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21 Cards in this Set
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Hx: young male/female without PMH found unresponsive with empty bottle
PE: afebrile / HR 50 / RR 9 / O2Sat 92% RA; GEN: Drowsy; HEENT: Pinpoint Pupils; CVS: Bradycardia; Neuro: Opens eyes to painful stimuli; Limited PE examination |
DDx: Narcotic overdose; Acetaminophen overdose; TCA overdose
ER STAT: Suction airway / DStick / IV NS / IV Naloxone / D50% / IV Thiamine / ABG / O2 ER WU: CBC / ECG / UPreg / UTox / UA / Acetaminophen lvl / salicylate lvl / INR / lactate / CXR (port) / Admit ICU ICU WU: Gastric lavage / Continuous monitoring / IV naloxone / Psych consult / Suicide precautions FU: Monitor at least 24 hours |
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Hx: Young female with severe headache with auras, visual field defects, sensory changes. May have numbness or weakness. +/- N/V. FHx: Migraine.
PE: VS Stable; GEN: NAD; PE: WNL |
DDx: Headache: Cluster, Migraine, Tension; Intracranial neoplasm, Partial seizure, Pseduotumor cerebri, Trigeminal Neuralgia
ER W/U: CT-Head CBC / BMP / ESR ER Rx: IV NS IV Metoclopramide ASA / NSAID / Acetaminophen Caffeine IM sumatriptan if refractory F/U 1 month PPx: Beta blocker / antidepressant / CCB / anticonvulsant Notes: Presence of neurological symptoms differentiates complex from simple migraine Metoclopromide / IVF for N/V |
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Hx: Young female with daily bi-lateral band-like throbbing pain in frontal-occipital region occurring when tired or stressed. Denies N/V, photophobia, phonophobia, aura. +/- Stiffness around neck, shoulder.
PE: Afebrile; VS Stable GEN: NAD; PE: WNL |
DDx: Headache: Cluster, Migraine, Tension; Intracranial neoplasm; meningitis; pseudotumor cerebri; sinusitis
Office W/U: CBC+diff / BMP / ESR Office Rx: Acetaminophen / NSAID Cold compress F/U 1 month relaxation exercises |
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Hx: Elderly female / male with sudden, severe, intermittant unilateral headache in temporarl region with blurry vision and jaw pain
PE: Afebrile/low fever; HEENT: tenderness on palpation of temporal artery; No nuchal rigidity |
DDx: Headache: Cluster, Migraine, Tension; Glaucoma; Intracranial neoplasm; Meningitis; Temporal arteritis; Trigeminal neuralgia
ER Stat: IV NS Prednisone 60 mg/day ER W/U: CBC / BMP / ESR (elevated) / CRP (elevated) CT head CXR Admit to Ward (if vision affected) Ward W/U: Ophtho consult Temporal artery biopsy ESR Daily Screen for polymyalgia rheumatica Ward Rx: Prednisone until ESR normalizes then taper F/U: Home Continue low dose prednisone Repeat ESR in two weeks Notes: Dx requires three of the following five items: Age of onset older than 50 years New-onset headache or localized head pain Temporal artery tenderness to palpation or reduced pulsation Erythrocyte sedimentation rate (ESR) greater than 50 mm/h Abnormal arterial biopsy (necrotizing vasculitis with granulomatous proliferation and infiltration) Elevated CRP is useful when ESR is normal Hospitalization not necessary (can do Biopsy as o/p) in this case warranted because of vision loss |
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Hx: Young male with high fever, headache, lethargy, photophobia and neck pain.
PE: VS: Febrile +/-HTN/tachy; GEN: distress; HEENT: nuchal rigidity; Neuro: (+)Kernig/Brudzinski |
DDx: Headache: Cluster, Migraine, Tension; Meningitis; Intracranial abscess; Sinusitis; SAH
ER Stat: IV NS BCx LP-CSF (cell count + culture) Ceftriaxone + Vancomycin CT-Head IV Dexamethasone ER W/U: CBC / BMP CXR Admit to Ward ER Rx: Acetaminophen Ward W/U: f/u CSFCx / BCx Ward Rx: Continue Ceftriaxone + Vancomycin + Steroids F/U: Home when improved f/u in 1 month Notes: Major Pathogens include: s Pneumo (not neonates) n Meningitides (Young adults / late winter + early spring) GBS (neonates) Listeria (newborn, elderly, immunocompromised) Hib (unvaccinated children, adults) Pts often have prodromal viral URI picture Rapid onset suggests bacterial meningitis Presence of papilledema and inability to fully assess fundi or neurologic status are indications for CT scan prior to LP. If concerned about ICP: Diuresis Mannitol 1 g/kg IV Furosemide 20mg IV Hyperventilate Tx based on age: <1 month (GBS, Listeria, eColi): Amp/Gent or Amp/Cefotaxime 1-3 months: Amp/Ceftriaxone 3 mo - 7 years (sPneumo, nMenigitides, HiB): Ceftriaxone +/- Vanco 7 y - 50 y (sPneumo, nMenigitides, Lysteria): Amp/Ceftriaxone +/- Vanco 50+ y or immunocompromised (Ceftriaxone + Vanco) Isolation if nMenigitides is suspected |
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Hx: Older man with PMH of HTN presenting with headaches, N/V and poorly compliant with HTN meds.
