Transcript ER Case Studies - Lock Haven University of Pennsylvania

Emergency Medicine
Board Review
Tiffany Allen PA-C
Case Study 1
History of Present Illness:
-A 50 y/o male presents
to the ER with chest
pain x 2 days
-Located in the left side of his
chest radiating into left
shoulder
-Constant, sharp, stabbing
-Gradually getting worse
-Severity 8/10
-Nothing really helps to
alleviate the pain, he took a
Nitro at home but it didn’t help
-When I lay down it seems to
get worse
Review of Systems:
+Fever (Subjective)
+Dry, non-productive cough
+ “hurts to breath”
-No diaphoresis
-No palpitations
Past Medical History:
-DM II
-High cholesterol
-MI 6 weeks ago with angioplasty,
-GERD
Social History:
-Smokes ½ PPD x 30 years
-Drinks ETOH socially
(3 beers/weekend)
Physical Exam
-Vitals: BP: 110/60, HR 100, T 99.9, RR 20, O2 sat 97%
RA
-General: A&O x3, moderate distress, holding chest,
leaning forward
-EENT: Normal limits
-Neck: supple, no lymphadenopathy, no bruit
-Heart: Friction rub noted at left lower sternal border,
muffled with distant heart sounds
-Lungs: Decreased otherwise normal
-Abdomen: soft, non tender, nondistended, + BS x 4
quadrants
-Extremities: Non tender, no pedal edema
Diagnostic Work-up
-CBC, BMP, Cardiac Enzymes
-Sed rate (ESR), C-reactive protein
-Chest x-ray
-EKG
-Later may consider an echocardiogram
EKG
Diagnosis
Pericarditis
-Dressler Syndrome (Post MI Pericarditis): thought to
occur from immune system attacking the
damaged area.
Cardiology Highlights
Pericarditis
-Usually Viral (Coxsackie, Echovirus-Most Common)
-Associated with:
-Cancer
-Autoimmune Disease
-Rheumatic Fever
-TB
-Hypothyroidism
-HIV/AIDS
-COMPLICATIONS: Arrhythmia, Cardiac Tamponade,
Constrictive Pericarditis (may lead to heart failure)
Cardiology Highlights
Pericarditis
• Pleuritic chest pain with inspiration and movement,
reduced by sitting up and leaning forward. Aggravated
by laying down.
•Becks Triad:
1. Distended neck veins
2. Hypotension
3. Muffled heart sounds
•EKG: Marked ST elevations over all precordial leads
Cardiology Highlights
Pericarditis
Treatment
-Ibuprofen 600-800 mg TID
-If Tamponade: Pericardiocentesis
-Recovery is 2 weeks- 3 months
-If bacterial (Rare): Antibiotics
Cardiology Highlights
EKGs
Cardiology Highlights
Myocardial Infarction
EKG
Cardiac Enzymes
ST elevation
> 1 mm limb leads
> 2 mm chest leads
CK-MB - Rapid fall to baseline
Troponin - More specific for AMI
Cardiology Highlights
Myocardial Infarction
I
Lateral
aVR
----
--------
V1 Septum
V4 Anterior
II Inferior
aVL Lateral
V2 Septum
V5 Lateral
III Inferior
aVF
Inferior
V3 Anterior
V6 Lateral
Cardiology Highlights
Myocardial Infarction
 Inferior: Posterior Descending Artery via RCA (2, 3, AVF)
 Lateral: Circumflex (1, AVL, V5, V6)
 Anterior:
Left Anterior Descending (V1, V2, V3)
Cardiology Highlights
Myocardial Infarction
Cardiology Highlights
Myocardial Infarction
Treatment
-Oxygen
-Aspirin 325mg chewed
-Nitroglycerin 0.4mg sublingually q3-5 minutes up to 3 doses.
-Hold NTG if
-Hypotension Systolic <90mmHg.
-Bradycardia <50 bpm
-Recent phosphodiesterase Inhibitor use (Viagra)
-Morphine - if unresponsive to NTG
Early Reperfusion Therapy Goals
-Fibrinolytic Therapy – ED door to drug time - 30 mins.
-PCI Therapy – ED door to balloon inflation time – 90 mins.
Cardiology Highlights
Arrhythmias
Arrhythmia?
Treatment?
Cardiology Highlights
Arrhythmias
Arrhythmia?
Treatment?
Cardiology Highlights
Arrhythmias
Arrhythmia?
