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HPI: The patient is a six-day-old female, brought to the Emergency Room by her mother because of difficulty arousing the baby for feedings, decreased intake and generally seeming less responsive according to the mother. Mom did not take patient ' s temperature. She has noticed that there are a decreased number of wet diapers from usual of around eight per day to only four since the same time the day prior to being seen. The baby shows some increased somnolence and when she is awake she seems to be more irritable. Mother notes that during breast-feeding the patient ' s sucking seems somewhat diminished. The patient has had no episodes of emesis or diarrhea, other than her usual loose yellow stools from breast-feeding. Mother has witnessed no cyanosis, episodes of apnea, gross hematuria, or seizure-like activity. BIRTH HISTORY: The patient was a 3.210 kg female born at 38-weeks gestation to a G2, P2, now L2, GBS positive, Rh positive 25-year-old nonsmoking mother who was in good health throughout the pregnancy and received regular prenatal care including intrapartum antibiotics. Birth was via spontaneous vaginal delivery with labor lasting approximately 14 hours and delivery occurring without complications. The patient ' s Apgar scores were 9, one point taken off for color, and 10 at one and five minutes, respectively. The patient was discharged home after 48 hours with the mother. The discharge weight was 3.002 kg. SOCIAL: The patient lives with parents and a three-year-old sibling. Father smokes in the house. ! There is no previous history for the mother of any elicit or IV drug use. The baby is being breast-fed on demand approximately every two to three hours for the first approximately four days of life. Each breast-feeding sitting lasting about 20 minutes. Mother reports that the baby is now feeding every three to four hours and only staying at the breast for about ten minutes before falling off to sleep. The baby did receive a hepatitis B immunization prior to discharge from the hospital.

1 – How to approach this case?

In an infant less than one month old presenting with decreased responsiveness, the suspicion for sepsis should be high, but the differential is broad and includes trauma (e.g., shaken baby), congenital abnormalities, and parental misinterpretation.

Physical exam:

Pulse Oximetry, stat

General appearance HEENT/neck Heart Lung Abdomen Neuro Musculoskeletal Skin

2 – Results: General: Well-developed, well-nourished white infant sleeping in her mother's arms. Pulse oximetry 91% on room air. HEENT: Normocephalic, atraumatic. Anterior fontanel is open, flat and soft. Mucous membranes are slightly dry. Pupils are equal, round and reactive to light. Red reflex is present bilaterally. Nares show mild flaring and are patent. Tympanic membranes are within normal limits. Oropharynx is clear. Neck flexion and extension are within normal and do not elicit irritability. Cardiovascular: Regular rate and rhythm without murmurs, rubs or gallops, S-1 and S-2 auscultated. Lungs are clear bilaterally. There are mild subcostal and suprasternal retractions. Abdomen is soft, nontender, and nondistended with normoactive bowel sounds. No hepatosplenomegaly appreciated. Umbilicus is without erythema or discharge around the umbilical stump. Extremities: Pulses are 2/4 in the radial, femoral, dorsalis pedis areas. Capillary refill is between 2 and 3 seconds with no evidence of cyanosis, edema or clubbing of the extremities. GU shows normal female genitalia.

At this point in the evaluation, one has a six-day-old infant with a fever of 38.6 and some evidence of respiratory compromise with diminished peripheral O2 saturation and tachypnea with retractions.

Orders:

Supplemental oxygen to keep saturations >94%

Place IV

For infection

CBC with differential, stat

Basic metabolic panel or chemistry panel, stat

Blood cultures,

Urine cultures, and, given this patient ' s age, à csf

CSF cultures.

CSF for protein, glucose, cell count, and Gram stain.

Chest X ray should be obtained to evaluate for pneumonia.

CRP is also useful to evaluate acute infectious processes but is nonspecific.