PE: tachycardic + HTN (>210 = emergency) GEN: distress; HEENT: papilledema; Signs of end-organ damage (chest pain / back pain / dyspnea / neuro symptoms) |
DDx: Cluster headache, Migraine; Intracranial hemorrhage; Intracranial neoplasm; Malignant hypertension; Partial seizure
ER Stat: O2 IV Labetalol BP both arms CT head (SAH / infarction / edema) ECG (MI / LVH) CXR (cardiac enlargement / pulm edema) ER W/U: Cardiac monitoring / BP monitoring CPK-MB, Troponin x 3 CBC (r/o microangiopathic anemia) BMP (eval renal impairment) UA (eval renal impairment) Beta HCG if female Admit to ICU ICU W/U: Continuous cardiac monitoring Lipid profile Echo ICU Rx: Labetalol ACEI if low EF HCTZ F/U: Transfer to floor / Discharge home Provide counseling regarding medication compliance f/u 1 week Notes: Signs of End-Organ Failure: Neurological: Encephalopathy / CVA / SAH Cardiovascular: MI / Left Ventricular Dysfunction / Pulmonary edema / Dissection Other: ARF / Retinopathy / Eclampsia / microangiopathic anemia |
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Hx: Elderly female with progressive memory loss with difficulties performing ADLs.
PE: afebrile, VSS; NAD; Neuro: MMSE poor attention, poor recall, no focal neuro findings |
DDx: AD; B12 deficiency; Chronic SDH; Depression; Hypothyroidism; Intracranial tumor; neurosyphilis; normalpressure hydrocephalus; vascular dementia
Office: CBC / CMP / TSH / Serum B12 / Serum folate / VDRL-RPR / CT-head Donepezil FU: counseling (patient and family) support group advance directives |
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Hx: Elderly male with progressive chronic history of difficulty walking + memory loss + urinary incontinence
PE: Afebrile, VSS (maybe mild HTN); NAD; Neuro: poor recall, spasticity & hyperreflexia all extremities, shuffling gait |
DDx: AD; B12 def; Chronic SDH; HD; Intracranial tumor; Meningitis; NPH; PD; Vascular Dementia
ED: CBC / BMP / LFT / TSH / Serum B12 / Serum folate CT-head (Enlarged lateral ventricles out of proportion to sulcal atrophy) LP Admit Ward: Neurosurgery consult Neurology consult VP shunt placement FU: Advance directives Family counseling |
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Hx: Middle-aged male s/p emergency trauma surgery two days prior now presenting with seizures, tremors, easily startled, anxious, irritable, nausea, diarrhea, sweating, insomnia & hallucinations.
PE: VS: +/- Fever; Tachy + HTN; Sat 92% on RA; GEN: sweating, cigarette burns, tatoos, rings; Abd: Hepatomegaly; Neuro: tremor, confusion, clouded sensorium |
DDx: Alcohol withdrawal; Amphetamine psychosis; Delerium; Sedative withdrawal; SLE; SDH
Ward: O2 IV NS CBC / BMP / LFT (Macrocytosis, hypokalemia, hypomagnesemia, GGT elevated) Urine Tox CT-head (cerebral atrophy; no SDH) CXR (note hypoxia in this case) Thiamine (100 mg IV) before giving D50 bolus (50ml bolus IV or PO) Pyridoxine Folic Acid IV diazepam (5-10mg IV bolus q5-15 mins until sedated) Atenolol Replete K / Mg (2gMgSo4 in 50ml of D5W over 20 minutes) IV Admit to ICU ICU: Cardiac Monitoring BMP to see corrected Mg/K IV NS IV diazepam Atenolol Naltrexone (50mg PO daily) FU: 1 month patient counseling smoking cessation dietary supplements SW consult Addiction consult Continue Naltrexone on discharge |
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Hx: young male/female brought to ER in drowsy state following episode of sudden stiffening, falling and LOC. Jerking movements of all four limbs noted. Unconscious for five minutes or more.