Cardiology Highlights
Murmurs
Innocent Murmurs:
-Still’s murmur: Most common innocent murmur. Systolic
murmur at left lower sternal boarder. Grade 1 or 2.
-Venous Hum: Most common continuous innocent murmur.
Systolic hum over mid-infraclavicular areas R>L. Grade 1-3.
-Pulmonary Systolic Murmur: Soft, blowing systolic murmur at
left upper sternal boarder. Grade 1-3.
Systolic Murmurs:
-Aortic Stenosis: Aortic area radiating to neck. “Ejection Click”.
-Pulmonary Stenosis: Pulmonic area radiating to left shoulder.
-Mitral Regurgitation: Mitral area radiating to left axilla.
-Tricuspid Regurgitation: Tricuspid area radiating to right of sternum.
-VSD: Holosystolic left sternal boarder. Harsh high pitched.
Diastolic Murmurs: Always pathological
-Mitral Stenosis: Mitral area with no radiation. “Opening Snap”
-Aortic Regurgitation: Aortic area radiating down sternal boarder.
Case Study 2
History of Present Illness:
Review of Systems:
+Fever
+Decreased appetite
+Congestion
-
A 3 year-old presents to the ED in
acute respiratory distress.
-
The parents relay a history of a
-N/V/D
recent upper respiratory illness
Past Medical/Surgical History:
that was followed by a sudden
-Asthma
onset of barking cough during the
night, but this morning they noted
Social History:
increased difficulty breathing.
-Father smokes in the house
Medication:
-Daily vitamin
Case Study 2
Diagnosis and Imaging:
PE:
listening for stridor/cough
prolonged inspiration or expiration,
wheezing, and decreased breath
sounds.
Chest xray (maybe)
Neck xray (maybe)
Pulmonology Highlights
Croup (laryngotracheitis) & Epiglottitis
Croup
Symptoms:
-"barking" cough, stridor,
and hoarseness
-Prodromal mild cold/flu symptoms
Organism: Parainfluenza virus (75%)
Imagining: “Steeple Sign”
(Subglottic Tracheal Narrowing)
Treatment:
-Supportive
-Cool or moist air
-Steamy bathroom
-Steroids / Nebulized racemic
epinephrine
-Intubation
Epiglottitis
Symptoms:
-Dysphagia (" hot potato" voice)
-Drooling
-Stridor
-Dyspnea
-Erect or tripod position
Organism: H. influenzae type B
Imagining: “Thumb Sign”
-Lateral c-spine
- No tongue blade or direct
laryngoscopy
Treatment:
-Ceftriaxone (Rocephin)
-Antipyretics (eg motrin)
-Intubation as needed
Case Study 3
History of Present Illness:
-A 22 y/o white college female
presents to the ER complaining of
right lower quadrant abdominal
pain for 2 days.
-Sudden onset of constant stabbing
pain without radiation.
-Severity 8/10
-Nothing seems to alleviate or
aggravate the pain
Review of Systems:
+Nausea
+Vaginal bleeding
“I have had vaginal bleeding
for the past 24 hours. It began as
just spotting, but is slowly
increasing.”
Past Medical/Surgical History:
-LMP 7 weeks ago
(typically q 28 days)
-Asthma
Social History:
-Currently sexual active and does
not use protection.
-Smokes ½ PPD x 5 years
-Drinks ETOH socially
(3 beers/weekend)
Medication:
-None
Case Study 3
Physical Exam
 Temp, 98.8, BP 108/72, HR 89, RR 20
 General: A & O x 3, Moderate distress, walking
slumped over holding abdomen
 EENT: normal limits
 Neck: supple, no lymphadenopathy
 Heart: RRR, no murmurs/rubs/gallops
 Lungs: CTA
 Abdomen: soft, moderate tenderness over right
lower abdomen. No masses palpated
 Pelvic: External exam normal, bright red blood noted
on speculum exam, bimanual exam reveals palpable
hard mass on right side.
