Intern Report Case 3.2

Case Presentation by Dr. Jeanise Butterfield

A 58-year-old woman presents to the emergency department with severe abdominal pain, generalized weakness and subjective fever.    She is able to tell you that the pain began yesterday and has been gradually getting worse since onset but she is so weak that she only speaks in short phrases.  The pain is constant and cramping in nature, getting worse.  She has had 2-3 episodes of emesis per day and decreased appetite.   She has been feeling very warm but has not taken her temperature.   No diarrhea, last BM yesterday. 

She has a history of COPD and hypertension and was recently discharged from an outside hospital after a lengthy stay for COPD exacerbation and pneumonia which required intubation.  She was given several prescriptions to fill including inhalers and pills but could not secondary to lack of insurance and financial issues.   

PMH: COPD, HTN but noncompliant with medications
Meds:  None
Allergies: NKDA
FH: Hypertension
SH: Occasional alcohol use.  25 pack year tobacco history but quit 5 years prior. Denied illicit drug use.


PE:     Vital Signs - BP 96/64, heart rate 108, respiratory rate 24, temp 38.2°C, pulse ox 96% on RA
           HEENT: Atraumatic, normocephalic; PERRL, EOMI; dry mucus membranes                 
General - Thin female lying still in fetal position on stretcher
Skin - Diaphoretic, pale, no rashes
           Cardiovascular - Tachycardic, regular rhythm, no murmurs
Respiratory - Tachypneic, decreased breath sounds at the right base, slight expiratory wheeze bilaterally, no accessory muscle use
Abdominal - Soft, nondistended, diffusely tender to palpation, + guarding, no rebound, normal bowel sounds,
            Musculoskeletal - Full ROM in all 4 extremities, no edema, symmetric pulses bilateral UE & LE
Neuro - A&O x 3, normal speech and hearing, face is symmetric, sensation equal and intact throughout, motor is decreased in all extremities but symmetric, patient not exerting much effort                 
                 
Pertinent Labs:
                  Sodium 128 mEq/L, potassium 5.8 mEq/L, glucose 55 mg/dL, cortisol 20 µg/dL. 

Questions

1.  Immediate management of the patient should include:
                  a. Surgical consultation
                  b. Abdominal CT
                  c. Morphine
                  d. Hydrocortisone
                  e. ACTH stimulation test

2. If an EKG was performed on this patient, which abnormality could be expected
                  a. ST elevation
                  b. Right bundle branch block
                  c. Peaked T waves
                  d. Prolonged QT interval
                  e. Prominent U waves

3. Which of the following is least likely to precipitate acute adrenal insufficiency:
                  a. Etomidate
                  b. Phenytoin
                  c. Ketoconazole
                  d. Rifampin
                  e. Nitroglycerine

Please submit your answers as a comment. Your submission will not immediately post.  Answers with a case discussion will post on Friday.  If you have any difficulty, please contact the site administrator at arosh@med.wayne.edu. Thank you for participating in Receiving's: Intern Report.


Intern Report Case 3.2

Case Presentation by Dr. Jeanise Butterfield

A 58-year-old woman presents to the emergency department with severe abdominal pain, generalized weakness and subjective fever.    She is able to tell you that the pain began yesterday and has been gradually getting worse since onset but she is so weak that she only speaks in short phrases.  The pain is constant and cramping in nature, getting worse.  She has had 2-3 episodes of emesis per day and decreased appetite.   She has been feeling very warm but has not taken her temperature.   No diarrhea, last BM yesterday. 

She has a history of COPD and hypertension and was recently discharged from an outside hospital after a lengthy stay for COPD exacerbation and pneumonia which required intubation.  She was given several prescriptions to fill including inhalers and pills but could not secondary to lack of insurance and financial issues.   

PMH: COPD, HTN but noncompliant with medications
Meds:  None
Allergies: NKDA
FH: Hypertension
SH: Occasional alcohol use.  25 pack year tobacco history but quit 5 years prior. Denied illicit drug use.


PE:     Vital Signs - BP 96/64, heart rate 108, respiratory rate 24, temp 38.2°C, pulse ox 96% on RA
           HEENT: Atraumatic, normocephalic; PERRL, EOMI; dry mucus membranes                 
General - Thin female lying still in fetal position on stretcher
Skin - Diaphoretic, pale, no rashes
           Cardiovascular - Tachycardic, regular rhythm, no murmurs
Respiratory - Tachypneic, decreased breath sounds at the right base, slight expiratory wheeze bilaterally, no accessory muscle use
Abdominal - Soft, nondistended, diffusely tender to palpation, + guarding, no rebound, normal bowel sounds,
            Musculoskeletal - Full ROM in all 4 extremities, no edema, symmetric pulses bilateral UE & LE
Neuro - A&O x 3, normal speech and hearing, face is symmetric, sensation equal and intact throughout, motor is decreased in all extremities but symmetric, patient not exerting much effort                 
                 
Pertinent Labs:
                  Sodium 128 mEq/L, potassium 5.8 mEq/L, glucose 55 mg/dL, cortisol 20 µg/dL. 

Questions

1.  Immediate management of the patient should include:
                  a. Surgical consultation
                  b. Abdominal CT
                  c. Morphine
                  d. Hydrocortisone
                  e. ACTH stimulation test

2. If an EKG was performed on this patient, which abnormality could be expected
                  a. ST elevation
                  b. Right bundle branch block
                  c. Peaked T waves
                  d. Prolonged QT interval
                  e. Prominent U waves

3. Which of the following is least likely to precipitate acute adrenal insufficiency:
                  a. Etomidate
                  b. Phenytoin
                  c. Ketoconazole
                  d. Rifampin
                  e. Nitroglycerine

Please submit your answers as a comment. Your submission will not immediately post.  Answers with a case discussion will post on Friday.  If you have any difficulty, please contact the site administrator at arosh@med.wayne.edu. Thank you for participating in Receiving's: Intern Report.


Asthma

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Asthma in kids is common… very common.  So we should know how to manage it in our Emergency Departments.  Occasionally we see a child with severe or critical asthma; when this happens it is useful to know what your plan is – a plan you can make beforehand, rather than in the heat of the moment…

Join us for this PEMcast as we navigate the current conventional wisdom on management of acute asthma, including what to do when things are not going as well as you would have liked…


Outline of this podcast: Asthma

CP: welcome, disclaimer

CP: intro (not discussing diagnostic controversies in infants & toddlers)

SF: definition (recurrent reversible wheeze?)

KB: incidence (worldwide vs WA – seems high in Perth)

CP: chronic stable asthma assessment & management

SF: assessment of acute asthma attack – overview (Asthma Management Handbook pg 43-46 – table 5)

KB: signs of severe / critical asthma

CP: put into context of treatment prior to attending ED

SF: management of mild & moderate: salbutamol (=albuterol), review response (is fall in SpO2 always bad?), decide disposition

CP/all: why spacers, not nebs?

All: Who should get steroids? What dose? How long? (controversy of steroids in under 5′s to be discussed another time)

KB: treatment options in severe / critical asthma (Atrovent, IV salbutamol, aminophylline, magnesium, mechanical ventilation)

All: any advantage of Adrenaline (=epinephrine) neb, IM or IV)?

CP: Non-Invasive Ventilation vs Intubation & IPPV (risks/complications)

All: Options for intubating drugs (midazolam, fentanyl, thiopentone, propofol, ketamine, muscle relaxant)

SF: Initial ventilator settings

CP/all: Resources (NAC, RCH asthma action plan generator), Summary, goodbye for now

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