PE: afebrile / VSS; NAD and WNL except for confusion and lethargy but oriented |
DDx: alcohol withdrawal; cardioembolic stroke; migraine headache; psychiatric condition; seizure; syncope; vascular
ER: CBC / BMP / LFT / ABG / Ca-Mg-Phos ECG (to look for arrhythmias) UA UTox CT-head MRI-brain EEG Admit to ward Ward: Neurology consult +/- IVF and O2 FU: 3-4 weeks patient counseling family counseling no driving or heavy machinery |
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Hx: elderly male/female with PMH of prior CABG Sx p/w episode of syncope. Pt notes fatigue and dizziness over previous five days with prodrome of lightheadedness prior to episode; No history of trauma with syncope; LOC x 3 minutes. Meds include: propranolol, digoxin & diltiazem.
PE: VS afebrile RR wnl BP wnl HR 34; NAD CVS: irregular s1 and s2, bradycardia otherwise WNL |
DDx: Aortic stenosis; asystole; cardiomyopathy: dilated, restrictive, myopathy; Heart block; MI; myocarditis; vasovagal
ED: IV NS O2 Continuous Cardiac Monitoring CBC / BMP / LFT / CK-MB, Troponins x 3 / Ca-Mg-Phos ECG (3rd degree heart block) CXR UA Temporary transcutaneous or transvenous cardiac pacemaker (indicated if symptomatic: dyspnea, chest pain, MI, CHF, altered mental status) Hold AV nodal agents (ie Beta blockers, CCBs) Admit to ICU ICU: Continuous Cardiac Monitoring ECG Echo Lipid profile +/- Statin Cardiology consult Cardiac cath Permanent cardiac pacemaker FU: Smoking sessation Limit alcohol No driving or heavy machinery Low-fat, low-sodium diet Cardiac rehabilitation program |
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Hx: elderly female found unconscious by spouse with bottle of amitriptyline next to him. EMS notes respiratory distress.
PE: febrile / tachycardic / tachypnic / hypoxic; GEN: acute distress, rapid, shallow breathing; HEENT: dilated pupils; CVS: tachycardia; Neuro Opens eyes to painful stimuli; Limited PE |
DDx: TCA Intoxication; Anticholinergic toxicity
ER Stat: Intubate / IV D5NS / Thiamine / Central Line placement / NG lavage / Activated charcoal / IV Bicarb ER WU: Cardiac monitoring / CMP / CBC / ABG / Serum lactate / Serum osmolality / Blood ketones / Urine Tox / ECG: (widened QRS) / Serum Mg / CXR / Cardiac enzymes / CT-head / Admit to ICU ICU WU: Continuous UOP monitoring / Continuous BP monitoring / Continuous Cardiac monitoring / Neuro check / Cardiology consult / Lidocaine for TCA-induced ventricular arrhythmias / IV MgSO4 |
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Hx: elderly male with PMH: HTN, DM, Smoking p/w 20-minute episode of slurred speech, unilateral facial drooping and numbness and unilateral hand weakness. Sxs resolved completely prior to arrival in ED
PE: afebrile; HTN; NAD; HEENT: Carotid Bruit |
DDx: Intracranial tumor; Seizure; Stroke; SDH/EDH; TIA
ER Stat: ABCs / O2 / DStick / IV NS / Head-CT ED WU: Continuous cardiac monitoring / BP monitoring / ECG / CBC / BMP / CXR / PT-PTT-INR / Neuro Consult / ASA / Admit to Floor Ward WU: Serial neuro exams / Continuous cardiac monitoring / BP Monitoring / Telemetry / Lipid Profile / HbA1c / Echo / Carotid Duplex / Vascular surgery consult / Elective Carotid Endarterectomy / ASA |
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Hx: 40y Female p/w numbness, lower extremity weakness and difficulty walking. Pt had URI symptoms two weeks prior. Weakness started in legs, progressed to hips and then upper limbs.