 

3 – Results: Chest X ray – Diffuse reticular nodular pattern bilaterally with slight hyperinflation, and a very small right pleural effusion. CBC: White count 16, hemoglobin 13.7, hematocrit 38, platelets 221, the differential shows 68% neutrophils with 5 band neutrophils, 10% lymphocytes. Chemistry panel shows sodium of 135, potassium 3.9, chloride 99, CO2 20, Bun 7, creatinine 0.3, calcium 10.1, glucose 71, CRP elevated at 2.7. Blood cultures were obtained and pending. Urinalysis – Specific gravity of 1.028, 1-4 white blood cells, 0 red cells, negative nitrate, negative esterase. Urine cultures still pending. Lumbar puncture was performed. CSF cell count, glucose and protein were within normal limits. Gram stain no organisms, no neutrophils. Culture is still pending.

Order:

Admit to floor

Continuous cardiorespiratory monitoring.

Inputs/outputs

Vitals signs q4

Diet no oral if respiratory rate is greater than 60

CBC with diff, BMP q daily

treatment

IVF D5 ¼ NS at maintenance rate

Ampicillin 100 mg/kg/day divided q 8 hr

Cefotaxime 150 mg/kg/day divided q 8 hr

 

4 – Results: Blood culture grows out gram-positive cocci in chains. (The likelihood of Group B strep infection is very high.)

Order:

Continue monitoring.

Examine the patient for every 2 to 4 hours until you see some improvement, then every 8 to 12 hours

Change diet to po when respiratory rate is < 60 and no significant respiratory distress.

Wean oxygen for saturations >94%

 

5- Results: Patient ' s oxygenation improves and she ' s weaned to room air. Respiratory rate normalizes; work of breathing normalizes. Patient tolerates po and maintains hydration status. Blood culture—group B strep. Sensitive to amoxicillin.

Order:

Discharge home

D/C Ampi IV, Cefotaxime IV

Change antibiotic to amoxicillin 50-80 mg/kg/day divided q 8

Discussion: This patient presents with signs and symptoms suggestive of a respiratory process; however, given her age and other nonspecific findings, the possibility of urinary tract or CSF infection or generalized sepsis is still in the differential and therefore one would want to begin empiric antibiotics to cover for the most likely organisms to infect this infant. For a child of this age with respiratory symptoms, the most likely etiologies are E. coli and Group B strep infections. Other causes of respiratory compromise with infectious etiologies include Haemophilus influenza, streptococcus pneumoniae, Group B strep, Listeria, and anaerobes. For many infants, the only indication that their infection is respiratory in nature is tachypnea which may at first be missed. Oftentimes these infants do not have typical rales or sounds of consolidation on auscultation.

Depending on how old the infant is, hyaline membrane disease and transient tachypnea of the newborn are differential considerations for the infant in the first 24-48 hours of life who exhibits respiratory symptoms.

Blood cultures obtained on newborns with respiratory illnesses frequently will grow out the offending organism. This patient has a risk factor for Group B strep infection because her mother was Group B strep positive. Despite the fact that the mother received intrapartum antibiotics, it is still possible for this infant to have a Group B strep infection. Likewise, for maternal histories in which the Group B strep screening is negative, it is still possible that the infant has GBS infection since screening is not 100% sensitive.

Empiric antibiotic coverage should be done as soon as possible after culture fluids are obtained. One regimen is ampicillin 100 mg/kg/d divided every 12 hours for infants who are less than 1.2 kg or every eight hours for infants who are greater than 1.2 kg and cefotaxime (Claforan) 100 mg/kg/d divided every 12 hours or 150 mg/kg/d divided every eight hours for infants who are greater than 1.2 kg and greater than seven days old. Gentamicin can be added as well or used as an alternative treatment when there is no evidence for meningitis. Infants should be treated at least ten days and possibly 14-21 days if they have a gram-negative infection.

An infant of this age with respiratory symptoms should be admitted and monitored closely for worsening respiratory compromise with decreased oxygenation and increased work of breathing. In an infant who does not respond to empiric antibiotic therapy but still has respiratory symptoms, then CMV (cytomegalovirus) pneumonia should be considered. If there is a maternal history of herpes simplex virus infection, particularly a primary infection, then that etiology should also strongly be considered and acyclovir begun.

 

Primary diagnosis: Group B streptococcal pneumonia

 

 

48/ Location: Emergency Room

CC: 7 yo altered mental status, stumbling.

Vital signs: B.P: 108/75 mm Hg; HR 88/min; RR: 8/min; Temp. 36.5C.