Case Study 3
Diagnostic Tests:
-CBC
-Urine hCG
-Serum hCG
-Progesterone Level
-Pelvic US
OB/GYN Highlights
Ectopic Pregnancy
Ectopic Pregnancy
-Fertilized ovum implants
anywhere other than
endometrium
- Most common area in fallopian
tube – distal third
Triad
-Amenorrhea
-Abdominal pain
-Abnormal vaginal bleeding
Risk Factors
-Pelvic inflammatory disease
-Previous ectopic pregnancy
-Endometriosis
-Previous tubal surgery
-Previous pelvic surgery
-Infertility & infertility
treatments
-Uterotubal anomalies
-History of in utero exposure to
diethylstilbestrol
-Cigarette smoking
OB/GYN Highlights
Ectopic Pregnancy
Diagnosis:
-hCG >6500 w/ no gestational sac on US
= 86% positive predictive value for ectopic pregnancy
-hCG levels normally double every 1.8 to 3 days for the first 6 to 7weeks
Treatment:
Methotrexate: Causes destruction of rapidly dividing fetal cells.
Indications - No evidence of rupture on US
- No fetal cardiac activity
- Tubal mass  3.5 cm in diameter.
- Stable with minimal symptoms (compliant)
OB/GYN Highlights
Abortions
Abortion : Termination of pregnancy before fetus
capable of extrauterine life <20 weeks
Still birth: > 20 weeks
Inevitable: Cervix dilated with bleeding. No uterine
contents passed.
Incomplete: Uterine contents protrude through
cervix.
Missed: Fetal death, no expulsion, risk of infection &
DIC
Threatened: Cervix closed with uterine bleeding
Complete: Empty uterus by US
OB/GYN Highlights
Placenta Abruption Vs. Previa
Placenta Abruption
Placenta Previa
-Painful vaginal bleeding
-Painless vaginal bleeding
-Causes:
-Maternal hypertension
-Increasing maternal age
-Increasing parity
-History of smoking
-Prior abruption
-Cocaine use
-Trauma
-Causes:
-Prior C-section
-Multiparity
-Treatment:
-Depends on gestational age.
Deliver or admit and monitor
closely.
-DO NOT do a pelvic, vaginal, or rectal
exam
-Treatment
-C-section
Case Study 4
History of Present Illness:
- 38 y/o female was brought to the Review of Systems:
-Unknown
ER via ambulance.
- Patient was only responsive to
painful stimuli.
Past Medical History:
-Unknown
- EMT stated, “Patient was found
Social History:
unresponsive and vomiting by
-Unknown
her daughter. The daughter also
found a pill container of
morphine on the dresser next to Medication:
-Unknown
her.”
-In route, EMTs administered 0.4
mg Narcan and started normal
saline at 500cc/hr. After narcan
was administered patient began
to be slightly more alert and
vomiting more.
Case Study 4
Physical Exam
-Vitals: BP: 70/43, RR 11, O2 Sat 86% on 2L NC
-General: Responsive only to pain. Cold clammy skin.
Shaking.
-Neck: supple, no lymphadenopathy, no bruit
-Heart: RRR / bradycardia
-Lungs: CTA bradypenia
-Abdomen: soft, nondistended, + BS x 4 quadrants
-Extremities: Non tender, no pedal edema. Weak pulses
Case Study 4
Diagnostic Work-up
-Pulse oximetry
-Continuous cardiac monitoring
-EKG
-IV access
-Labs
-CBC, BMP, ABG
-Tox screen
-Urine drug screen
-Tylenol / Acetominophin
-Salicylate
-Alcohol Level
Poisoning Highlights
Antidotes
-Opiates: Naloxone (Narcan)
-Iron: Deferoxamine (Desferol)
-Acetaminophen: Nacetylcysteine
-Heparin: Protamine sulfate
-Benzodiazepines: Flumazenil
(Romazicon)
-Digoxin: Digoxin immune fab
(Digibind)
-ASA: Sodium bicarbonate
-Cyanide: Amyl nitrate
-Beta blockers: Glucagon,
calcium, insulin + dextrose
-Calcium channel blockers:
calcium, glucagon, insulin +
dextrose
-Carbon monoxide: Oxygen
-Warfarin: Vitamin K / FFP
-Methanol: Ethanol
-Extrapyramidal Reaction
(Reglan): Benadryl
-Theophylline: Beta Blocker
-Organophosphates
(insecticides): Atropine
Orthopedic Highlights
Fractures
7 Year old Male
What type of
fracture is this?
Orthopedic Highlights
Salter-Harris Factures
Salter-Harris Type I: Fx occurs transversely through the
physis cartilage. Xray are commonly negative. Growth
impairment is rare.
Salter-Harris Type 2: Fx through the physis that exists
through the metaphysis. Good prognosis. The most common
growth plate injury.
