Dr. Idaly Hidalgo and Jenny Luo 8.31.2012. Case #1 AH 3108356 7 yo male with hx of ADHD presents...
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Transcript of Dr. Idaly Hidalgo and Jenny Luo 8.31.2012. Case #1 AH 3108356 7 yo male with hx of ADHD presents...
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FOLLOW UP ROUNDS
Dr. Idaly Hidalgo and Jenny Luo
8.31.2012
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Case #1
AH 3108356
7 yo male with hx of ADHD presents with excessive sleepiness x 1 day with one episode of “throwing up and turning blue” while sleeping.
What would you like to know?
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Case #1
HPIPatient was noted to be more tired than
usual, slept until 10am this morning.During the day he was playful and
interacting appropriately with his siblings. Throughout the day he complained of
tiredness and nausea but was able to tolerate food and took his usual medication.
Went to bed at 6pm because he felt nauseous and tired.
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Case #1
HPI cont.Around 11pm, family noticed patient
vomiting in his sleep and “turning blue”.Patient was not responding to verbal or
tactile stimulation.Brother threw water on patient’s face, after
which he awoke but remained lethargic.
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Case #1
Deniedabnormal movement or incontinencerecent traumafeverheadachesick contact
ROS otherwise negative
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Case #1
PMHxADHDODDImmunizations UTD
MedsRitalin (10mg at 7am, 10mg at 12pm, 5mg at 4pm)Refilled medication two days ago, no change in
dosage but these pills are “made by a different company”
No known allergies
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Case #1
FHxBrother- ADHDMother- Asthma
SHxLives with mother and three older brothersNo one else in the household takes
medicationNo history of child abuse
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Case #1 Physical Exam
v/s: T 100.1F HR115 BP109/73 RR28 O2 95%RA General: patient observed walking into ED and climbing onto
stretcher in NAD. Falls asleep minutes later, arousable but lethargic.
HEENT: NCAT, Pupils equal ~2mm, EOMI, MMM, nares patent, TMs nl, no tonsil erythema or exudate
Neck: supple, no LADLungs: slow and shallow, RR 12. CTABCV: HR 60, s1s2 nlAbd: Soft, NT/ND, +BSNeuro: lethargic, orientedx3, CNs II-XII intact, motor 5/5 upper
and lower extremities, steady narrow based gaitSkin: no rash or lesions
What would you like to do next?
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Case #1 During the exam patient was placed on the
monitorrepeat vitals HR 58 BP 110/65 RR 10 @86%patient lethargic, arousable by painful stimulionly complaining of being tiredO2, IV access and labs, EKG in progress
Obtained medication bottle from mom, it is labeled methylphenidate hydrochloride 5mg.
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Case #1
Labs?
Imaging?
EKG?
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Case #1
LabsCBC: 13.7>12.1/37.6<323BMP: 136/3.9-100/26.8-6/0.5<103 Ca 9.8PT10.4 INR1.1 PTT24.8UA: Yellow, turbid; SpGrav 1.025;
unremarkable
EKG- sinus brady 56
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Case #1 Differential Diagnosis for AMS in Children
Medical Hypoxemia Hypoglycemia Hypo/Hyperthermia DKA Sepsis Inborn errors of metabolism Intussusception Meningitis and encephalitis Exogenous toxins Electrolyte abnormality Psychogenic Postictal Uremia
Structural
CVA Cerebral venous
thrombosis Trauma- cerebral edema,
mass lesion Hydrocephalus
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Case #1
Methadone Hydrochloride 5mg
What would you do next?
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Opioid OD Signs
Decreased mental status, respiratory rate, tidal volume, bowel sounds and pupil size
TreatmentABCNaloxone
○ competitive antagonist to all opioid receptors. ○ onset of IV naloxone is 1-2min, duration of
action 20-90min.
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Opioid OD
Naloxone dosingOpioid-dependent with depressed mental status but
minimal respiratory depression – 0.05mg IVNon-opioid-dependent with depressed mental status
but minimal respiratory depression – 0.4mg IVApnea or near apnea- 2mg IV Q3min until maximum
dose of 10mg or improved respiratory statusDue to short duration of action, multiple does or
continuous infusion may be necessary. ○ Infusion rate= (2/3 x wake up dose)/hr
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Methadone Onset of action 0.5-1 hour Peak effect for continuous dosing 3-5 days Half-life 8-59 hours QTc prolongation, torsades
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Case #1ED course
○ Naloxone 2mg IVP x1Patient became very agitated, but his v/s improved
○ Poison control notifiedrecommend observation for 24hours and at least 4
hours after stopping continuous infustion
○ Hospital administration notified○ Admit to PICU for airway monitor and
naloxone drip.
