52 yo man - 6 hrs after onset of severe, epigastric abd pain
> began at cocktail party
> was there for 4 hrs - 3 martinis, lot of food
PMHx: HLD
... [Show More] (statin)
100.4F
104/min
150/92 mmHg
PE: diffuse tenderness over upper quadrants BL - esp epigastrium; no guarding/rebound
labs: WBC WNL, BR 3 (direct 2.4), alk phos 210, AST 325, ALT 360, amylase 1200, lipase 600
most likely cause of symptoms?
common bile duct obstruction
choledocholithiasis = stone in CBD
lipase high so think pancreatitis
2 MC causes: alcohol and gallstones
if alcoholic cause - the AST should be higher than ALT (A Scotch and Tonic)
abd pain that started right after eating a lot of food > think gallstones
he also has PMHx of HLD - another RF for pancreatitis
42 yo man - 30 min after onset of gen weakness, SOB, severe abd cramps, sweating
> began while gardening
99.2F
52/min
RR: 24/min
98/60 mmHg
POx: 98% RA
PE: diaphoresis, excessive lacrimation, 2 mm pupils reactive to light; diffuse wheezes; abd - no tenderness; muscle strength 4/5 in ext - muscle fasciculations; DTRs 2+; no Babinski; intact sens
after decontamination - most app tx to immediately relieve current symptoms?
administration of atropine
homeboy was gardening - exposure to spray insecticides (aka organophosphates - AChE inhibitors)
> these can cause acute cholinergic toxicity = DUMBBELLS (diarrhea, urination, miosis/muscle weakness, bradycardia/bronchorrhea, emesis, lacrimation, sweating/salivation)
pralidoxime regenerates AChE at musc/nic receptors - only peripheral
> useless once aging of bonded complex has occurred
atropine reverse peripheral and central musc toxicity
54 yo - 2 hrs of chest pain, SOB, nausea
> began while sitting/working at desk
> 1 episode of vomiting
> pain 7/10, radiates to shoulders, "pressure"
3 similar episodes during past 3 months
> occurred on exertion, resolved after 15 min of rest
PMHx: HTN, T2DM
meds: ASA, metformin, enalapril
SHx: smokes 1 pack qd 30 yrs
98.6F
90/min
20/min
154/85 mmHg
POx: 99%
PE: gucci
labs: WNL (including trop)
ECG, CXR: gucci
ED course: ASA, NTG, morphine administered > 15 min later, pain is now 2/10; pt being observed; repeat trop 4 hrs later WNL; symptoms have resolved
most app next step in mgnt?
myocardial perfusion testing within 3 days
trops aren't elevated and pt is stable - okay to d/c him and f/u really soon
he has RFs for CAD and has had similar episodes of chest pain in the past
this episode is diff bc occurred w/o exertion - suggesting the etiology has gotten worse
2014 AHA guidelines:
1. for patients with possible ACS who have normal serial ECGs and cardiac troponin levels: it is reasonable to obtain a treadmill ECG (level of evidence: A), stress myocardial perfusion imaging, or stress echocardiography before discharge or within 72 hours after discharge (level of evidence: B).
> our guy falls under this category due to his prior episodes
2. in patients with possible ACS and a normal ECG, normal cardiac troponin levels, and no history of coronary artery disease (CAD): it is reasonable to initially perform (without serial ECGs and troponin levels) coronary computed tomography angiography to assess coronary artery anatomy (level of evidence: A) or rest myocardial perfusion imaging with a technetium-99m radiopharmaceutical to exclude myocardial ischemia (level of evidence: B)
47 yo - 1 hr after can of gas exploded 5 ft from him
> pain/loss of hearing in R.ear
ED: mild distress
98.8F
90/min
14/min
120/80 mmHg
PE: abrasions over R.face/neck/upper chest; blood in ext auditory canal; swelling/ecchymosis of R.pinna; can't hear whispered voices; L.ear - gucci
most likely explanation of symptoms?
