| OCR Text |
Show Figure 1: ACSC Scenarios Posed to Physicians CHF A 68 year old Hispanic male presents to the Emergency Room (E.R.) with shortness of breath. He is your regular patient. He has hypertension, with fair control, on an ACE inhibitor. He has no other major medical problems. He has gotten progressively worse over the past week including ankle swelling, weight gain, mild orthopnea and dyspnea on exertion. He denies having any chest pain. Pertinent findings include: blood pressure of 180/100, pulse is regular at 90, respiratory rate is 20, neck veins show JVD at 30 degrees, chest reveals bibasilar rales, heart reveals an S4 gallop without murmur, abdomen reveals a prominent liver edge (slightly tender), and extremities reveal normal color and pulses with 3+ pitting edema to the knees, EKG shows tachycardia without ischemic changes, CXR shows increased markings peripherally. Initial laboratory studies include normal cardiac enzymes, CBC, electrolytes and U/A, but the pulse oximeter shows 85% saturation. Initial treatment in the E.R. includes oxygen at 2 LPM (which brings the oxygen saturation to 91%) and IV Lasix with electrolytes which results in a positive diuresis and partial improvement in symptoms. Pneumonia A 70 year old white female presents to the Emergency Room (E.R.) with shortness of breath and productive cough. She is your regular patient and is being treated for mild COPD secondary to a past history of smoking (40 pack years, stopped 10 years ago). Her only regular medication is a beta-agonist inhaler used on a prn basis, and recent use of an over the counter cough syrup (Robitussin DM). She has had a pneumovax vaccination and recent influenza vaccination. She has gotten progressively worse over the past week including increasing cough, dyspnea on exertion, low grade fevers with occasional chills. She denies having any chest pain, or upper respiratory symptoms. Pertinent findings include: blood pressure of 145/86, pulse is regular at 96, respiratory rate is 18, temperature is 101.4 degrees F., ENT exam is normal, chest exam reveals prolonged expiratory phase and diffuse rhonchi throughout with right lower lobe end-inspiratory rales, heart exam is normal except for the tachycardia, and extremities reveal slight distal cyanosis with normal pulses and no edema, EKG shows tachycardia without ischemic changes, CXR shows increased markings/infiltrate in the right lower lobe. Initial laboratory studies include normal cardiac enzymes, electrolytes and U/A, but the pulse-oximeter shows 85% saturation, the CBC shows a WBC of 15,500 with a left shift (normal Hct and Hgb), and a sputum smear shows many WBCs with numerous Gram + cocci. Initial treatment in the E.R. includes oxygen at 2 LPM (which brings the oxygen saturation to 90%) and a nebulizer treatment with albuterol which results in a partial improvement in symptoms. Cellulitis A 72 year old white male presents to the Emergency Room (E.R.) with pain and swelling of his left lower leg. He is generally in good health, has had bilateral cataract removal with lens implants, has achieved good control of his weight and cholesterol levels (formerly elevated) through diet and mild exercise (regular walking). He takes no regular medications and is able to enjoy his full-time avocation of wood working. The patient reports that he was chopping wood last week when something struck his left lower leg causing a skin wound. He is unsure if there was a foreign body present. He treated his injury with bathing and Bandaids. He has deteriorated to the point that he can't walk without pain in his left lower leg and he's concerned about the amount of swelling and redness. He denies any drainage from the initial, small wound. Pertinent findings include: blood pressure of 160/92, pulse is regular at 85, respiratory rate is 14, temperature is 100.8 degrees F., chest is clear, heart reveals a regular rhythm without murmur, and the extremities are normal except for the left lower leg which reveals a small wound over the medial aspect of the mid-lower leg with a surrounding area of induration, erythema and tenderness covering approximately 10 x 15 cm, with some early ascending lymphangitis superiorly; there is no inguinal adenitis. X-ray of the left lower leg shows no bony involvement or foreign body. Initial laboratory studies include a normal U/A, but a CBC shows a WBC of 13,400 with a slight left shift (normal Hct and Hgb). Initial treatment in the E.R. includes an attempt to culture the wound although minimal drainage is obtained, and the administration of Acetaminophen 1000 mg for pain and slight fever which makes the patient feel better. 25 |
