Stuff You Need, In Your Pocket
ER Nurses Week was October 7th-13th. If you forgot to show your appreciation it’s not too late for belated gifts. Order medical pocketbooks as gifts. Until October 19th, for every 4 books you order we’ll throw in a 5th book free! That’s 20% off. Don’t people appreciate a belated gift almost as much as an on-time one?
Instead of a case this month I have a number of questions regarding odd medical observations. Interstingly most have something to do with the eye. Please share your own body oddities with your colleagues. Just submit a “comment” below or at the end of the answer page. For the answer page, click the link below.
Question 1: Using your ophthalmoscope you notice that not only is the exam amazingly easy, but that the retina is a beautiful patchwork of blues and greens with red arteries and a white optic disc. What condition does your patient have?
Question 2: How can you see the arterial ramifications of your own retina?
Question 3: How can you use your hands alone to see clearly underwater, as if you had a mask?
Are you a PA? Well then, from all of us at ERPocketbooks.com, happy PA week and keep up the good work!
Are you an MD or RN? Do you work with PA’s in your ED? Remember that praise beats criticism hands down, so be sure to let them know what a good job they are doing and be sure to wish them a happy PA week.
If you would like to show your appreciation with a small gift it’s not too late. Food is great, but ER Pocketbooks are better. Have a look at our books (menu bar at left)
ERPocketBooks.com offers 
Secret Ingredients of the Ultimate ER by John Frey, MD
Would you be curious about what is going on in an ER that has Press Ganey scores in the 97th percentile and a waiting list of nurses to select from? Challenges arise in the operation of ER’s every day and are met with varying degrees of effectiveness. The Secret Ingredients of the Ultimate ER takes you inside the minds of the nurses, administrators, physicians, clerks, and others who make up an extraordinary team. You will discover what highly effective leadership looks like…prepare to be surprised! You will discover the structures, processes, practices, and attitudes that enable a workplace to function powerfully…and then be able to share them with your own workplace.
A 73 year old man is brought to the ED by his neighbor after a witnessed trip & fall over a hose in his back yard. It was a ground level fall and he hit the right side of his head against a knee-high brick wall in the garden. There was no loss of consciousness and he felt fine prior to tripping. He has a mild headache, but no other injuries. He talkes HCTZ, omeprazole and warfarin. His exam is normal except for a small contusion over his right ear.
His labs are normal except for an INR of 2.4. His head CT is normal. He feels fine and wants to go home. Where’s the mystery you ask? The mystery is to answer these question: 1.) What is the “standard of care” for such a presentation. 2.) What is optimal care for such a presentation, i.e. under what circumstances should there be consideration for FFP? for Vitamin K? for admission?
Before answering, check out my Coagulation Cascade and the location of action of Coumadin. Please submit any comments for improvements.
Thirty minutes into your shift you take pass-ons from your colleague. The one case with loose ends is a 26-year-old woman who presented with 5 days of worsening right upper quandrant pain. The pain is pleuritic and non-radiating without fever, vomiting, shortness of breath, cough or urinary symptoms. Her past medical history and systems review is unremarkable. On exam she is very tender in the right upper quadrant, but otherwise normal, including a pelvic exam with no discharge or cervical motion tenderness. All labs including UA, LFT’s, lipase, beta-HCG, CBC and wet mount are normal except for a very elevated D-dimer. A CXR and CT of the abdomen have already been done and are negative. Your colleague leaves you with a request to “check a V/Q scan” and send her home if it’s normal - which it is.
What test needs to be done to confirm the correct diagnosis? ***
HINT: This is a classic case of a rare presentation for a common disease with significant morbidity. You’ve probably heard of this condition, and even seen it, though maybe not diagnosed it.