HPI: The patient is a seven-year-old boy brought in by his parents after he came home from a playmate ' s house and his parents found him to be confused and stumbling; he then became less responsive with garbled speech and somnolence. He had been previously well with no recent infections, no sick contacts. He had gone to school that day and come home appearing to be normal at that time. He then went to a schoolmate ' s house and returned home several hours later with the above symptoms. SOCIAL HISTORY: He attends second grade at a suburban school. He lives with his parents and two other siblings. His development has been normal. His immunizations are up to date. ROS: no headache, fevers, vomiting, diarrhea, photophobia, joint complaints, rashes, urinary complaints, no seizure activity.

1 – How to approach this case?

This child has suffered an acute change in mental status. Initial management should focus on the ABCs. He needs a brief focused physical exam to guide the differential.

Order:

Pulse oximetry, stat

Supplemental oxygen

Continuous cardiorespiratory monitoring

IV lock

universal

Finger stick glucose

Urine toxicology screen

Narcan (naloxone), IV

Physical exam:

General appearance HEENT/neck Heart Lung Abdomen Musculoskeletal Neuro

2 – Results: O2 sat 94% on room air. General: well-developed, well-nourished seven-year-old boy; he appears diaphoretic and cool. Neuro: He mumbles a response that cannot be understood and will not open his eyes to command; he localizes to painful stimuli. HEENT/Neck: Pupils 3mm bilaterally and responsive. Neck supple, no adenopathy: mucous membranes tacky. He has the odor of alcohol on his breath. Heart: regular without murmurs. Lung: respirations are shallow and slow. Abdomen: normal. Musculoskeletal: There is no evidence of trauma. There is no change in level of responsiveness after Naloxone. Finger stick glucose is 48 mg/dl.

Order:

D50, 1 ampule, IV

IVF Normal saline bolus 500cc, then at maintenance

Accuchecks q 1 hour until stable

Test to monitor

Blood alcohol level (BAL)

Serum toxicology panel

Basic metabolic panel, stat

CBC with differential, stat

3 – Results: BAL is elevated. Urine toxicology screen positive for ethanol. Serum toxicology panel positive for ethanol only. BMP is normal. CBC with diff is normal. Accuchecks normalize.

Order:

Admit to observation unit/floor.

Continuous cardiorespiratory monitoring.

NPO until awake

IVF D5 ½ NS with 20 meq/L KCL at maintenance

BMP in AM

Repeat blood alcohol level in 12 hours.

4 – Result: Patient becomes more responsive after 4 hours and is fully awake and back to his baseline by the next morning. Repeat BAL is within normal limits.

Order:

Discharge home.

Patient education on drug use/toxicity.

Screen for abuse and domestic violence prior to discharge.

Discussion:

This is a school-aged child who presents with altered mental status and hypoglycemia. He had a depressed mental status with shallow and slow respiratory rate and hypoglycemia. This presentation along with helpful information obtained during the physical exam, such as the smell of alcohol, can direct the clinician to look for ethanol intoxication as the cause of this patient ' s syndrome. Typically children get hypoglycemia and it is not necessarily related to the dose or blood level of the ethanol. They have a depressed CNS secondary to ethanol as a CNS depressant.

EVALUATION involves ruling out trauma, infectious processes (particularly CSF infections), sepsis, or other drug intoxication, and then beginning supportive care with detection and maintenance of the airway. IV fluids are given for fluid balance, correction of any electrolyte imbalances and correction of hypoglycemia. Most children respond well to supportive therapy and their prognosis for a full recovery is excellent in the absence of prolonged hypoglycemia and respiratory arrest.

 

Primary Diagnosis Child Intoxication

 

49/ Location: Emergency room

C.C: 65 yo Shortness of breath and chest pain

Vitals: BP: 90/60 mmHg; PR: 112/min, regular; Temperature is 36.7C(98F); RR: 34/min..

