GetMeOuttaThisMess Posted April 19, 2014 Share Posted April 19, 2014 90 y/o with fatigue? What 90 y/o ISN'T fatigued? The fact that this is the presenting c/o would certainly get my attention. Sky, why did you choose to scan head with fatigue c/o and no subjective/objective "new" neuro findings? Quote Link to comment Share on other sites More sharing options...
LoRezSkyline Posted April 19, 2014 Share Posted April 19, 2014 90 y/o with fatigue? What 90 y/o ISN'T fatigued? The fact that this is the presenting c/o would certainly get my attention. Sky, why did you choose to scan head with fatigue c/o and no subjective/objective "new" neuro findings? Beat me to it. I mean, good thing you did - but what pointed you in that direction other than the trifecta of Coumadin/Plavix/ASA?!? 1 Quote Link to comment Share on other sites More sharing options...
skyblu Posted April 19, 2014 Share Posted April 19, 2014 Trifecta of anti coagulation, plus the mild left sided motor deficits, which patient said were her baseline but she also said her recent antibiotic was called "gabasaurus", and generally seemed a tiny bit confused. It was all pretty subtle though. Since her PT noticed a change, I just had a little voice in the back of my head that told me to scan. Quote Link to comment Share on other sites More sharing options...
GetMeOuttaThisMess Posted April 20, 2014 Share Posted April 20, 2014 This is blatant malpractice on the part of the prescriber! Anticoagulants taken in combination with dinosaurs are clearly contraindicated in the literature. 5 Quote Link to comment Share on other sites More sharing options...
Moderator EMEDPA Posted April 20, 2014 Author Moderator Share Posted April 20, 2014 Anticoagulants taken in combination with dinosaurs are clearly contraindicated in the literature. as are anticoagulants given TO dinosaurs.....:) 1 Quote Link to comment Share on other sites More sharing options...
skyblu Posted April 20, 2014 Share Posted April 20, 2014 LOL! I actually told her, "Hmm, not sure if that's an antibiotic...or a dinosaur." (it was nitrofurantoin, by the way) Quote Link to comment Share on other sites More sharing options...
GetMeOuttaThisMess Posted April 20, 2014 Share Posted April 20, 2014 Not a contraindication then. Studies have shown that nitro blows up dinosaurs. Quote Link to comment Share on other sites More sharing options...
Administrator rev ronin Posted April 20, 2014 Administrator Share Posted April 20, 2014 (it was nitrofurantoin, by the way) In a 90 year old? I sure hope they checked her GFR first and she had allergies to other meds that made it a reasonable choice... 2 Quote Link to comment Share on other sites More sharing options...
Moderator EMEDPA Posted April 20, 2014 Author Moderator Share Posted April 20, 2014 Not a contraindication then. Studies have shown that nitro blows up dinosaurs. but then you change the future, don't you? Quote Link to comment Share on other sites More sharing options...
lov2xlr8 Posted April 20, 2014 Share Posted April 20, 2014 but then you change the future, don't you? Quote Link to comment Share on other sites More sharing options...
Moderator ventana Posted May 1, 2014 Moderator Share Posted May 1, 2014 In a 90 year old? I sure hope they checked her GFR first and she had allergies to other meds made it a reasonable choice... I used to use macrobid a lot - then read up on it and now tend to use bactrim and FQ's (yup toxic stuff but it works) as for nitro and elderly..... http://www.medscape.com/viewarticle/803715 QuestionWhy is nitrofurantoin listed in the Beers List as being inappropriate for use in the elderly? Response from Darrell Hulisz, PharmD Associate Professor, Case Western Reserve University School of Medicine; Clinical Specialist in Family Medicine, University Hospitals, Case Medical Center, Cleveland, Ohio Nitrofurantoin is a broad-spectrum antibiotic with gram-negative and gram-positive activity that is commonly used for lower urinary tract infections (UTIs). Nitrofurantoin is susceptible to enzymatic degradation, so tissue drug concentration is low. The drug is eliminated rapidly by glomerular filtration, and approximately 30% of the active drug is excreted in the urine.[1] In patients with renal impairment, including elderly patients, nitrofurantoin excretion is decreased, and it may not reach adequate urinary minimum inhibitory concentrations.[2] Thus, a primary reason that nitrofurantoin is on the Beers List of medications to avoid in the elderly is inadequate drug concentration in the urine when creatinine clearance falls below 60 mL/min.[3] Besides the potential subtherapeutic effect of nitrofurantoin in patients with renal impairment, patients may be at increased risk for adverse events secondary to drug accumulation.[3] Case reports of pulmonary toxicity in patients receiving chronic UTI prophylaxis, including pulmonary fibrosis and interstitial pneumonitis, have been reported.[4,5] Peripheral neuropathy, which is mostly seen in elderly women with renal impairment, has also been observed in patients with normal renal function.[6,7]Hepatotoxicity has also been documented in several cases involving women over 50 years old taking nitrofurantoin for acute UTI, recurrent UTI, or prophylaxis.[8] It is unclear whether pulmonary, neuropathic, and hepatic toxicities are directly related to renal impairment or to an accumulation of drug in pulmonary or neurologic tissue due to long-term use or a combination of these 2 processes. Surprisingly few studies have been published to support the notion of decreased efficacy with nitrofurantoin in the elderly. A retrospective chart review of 356 patients was conducted in 2009 that assessed the efficacy and safety of nitrofurantoin in patients with renal impairment. The study concluded that nitrofurantoin cure rates for UTI and adverse events were similar between those with and those without renal impairment.[1] However, the usual caveats apply when attempting to interpret retrospective data to discern clear answers to clinical questions that are best answered with randomized prospective trials. It is generally accepted that nitrofurantoin may be ineffective for UTIs in the elderly because age-related declines in renal function result in subtherapeutic concentrations in the urinary tract.[9] However, the recommendation to avoid the drug in the elderly is not because it causes nephrotoxicity. Although not well-documented, it is plausible that the risk for other toxicities from nitrofurantoin, such as pulmonary fibrosis, would increase secondary to drug accumulation. Acknowledgement: The author wishes to thank and recognize Kady Lynn Lordan for providing technical assistance. Quote Link to comment Share on other sites More sharing options...
