26 April 2009

cases for the weekend

21 y/o morbidly obese female presents to ED with bruising to upper extremities and lower back. Patient looks well though is anxious, PE unremarkable except for eccymosis on upper arms, right wrist and lower back.
Pmhx: suppurativa adenitis. Seen in ED 3 months ago for r/o Meningitis and ED course was pain meds and an LP which was unsuccessful due to body habitus. Labs drawn in previous visit platelet count 75, today her platelet count is 7. What's your ddx? What do you want to do?

67 y/o black female present to ED Friday night (while everyone is in the trauma room working on a GSW to the abd of a 17 y/o who we later determined was DOA) and is c/o itching all over and the feeling that her throat is closing. Seasoned RN gives 50 benedryl and 40 of solumedrol before being able to grab a clinician.
Patient states she had fish for dinner at 7pm and felt fine when around 11pm she gradually started to itch everywhere, took some benedryl with no relief and came to the ED. She states she had hives everywhere, though there is currently no evidence of rash/hives and she states she feels much better. Patient denies any travel, new pets, soaps, foods, etc.
Patient received pepcid, IVF and is observed for anaphylaxis for 5 hours. No changes, patient is d/c home with epipen and follow-up with Immunology on Mon. Patient returns to ED Saturday night, states she itches again and it's worse. Patient states she took some benedryl at home without relief also took the epipen and came in (though she reports never having the sensation of SOB, throat, lips or tongue swelling and obviously wasn't listening when I explained WHEN to use the epipen). Patient has diffuse uritcarial hives all over body surfaces best visualized on her back where she can't reach to scratch. She also has blanchable purpuric rash on her palms and feet. There appears to be no mucosal involvement and she is breathing well without wheezing. Tonight she reports she was recently visiting relatives in North Carolina. Patient is admitted to medicine. WTF? What is your ddx? What do you do?

36 y/o female presents to ED with worst HA of her life. She complains of subjective fever, some associated neck pain, and mild nausea. Initial POC work-up indicates she is pregnant and she elects to keep the pregnancy though not planned. How do you work this patient up? How do address her pain?

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