HPI: A 65-year-old white female, with a past medical history of ovarian carcinoma treated with chemotherapy, presents to the emergency room with the sudden onset of severe shortness of breath associated with right-sided chest pain. The patient reports that while watching the baseball game she suddenly noticed severe shortness of breath. The pain is constant, 7-8/10 in severity, increases with deep breaths, and non-radiating. She is nauseated but denies any vomiting. She denies any fever, chills, cough, and hemoptysis. She denies orthopnea, PND, or exertional chest pain. There is no H/O leg swelling, or claudication symptoms. PMH is significant for ovarian cancer treated with TAH + BSO, followed by chemotherapy. She is disease free for the past 3 years. SH: She smoked 1 PPD for 30 years. Drinks alcohol occasionally. She is allergic to penicillin. FH: Father died from acute MI at the age of 60. Mother died from breast cancer at the age of 65. ROS: Her ROS is unremarkable.

1 – How would you approach this case?

Based on history the most probable diagnostic possibilities are – MI, pulmonary embolism, aortic dissection, tension pneumothorax, acute heart failure, and acute pericarditis. All of these are associated with very high mortality. Always stabilize the patient first. Once the patient is stable you have to do really focus examination and the most important investigations.

Order:

Pulse oximetry, stat

Oxygen inhalation

IV access, stat, continuous

Cardiac monitoring continuous,

Elevate the patient head

Aspirin, sublingual, one dose

Sublingual nitroglycerine is not indicated in this patient, as his BP is borderline low.

2 – Results: Pulse oximetry showed oxygen saturations of 83% on room air and 94% on six liters of oxygen.

Order focused physical exam:

General Lungs Heart Abdomen Extremities

3 – Results: Pulse oximetry showed oxygen saturations of 85% on room air and 87% on four liters. Lungs are clear to auscultation (excludes tension pneumothorax). Heart exam is remarkable for loud pulmonic component of S 2 . Rest of the exam is WNL. Patient is still having shortness of breath.

Review orders:

12 lead EKG, stat

CK-MB, stat Troponin I, stat

ABG, stat

Portable chest X-ray, PA view, stat

prep

PTT, stat, one time PT/INR, stat, one time

CBC with diff, stat

Basic metabolic panel, stat

Normal saline, IV, continuous

4 – Results: EKG showed sinus tachycardia and new onset right bundle branch black. Chest x-ray is within normal limits. ABG, showed PO2 of 60, PCO2 of 34, and PH of 7.50. CK – MB, and Troponin I or T are within normal limits. PTT is 30 PT is 12.5 and the INR is 0.9 CBC with differential: Mild leukocytosis but no bandemia, Hb is 14, Platelets count: 250,000 BMP is completely normal.

Review orders:

FOBT (Fecal Occult Blood Testing), stat (Result-Negative)

Heparin, IV, continuous

V/Q scan, stat

D-dimer, stat

5 – Results: V/Q scan: Intermediate to high probability for PE. D-dimer is elevated. Results: Patient is slightly better on oxygen

Review orders:

Admit the patient to ICU

Continue cardiac monitoring (telemetry)

Pulse oximetry, every 2 hours

Maintain oxygen saturations >90-92% with high flow oxygen (100% Non-rebreather mask)

NPO

Vitals: ICU routine

Complete bed rest Urine output

test

CBC with diff in 24-hours

PTT for every 6 hours (adjust the heparin drip to a goal aPTT of 55-70)

*Perform brief history and physical exam for every 2 to 4 hours until you see clinical improvement.

Next day, review order:

Consider weaning oxygen

Stop IV fluids if the BP is stable

Start regular diet

Change vitals to Q 8 hours

D/C continuous cardiac monitoring

Treat and follow

Start Coumadin (warfarin), once daily (for a female of reproductive age always rule out pregnancy before you give warfarin i.e. order a pregnancy test).

Daily PTT/PT/INR

Check the platelet count and Hb (CBC with diff), as heparin is associated with thrombocytopenia and bleeding.

Discharge the patient:

Once the INR is above 2, plan for discharge (goal is 2-3)

D/C heparin on 4th or 5th day

Anticoagulation teaching

Patient counseling

·        Follow-up in 2 days for PT/INR checked.

·        Continue warfarin for 12-months and monitor INR twice weekly.

·        During follow up look for any sites of bleeding. (In general, menstruation is not a contraindication of warfarin. If patient wants to become pregnant D/C warfarin and start heparin.)

