Core Cases of the Month

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Altered mental status

HPI

58yF PMH thoracoabdominal aortic aneurysm s/p stent and HTN p/w AMS. Per husband, the patient was in her USOH, walked home from work and suddenly complained of chest pain and bilateral arm tingling. She sat down and suddenly seemed to fall back into the chair. Per EMS, the patient was unresponsive on arrival and never was able to give any history. They report that the patient had a HR in the 60s, and RR of 15, but could not obtain a BP. FS 120.

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Abnormal movements x1 week

HPI

7yF w/ no PMH brought in by her parents with progressively worsening involuntary movements x 1 week, slurred speech x 3 days. The movements improve but persist during sleep. No trouble eating/swallowing or handling her secretions. She has remained alert, coherent, interactive over this time course.

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Cardiac arrest s/p ingestion

HPI

58yF w/ unknown PMHx arrives via EMS in cardiac arrest. Per EMS, patient called 911 stating that she wanted to kill herself. When they arrived they found her pulseless on the floor with a bag of medications beside her, all containing at least some pills. No drugs, liquids, alcohol or other items found strewn beside her. Medications found in her bag her bag, some in multiples, listed alphabetical order: Baclofen, Gabapentin, Hydromorphone, Hydroxyzine, Ibuprofen, Methocarbamol, Simvastatin

EMS initiated ACLS, placing an ETT and a L tibial IO, w/ 2 rounds of epinephrine and 2mg Narcan administered, with a total of 15-25 mins of prearrival CPR.

On arrival to ED in persistent PEA arrest, ACLS was continued with adjunct medications given as deemed appropriate. Approximately 5-10 minutes after arrival, after several rounds of ACLS, ROSC was achieved. Hypothermia protocol started, epinephrine drip started for persistent hypotension, and an ECG was obtained.

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Extremity weakness

HPI

67yM PMH HTN, HLD, gastritis, MI s/p stent on prasugrel, chronic low back pain presents with RUE weakness s/p fall. Patient exacerbated his back pain a week ago and has been mostly resting in bed since. This evening, he was taking a hot bath and when he stood up and started to feel lightheaded and then lost consciousness. He fell backwards striking the left side of his head. He estimates he was unconscious for 3 minutes. He denies tongue biting, urinary incontinence, or seizure history. When he woke up, he felt slightly confused, and noted that he was unable to use his right upper extremity normally. He now has difficulty lifting his right arm with some slight tingling in the shoulder radiating down the lateral aspect. He denies pain.

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Dizziness

HPI

31 y/o M presents with acute onset dizziness w/ nausea and vomiting. Sx started suddenly yesterday PM w/ dizziness described as “sensation of room spinning around me” that lasted for approximately 15 min, a/w nausea and mild bifrontal headache (similar to headaches he has had in the past) and flashes of light.

He had another episode early this AM w/ room spinning sensation that has continued since w/ severe nausea and multiple episodes of NBNB emesis. He is dizzy now. His HA has gradually increased in intensity to 7/10. He also now complains of R neck pain. The dizziness is worsened by head movements and standing.

Patient denies tinnitus/hearing change, f/c or recent illness. Denies weakness or numbness. Denies visual changes at this time. No family or personal history of migraines, ROS otherwise negative.

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Bizarre, disorganized behavior

HPI

23 yo M with unknown pmh sent from Rikers c/f psychosis and med/psych evaluation in light of “bizarre, disorganized behavior.”  Per records sent from Rikers, patient has history of cannabis and alcohol abuse and tested positive for benzos at Rikers.  No known prior psychiatric history.  Initially sent to CPEP but was brought to ED after witnessed seizure-like activity, though patient responded to sternal rub and did not appear to have have postictal state.

Patient was reportedly yelling and talking to himself in his cell, stating people are “plotting to kill me” and appeared scared and paranoid.  He answers some questions but continues to yell “turn the music off” and intermittently fights against restraints, yells, kicks, and screams at cops begging them to remove handcuffs. Reports benzodiazepine use one month ago. Denies any additional past medical history.

On ROS states his throat hurts a little, unable to state when this started.  Denies any HA, n/v, pain, sob, cp, abd pain, f/c, neck stiffness.

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Abnormal lab values

HPI

68 yo F sent to ED by PMD for abnormal lab values. Patient states she had a prolonged episode of epistaxis lasting about one hour 7 days ago and subsequently developed exertional dyspnea and increased lower extremity swelling. Patient endorses decreased exercise tolerance and is unable to walk more than one block now. Patient states she was unable to sleep last night as she was unable to laydown due to difficulty breathing. Patient denies chest pain, melena, bright-red-blood-per-rectum. Patient states she had taken furosemide in the past, but was stopped due to kidney injury from concurrently taking gout medication.  Patient saw her PMD yesterday, had labs drawn and was prescribed furosemide again, but states she has not yet started taking it.
Patient also states she noted her blood pressure to be intermittently very low with sBP in 70s 3 days ago. Patient also feels her blood pressure is less than it normally is today. States her sBP is usually 160-170s.

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"a piece of turkey stuck in my throat"

HPI

39 yo F with no PMH presented with “a piece of turkey got stuck in my throat” during dinner. Immediately afterwards, reports non-bloody, non-bilious vomiting with relief of foreign body sensation. Now unable to swallow saliva. Denied any fever, throat pain, chest pain, shortness of breath, trouble breathing, voice changes, cough, nausea, abdominal pain, back pain. Currently has no pain.

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