Salter-Harris Type 3: Fx through the physis that exits through
the epiphysis. Requires open reduction & internal fixation to
preserve the growth plate.
Salter-Harris Type 4: Fx extends upward from the joint line
across the epiphyseal plate, passes through the physis & exits
at the metaphysis. Requires open reduction & internal fixation
to preserve growth plate
Salter-Harris Type 5: Crush injury that obliterates the growth
plate & results in growth arrest. Requires open reduction.
Orthopedic Highlights
Salter-Harris Factures
Orthopedic Highlights
Dislocations / Compartment Syndrome
Shoulder Dislocations:
-Anterior dislocation is most
common (90%)
-After a seizure, think posterior
dislocation
Hip Dislocations:
-Posterior dislocation is most
common (90%)
-May result in avascular necrosis
Compartment Syndrome
PE (5 P’s)
-Pain out of proportion to
injury
-Paresthesia
-Pallor
-Paralysis
-Pulselessness
Treatment:
-Remove offending agent
(eg spint, cast)
-Fasciotomy effective if
performed within hours
of onset
Nephrology / Urology
Highlights
Nephrolithiasis
Nephrolithiasis
-Most common type: Calcium Oxalate
- Less that 5mm patient can pass
-Radiolucent: Uric acid stones
-Radiopaque: All the other ones
- Noncontrast helical CT
OB/GYN Highlights
Pelvic Inflammatory Disease
PID- Ascending infection from GU to pelvis
Signs / Symptoms:
-Lower abdominal tenderness
-Bilateral uterine and adnexal tenderness
-Cervical motion tenderness
-Signs of lower genital tract infection (discharge)
Treatment:
-Chlamydia trachomatis:
-Doxycycline 100 mg po BID x 7 days
-Azithromycin 1 gm po single dose
-Neisseria Gonorrhea
-Rocephin (Ceftriaxone) 250 mg IM single dose
-Cipro 500 mg po single dose
Complications:
-Ectopic Pregnancy
-Infertility
-Fitz-Hugh-Curtis Syndrome (bacteria from pelvis spread through
abdomen and cause inflammation of tissue surrounding the liver
Nephrology / Urology
Highlights
STIs
-Chancroid
-PAINFUL
-Organism: Haemophilus Ducreyi
-Sharply defined irregular borders
base is covered with a gray
or yellowish-gray material.
-Treatment: Azithromycin
-Syphilis
-PAINLESS
-Organism: Trepenoma Pallidum
-Stages
-Primary- Ulcer Stage
-Secondary-Systemic (Rash on
hands and feet, mucocutaneous
lessions
-Tertiary: Cardiovascular
-Gold Standard: Darkfield exam
-VDRL / RPR
-Treatment: Benzathine penicillin G IM
-Herpes
-PAINFUL
-Tzanck Prep, Viral Culture, PCR
-Treatment: Acyclovir
-Granuloma Inguinale
-PAINLESS
-Organism: Klebsiella granulomatis
-Beefy red “friable”
-Donavan Bodies on Biopsy
-Treatment: Doxycycline
-Lymphogranuloma Venereum
-PAINLESS
-Organism:Chlamydia Trachomatis
- Buboes
-Groove formed by the inguinal
(Poupart’s) ligament
-Treatment: Doxycycline
Dermatology Highlights
Burns
Dermatology Highlights
Burns
Solution to Pollution is Dilution
Fluid Resuscitation
-Ringers Lactate in adults, D5RL in children
-Parkland formula
-4ml x weight(kg) x % 2nd/3rd degree burns over 24 hours
-50% of required fluids given over the first 8 hours
then 25% over next eight and 25% over last eight
-Titrate to urine output of 1 ml/kg/hr for over 30kg
Trauma Highlights
Spinal Trauma
Spinal Tracts
Corticospinal – motor, ipsilateral,
upper motor neuron
Spinothalamic – sensory, crosses
over in cord, deep pain and
temperature
Dorsal Column – sensory,
ipsilateral, proprioception,
vibration, kinesthesia, light touch
Cord Lesions
Complete Cord Lesion
- Total loss of motor and sensory
function distal to the site of injury.
Anterior Cord Lesion
-Paralysis and hypalgesia below
level of injury, but with
preservation of posterior column
functions, position, touch,
vibratory sense
Brown-Sequard
-Ipsilateral motor paralysis,
proprioceptive loss, vibratory
loss, in conjunction with
contralateral sensory
hypesthesia and
temperature.
Questions?