Annals of B-Pod: Shortness of Breath

Annals of B-Pod: Shortness of Breath

A Case of Postpartum Preeclampsia

The patient is a multiparous female in her 20s, post-operative day 8 from an uncomplicated repeat low transverse cesarean section at 39 weeks gestation after an uncomplicated pregnancy, who presents with SOB. She was discharged home on post-operative day 2 with a healthy female infant. She returns today with complaints of shortness of breath for 3 days and swelling in her bilateral lower extremities for 6 days. Over the same time course she endorses orthopnea, paroxysmal nocturnal dyspnea, weight gain, and chest pain. She describes the chest pain as substernal and intermittent. She also feels as if her chest is making a crackling noise when she exhales. She denies fevers, cough, nausea, vomiting, headache, or abdominal pain. She reports that her incision is healing well. She denies pain or drainage from the incision. She is breast-feeding her daughter, who is doing well at home. She has not yet seen her Obstetrician in follow-up but did receive all appropriate prenatal care.

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The Approach to the Undifferentiated Patient

The Approach to the Undifferentiated Patient

Welcome to Bread and Butter Emergency Medicine; a back to basics, chief-complaint-based podcast series where we get a chance to pick the brains of various faculty members and residents regarding their plan of attack for a particular presenting symptom.  Imagine your first shift in the emergency department (or think back on it if you’ve been doing this for a while); a man or woman with the label of “chest pain” or “headache” or “medication refill” is sat down in front of you, staring at you through the glass of your workstation. 

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Annals of B-Pod: Quick Hit Case

Annals of B-Pod: Quick Hit Case

Fibular Head Dislocation: An Uncommon Cause of Knee Pain

The patient is a male in his 20s who was playing soccer and felt a pop in his left knee followed by pain in his left knee. He has not been able to ambulate since the injury. He has an obvious deformity to the lateral aspect of his left knee. His x-ray was read as normal. Given his pain and mechanism, there was concern for fibular head dislocation so a CT of the knee was ordered. This showed an anterior, inferior subluxation of the fibular head. 

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Grand Rounds Recap 8/26

Grand Rounds Recap 8/26

M&M with Dr. LaFollette

Case 1: Troponin Use in ESRD

  • Evaluating cardiac ischemia in ESRD patients can be difficult due to baseline troponin elevations. However, all is not lost...
  • Troponins can be used as a reliable marker of ischemia, even despite its collection in proximity to dialysis, if you take some things into account:
  • Studies vary widely on troponin levels during dialysis, consensus being that troponin levels do not vary significantly vary with dialysis.
  • Although the baseline may be abnormally elevated, ESRD patients nonetheless have a new baseline. Changes above this baseline and especially up trending troponins should trigger alarms that the patient may be having active ischemia.  
  • Troponin elevation in ESRD patients, even if at their baseline, is an independent risk factor for short term mortality
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STEMI and STEMI Equivalents, i.e. Who Needs the Cath Lab Now!

STEMI and STEMI Equivalents, i.e. Who Needs the Cath Lab Now!

1. The ACC/AHA Criteria (1) (2) 

ST-elevation in 2 contiguous leads that is:

  • Men < 40: 2.5 mm ST-elevation in V2 or V3, 1 mm in any other lead

  • Men > 40: 2.0 mm ST-elevation in V2 or V3, 1 mm in any other lead

  • Women: >1.5 mm ST-elevation in V2 or V3, 1 mm in any other lead

STEMI's have a 90-minute door-to-balloon time mandate from the Center for Medicare Services (CMS). To be good stewards of our resources we need to be familiar the false positive STEMI patterns.  Ultimately, however, some degree of over triage and activation for false positives is expected and (potentially even) desirable.