PE: Afebrile tachycardic and orthostatic changes in BP; GEN: NAD Neuro: Loss of motor strength in LEs, absent DTRs, sensation intact. |
DDx: Guillain-Barre, Conversion disorder, Myasthenia gravis, paraneoplastic neuropathy, poliomyelitis, polymyositis
ED WU: CBC / BMP / TSH / ESR / CRP / RF / VDRL / Serum B12 / Serum Folic Acid / ECG / CPK / CXR / LP (elevated CSF Protein) / HIV test / Admit to Ward Ward WU: Immunoglobulins / plasmapheresis / Rehab consult / Neurology consult / Immunology consult / Spirometry FU: 3-4 weeks / Pt counseling / family counseling |
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Hx: 40yo F p/w fatigue, wt gain, sleepiness, cold intolerance, constipation & dry skini
PE: afebrile; bradycardic; hypotensive; GEN: Obese Skin: Dry HEENT: scar on neck from thyroidectomy Neuro: Delayed DTRs |
DDx: Hypothyroidism; Anemia; Depression; Diabetes
Office WU: CBC / CMP / TSH (++) / FreeT4 (--) / ECG / Lipid Profile / Depression index Office Rx: Thyroxine FU: 1 month to follow TSH level |
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Hx: 16yo M with myalgia, fatigue & sore throat; loss of appetite and nausea without vomiting; girlfriend recently had similar symptoms for a few weeks
PE: febrile to 101; GEN: maculopapular rash; HEENT: posterior & auricular lymphadenopathy and pharyngitis with diffuse exudates and petechiae at junction of hard and soft palates + bilateral upper-lid edema; ABD: soft NT/ND mild HSM |
DDx: Infectious Mononucleosis; CMV; Viral hepatitis; Primary HIV; Strep pharyngitis
Office WU: CBC / CMP (+AST/ALT) / ESR / CRP / Serum EBV titer / Rapid Strep / Monospot / Peripheral Smear (Atypical lymphocytes) Office Rx: NSAID or Acetominophen / Hydration FU: 2 weeks for CBC / Rest at home / avoid sports! |
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Hx: 40y F feeling tired, hopeless, worthless; depressed mood, insomnia, poor concentration, missing work; denies suicidal thoughts or hallucinations; no drug or alcohol abuse;
PE: afebrile, VSS; NAD WNL |
DDx: Depression; Adjustment disorder; Anemia; Anxiety; Cancer; Chronic Fatigue Syndrome; Dementia; Fibromyalgia; Hypothyroidism
Office WU: CBC / CMP / TSH / UTox Office Rx: Suicide contract / SSRI (fluoxetine 20 mg PO qAM) / Psych consult FU: 1 week / supportive psychotherapy / exercise program / counseling |
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Hx: 2yo with sudden onset SOB and cough. URI four days prior. Playing with peanuts earlier in the day. Imm: UTD
PE: Afebrile, tachycardic, tachypnic; Respiratory distress, using accessory muscles; HEENT: WNL CHEST: Insp. stridor, decreased breath sounds in RLB; CVS: tachycardia |
DDx: Foreign-body aspiration; Angioedema; Asthma; Croup; Epiglotitis; Laryngitis; Peritonsillar abscess; PNA; Retropharyngeal abscess
ER Stat: CXR (PA & Lateral) / XR Neck / Bronchoscopy ER Rx: Consider methylprednisolone prior to bronchoscopy FU: Two weeks |
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Hx: 75yo F p/w chest pain and SOB. She fell five days prior and has casted femoral fracture
PE: Afebrile, Tachycardic, Tachypnic; Respiratory distress, CHEST: rales, wheezing & decreased breath sounds in LLL; CVS: loud P2 splitting S2 |
DDx: Pulmonary Embolism; CHF; Lung CA; MI; Pericarditis; Pneumothorax; Syncope
ER WU: IV NS / NPO / CBC / CMP / ABG (hypoxia, hypocapnia) / CXR (LLL atelectasis) / CT Chest (PE) / ECG / DVT U/S: Venous DVT ER Rx: Heparin IV and warfarin / Admit to Ward Ward WU: Cardiac & BP monitoring / Pulmonary consult / PT, PTT, INR Ward Rx: Discontinue heparin after two days when INR is therapeutic / Continue Warfarin FU: 2 weeks with PT, PTT, INR / Chest PT / Continue Warfarin / Rehab Consult |
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Hx: 2yo in winter with harsh barking cough x 1 week following URI with coryza, nasal congestion and sore throat
PE: T101 VSS; GEN: Pallor and respiratory distress, flaring and retractions; Chest: stridor, hoarseness, barking cough |
DDx: Croup; Bacterial tracheitis, Diptheria, Epiglottitis, Measles, Peritonsillar abscess, Retropharyngeal abscess
ER WU: O2 / CBC / BMP / Throat Cx / XR-Neck (subglottic narrowing) / Admit to Ward Ward WU: Humidified air / Epinephrine / Dexamethasone FU: one month |
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Hx: 75yo with SOB, cough and hemoptysis, progressive malaise and weight loss over previous six months. Hx of smoking
PE: Afebrile VSS; CHEST: Barrel-shaped, gynecomastia, rales, wheezing, decreased breath sounds with dullness in LUL. ABD: Mild tenderness RUQ + mild hepatomegaly; EXT: Finger clubbing; dark, pruritic rash on forearms |
DDx: Lung Cancer, Lymphoma, Sarcoidosis, Tuberculosis
Office WU: CBC ([-] H&H) / BMP / LFT ([+] ALT) / ESR (++) / ABG / CXR: Infiltrate & nodules in LUL / Sputum cytology (adenoCA) / Sputum culture / PPD / CT-Chest / PFTs / Oncology Consult / Surgery Consult / Dietary consult / Bronchoscopy +Biopsy / CT-head / CT-AP FU: Smoking cessataion / family counseling / patient counseling / 3-4 wks for CXR & CBC |