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Case #1
Hospital CourseNaloxone drip started at 0.5mg/hr and
monitored for changes in mental status, respiratory depression and cardiac abnormalities.
Drip weaned off over 16hrsTransferred to floorDischarged on HD#3
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Case #1
Take Home PointTrust no one!
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Case #2
TH 03573339
34 yo F presents to ED with headache and AMS.
What would you like to know?
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Case #2
HPIPatient complaining of generalized HA for past
2-3 days, not improving with her BP medication.
S/P c-section 8 days ago, discharged from OSH one day PTA.
Denies nausea, vomiting, photophobia, fever, chills, neck stiffness, sick contact or trauma.
ROS otherwise negative Per friend, patient is more confused and
forgetful today. Also noted slurred speech.
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Case #2 PMHx
Gestational HTN PSHx
C-section x2 Meds
Labetalol 300mg POIron supplements
SHxDenies tobacco, alcohol and illicit drug use
FHxNoncontributory What would you like to know on PE?
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Case #2 Physical Exam
V/S: T97.9 BP188/117 HR72 RR16 O2 100% General: NAD, AAOx3 HEENT: PERRL ~3cm, EOMI, no nystagmus, no icterus Neck: supple, no stiffness Lungs: CTAB CV: RRR, s1s2 nl Abd: Soft, NT/ND, +BS, c/s incision d/c/I Ext: 2+ b/l LE pitting edema Neuro: AAOx3, follow commends, able to recall 2/3 objects after 5
minutes. Slow speech with word finding difficulties. Able to name items/read/write. CN II-XII intact. Motor and sensory intact.
Skin: intact, no rash What would you like to do next?
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Case #2 Labs
CBC: 9.1>8.7/26.6<265BMP: 140/3.6-104/24-11/0.8<80LFT: WNLTrop <0.01, CPK 174 UA: trace protein
ImagingCTH: normal, no acute hemorrhage,
hydrocephalus, sulcal effacement, midline shift or mass effect.
CXR: normal, no cardiomegaly
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Case #2 Differential Diagnosis
Encephalitis Hemorrhagic/ ischemic stroke TIA CVA SAH Subdural hematoma Migraine HA Tension HA Hyperthyroidism (thyroid storm) Toxicity Metabolic disease Seizure disorder Postpartum depression/psychosis Postpartum preeclampsia
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Hypertensive disorders of pregnancy Chronic hypertension- BP>140/90 on
two occasions before 20 wks of gestation or persisting beyond 12 wks postpartum
Gestational hypertension- BP>140/90 without proteinuria after 20 wks of gestation
Preecalmpsia- BP>140/90 WITH proteinuria after 20 wks of gestation
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Severe Preeclampsia Diagnostic Criteria
BP≥ 160 systolic or 110 diastolic on two occasions at least six hours apart during bed rest
Proteinuria ≥ 5 g in a 24-hour urine specimen or 3+ or greater on two random urine specimens collected at least four hours apart
Any of the following associated signs and symptoms: Cerebral or visual disturbances Epigastric or right upper quadrant pain Fetal growth restriction Impaired liver function Oliguria < 500 mL in 24 hours Pulmonary edema Thrombocytopenia
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Severe Preeclampsia- Management
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Severe Preeclampsia- Management ABC Magnesium Sulfate- first line treatment/prevention for eclamptic
seizures. 4-6gm IV over 5-10minutes followed by 1-2gm/h for 24 hours. additional 2gm bolus for recurrent seizures lorazepam and phenytoin are second line
Hydralazine- first line antihypertensive in pregnancy 5-10mg IV bolus, then Q20min to max of 30mg onset of action 20min
Labetalol 20mg IV with q10min to max of 300mg onset of action 5min
Nifedipine 10mg PO Q15-20min, max of 3 doses commonly used postpartum
Nitroprusside last resort, can cause severe rebound hypertension and cyanide
poisoning in fetus
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Case #2
ED coursePatient received Labetalol 20mg IV,
Labetalol gtt at 2mg/min, hydralazine 5mg IV x2 and Mg 6mg IV
BP improved to 167/106, HA improved but neuro exam unchanged.
GYN, Neuro and ICU consultPatient admitted to MICU
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Case #2
Hospital CourseHD#1: Mild HA, neuro intact. No sign of
HELLP. Continued labetalol drip and 2g Mg infused over 24hrs .
HD#2: HA resolved, neuro intact. Transitioned to PO labetalol 500mg PO q8h. MRI, MRA, MRV head all normal, MRA brain normal.
HD#3: patient eloped without prescription.
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Case #2
Take home pointPre-eclampsia can occur postpartum Patients will elope no matter how sick they
are