Core Cases of the Month

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AMS

HPI

52yM unknown PMH BIBEMS found minimally responsive in the field. The patient is undomiciled-appearing male found on a wet sidewalk in the rain. EMS administered 2 amps D50 IV, 2 mg Narcan IV, and 1L NS without improvement in mental status. He was seen in the ED two times in the previous month for IV heroin intoxication and was discharged after his mental status improved without intervention. On arrival he is lethargic and wet, mumbling incoherently and localizing to sternal rub and his breathing is spontaneous. EKG, CXR, POCUS of the heart are included. NCHCT was unremarkable.

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Fever and cough

HPI

59yF HIV on ART last CD4 716, undetectable VL, HTN, CKD p/w non-productive cough and fever x10d. 5d PTA she presented to the ED for dry cough, had CXR WNL, lab values WNL except Cr 3.2 and was discharged with f/u. Symptoms have continued since and she returns now because she has dyspnea at rest x 1d. Also c/o fatigue, chills and loose stools. She denies chest pain, headache, change in vision, rash, sick contacts or recent travel.

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Abdominal pain

HPI

27yF with h/o anxiety p/w abdominal pain x1d. Pain started yesterday evening, intermittent, a/w nausea and diaphoresis. Began as generalized pain but when supine, radiates to chest a/w mild SOB, otherwise localizes to the right abdomen with radiation to the pelvis.

Denies fever, chills, diarrhea, anorexia, blood in stool, recent travel, sick contacts. Sexually active with one male partner, denies STIs, uses OCPs, LMP 3 weeks ago. Denies vaginal bleeding or discharge.

The remainder of the patient’s labs other than those given are pending. On assisting the patient to the OBGYN room, she becomes markedly diaphoretic, lightheaded, tachycardic to 125, and hypotensive to SBP in the 60s. Repeat EKG shows sinus tach, portable CXR is unremarkable, and a RUSH bedside ultrasound exam notable for free fluid in the pelvis.

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Cyanosis

HPI

83yF PMH HTN, HLD p/w fatigue and cyanosis. Reports that all day she has been feeling fatigued and was noted to have a blue color so her son called 911. On arrival she is cyanotic and hypoxic to 80-85% on NRB. Denies fevers, chills, chest pain, shortness of breath, cough, abdominal pain, nausea, vomiting, diarrhea, dysuria, hematuria. Patient denies any toxic ingestions or recent medication changes.

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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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