Moderator True Anomaly Posted May 17, 2014 Moderator Share Posted May 17, 2014 Had a great case of "oh by the way" while covering fast track yesterday 21 y/o female comes in one week after sustaining two stab wounds to her left leg, which she was evaluated, treated and discharged from our trauma bay- seen by both ED staff and trauma team. One wound was distal anterior thigh, and the other was just over the L fibular head. Looked like some sutures were vertical mattress-style, and some simple interrupted. No big deal- I take them out, wound looks great. "Oh by the way....I can't bend my left foot up". Hmmm. Indeed, she had a complete foot drop. Said she had it ever since the stabbing. I go to the ER chart from the stabbing, and it's of little use- it refers to the trauma form (we have a separate H&P filled out when we "level" a trauma patient in the trauma bay). On the trauma form, it notes no neurologic deficit, and the entire procedure note for the lac repair literally says "Lac repair x 2". So I have no idea how deep the wounds were, and subsequently if there was any deep repair of the wounds. All it says in our ER texts for stabbing injury to the peroneal nerve is "surgical exploration and repair". Well, we're a week out now with a wound that has been sutured closed, and the ortho literature I'm able to review just talks about compression injuries to the peroneal nerve around the fibular head which are initially treated conservatively and then possible operative repair after a couple months. Ortho team comes down and agrees- complete foot drop, and it's either an incision wound to the peroneal nerve or the nerve was twisted during possible deep repair of that wound over the fibular head- which I have no way to tell. She gets a cam boot to keep the foot aligned, referral for EMG study and f/u with ortho within a week. Quote Link to comment Share on other sites More sharing options...
delco714 Posted May 17, 2014 Share Posted May 17, 2014 Had a great case of "oh by the way" while covering fast track yesterday 21 y/o female comes in one week after sustaining two stab wounds to her left leg, which she was evaluated, treated and discharged from our trauma bay- seen by both ED staff and trauma team. One wound was distal anterior thigh, and the other was just over the L fibular head. Looked like some sutures were vertical mattress-style, and some simple interrupted. No big deal- I take them out, wound looks great. "Oh by the way....I can't bend my left foot up". Hmmm. Indeed, she had a complete foot drop. Said she had it ever since the stabbing. I go to the ER chart from the stabbing, and it's of little use- it refers to the trauma form (we have a separate H&P filled out when we "level" a trauma patient in the trauma bay). On the trauma form, it notes no neurologic deficit, and the entire procedure note for the lac repair literally says "Lac repair x 2". So I have no idea how deep the wounds were, and subsequently if there was any deep repair of the wounds. All it says in our ER texts for stabbing injury to the peroneal nerve is "surgical exploration and repair". Well, we're a week out now with a wound that has been sutured closed, and the ortho literature I'm able to review just talks about compression injuries to the peroneal nerve around the fibular head which are initially treated conservatively and then possible operative repair after a couple months. Ortho team comes down and agrees- complete foot drop, and it's either an incision wound to the peroneal nerve or the nerve was twisted during possible deep repair of that wound over the fibular head- which I have no way to tell. She gets a cam boot to keep the foot aligned, referral for EMG study and f/u with ortho within a week. Poor documentation.. how to fix that? Shame. Hope it works out for her, though. Steve PA-C, Maine, urologic surgery Quote Link to comment Share on other sites More sharing options...
GetMeOuttaThisMess Posted May 17, 2014 Share Posted May 17, 2014 Or distal neuro exam wasn't actually performed even though it was noted. If a more recent injury, one couldn't exclude a compartment syndrome. Quote Link to comment Share on other sites More sharing options...
KMD16 Posted May 17, 2014 Share Posted May 17, 2014 Not necessary poor documentation. Yes, I Agreed. More better description to how the lac/wound was repair would have being nice. It's possible that during pt initial eval that pt was neurovascularly intact. Possible current neurologic deficit develop overtime. And why Ortho consult? Why not neurologist or neurosurgery consult? Quote Link to comment Share on other sites More sharing options...
