Emergency Medicine Cases with Dr. Barlock

Contributors: Travis Barlock MD, Jeffrey Olson MS4

Feel free to use the cases below for your own practice. All of the scenarios are completely made up and designed to hit several teaching points.

Case 1

25 M, presents to the ED with chest pain.

Stabbing, started a few hours ago, substernal. Thinks it is GERD.

After 2-3 minutes, pain worsens and radiates to the back.

VS: BP 125/50 (Right arm 190/110). HR 120. RR of 18. Sat 98% on RA.

Additional VS: Temp of 37.2, height of 6’5”, BMI of 18.

PMH: None, doesn’t see a doctor. Meds: None

FH: Weird heart thing (Mitral Valve Prolapse), weird lung thing (spontaneous pneumothorax), tall family members with long fingers and toes

Physical Exam:

Cards: Diastolic decrescendo at the RUSB, diminished S2. UE pulses are asymmetric, LE pulses are asymmetric, carotid pulses are asymmetric, BP is asymmetric

MSK: Knees, elbows, and wrists are hypermobile.

Imaging: CXR #1 normal, #2 widened mediastinum (no read yet but shows widened mediastinum), POCUS shows small effusion

CTA/MRA doesn’t come back until after the case. 

ECG: Sinus Tach

Labs:

NT-proBNP 500 pg/mL

D-Dimer: 7000 ng/L

CBC: Hemoglobin: 13.5 g/dL, WBC: 20,000/µL, Platelets: 250,000/µL

Chem 7: Na 138, K, 5.7, Cl 102, Bicarb 17, BUN 45, Creatinine: 3.5 mg/dL, Glucose: 180

LFTs: Albumin 2.4, Total protein 5.5, ALP: 140, AST: 3500, ALT: 2800, TBili: 3.2, DirectBili: 2.4,

Ca: 7.8

LDH: 2200

PT: 20.5, INR: 2.2, Fibrinogen: 170

5th gen High-Sensitivity Troponin:

Lactate: 7 mmol/L

VBG: pH 7.22, paCO2 28, bicarb 15

Notes: Can have patient crash somewhere in middle and show 2nd xray

 

Case 2: 

A 67-year-old female is brought to the ED by her daughter due to progressive weakness, confusion, and fatigue that have worsened over the past week.

Unable to get out of bed and has become increasingly lethargic. Also having some nausea, constipation. The daughter denies any preceding illness, recent trauma, or travel. Does not know her meds but will head home to get them after talking with you.

 VS: BP 88/55 mmHg, HR 110, RR 20, O2 Sat 98% on room air.

Additional VS: Temp 36.8°C.

PMH: Hypertension, osteoarthritis, and depression.

Physical exam:

General: Thin, somnolent but arousable.

HENT: Dry mucous membranes

Neuro: Confused, A&Ox1 (self), hyporeflexia

Labs (Includes many that would not return in the ED in case you want to take this case forward to the floor)

CBC: WBC 9,500, Hb 16.5, Hct: 50%, Platelets 220,000

Chem7: Na 129, K 2.1, Cl 95, HCO3 34, Creatinine 1.6, BUN 40, Glucose 115

LFTs: normal

Magnesium: 1.1

Calcium: 10.8 mg/dL (corrects to 12.8)

iCal: 3.2

Phosphate: 2.3 mg/dL

Albumin: 2

BUN:Cr ratio: 25

VBG: pH: 7.49, PaCO2 45, HCO3: 34

Lactate: 2.8

Serum Osmolality: 276 mOsm/kg (Osmolal gap of 2)

Urine Osmolality: 550 mOsm/kg

Urine Sodium (UNa): 10 mEq/L (low). Urine Potassium (UK): 25 mEq/L (elevated). Urine Chloride (UCl): 12 mEq/L (low). Urine Magnesium (UMg): 20 (Elevated). Urine Calcium (UCa): 50 in 24 hrs (Low)

100 cc of urine with foley

FeNa

Plasma renin activity: 15 mg/mL/hr (elevated), Aldosterone: 25 ng/dL (Elevated), ADH: Elevated, Diuretic screen: Positive for thiazides

PTH: 8 (low), HsTrop: 32, Cortisol and ACTH: Normal.

EKG: Hypokalemia