rupture of the tympanic membrane
blast injuries - potential cause of barotrauma
barotrauma = results from the air pressure wave generated by an explosion
> rapid pressure change allows no time to equalize the pressure
> potential injuries: bruising of the eardrum, bleeding into the drum and middle ear, eardrum rupture, ossicular disruption, and inner ear injury resulting in dizziness and tinnitus
13 yo - 30 min after fell off sailboat into freshwater lake
> underwater for about 2 min
> rescued - cyanotic and unresponsive
> began coughing/breathing again after mouth2mouth
ED: awake/alert; mild SOB and cough
98.6F
108/min
20/min
93/45 mmhg
POx: 94% RA
PE: mild wheezes; no signs of ext trauma
CXR: mild diffuse int markings
most app next step in mgnt?
admission to the hospital for observation
I guess you don't give assisted ventilation until O2 really drops - UTD suggests maintaining SpO2 > 94%
> if needs oxygen - give noninvasive positive-pressure ventilation via BLPAP or CPAP
def needs hospital admission bc CXR looks junky and currently has SOB/cough
> make sure she doesn't develop ARDS
~ can develop insidiously over next 72 hrs
~ monitor closely for dyspnea, cough, crackles, and cyanosis
26 yo female - 2 hrs of SOB and mod R.chest pain
> SOB when walking up flight of stairs this morning and walking w/ friends at mall earlier
> 2 days of nonproductive cough
PMHx: sickle cell dz
meds: hydroxyurea, acetaminophen w/ codeine prn
1 yr ago: hospitalized for vaso-occlusive crisis
ED: mild resp distress
BMI: 21
101.1F, 38.4 C
104/min
20/min
128/82 mmHg
POx: 91% RA > 95% on 2L O2 NC
PE: fine crackles at R.lung base
labs: Hgb 8.9, Hct 25.2, WBC 12,600, plt 457,000
CXR: consolidation and infiltrates in R.lung base
most likely underlying cause of pt's current condition?
infection
homegirl has acute chest syndrome 2/2 sickle cell dz
> due to infection and occlusion of pulm microvasculature
ACS defined as radiographic evidence of consolidation + at least one of the following: temp > 38.5C, >2% dec in SpO2, PaO2 < 60 mmHg, tachypnea, intercostal retractions/nasal flaring/use of accessory muscles, chest pain, cough, wheezing, rales
> HOWEVER: presence of PNA meets the criteria since they can't be distinguished from one another
due to the hits that the spleen has been taking over the yrs > autosplenectomy (it shrinks up) > pt more prone to encapsulated organisms
make sure to r/o PE w/ VQ scan or CT angio
tx: monitor oxygenation; Abx; hydration; exchange transfusion if severe
62 yo man - 2 days of feeling light-headed
> no chest pain/palp
> usually constipated - BMs qd for past 5 days
~ stools dark reddish brown
PMHx: chronic low back pain
98.6F
140/min, reg
24/min
80/50 mmHg
PE: too LH to check orthostatics; lungs clear; abd - soft, nontender, not distended; rectal exam - soft, dark red stool; pos for occult blood
fingerstick bG: 92
labs: H/H 8.0/22%; WBC 8000; plt 240; LDH 6; coags WNL
ECG: sinus tachy
ED course: blood sample sent for typing/crossmatch; subclavian cath inserted/confirmed by CXR
after 0.9% NS 2L administered:
> 120/min, reg
> 100/70 mmHg
> LDH 4.5
> CVP: 11 (inc) (N3-8)
most app next step in mgnt?
packed red blood cell transfusion
give whole blood for volume replenishment in blood loss when CVP is high
> doesn't inc volume
RBC transfusion thresholds:
> <7: gen indicated
> 7-8: cardiac surgery, HF, oncology pts in tx
> 8-10: ongoing bleeding, symptomatic anemia, ACS, noncardiac surgery
> >10: not gen indicated
don't give hypovolemic shock pt any vasopressors - already max vasoconstricted !!
