Case 1- Page 1
Initial Presentation:
EMS brings in a 27 year old male. He was running in a marathon in 30 degree Celsius weather. Unwitnessed collapse. Found on ground by other runners twitching or having a seizure- some type of non-specific abnormal movement. Friends report he told them that he “took a little something special” to help his performance. Has been known to occasionally use street drugs in the past. Seemed to be getting tired early in the race and stopped frequently at water stations.
Remote hx of a seizure disorder. Off anticonvulsants for 10 years.
Takes an SSRI for anxiety
Vitals: GCS-3, Temp- 40.5, HR- 120, BP- 140/90, O2- 98%RA, Normal chemstrip.
Questions:
1)What are your top 5 to 10 considerations in the differential diagnosis? Can you organize them into clinically useful categories based on history, physical or investigations?
2)What are the most important things you want to know from the physical exam and why?
3)What immediate interventions would you consider?
4)What are the 5 most important investigations you want and why?
5)List the most likely toxicological causes for this presentation?
Case 1- Page 2
Supplemental Information:
Physical Exam: PEARL, no abnormal ocular movements. No rigidity, or clonus. Normal tone and reflexes. Occasional, rhythmic brief facial grimacing. No focal neurological signs.
Normal Cardiovascular and respiratory exam. No abnormal breathing patterns.
No evidence of trauma.
Normal abdomen, rectal tone
Mild diffuse maculo-papularblanchable rash
Diaphoretic on arrival
Investigations: Mild white blood cell count elevation. Normal electrolytes and renal function. Normal ABG.
Course: Intubated easily without induction meds. Ventilating well on minimal settings. IV fluids and active cooling rapidly bring his heart rate down to 85bpm, and his rectal temperature to 37.8. GCS remains 3. It is now 1 hour since EMS picked him up.
Questions:
1)What are the top 3-5 items on your differential with this new information? How important is the temperature in your thought process?
2)Would you do an LP, and why/why not? CT first?
3)What features do you look for in a diagnosis of exposure or exertional hyperthermia?
4)How does acute water intoxication present? How do you treat it?
5)How do you differentiate a prolonged post-ictal phase from non-convulsive status epilepticus?
Case 2- Page 1
Initial Presentation:
EMS brings in a 73yo woman from an assisted living facility. She had been noted to be growing more tired and less energetic over the last few days, and today she was found lying in her bed, difficult to rouse. Too confused to provide much history.
PMhx: Mild CHF, CAD, A fib, Osteoarthritis
Meds: daily ASA, warfarin, metoprolol, ramipril, furosemide, Tylenol arthritis
Vitals: GCS- 9-10, Temp- 36.4 forehead, HR- 58, BP-102/58, RR-30, O2- 91%RA, 99% 4LNP
EMS glucose 5.2
Nursing did a stat catheter: urine dip shows +2 leuks, +2 blood, nitrite positive
Questions:
1)What are your top differential diagnostic considerations? Categorize them based on rapidly available clinical decision making tools.
2)What is your initial emergent treatment going to include?
3)What will you order in the initial work-up?
4)Which of her medications could cause this presentation and how?
5)How would a rectal temperature of 38.1 change your approach?
Case 2- Page 2
Supplemental Information
Physical Exam: No evidence of head trauma, no focal neurological findings. No meningismus, but cries with movement of her head. Normal ENT.
Mild bilateral respiratory crackles and tachypnea without increased WOB- nothing focal.
Normal heart sounds, cool mottled extremities
Mild abdominal tenderness
No rashes
Investigations: Mild pulmonary edema on CHXR, no focal findings
ABG: 7.30/22/109/12 lactate- 4.5
Hg-109, WBC-15, Na-142, Cl-100, Creat-105.
Urinalysis- nitrites, leuks, bacteria and red cells.
EKG- sinus brady, old posterior MI.
Head CT- nil acute
Course: Family reports they saw her yesterday. She complained of a recent flare in her arthritis which she wasn’t able to settle with increased pain meds. She was tired, had a headache, and had to have things repeated to her more often than usual.
Her BP improved slightly with fluid administration, but her GCS has now declined to 8-9.
Questions:
1)With this new information, what is your most likely differential diagnosis?
2)What further treatments and investigations will you order?