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Ground Rounds Summary 8/19/15

Ground Rounds Summary 8/19/15

Simulation - Clonidine Overdose

  • 30 yo FM presents after having taking a handful of pills with the following VS: HR 45, BP 83/60, RR 8, 100% RA, T 98.  FS101. It gets better—there's a baby behind that baby bump.  
    • Ddx for AMS, hypotension and bradycardia? Tox, hemoperitoneum, spinal shock, myxedema coma, and a quite atypical sepsis. 
    • By EMS report this lady reportedly took a handful of unknown pills in an effort to harm herself. Remember to consider clonidine overdose in addition to beta blockers and calcium channel blockers. This lady found herself a bottle of clonidine and a near successful suicide attempt.
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Grand Rounds Summary 8/12/15

Grand Rounds Summary 8/12/15

VISITING LECTURER SERIES WITH DR. MATT DAWSON

1) On Technology, Emergency Medicine, and New Frontiers

Today’s tech explosion is leading to health innovations that may make some big differences leading to big changes. Here’s a sneak peak:

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Thromboelastography aka The TEG

Thromboelastography aka The TEG

What is TEG?

Thromboelastography (TEG) measures the dynamics of clot development, stabilization/strength, and dissolution. Assuming the body’s ability to achieve hemostasis is a function of these clot properties, TEG provides specific, real-time indicators of a patient’s in vitro hemostatic state. This is in contrast to routine screening coagulation tests such as aPTT and PT/INR which are run with blood plasma alone and therefore do not take into account the cellular components of clotting.

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Grand Rounds Summary 8/5

Grand Rounds Summary 8/5

Taming the SRU Case Follow-Up: GSW to the Head with Dr. Grosso

  • In one census: 66% of violent deaths are suicide, with 30k suicide deaths annually in the US
  • ~50% of suicide attempts include firearms
  • GSW to head mortality is 80%, and 71% die on scene
  • ~40% of those who survive to hospital have favorable outcomes
  • Favorable prognosis: GCS>8, normal pupillary reaction, absence of coagulopathy of trauma/hemodynamic instability
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Grand Rounds Summary - July 29th, 2015

Grand Rounds Summary - July 29th, 2015

Morbidity and Mortality Pearls with Dr. Curry

Nephrolithiasis

Incidence in the US is 0.5-1% (lifetime risk 10-15%). There is a 2:1 male predominance and the recurrence rate is fairly high (37% at 1 year, 50% at 10 years and 75% at 20 years).

Patients at risk for poorer outcomes with ureterolithiasis are those with risk factors for diminished renal function, history of difficulty with stones/urologic intervention and symptoms of infection.

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Moonlighter - Recap

Moonlighter - Recap

This is our final recap of our "Out on a Limb" Case Series!  If you missed the initial "Moonlighter" case and discussion you can check it out here.  There were a number of great responses to the questions which we'll recap below.

Q1 - What are your options in handling this situation?

You have a few options in handling this situation. As many of the respondents chimed in, the wound definitely needs to be cleaned out and closed and the patient requires antibiotics as soon as is reasonably and safely possible, especially since the injury is already 6 hours old. The first option is to complete a sedation and multilayer repair in the ED yourself. As many people point out, this is not an excellent proposition unless there are extreme extenuating circumstances.

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Trouble Abroad - Recap and Commentary

Trouble Abroad - Recap and Commentary

The responses provided so far have been phenomenal, both insightful and provocative.  I am truly impressed.  As mentioned by several of my colleagues, many of these cases are deeply personal, not only because they involve highly vulnerable populations, but also because they may put clinical providers in harm’s way.  When we begin to discuss ethics, especially global health ethics, there is often no single correct answer to a given scenario.   We often deal with hard science and hard facts but sometimes you just have to go with your gut and do what you think is right.  If you missed the first case and initial discussion, check it out here.

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Grand Rounds Summary - July 22

Grand Rounds Summary - July 22

Dr. Miller - Leadership Curriculum

"Give me six hours to chop down a tree and I will spend the first four sharpening the axe" - Abraham Lincoln

In order to lead the team, you need a reflection of what you need to improve as a leader:

  • In a survey of academic chairs, communication, decision making, collaboration and trustworthiness were the top rated characteristics
  • In a survey of UC EM residents and faculty confirmed that these apply to every level of training
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