Case-based-Learning

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Case Based Learning for June 2025

A 53-year-old female with past medical history of type 1 diabetes, asthma, anxiety, and depression, was brought in by EMS with CPR in progress. She called EMS with complaint of difficulty breathing. When EMS arrived, patient was talking and using a nebulizer treatment. Shortly after their arrival, she became unresponsive, apneic, and pulseless. CPR was initiated. An iGel was placed and Lucas chest compression device was placed. On rhythm check, no shock was advised. On arrival to the hospital, SpO2 was 55%, despite bilateral breath sounds and 100% oxygen and adequate bagging. An IV was placed and patient was given Narcan 2 mg, SoluMedrol 125 mg, and magnesium sulfate 2 g IV. She also received epinephrine 0.3 mg IM and a DuoNeb inline.  On rhythm check, sinus tachycardia with a pulse was noted and compressions discontinued. Patient continued to have only agonal respirations. The iGel was removed and she was intubated using etomidate and rocuronium. Her heart rate and blood pressure were increasing and a second dose of etomidate was given while a ketamine infusion was being initiated. EKG showed sinus tachycardia with rate 121 and RBBB. There was also ST depression in the inferior leads and inverted T waves in the lateral leads.  CXR showed ETT in good position 3 cm above the carina and no infiltrates or effusions. Labs: WBC 15.6, H/H 14.2/45.0, plt 322.  INR 1.0, PTT 33.0, dimer 812 (normal 100-599). VBG pH 6.786, pCO2 104, pO2 47, HCO3 15.8, O2 sat 41%. K 5.6, anion gap 23.6. Glucose 399. Trop-I (high sensitivity) 153. After receiving the VBG results, the patient was given bicarb 1 amp. Increased ventilatory rate was used to decrease ETCO2 down to the 40s. Accepting intensivist requested CT head and CTA chest/abd/pel and recommended 2 more amps of bicarb and ceftriaxone be…

By Karen Wink
Newsletter

Case Based Learning for May 2025

Following is the presentation a patient I recently had in the ED, where I felt I could have done better, especially with documentation. I think it brings up a number of good issues for possible learning/discussion, several of which I’ll mention below. I welcome any thoughts people have. – Gordan Luther, M.D.  HPI: 70 y.o. male, presented for evaluation of a possible stroke. He stated that the prior evening at about 8:00, almost 17 hours prior to his presentation, he had sudden onset of weakness of his left arm and leg. The weakness was severe enough that he had a hard time walking and he feels he had a couple light falls that did not result in injury. He denies any speech or visual change. The same areas have decreased sensation. He had no other complaints. He denied any palpitations, chest pain or SOB. He stated he did not have a history of diabetes despite the blood sugar in the 400s we found on arrival. There was almost no history in the EMR, and he stated he hadn’t seen a doctor for many years. PMH: None other than minor orthopedic injuries No allergies or meds. Lives alone. A friend talked him into coming in for evaluation. VS: BP 202/116 Pulse 102 Temp 36.7 °C Resp 20 SpO2 96% Physical Examination. General: No distress. Cooperative. Appears pale, although nontoxic. Head: Normocephalic. Atraumatic. Eyes: EOMI. PERRL. ENT: No nasal congestion. No pharyngeal erythema or exudate. Mucous membrane moist. Neck: Nontender. Supple. Lungs: Clear bilaterally. No rales, rhonchi, or wheezing. Heart: Regular rate and rhythm. Abdomen: Bowel sounds normal. Soft. Nontender. No rebound or guarding. No palpable masses. Neuro: Alert. Oriented x3. Speech fluent. Cranial nerves 2-12 intact. He has 4 out of 5 muscle strength on the left compared with 5 out…