Moderator True Anomaly Posted May 17, 2014 Moderator Share Posted May 17, 2014 Not necessary poor documentation. Yes, I Agreed. More better description to how the lac/wound was repair would have being nice. It's possible that during pt initial eval that pt was neurovascularly intact. Possible current neurologic deficit develop overtime. And why Ortho consult? Why not neurologist or neurosurgery consult? My attending and I went round and round with this as to who to talk to- it's not exactly clear which service would be the first call in this situation, particularly because each shop's specialists have their own "turf" so to speak (perfect example- cauda equina is treated by neurosurgery in some shops, and by ortho in others). We decided ortho because if there was going to be a surgical repair, they are the ones in our shop that would be doing it. Quote Link to comment Share on other sites More sharing options...
Moderator True Anomaly Posted May 17, 2014 Moderator Share Posted May 17, 2014 And believe me, the documentation was piss poor 1 Quote Link to comment Share on other sites More sharing options...
KMD16 Posted May 17, 2014 Share Posted May 17, 2014 ^ OK. Still I would have refer to neurosurgery instead of ortho. I've worked in both specialty in the past as a PA. Just saying. Injury at the level of the leg vs spine much better prognosis. Quote Link to comment Share on other sites More sharing options...
RRivas2004 Posted October 16, 2014 Share Posted October 16, 2014 Last night - Triaged to fast track: 17 yo male with "Scrotal Pain". Vital signs stable, no distress. Actual patient: 17 yo male with 10cm laceration to the scrotum with left testicle protruding completely from the scrotal sack. No active bleeding. Testicle viable no sign of torsion on US. Given TD shot, Ancef 2 grams, admitted to hospital for repair under anesthesia by Urology. Rodolfo Rivas EM PA-C Georgia 1 Quote Link to comment Share on other sites More sharing options...
delco714 Posted October 20, 2014 Share Posted October 20, 2014 Last night - Triaged to fast track: 17 yo male with "Scrotal Pain". Vital signs stable, no distress. Actual patient: 17 yo male with 10cm laceration to the scrotum with left testicle protruding completely from the scrotal sack. No active bleeding. Testicle viable no sign of torsion on US. Given TD shot, Ancef 2 grams, admitted to hospital for repair under anesthesia by Urology. Rodolfo Rivas EM PA-C Georgia Happens more than you think ;). Quote Link to comment Share on other sites More sharing options...
medic25 Posted October 20, 2014 Share Posted October 20, 2014 Last night - Triaged to fast track: 17 yo male with "Scrotal Pain". Vital signs stable, no distress. Actual patient: 17 yo male with 10cm laceration to the scrotum with left testicle protruding completely from the scrotal sack. No active bleeding. Testicle viable no sign of torsion on US. Given TD shot, Ancef 2 grams, admitted to hospital for repair under anesthesia by Urology. Rodolfo Rivas EM PA-C Georgia Funny what you can learn from a good physical exam... I recently had to remediate an EMS crew for bringing a victim of an MVC to a community ED instead of our trauma center; they documented blood on his shirt, but never removed it to find the source. The ED staff took his shirt off and were surprised to find a large quantity of his bowel spilled out from the evisceration he had suffered in the crash! 2 Quote Link to comment Share on other sites More sharing options...
MrsGPAC Posted October 20, 2014 Share Posted October 20, 2014 75 y/o F with remote history of TKA ℅ knee pain. Purely mechanical fall at home (rolled ankle and went down directly on the knee). Waited over an hour in the waiting room then brought back to fast track to wait another 45 min before I made it into the room. When I do get there, she's (OF COURSE) still in jeans but sitting in a wheelchair with an obviously swollen right knee, even through the jeans. But above the knee, so not classic knee effusion. Talked for a moment, did a little bit of palpation. Hello displaced femur fracture. In fast track. Triaged as a 4. I guess the fact that she looked reasonably comfortable, and was pleasant and conversational threw them--she was definitely tougher than your average bear. But a 75 year old who is telling you they can't put weight on their leg after a fall warrants at least a glance in the direction of that leg to decide fast-track vs. main ED! At which point you would have noticed the OBVIOUS swelling and deformity. Needless to say, I single handedly killed our long bone fracture time-to-pain-control measures for a few months. Thanks triage! 1 Quote Link to comment Share on other sites More sharing options...
primadonna22274 Posted October 21, 2014 Share Posted October 21, 2014 Haha I've had the displaced femur fracture in an old lady in fast track too. Must be a not-uncommon bad triage. Quote Link to comment Share on other sites More sharing options...
Moderator EMEDPA Posted October 22, 2014 Author Moderator Share Posted October 22, 2014 typical triage nurse move: don't bother to look at the injured area before deciding where to send pt. I have see many open fxs, dislocations, etc because of this over the years. 1 Quote Link to comment Share on other sites More sharing options...
Moderator ventana Posted October 23, 2014 Moderator Share Posted October 23, 2014 I think triage should 1) have to look at a physical injury ALWAYS with out any clothing blocking view 2) listen(yup actually listen) to the chest with a stethoscope..... these two things would help 1 Quote Link to comment Share on other sites More sharing options...
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