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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

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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

Thoughts?

Clenched Fist Injury (CFI)

CFI

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

Thoughts?

Abdominal Aortic Aneurysm (AAA)

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

Thoughts?

Ludwig’s Angina

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)

Molars

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

Thoughts?

Stevens-Johnson Syndrome (SJS)

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

Disposition

• Influenza

• Tylenol for headache

• Fluids

• Rest

Thoughts?

Carbon Monoxide Poisoning

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

ECG

Thoughts?

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

Treatment

• Beta-blockers

• Implantation of an automatic internal cardioverter defibrillator

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

Thoughts?

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

Measuring Pressures

Fasciotomy

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)

Questions ?