By Karen Wink
Newsletter

Case Based Learning for April 2025

Shoulder dislocation HPI: 20 yo otherwise healthy individual presents to you with acute left upper arm pain. The patient reports that they were mountain-bike riding, lost control of their bike and crashed. They are not sure how they landed but report immediate pain and numbness in their left upper extremity post-crash. Patient is concerned since they cannot move their upper arm and report it feels numb over the lateral aspect of their shoulder. They were able to ambulate into your emergency department and deny other injuries. They deny prior UE trauma, chronic joint pains, illnesses, or systemic symptoms.   Question 1: Based on your knowledge of anatomy, describe some potential causes of traumatic upper arm pain. Common causes of acute traumatic upper arm pain include humeral fracture, clavicular fracture, Acromioclavicular (AC) joint separation, glenohumeral dislocation, rotator cuff tear.   Question 2: What is the typical mechanism of injury for each of the above potential items? Think about the anatomy and how it might be disrupted. Proximal Humeral Fracture: Most often are caused by a fall or direct blow to the lateral shoulder. Type of fracture is determined by the body and arm position when the direct force is applied. (i.e., outstretched vs adducted arm) Clavicular Fracture: Often occurs with a fall onto a shoulder or being stuck over the clavicle with a heavy object. AC separation: Typically occurs from direct trauma to the superior or lateral aspect of the shoulder with the arm adducted Glenohumeral dislocation: An anterior shoulder dislocation is usually caused by a blow to the abducted, externally rotated, and extended arm. Examples would be fall on an outstretched arm, blocking a basketball shot, or blow to the posterior humerus. Rotator cuff tear: Most rotator cuff tears are seen in the middle aged or older adults and are…

By Karen Wink
Newsletter

Case Based Learning for March 2025

36-year-old male patient, past medical history of asthma not taking any medications for it, presents to the ER for cc of ”body aches.” Reports myalgias, cough, shortness of breath, intermittent fevers and chills for several days. Taking Motrin and Tylenol for symptoms with temporary relief. Has sick contacts at home. Denies any other complaints at this time. PMH: asthma PSH: Denies HR 134, BP 113/74, RR 22, SpO2 98%, Temp 99°F PE: appears fatigued, tachycardia, appears fatigued, lungs clear, otherwise normal Workup: CXR normal, viral panel negative, WBC 18.9, ANC 16.4, CO2 22 Diagnosis: Cough, back pain, shortness of breath Plan: Discharged on doxycycline, ibuprofen, acetaminophen (ER note reports uncertain cause of infection and empiric coverage with doxycycline) RETURN TO ER 2 days later patient presents via ambulance with cc of non-productive cough and fatigue. Patient worried he has mono as his son recently had it. Paramedics report a “sore” on the buttock. Treated 250mg fluid bolus prior to arrival HR 130, BP 113/69, RR 23, SpO2 97% Temp 99.5°F PE: tachycardia, lungs clear. Then taken into resusc bay for quick exam of buttocks showing 1.5cm x 1cm dark bullae to right inguinal/perineal region, no pain beyond boundaries, no crepitus, no dusky appearance of skin DDx: most likely cellulitis, folliculitis, necrotizing soft tissue infection; less likely PNA, mono, viral Sepsis workup and treatment initiated. Labs and cultures ordered, 30mL/kg fluid bolus, Zosyn and Vancomycin WORKUP: WBC 15.63, H/H 13.4/38.1, CMP Na 139, Cr 1.3, Glu 127, Lactate 1.7, CRP 33.8 mg/dL, blood cultures sent General Surgery contacted within 1 hour. Surgery planning on seeing in the morning as LRINEC score 5, WBC improving, exam only bullae to area. IVIG added to treatment regimen.     Surgery contact and taken emergently to the OR. Total of 3 surgeries during 17 day…