·        No smoking

 

Discussion:

Pulmonary embolism should be suspected in any patient who presents with sudden onset of SOB, and chest pain. Findings suggestive of PE:

1. Positive D-dimer assay. D-dimer is a very sensitive assay for ruling out PE. Normal D-dimer essentially excludes PE. But the positive D-dimer may be a false positive.

2. ABG: Increased A – a gradient, low PO2 , low PCO 2 , and respiratory alkalosis. A-a gradient is more sensitive than PO 2 alone.

3. EKG: Right ventricular hypertrophy & new onset RBBB.

4. Chest –X-ray may be normal. Some times a wedge shaped consolidation may be seen in the middle and lower lobes ( Hampton ' s hump). This patient clearly has risk factors for a hypercoagulable state (ovarian carcinoma). Based on history and physical examination and the results of the V/Q scan this is a case of pulmonary embolism.

V/Q scan is the most helpful initial evaluation to rule out pulmonary embolus after chest x-ray, ABG and EKG are obtained. But V/Q Scan is not necessarily done prior to the use of heparin, and so are other diagnostic tests. If you suspect a pulmonary embolism clinically, and chest X ray, ABG and EKG results rule out other differential diagnoses then you should begin treatment with heparin without waiting for a V/Q scan to confirm your diagnosis. If the classic pattern of mismatched perfusion defect is observed, you should proceed with treatment. If the scan is normal, you can actually rule out significant pulmonary thromboembolism.

But, in a substantial number of patients, the ventilation/perfusion scanning results are inconclusive. The next best step in this case is venous ultrasonography to reveal DVT or CT angiogram of the chest. Diagnosing DVT makes the probability of pulmonary thromboembolism very high, and you should proceed with treatment.

Although considered the ' gold standard, ' pulmonary angiography, an invasive procedure is employed if venous ultrasonography or CT angiogram is negative. A negative result by pulmonary angiogram essentially excludes pulmonary thromboembolism as the diagnosis. ChestCT angiogram is also frequently used in indeterminate cases of pulmonary embolism, but the problem with CT angiogram is that it can diagnose only large emboli. Small emboli can be easily missed.

The treatment of choice is low molecular weight heparin. Low molecular weight heparin is associated with a lower risk of thrombocytopenia and hemorrhage and it appears to be as effective as unfractionated heparin in the treatment of venous thromboembolism. However, FDA has not approved LMWH for he treatment of PE. So, we usually continue with unfractionated heparin. All patients should be followed with regular platelet counts. Thrombolytic therapy with streptokinase or t-PA may accelerate resolution of emboli compared with standard heparin therapy. However, at one week and one month after diagnosis, there is no difference in outcome compared with heparin and warfarin. The major disadvantage of the thrombolytic therapy compared with heparin is its greater cost and a significant increase in major hemorrhagic complications like stroke.

Thrombolytic therapy for patients at high risk despite heparin therapy or for those in whom thromboembolism may be life saving. Thrombolytic therapy is absolutely contraindicated in any patient with active bleeding or stroke within the past two months, or patients who have had major surgical procedures or trauma within six weeks.

Placing an IVC filter is routinely used for patients who have contraindications for anticoagulation or in patients with recurrent pulmonary thromboembolism from the pelvis or lower extremities despite adequate medical therapy. However, placement of IVC filter does not guarantee prevention of emboli as clots may form above the filter. IVC filters are also associated with a two-fold increased recurrence of venous thrombosis in the first two years following the placement.

How long do you treat with warfarin?

1. Reversible risk factors such as use oral contraceptive pills, immobilization, or surgery should be treated with 3 to 6 months of warfarin therapy.

2. If the first episode of thromboembolism occurs in the setting of underlying malignancy, anticardiolipin antibody, and antithrombin deficiency patient should be treated with at least 12 months of warfarin therapy.

3. Patients with first episode of idiopathic thromboembolism should be treated for at least 6 months with warfarin. 3 months of therapy is inadequate in this patient group.

4. Patients with recurrent thromboembolism or a continuing risk factor should be treated indefinitely.

Người đăng: Phong hai vào lúc 18:33

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