 week in the hospital.

Congratulations to Dr. Anthony, Dr. Ebeid, Dr. Mbinga, Dr. Park, and Dr. Salah — this week’s winners of Emergency Medicine Practice’s “Traumatic Hemorrhagic Shock: Advances In Fluid Management!” For an evidence-based review of the treatment of critically injured patients in hemorrhagic shock, read this issue.

Trauma Patient…

ebmedicine — Wed, 19 Oct 2011 18:28:15 +0000

EMS arrives with a 24-year-old male who was the victim of a hit-and-run accident in which the driver apparently backed over him after first clipping him with the car and knocking him to the ground. When you walk into the patient’s room, you find him awake and angry, complaining of pain in his right upper quadrant. He is on a backboard, wearing a cervical collar, and has obvious bruising to the right chest and abdomen. His airway is patent and his breath sounds are equal bilaterally. The patient’s initial vital signs are: heart rate of 125 beats per minute, blood pressure of 120/80 mm Hg, respiratory rate of 20 breaths per minute, temperature of 98°F (36.6°C), and SpO₂ of 94% on room air. Per EMS, the patient was hypotensive on their arrival, with initial blood pressure of 80/40 mm Hg, but it rapidly improved with 2 L of crystalloid given in the field. A second large-bore IV is placed and labs are drawn. The FAST examination reveals significant hemoperitoneum. He then becomes diaphoretic, and repeat blood pressure is now 75/40 mm Hg. The nurse asks if you want 2 more liters of crystalloid.

What is your next step?

(Enter to win the latest issue of Emergency Medicine Practice, including CME, by submitting your answers to the questions above. To do so, simply enter your response in the comments box. The deadline to enter is November 6^th.)

“Upset stomach” … Case Conclusion

ebmedicine — Fri, 07 Oct 2011 13:46:52 +0000

The patient in the second case presented very atypically. The emergency clinician was going to send her home with a UTI, but luckily she started vomiting while in the ED and then spiked a fever. A CT with rectal contrast demonstrated an enlarged, necrotic appendix, and the patient underwent laparoscopic appendectomy without complication. This patient was a reminder that elderly patients with appendicitis often present atypically and that a high clinical suspicion and a low threshold to order imaging in this patient population is warranted. Furthermore, urinalysis may demonstrate nonspecific inflammatory signs in an appendicitis patient of any age.

Congratulations to Dr. Dube, Imad, Dr. Orecchioni, Dr. Shafey Dr. Zubair — this week’s winners of Emergency Medicine Practice’s “Evidence-Based Management Of Suspected Appendicitis In The Emergency Department!” For an evidence-based discussion of the most current findings in regard to the diagnosis of appendicitis in the emergency department (ED) (with particular attention towards elucidating the elements of history, physical examination, and laboratory testing that will most benefit the emergency clinician faced with the dilemma of diagnosing possible appendicitis), read this issue.

“Upset stomach…”

ebmedicine — Tue, 20 Sep 2011 19:38:16 +0000

A 62-year-old female presents with an “upset stomach,” suprapubic discomfort, and dysuria over the last 12 hours. She said this feels similar to UTIs that she’s had in the past, so she took a ciprofloxacin this morning with no relief. She is afebrile with stable vital signs and a soft abdomen with mild suprapubic tenderness with trace rebound, no guarding. Labs returned with WBCs of 10 and RBC of 5, with negative nitrates, bacteria, and squamous cells. She states that she still feels “uncomfortable in her stomach” but otherwise is without complaints.

What is your next step?

“Possible Depression…” Case Conclusion

ebmedicine — Wed, 07 Sep 2011 00:06:33 +0000

The Conclusion Is…

After a more detailed psychiatric history and examination, the 28-year-old man admitted having thoughts of hurting himself on and off over the last 3 months and that he has been feeling worse over the last 3 weeks with thoughts increasingly of “drinking himself to death.” In fact, the weekend before, he said he attempted to drink a liter of vodka by himself to “put myself out of my misery.” With this concerning history for possible dysthymia with an overlying major depressive episode history and suicide attempt, psychiatry was consulted and the patient was evaluated for safety. Given his active suicidal ideation and depressed mood, the patient was placed for psychiatric hospitalization. The patient was cooperative and amenable to the plan but given his active suicidal ideation and concern for his wellbeing, the patient was formally sectioned (ie, placed on a temporary involuntary hold).

Congratulations to Dr. Banimahd, Dr. Gozhansky, Dr. Hamdan, Dr. Kietzman, and Dr. Olabode — this week’s winners of Emergency Medicine Practice’s “The Depressed Patient And Suicidal Patient In The Emergency Department: Evidence-Based Management And Treatment Strategies!” For an evidence-based review of risk factors associated with depression and suicide as well as management strategies, read this issue.

Possible Depression…

ebmedicine — Wed, 24 Aug 2011 16:52:30 +0000

You treat a young man for a URI, but you also find out that he recently moved to the city and states that he is just feeling “overwhelmed” and “sad” and at times thinks he would be “better off dead.” He has never seen a psychiatrist and has never been told by his primary care clinician that he has any sort of psychiatric illness.

Is this person pathologically depressed? Can you diagnose this in the ED? Is this person safe to go home or does he require a psychiatric consultation and possible psychiatric admission?