No case details, just a few take home points.
If a patient has signs of cardiac strain from PE or has other high risk factors (PESI score), consider admitting patient to the ICU or Step-down rather than the floor.
All the above indicators should prompt consideration of admission to a higher level of care (Step down or ICU)
Putman HEENT Study Guide
We commonly associate HSV keratitis with a dendritic pattern on the cornea
If HSV involves the deeper layers of the cornea, you can also see a disciform HSV keratitis.
Walchuk/Robinson Oral Boards
Case 1. 61yo female brought in by EMS with “stroke” symptoms. Dexi=155. Patient is altered and has slurred speech. Last time patient was normal is unclear. On further history, patient states she has been dizzy for a week. Patient is on phenytoin for seizures. Her phenytoin level is markedly elevated to 63. Treatment of phenytoin toxicity is supportive. Very severe toxicity may benefit from dialysis.
Phenytoin has a long and erratic absorption phase after oral overdose, so the decision to discharge or medically clear a patient for psychiatric evaluation cannot be based on one serum level. After acute ingestions, serum level should be measured every few hours. Patients with serious complications after an oral ingestion (seizures, coma, altered mental status, or significant ataxia) should be admitted for further evaluation and treatment. Those with mild symptoms should be observed in the ED and discharged once their levels of phenytoin are declining and they are clinically well. Mental health or psychiatric evaluation should be obtained, as indicated, in cases of intentional overdose. (Tintinalli 8th edition)
Case 2. 61 yo male brought in by EMS after a motorcycle crash. It was low speed accident and patient struck his head on the other vehicle. Patient has bilateral hand weakness. CT head and CT cervical spine show no acute abnormalities. MRI of the cervical spine shows:
The patient required C-spine stabilization and Neurosurgery consultation. Steroids are no longer recommended for central cord syndrome.
Case 3. 18yo male with right wrist injury from playing football.
Treatment is closed reduction, splinting the wrist, and orthopedic follow up. In some cases surgery is required.
Davis/Shroff/Friend ED BounceBacks
No case details, just a few take home points.
3 cases were presented. Each patient returned to the ED with a change in clinical picture. If the patient has an unclear diagnosis (belly pain, vague neurologic symptoms, back pain) and you are discharging them home, be sure to give clear discharge instructions describing signs/symptoms that should prompt return to the ED.
Dr. Williamson comment: These cases demonstrate the importance of communication with the patient. You want the patient to feel totally comfortable about returning to the ED for further evaluation.
Dr. Ryan comment: I tell the patient, “if your pain is getting worse, or you get a fever, or some new problem develops, that should not be happening. If it does happen, that is a sign that something is wrong and you need to come back to the ER.” Also give patients a time frame on when they should be feeling better. If they are not feeling better by then, they need to return for further evaluation.
Ebeledike/Johns Safety Lecture Choosing In-Patient Level of Care
Choosing the appropriate level of inpatient care for a specific patient (Floor, Telemetry, Step Down, or ICU) can be challenging.
Examples of diagnoses suitable for telemetry: Stable NSTEMI, syncope presumed to be cardiac, arrhythmia/heart blocks, pacemaker or ICD problem.
Examples of Patients suitable for Step-Down: Patient on a single pressor, chronically ventilated patients, patients requiring a high level of nursing care, and patients with significant risk of deterioration.
In general, if you are concerned that a patient may deteriorate or decompensate, strongly consider placing them in Step-Down rather than the floor.
If the patient is critically ill put them in the ICU.
Dennis Ryan comment: Consult with the ICU attending to collaborate on whether a patient belongs in Step-Down or the ICU to better determine level of care.
Editor’s comment: Suggested simplified algorithm. Stable patients go to the floor/med-tele/telemetry. If you are worried the patient may deteriorate consider Step-down. Critically ill patients go to ICU.
Lorenz/Shroff Visual Diagnosis
The Chiefs presented multiple clinical pictures for pattern recognition. This outstanding presentation moved too fast for me to capture.