By Karen Wink
Newsletter

Case Report: Acute Angle-Closure Glaucoma in a 43-Year-Old Male

Introduction Acute angle-closure glaucoma (AACG) is an ocular emergency resulting from a rapid increase in intraocular pressure (IOP) due to obstructed aqueous humor outflow. It is commonly associated with a shallow anterior chamber angle, predisposing individuals to blockage. Without timely intervention, AACG can lead to permanent vision loss or blindness. This report describes the presentation, diagnosis, and management of AACG in a patient presenting to the emergency room (ER). Patient Presentation A 43-year-old male with no significant past medical history presented to the ER on a Sunday afternoon with blurred vision and pain in the right eye that began the day before. He initially hoped the symptoms would resolve on their own but sought medical attention after consulting a healthcare provider. He reported a sharp, constant headache behind the right eye rated 6/10, accompanied by nausea and blurred vision, described as though a film was over the right eye. He also noticed mild redness in the right eye but denied discharge, pain with eye movement, photophobia, fever, chills, respiratory, gastrointestinal, or genitourinary symptoms. Physical Examination Vital Signs: T 98.7°F, P 85 bpm, R 16/min, BP 151/87 mmHg, SpO₂ 97% on room air.Visual Acuity: Right Eye 20/40, Left Eye 20/20. Extraocular Movements (EOM): Full range of motion without pain. External Eye Exam: Eyelids everted—no foreign bodies. Mild conjunctival erythema, no discharge. Corneal Staining: Fluorescein stain showed no corneal uptake. Funduscopic Exam: Right Eye: Cloudy cornea, retina not visualized. Left Eye: Retina visualized, no gross abnormalities. Intraocular Pressure (IOP): Right Eye 76-80 mmHg, Left Eye 14-17 mmHg. Slit Lamp Exam: Not available in the ER. Working Diagnosis Acute Angle-Closure Glaucoma (AACG) Treatment Provided in ER Acetazolamide (Diamox): 500 mg PO (IV formulation unavailable) Timolol 0.5%: 2 drops in the right eye Apraclonidine and Prednisolone ophthalmic solutions were not available. Ophthalmology Consultation: Arranged…

By Karen Wink
Case-based-Learning

January 2025 Case Study – Abdominal Pain

  ABDOMINAL PAIN HPI:  This is a 67-year-old female who presents to the ER at 06:15 complaining of nausea, vomiting, sweating, a feeling of general malaise, and dizziness. She was brought in by family. The patient states she was awakened from sleep at approximately 03:45 with a feeling of bilateral upper quadrant abdominal pain, nausea and vomiting. She has sweating with the vomiting. She has had multiple episodes of vomiting and began to feel dizzy starting approximately 30 to 45 minutes prior to arrival. She states she feels weak all over and just doesn’t feel “right.” She denies any new or restaurant foods in the past 48 hours. She denies eating any “left-overs” in the past 48 hours. She was unable to take her morning medications due to her inability to keep anything down. She denies any bloody or dark vomit or stools. She denies anyone else in the household being ill. COVID immunizations are up to date. ROS:  She denies any, fever, chills, change in her vision, diplopia, change in hearing, ear pain, rhinorrhea, sore throat, difficulty swallowing, chest pain, shortness of breath (except with vomiting), abnormal heart beat, physical difficulty breathing, abdominal distention, dysuria, hematuria, incontinence of urine or stool, retention of urine or stool, back pain, muscle pain, focal weakness, focal numbness, environmental or food allergies. DRUG ALLERGIES: COMPAZINE, PENICILLIN, BACTRIM. MEDS: Glyburide/Metformin 5mg/500mg, 2 tablets, P.O., BID Reglan 10mg, P.O., QID PRN Amlodipine 5mg, P.O, Q Day Omeprazole 20mg, P.O., Q Day PMHX: Hypertension Diabetes Mellitus, Type II, diet and medication controlled. Gastroparesis GERD GALLSTONES DYSFUNCTIONAL UTERINE BLEEDING LEFT WRIST FRACTURE – Age 8 PSHX: CHOLECYSTECTOMY – three months ago VAGINAL HYSTERECTOMY – Age 57 Ovaries still In-Situ ORIF – Left Wrist Age 8 SOCIAL HX: Tobacco – Never Alcohol – One glass of wine per…

By Karen Wink
Case-based-Learning

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…

By Karen Wink
Newsletter

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…

By Karen Wink
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