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Case-Based Learning, June 2024

81-year-old female presented to the emergency department with complaints of generalized body aches and increasing illness over the past week. She reported fever, nausea, vomiting, and anorexia at home for the previous 8 days. She stated that because of the decreased appetite and nausea with vomiting, she has lost 15 pounds in the past week and a half. She also noted that she has a history of gallstones. On initial examination, she is afebrile. She does not meet SIRS criteria. Blood pressure is 116/73. She had tenderness in the right upper quadrant with palpation. She was administered hydromorphone 0.5 mg IV per pain protocol and morphine 4 mg IV per pain protocol. Workup included CBC, CMP, lactic acid, CRP, sed rate, urinalysis, and nasopharyngeal PCR 4 plex swab. She had both a limited right upper quadrant ultrasound and a CT angiography of the chest, abdomen, and pelvis during her evaluation in the emergency department. White blood cell count was 16.7 with left shift. ESR 94. Sodium 131. Alkaline phosphatase 317. AST 92. A LT 415. Lactic acid 1.3. CRP 36.8. 4 plex swab is negative for COVID-19, influenza, and RSV. Urinalysis with small bilirubin, otherwise normal. Ultrasound demonstrated gallbladder distention with gallbladder wall thickening and cholelithiasis. There also appeared to be an oval shaped structure in the gallbladder lumen that probably represented tumefactive sludge. The overall appearance was concerning for cholecystitis although it is reported that a sonographic Murphy sign was absent per TeleRadia report. CT chest, abdomen, and pelvis demonstrated central lobular emphysema. Cholelithiasis was noted and the gallbladder wall thickness was measured as much as 9 mm. Findings were reported consistent with cholecystitis per TeleRadia report. General surgery was consulted. At the time of the general surgeon’s examination, patient had received IV pain medication and was feeling better.…

Meet our team – Tim Cogar

Tim Cogar is the newest addition to our administrative team in Knoxville, TN. He will be working as our Controller. Tim has over 10 years working in finance and accounting. His expertise will bring consistency and efficiency to our finance ecosystem to improve our payroll and clients’ services. Tim is originally from Beckly, WV. His bachelor’s degree is from Marshall University, which gained fame from the 2006 movie “We are Marshall”. After college, he served in the US Army and was deployed to Iraq in 2004 for an 18-month tour. Tim has also earned a master’s from the University of Tennessee in Knoxville. Tim can be reached at 865.777.1300 Ext. 307 and

May Case-based Learning – IV Contrast for Trauma

66 y.o. otherwise healthy female presented to the emergency room in full spinal precautions after being involved in a high speed MVA. Patient was a restrained driver with a prolonged extrication. On arrival to the ED, patient was anxious, but conscious and complained of right-side chest pain, right lower extremity, and left wrist pain. Key findings on EXAM: GCS: 14/15, VS: 102/54, 110, 18, 96% on non-rebreather. HEENT: Negative except dried blood right forehead with small abrasion and surrounding 5 cm hematoma. PERRL EOMI. Neck: in collar, no tracheal deviation, no crepitus, neck tender along right paraspinal region. HEART: RRR No murmurs, rubs, gallops, no carotid bruits, no JVD; radial, dorsal pedal, post tibialis pulses 1+ bilaterally. Lung: Shallow rapid breath, no wheezes, no crackles Chest: Bruising over right upper chest. No crepitus. No deformity. ABD: bruising over lower abd consistent with a seat beat sign. Diffusely tender. Non distended. Back: No step offs, no focal tenderness T/L spine. No bruising Pelvis: stable, no pubic or iliac spine tenderness. UE: obvious closed left wrist fracture. LE: Bruised swollen right anterior lateral thigh; tender to palpation midshaft Neuro: GCS: 14/15 secondary to confusion, sensation intact both distal UE/LE Psych: confused anxious Skin: pale, no rashes, cap refill at 2 seconds. ORDERS: Non contrast CT: Head, c-spine, and abdomen/pelvis; left wrist XR, right femur XR, Chest XR, CBC, CMP, PT, PTT, Urinalysis, ETOH, UTOX, Lactic Acid. Cardiac Monitor, two large bore peripheral IVs and lactated ringers. Initial findings: Right Femoral shaft fracture, Left Colles fracture, Scalp hematoma right frontal bone, right anterior rib fractures (6 & 7th), HCT 31, Lactic Acid 3.2, UA 10 RBC HPF. CT abd/pelvis did not identify a cause for patients’ abdominal pain and provider called the transfer center to discuss the case with the surgeon on call.…

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