The "effective blood volume," or that volume which restored arterial blood pressure, urine output, and tissue perfusion, exceeds the "normal blood volume" or the apparent improvement in BP.
> which is why most pts in hypovolemic shock get transfused until CVP 10-15
Dr. Pestana: volume replacement starting w/ 2L > follow w/ packed red cells, FFP, plt packs in 1-1-1 ratio
60 yo Hispanic female - 1 wk of cough and low-grade fever
> understands some English; doesn't speak fluently
> son speaks fluent English/Spanish
> physician not fluent in Spanish - can communicate limitedly w/ pt
100F
80/min
16/min
140/70 mmHg
POx: 98% RA
PE: breath sounds dec at lung bases w/ occ rhonchi that clear w/ cough
CXR: no PNA; 1 cm mass that requires f/u in LLL
ECG: NSR
pt anxious to leave but hospital interpreter w/ another pt
most app way to communication the need for further eval of a potential malignancy?
wait for the interpreter before issuing the discharge instructions
so many things can get lost in translation - make sure you have a professional to help you relay the info
> save your ass, don't get sued
77 yo female - fell at home
PMHx: T2DM
meds: metformin, insulin
ED: somnolent
99.9F
130/min
16/min
78/40 mmHg
POx: 98%
PE: basilar crackles at L.lung base
labs: Hgb 13.2; CMP WNL; HCO3 15; glucose 90
blood cx and CXR ordered
most app next step in mgnt?
administration of 0.9% saline
remember your ABCs mofo - esp since homegirl is unstable (tachy and HoTN)
Dr. Pestana: even though fast CT scanners are available in Level I trauma centers - pt needs to be hemodynamically stable so pics can be taken w/o all the commotion of continuing resuscitation efforts
60 yo female - 12 hrs of mod, diffuse abd pain/vomiting
> 2 wks ago: sigmoidectomy for perforated diverticulitis
> no fever/diarrhea/dysuria
> last BM yest - normal
> no flatus today
meds: cipro, metro, oxy-acet
ED: mod distress; awake/alert
100.2F
100/min
20/min
140/65 mmHg
POx: 98% RA
PE: heart/lungs gucci; abd - mod distended and diffusely tender in all quadrants; surg incision clean/dry/intact; bowel sounds dec
abd x-ray: mult loops of distended small bowel w/ air-fluid levels; no air in rectum
most app next step in mgnt?
insertion of a nasogastric tube
homegirl clearly has SBO 2/2 adhesions from her prior surgery
> classic BOARDs question
> MC cause of SBO
UTD: pts w/ SBO associated with significant distension, nausea, and/or vomiting > recommend NG tube decompression
Dr. Pestana: colicky abd pain, protracted vomiting, prog abd distention, no passage of gas/feces
x-rays: distended loops of small bowel w/ air fluid levels
> "step-ladder" appearance
tx: NPO, NG suction, IVF
> if unsuccessful - surgery
~ 24 hrs for complete obstruction
~ few days for partial
52 yo - 2 hrs of fever, severe malaise, joint stiffness
> wrists, hands, knees
PMHx: RA, HTN, hyperchol
meds: pred, etanercept, enalapril, HCTZ, ibuprofen
ED: sleepy, easily aroused
101.2F
120/min
26/min
90/50 mmHg
POx: 92% RA
PE: ext cool to touch; mottling over lower ext; no JVD; crackles over L.lung base; cardiac - hyperdynamic precordium; 2/6 sys ejection murmur at base; no S3/S4
labs: Hgb 9.5; WBC 20,500; plt 90,000; PT 16 sec; CMP WNL; BUN 35; albumin 2.1
ECG: sinus tachy but unchanged from prior ECG
most likely dx?
sepsis
wtf is mottling = veins swell > lacy bluish discoloration on the extremities
the other choices just didn't make sense for this case (cardiac tamponade, GIB, NSTEMI, PE)
I believe this pt is heading to DIC
> inc PT, dec plt [Show Less]