recognizing a sick patient: a case-based...
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Recognizing a Sick Patient: A Case-Based Approach
Shirley Strachan-Jackman RN (EC) MN ENC(C)
Nurse Practitioner- Emergency Medicine
Toronto Western Hospital- UHN
Overview
• Present cases one might encounter in a emergency department or primary care setting
• Recognize the importance of detail in history taking to help guide you to differential diagnosis
• Identify important observations that could save a person’s life
Case One
• 18 y.o. male presents with a left hand laceration at 0800
• Injury sustained at 0200 hrs while play fighting with a friend and his hand hit a brick wall
• Left hand dominant
• Tetanus: Up-to-date
• PMH: None; Meds: None; Allergies: None
Exam
• Alert and orientated; no acute distress
• 1 cm laceration over the dorsum of the 3rd MCP joint
• Edema and erythema with swelling between 2nd and 4th metacarpal
• Experienced pain with both flexion and extension
Investigations
• Left hand x-ray; negative for fracture
• 1% lidocaine; wound was explored- no evidence of extensor tendon laceration
• Wound was closed with 2 sutures- 4.0 nylon
• Polysporin and dressing
Disposition
• Diagnosis: left hand laceration with ? Cellulitis
• Script for Keflex 500 mg qid given x 7 days
• Sutures out in 10 days
Tenosynovitis
• Tenosynovitis is inflammation of the lining of the sheath that surrounds a tendon (the cord that joins muscle to bone).
CFI’s
• Irrigate the wound with 300 cc normal saline using a 18 g needle and a 20-30 cc syringe
• Do not close the wound
• Splint hand in position of function
• Elevate
• Antibiotic: amoxicillin/ clavulanate 500 mg tid x 7 days
• Re-evaluate in 24-48 hours
Take Home
• Patients do not always tell the truth
• Always remember a significant laceration over the knuckle- human mouth that is full of “bugs”, “as in a fight” until proven otherwise
• Make patients aware of the potential bad outcomes if correct cause is unknown
• Increased index of suspicion, treat regardless of patient’s story
Case Two
• 71 y.o. male was watching TV and had a sudden onset of left lower back pain
• Denies any twisting, bending, lifting earlier in the day
• Took Advil 600 mg with no effect
• Called 911 for transfer to hospital- back felt like spasms
• Denies previous back pain
• No bowel/ bladder dysfunction; no UTI complaints
• No weakness/ numbness to extremities
• Presently non-smoker; quit at age 50
• PMH: renal colic, HTN; Meds: Ramipril; Allergies: None
Exam
• Alert and orientated x 3; well appearing
• Vitals: T- 36.5; HR- 72; RR- 18; BP- 160/80
• Lying on back- pain when sitting up but can roll onto his side
• Chest: clear; A/E equal to bases
• CVS: S1 S2 normal; no EHS’s
• Abdomen: soft, non-distended, no masses, has some tenderness RUQ with negative Murphy’s sign
Exam- cont’d
• Back: no midline tenderness
• Extremities: 5/5 strength; sensation R=L; DTR patella/ Achilles 2+ bil.; negative SLR; pulses bil.
Treatment
• Pain meds given: Tylenol 1 Gm plus Toradol 30 mg IM
• Urine dip negative blood
• Re-evaluated in 1 hour- abdominal exam benign although he reports the abdomen is sore with palpation on the RUQ and LUQ
• Able to ambulate
Dispositon
• Muscle spasms lower back
• Script for Naprosen 500 mg bid prn and suggested Tylenol 1 Gm every 6 hours
• Ice or heat
• If any urinary retention or rectal numbness- return to ED
AAA
• Incident- 11% in males > age 65
• More prevalent in men- 7:1 ratio
• Most aneurysms are asymptomatic until they rupture
• Classic triad: HTN; abdominal or back pain; pulsatile abdominal mass (<50%)
Take Home
• Include AAA in the differential diagnosis of older patients (age 55) with back pain and younger patients with risk factors (Marfan syndrome)
• Positive physical exam findings such as abdominal tenderness needs to be explored
• Bedside ultrasound of the abdominal aorta plays an important role
• If you suspect AAA- CT
Also Keep in Mind...
