Core Emergency Medicine

Penetrating Neck Injuries

This post reviews the presentation and management of penetrating neck injuries.

Neutropenic Fever

This post explores neutropenic fever with a focus on the evaluation, work up and management.

Core Podcast See More →

Core Procedures See More →

Digital Nerve Block

This is a brief video detailing how to do regional anesthesia for the fingers.

Read more

How to Apply a Pelvic Binder

This post discusses the application of both a commercial pelvic binder as well as a sheet for pelvic stabilization.

Read more

Core Blog See More →

May042018

Teaching on a clinical shift can sometimes be difficult: it’s busy, everyone’s running around and it’s hard to capture a trainees attention. Recently, on twitter, Amal Mattu (@amalmattu) has been posting pictures of his white board teaching: discrete pearls written down and shared with anyone who walks by. The pearls are often prompted by patients presenting during that shift but they don’t have to be.
Read More

Apr062018

“Code Blue in the waiting room!”

As my co-resident, attending, and I sprinted down the hall, I vividly remember thinking to myself that I probably shouldn’t be here right now. I was working upstairs in the surgical ICU. On a particularly slow overnight, I decided to head down to the ED to visit some friends.
Read More

Nov172017

The Paradox

“Go take a break.” “Let me quickly pick up these two patients.” “Go grab some food and come back.” “I’m fine, I’ll just…” “Sanjay, get the hell out and don’t come back for fifteen minutes.”

It was my sixth overnight in a row. After having struggled for over 15 minutes with trying to place an ultrasound guided IV in a sickle cell patient,
Read More

Core Journal Club See More →

: High-Flow Nasal Canula in Bronchiolitis

A Randomized Trial of High-Flow Oxygen Therapy in Infants with Bronchiolitis NEJM, 2018

This analysis was originally posted on REBEL EM here

Bronchiolitis is an acute inflammatory injury of the distal smaller airways,
Read More

Core Case of the Month More Cases →

Case: July 2018

CC

Aphasia and R-sided hemiparesis

HPI

29yo FTM on testosterone cypionate, no other sig pmh, presents with worsening headache, expressive aphasia, and R sided hemiparesis. Pt had been having moderate L sided headache x 1 week prior to this presentation. No hx of headaches or migraines. Pt was at the theater with his sister, noticed some R sided hand weakness, but then was noted to have expressive aphasia by sister and brought to ED.

In ED pt had aphasia, R sided hand numbness, clumsiness, initial head CT negative, given tPA, and admitted to stroke unit. Over next 24 hours, pt had CT angiogram, MRI brain, MRV brain without evidence of ischemia, mass, or bleed. By this time aphasia and motor symptoms had resolved, although still with some headache.

Physical Exam

HR 45 BP 164/87 RR 22 SpO2 100% T 101.2˚
General Appearance: Alert, in no acute distress
ENMT: Atraumatic, moist mucus membranes
Cardiovascular: RRR no RMG
Pulmonary: CTABL
GI: No tenderness or guarding, no masses or hepatosplenomegaly on palpation
Extremities: Palpable pulses.  No edema, clubbing, or cyanosis
Skin: No evident rash or skin breakdown, normal temperature on palpation
Psych: Appropriate affect
Neurologic: AAOX3,  PERRLA, EOMI, Visual fields are intact to finger counting. There is no dysarthria.  Hesitation with word finding, naming (able to say knuckle, not watch or pen), Difficulty following complex commands. Facial strength and sensation are symmetric and intact.  Strength is 5/5 throughout without pronator drift. Sensation to temperature is symmetric. Finger-nose-finger is intact. There is no neglect.

Labs

CBC 9.7> 11.5/38<376 BMP 144/4.5/107/26/18/0.94<113 LFT 7.7/0.2/4.5/36/49/0.4/29 INR 1.1 Troponin 0.0 VBG: 7.325/51/37/26 lactate 4.37 CT head without IV contrast: No acute intracranial findings CT angio head and neck: no evidence of aneursym MRI brain with and without IV contrast: No evidence of acute infarction, intracranial hemorrhage or mass, no abnormal intracranial enhancement. MRI head: great cerebral veins, vein of galen, major dural sinuses are patent

Questions

  1. What is your differential?

  2. What other labs or studies would help you confirm this diagnosis?