Core Emergency Medicine

Ocular Ultrasound

A brief article on the use and utility of ocular ultrasound in the ED.

The Critically Ill Infant

An overview of how to approach the critically ill infant

Core Podcast See More →

Episode 163.0 – Croup

A look at one of the most common and potentially concerning upper respiratory infections in children.

Episode 162.0 – Stevens-Johnson Syndrome/Toxic Epidermal Necrolysis

A look at this deadly mucocutaneous reaction and how to best manage these patients in the ED

Core Procedures See More →

Push-Dose Pressors

A brief video reviewing how to prepare and administer push-dose epinephrine and push-dose phenylephrine.

Read more

Digital Nerve Block

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

Read more

Core Blog See More →

Sep252018

“What’s your airway plan, Michelle?”

To be quite frank, I don’t think I actually listened to what my junior said in response. Without much thought, I promptly replied (in my big boy voice), “Awesome, I’m going to help you set up.”

Since July, I’ve been told that I’m a “senior resident.” I’ve also been told (by Uncle Ben),
Read More

Jul272018

For most of this site’s readers, first year of med school is well in the past. You’ve moved on from the monotony of books and PowerPoints to the revelation of actual cases. You see the subtle connections between text and reality, develop pattern recognition, and learn how medicine actually works. If you entered medical school expecting to heal the world,
Read 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

Core Journal Club See More →

: Effect of Intranasal Ketamine Vs Fentanyl on Pain Reduction for Extremity Injuries in Children: The Prime Randomized Clinical Trial

Effect of Intranasal Ketamine Vs Fentanyl on Pain Reduction for Extremity Injuries in Children: The Prime Randomized Clinical Trial JAMA Pediatrics, 2019

Pain is typically under-treated in children. Intranasal administration of analgesics has the benefits of rapid, needleless administration and a more rapid onset compared to oral administration.
Read More

: PECARN: Febrile Neonate Decision Rule Derivation and Internal Validation

A Clinical Prediction Rule to Identify Febrile Infants 60 Days and Younger at Low Risk for Serious Bacterial Infections. JAMA Pediatr., 2019

The evaluation and management of febrile neonates remains controversial. Approximately, 10% of these patients will have a serious bacterial infection (SBI).
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?