• Back pain is a very common complaint...often we focus on MSK pain
• Use Naprosen with caution in the older population- cause GIB
• A history of fever with back pain attempt to find a correlation- UTI/ pylonephritis
• Remember to ask in your social history re: IV drug abuser- a drug abuser with back pain is an abscess until proven otherwise
Case Three
• 38 y.o. Caucasian male presents with neck stiffness, headache 6/10 (gradual onset), sore throat and decreased appetite
• 1 month previously had a tooth extraction and had a sinus congestion and cough
• Had an antibiotic course (not sure what antibiotic)
• No PMH; No Meds and No Allergies
Exam
• Looks unwell; skin warm
• Vitals: T- 38.5; HR: 100; RR: 24; BP: 130/80; O2 saturation 97% R/A
• No nuchal rigidity; ROM neck normal
• Cervical adenopathy
• Throat- tonsils red, slightly swollen, exudate noted on the right tonsil; slight protrusion of the tongue
• Slight trismus noted
• Chest: clear; A/E equal to bases
• CVS: normal findings
Ludwig’s Angina
• Serious, life-threatening cellulitis or connective tissue infection of the floor of the mouth
• Dental procedures involving the 2nd and 3rd molars are common sources of infection- the roots extend into the mylohyoid muscle- provides a route to the primary mandibular spaces
• Route of infection in most cases is from infected lower molars or from pericononitis (infection of the gums) surrounding the partially erupted lower molars (usually third)
Treatment
• Adequate airway management
• Antibiotics should be initiated as soon as possible. Antibiotics should initially be broad-spectrum and cover gram positive, gram negative and anaerobic organisms. Combinations of penicillin, clindamycin, and metronidazole are typically used
• Intravenous corticosteroids may play a role (Dexamethasone) to avoid the need for airway management
• CT scan- depending on the degree of infection- may require a surgical procedure to drain the infection
• ENT consult
Take Home
• Mortality rates 8-10%
• Look for swelling, pain and raising of the tongue as well as swelling of the neck and the tissues of the submandibular and sublingual spaces
• Can also be associated with piercings of the lingual frenulum
Case Four
• 14 y.o. female presents with a four day history of increasing dysphagia, photophobia and a macular rash extending from the trunk to the extremities
• States she had an URTI about two weeks ago
• Immunizations: Up-to-date
• PMH: None; Meds: tetracycline; Allergies: None
Exam
• Looks well
• Vitals within normal limits
• Eyes: conjunctivia red bil.; some purulant drainage noted
• Lips- slightly swollen with a small vesicle noted
• Skin: erythematous rash on the trunk with small vesicles some forming bullae
SJS
• Occurs most often in children and young adults
• Can be preceded by a prodrome consisting of fever, malaise, sore throat, N/V, arthralgias and myalgias
• Followed generally 14 days with conjunctivitis and by bullae on the skin and on the mucosal membranes
• Syndrome affects multiple organs and esophageal strictures develop in some patients
Treatment
• Withdraw any offending agent
- Medications most common: NSAIDS; anticonvulsants, antibiotics, allopurinol, corticosteroids
• If extensive- transfer to a burn unit
• Nutrition
• Systemic antibiotics if signs of sepsis
• Pain medications
Take Home
• SJS is a potentially fatal multi-organ condition with a strong etiologic link to some medications
• When you see conjuctivitis and mucous membrane involvement- think SJS
• Positive Nikolsky sign
• Early recognition is key
Case Five
• 50 y.o. stay at home mom presents with headache (dull frontal- gradual onset), nausea, fatigue, malaise
• She feels like she has the “flu”
• Reports that her husband and 16 year old son had similar symptoms (flu season- November)
• Denies fever
• Review of symptoms- no other complaints
Exam
• Alert and orientated
• Vitals stable; afebrile
• Chest: clear; A/E equal to bases
• CVS: normal
• Abdomen: soft, non-tender
• Neuro exam: normal
Carbon Monoxide Poisoning
• Colourless, odourless, tasteless and initially non-irritating gas
• Family and group poisoning is surprisingly common
• Combines to the hemoglobin reducing oxygen-carrying capacity of the blood leading to hypoxia
Carboxyhemoglobin Levels
• Cigarette smokers 2 ppd- level of 9%
• Serious toxicity occurs when ratio is above 25%
• Risk of fatality is high with levels over 70%
Remember
• The use of a regular pulse oximeter is not effective in the diagnosis of carbon monoxide poisoning as patients suffering from carbon monoxide poisoning may have a normal oxygen saturation level. This is due to the carboxyhemoglobin being misrepresented as oxyhemoglobin
Treatment
• High flow oxygen- increases the removal of carbon monoxide from the hemoglobin
• Hyperbaric oxygen therapy
Take Home
• Cooler weather is fast approaching
• Symptoms often mistaken for a virus such as influenza
• People experience different symptoms- not all impacted in the same way
• Family and group poisonings are common
Case Six
• 42 y.o. Male presents with a syncopal episode lasting ? 15 seconds
• States he felt heart palpations just prior to fainting
• Denies chest pain, SOB, headache, abdominal pain
• Family history- father died suddenly at age of 50- not sure why
Exam
• Looks well
• Vitals: stable
• Chest: clear; A/E equal to bases
• CVS: S1 S2 normal; no EHS’s
• Abdomen: soft, non-tender
• Neuro exam: normal
• Blood sugar- 5.6 mmol/L
Brugada Syndrome
• Is a syndrome consisting of syncopal episode(s) and/ or sudden cardiac death in patients with a structurally normal heart
• ECG changes: incomplete RBBB; ST segment elevation in the V1-V3 leads and terminal T wave inversion
• Genetic disposition and predominately affects males
Take Home
• The syndrome should be considered on the basis of history and family history of sudden cardiac death (SCD)
• Consult a cardiologist- without treatment, the incidence of SCD is high
Case Seven
• 15 year old girl decides to try out for the cross country team at her high school
• After a couple of days of training she went to her coach and complained of pain in the fronts of her lower legs- “shin splints”
• The pain got worse overnight so her parents took her to the ED
• Healthy child; immunizations UTD
Exam
• Looks well
• Afebrile; VSS
• Legs were red and swollen with the anterior component very sensitive to palpation- felt harder and warmer compared to other parts of her legs
• Dorsiflexion of the foot/ toes were limited
• Decreased sensation between the 1st and 2nd toes
• Weaker dorsalis pedis pulse was noted
Compartment Syndrome
• Painful condition that occurs when pressure within the muscle builds to dangerous levels
• The pressure can decrease blood flow which prevents nourishment and oxygen from reaching nerve and muscle cells
Take Home
• If not recognized and left untreated- ACS can lead to loss of the affected extremity
• No gold standard exists for diagnosing ACS
• Key- pain out of proportion
• Rhabdomyolysis should be part of your differentials (brown urine)