South Dakota ACEP Winter Conference 2018 Panel discussion

South Dakota ACEP Winter Conference 2018 Panel discussion

76 yo MVC • 76 -year-old female presents after a motor vehicle collision. She was the restrained driver of the vehicle traveling approximately 70 mi. /h that was rear-ended and hit ice losing control and rolling multiple times. She hit her head but denies loss of consciousness. She complains of chest pain, back pain, and a mild headache. She takes an unknown medication for blood pressure. • VS T 37. 2, P 80, RR 16, BP 190/96, SAT 98% on RA • PE – 1 cm scalp laceration. Heart: regular rate and rhythm. Tender to palpation over the sternum. Breath sounds clear and equal. No bony tenderness or deformity. No abdominal tenderness.

Narcotics anyone? • Approach to narcotics – Objective criteria for you to prescribe narcotics? • • • Fracture? Kidney stone? Abdominal pain? Contusion? MVC? – Does socioeconomic status influence your decisionmaking? – Systems in place at your institution? • Narcotic usage tied to patient satisfaction?

53 yo Hematuria • 53 -year-old patient presents with hematuria. She has a LVAD in place for biventricular heart failure. She denies fever, nausea, vomiting, or other urinary symptoms. No history of kidney stone. She recently returned from Denver after undergoing workup for a heart transplant. • VS: T 36. 8 HR 60 RR 18 • PE: – heart: LVAD hum with appropriate oscillations – Otherwise benign exam

6 yo Sore throat • You are approached by the triage nurse during the morning shift. She states that she has a throat culture positive for Strep from a patient seen by your partner two days ago.

Antibiotics anyone? • Antibiotic usage – Antibiotics for otitis media • < 2 yo • > 2 yo – Antibiotics for strep pharyngitis – Antibiotics for pneumonia – Antibiotics for abscess – Antibiotics for cellulitis • Antibiotic usage tied to patient satisfaction?

3 yo Abdominal pain • 3 -year-old male presents with abdominal pain. His mother states that for the past two days he has had intermittent abdominal pain with episodes lasting up to an hour. She’s given him Tylenol and is unsure if that is help the pain or whether the pain is resolving spontaneously. No fever or vomiting. Mother states his last bowel movement was this morning. When you ask the patient where he hurts, he points at his umbilicus. • T 37. 2, P 78, RR 18, BP 150/92, SAT 98% on RA • PE: Abdominal exam soft with no peritoneal signs.

30 yo Fall • 30 -year-old male presents to the emergency department with right wrist pain. He states that he felt proximally 10 feet off of a ladder landing on his right hand. He denies head injury or loss of consciousness. He complains of mild neck stiffness and was placed in a cervical collar in triage. • VS: T 37. 2, P 78, RR 18, BP 150/92, SAT 98% on RA • PE: – Well-developed male with a 5 o’clock shadow – Right wrist swelling with a mild deformity. No lacerations. Neurovascular intact. – No midline cervical spine process tenderness or step offs.

Wrist x-rays

Bet you weren’t expecting that…

25 yo with Cold feet • 25 -year-old male found outside in subzero degree weather wandering the streets without shoes. On arrival he is agitated and states that they are all out to get him. His parents arrived and state that he is not taking his medications and has been increasingly paranoid at home. • VS: T 33. 2, P 120, RR 18, BP 140/82, SAT 98% • PE: Agitated, responding to internal stimuli. Third degree frostbite to both feet.

26 yo Suicidal ideation • 26 -year-old female presents with suicidal ideation. She has had thoughts of suicide for the past two days and yesterday cut both of her forearms. Her mother discovered this today and brought her to the emergency program for evaluation. The patient denies suicidal ideation this time. No previous suicide attempts. • VS: T 36. 6, P 65, RR 16, BP 110/62, SAT 100% • PE – Superficial lacerations to the forearms bilaterally. Neuromuscular intact. Tearful.

57 yo Overdose • 57 -year-old female presents after a polysubstance overdose. She took an unknown quantity of Xanax, Seroquel, and ibuprofen. She reports taking this approximately 3 hours prior to arrival. She is somnolent but arousable. Her husband who is a good historian states that she had access to no more than 30 Xanax 0. 5 mg tablets and no more than 60 Seroquel 100 mg tablets. He reports that she took the overdose 2 -3 hours prior to arrival. • VS T 37. 6, P 92, RR 18, BP 132/78, SAT 92% on RA • PE: protecting her airway. Somnolent and needs to be aroused after each question.

56 yo CP • HPI: 56 -year-old male with no past medical history presents with chest pain. He states the pain has been constant for the past 12 hours and is aggravated by exertion. No alleviating factors. • VS: T 37. 4, P 87, RR 16, BP 160/96, SAT 99% on RA • PE: Chest pain is reproducible. Exam is otherwise normal.

23 yo Abdominal pain • 23 -year-old male presents with abdominal pain. He states that for the past 12 hours he has had right lower quadrant abdominal pain aggravated by the bumps in the car ride. He is taken Tylenol and ibuprofen without improvement. He has had a subjective fever and has been nauseated. No history of previous abdominal surgeries. • VS T 38, P 94, RR 12, BP 144/88, SAT 96% • PE: – Tender to palpation in the RLQ with localized guarding. No rebound tenderness. him

81 yo Hip pain • 81 -year-old female presents with hip pain. She slipped and fell landing on her right hip. She denies head injury or syncope. She has been unable to ambulate and complains of severe right hip pain. She denies other injury or pain. • VS T 37, P 85, RR 16, BP 92/60, SAT 96% • PE: Right lower extremity is foreshortened and externally rotated

25 yo Snake bite 25 yo male out golfing presents with a snake bite. He was intoxicated and saw a snake and reached down to grab it. The snake bit him on the left hand. VS: T 37, P, 102, RR 16, BP 140/88 PE: No significant swelling or erythema surround two puncture marks on the right forearm

22 yo Seizure 22 yo female presents with seizures. She has a seizure disorder and takes Keppra and Vimpat. She has a seizure everyday. Today she had a seizure lasting less than 2 minutes. She has had a fever and headache that started today prior to her seizure and her headache persists. VS: T 39, P 90, RR 16, BP 120/70, SAT 97% PE: BMI 45. No meningismus, normal neuro exam.