3)List any indications this case highlights to perform CT before LP
4)How reliable are physical exam findings and laboratory tests in diagnosing/excluding meningitis? What do you put the most value in?
5)What would you need to find (or not find) to attribute her presentation to Urosepsis?
6)Describe the presentations of acute and chronic salicylate toxicity.
Case 3- Page 1
Initial Presentation:
You’re in a rural emergency department when a 32yo woman is escorted in by 2 family members. She is visibly confused and unsteady on her feet. She is coming in and out of consciousness as she is being helped onto the stretcher. Her family quickly tells you that she has been sick for a “long time” with fatigue, headaches, poor appetite, abdominal discomfort, frequent vomiting and some diarrhea.
Her family found her today wandering outside in -15C weather with no jacket and bare feet. She was confused when they found her, and unable to remember why she was outside. She was reportedly paranoid that someone was trying to abduct her, but was having trouble finding the right words to communicate. You quickly estimate her GCS now to be about 9.
Vitals: T-34.5, HR-115, BP- 75/40, O2- 95%RA, glucose- 2.5
Questions:
1)What are your initial top diagnostic considerations? Categorize them based on rapidly detectable clinical or historical signs.
2)What urgent interventions will you do?
3)What initial physical exam findings and investigations are most important?
4)What is the presentation of hypothermia? At what temperature is there an alteration in consciousness?
5)What aspects of this case fit a viral encephalitis and what do not?
Case 3- Page 2
Supplemental information:
She saw her family doctor earlier in the week, and her synthroid prescription was increased for the third time this year. She is on no other medications, and has no recent hospitalizations.
Exam: No focal neurodefs. No meningismus. Slightly hypotonic throughout. Sluggish pupils.
Mild tachypnea, no respiratory findings
Rapid heart rate, normal heart sounds.
Benign abdomen
No rashes, slightly darkened scars, and hyper-pigmentation on gums. Coarse hair, thick, dry skin.
Investigations: Normal CHXR. Normal ECG.
ABG: mild metabolic acidosis, lactate 3.
Hg-120, WBC-5, Na- 130, K- 5.9, Cl-99
No CT available
Course: SBP up to 80 post 2L NS and dextrose bolus. No improvement in mental status
Questions:
1)What is your top differential now?
2)Describe the features and treatment of myxedema coma
3)Describe the features of and treatment of adrenal crisis
Case 4- Page 1
Initial Presentation:
EMS calls in to report that they are returning from a ski hill with a patient who is in withdrawal. He’s a 52yo male, hemodynamically stable with a mild tachycardia, normal glucose, slightly confused and disoriented. He had been witnessed staggering around in the ski lodge looking unsteady, then collapsed into a seizure. Prior to awakening, EMS noticed his eyes persistently deviating to the left, and some weakness in his left arm and leg, which is now resolving. The patient reported he is a heavy drinker, but stopped a few days ago to “get sober” for a ski trip with his family. No medications.
Questions:
1)What is your initial broad differential diagnosis? If he had signs of shock what would you add?
2)What will you focus your initial physical exam, history and investigations on?
3)What does and doesn’t fit with a diagnosis of EtOH withdrawal?
4)In what different ways can Thiamine deficiency present? In what patients do you suspect it?
Case 4 – Page 2
Supplemental Information
When the patient arrives, he is found to have a HR of 95, and all other normal vitals including glucose. His GCS is 13-14. He answers questions appropriately, but appears slowed and deliberate in his responses. He reports feeling non-specifically unwell for about a week, including progressive intermittent feeling of being unsteady on his feet. No seizure history. Mild headache. Has been a heavy drinker, but still eats well and has a full time job. No history of withdrawal symptoms.
Further EMS questioning confirms the presence of seizure features, and that it possibly began with left sided focal signs.
He has occasional left beating nystagmus, equal and reactive pupils, otherwise normal cranial nerves. 4/5 strength in left arm and leg, normal on right. Normal cerebellar testing.
CV/resp/abdominal/MSK exams normal
Normal EKG, CHXR, CBC, lytes, creatinine, LFT’s.
Questions:
1)What are the primary diagnoses on your differential now?
2)Why not triage this patient directly to stroke team?
3)If the dry head CT is normal, what is your next step? What will you be looking for?
4)Describe some common neurological signs you look for in an altered patient and what they suggest.