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Kaplan Emergency Medicine Pdf 32
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(M2.OB.14.121) A 32-year-old G1P0 woman presents to the emergency department at 34 weeks gestation. She complains of vague upper abdominal pain and nausea which has persisted for 2 weeks, as well as persistent headache over the past several days. Her temperature is 99.0F (37.2C), blood pressure is 164/89 mmHg, pulse is 88/min, respirations are 19/min, and oxygen saturation is 98% on room air. Hemoglobin: 10 g/dLHematocrit: 30%Leukocyte count: 7,800/mm^3 with normal differentialPlatelet count: 25,000/mm^3 Serum:Na+: 139 mEq/LCl-: 100 mEq/LK+: 4.3 mEq/LHCO3-: 25 mEq/LBUN: 20 mg/dLGlucose: 99 mg/dLCreatinine: 1.1 mg/dLCa2+: 10.2 mg/dLAST: 199 U/LALT: 254 U/LUrine:Color: YellowProtein: PositiveBlood: PositiveThe patient begins seizing. Which of the following is the most appropriate definitive treatment for this patient
(M2.OB.14.6) A 20-year-old woman presents to the emergency department with painful abdominal cramping. She states she has missed her menstrual period for 5 months, which her primary care physician attributes to her obesity. She has a history of a seizure disorder treated with valproic acid; however, she has not had a seizure in over 10 years and is no longer taking medications for her condition. She has also been diagnosed with pseudoseizures for which she takes fluoxetine and clonazepam. Her temperature is 98.0F (36.7C), blood pressure is 174/104 mmHg, pulse is 88/min, respirations are 19/min, and oxygen saturation is 98% on room air. Neurologic exam is unremarkable. Abdominal exam is notable for a morbidly obese and distended abdomen that is nontender. Laboratory studies are ordered as seen below.Serum:hCG: 100,000 mIU/mLUrine:Color: AmberhCG: PositiveProtein: PositiveDuring the patient's evaluation, she experiences 1 episode of tonic-clonic motions which persist for 5 minutes. Which of the following treatments is most appropriate for this patient
Consecutive adults aged 18 or over presenting with chest pain in three emergency departments (ED) in Victoria, Australia during the five-year study period were eligible to participate. A relative index of inequality of socioeconomic status (SES) was estimated based on residential postcode socioeconomic index for areas (SEIFA) disadvantage scores. Admission to specialised care units over repeated presentations was modelled using a multivariable Generalized Estimating Equations approach that accounted for various socio-demographic and clinical variables.
Socioeconomic inequalities in cardiovascular morbidity and mortality have been reported in many regions including the US [1], the UK [2], Australia [3] and other Organisation for Economic Cooperation and Development (OECD) countries [4]. Cardiovascular morbidity measures such as admission rates for cardiac related conditions have generally dropped over the past two decades [5]. However, relative inequality in cardiovascular emergency admissions and cardiovascular related mortality actually increased in the most disadvantaged compared with the least disadvantaged [6]. These disparities have been attributed to a range of socioeconomic determinants of health and health behaviours, rooted in social rank as determined by education, occupational hierarchy and income [1, 4, 7, 8]. The relationship between socioeconomic status and general health, and, in particular, cardiovascular health, has been demonstrated within different races and ethnic groups [9], suggesting that cultural and ethnic dissimilarities do not explain the socioeconomic differences. These associations were also observed in countries with universal access to health care [2, 3], and when comparing those who have similar rates of smoking, obesity and alcohol use [9].
Chest pain is a frequently seen symptom in emergency departments, being the most common reason for presenting in the ED among Americans over the age of 65 and contributing to approximately 6 million visits per annum under the US Medicare system [15]. Clinical management of chest pain is highly variable, often depending on the underlying causes and is considered a medical emergency until all life-threatening causes have been ruled out. Potentially life-threatening causes of chest pain include acute myocardial infarction and other acute coronary syndromes as well as aortic dissection, pneumothorax, pneumonia and pulmonary embolism. Patients presenting with chest pain who require critical care are often more likely to be severely ill and / or are at risk of imminent death [16, 17]. This study used emergency admissions following repeated non-traumatic chest pain presentations to emergency departments (ED) to explore the associations between sex, age, geographic-based socioeconomic disadvantage score and cardiovascular morbidity, expressed as admission to specialised care units.
Consecutive adults aged 18 or over presenting with chest pain (including chest heaviness, heart pain, and chest tightness) in three emergency departments in Victoria, Australia during January 2009 and December 2013 were eligible to participate in this population-based panel study. Cases were identified using the International Classification of Diseases, 10th Revision, (Australian Modification) (ICD-10-AM) code of R07. Patients presenting with chest pain due to trauma or other injury were excluded from this analysis.
Sociodemographic and presentation-related variables together with clinical variables were collected from the ED electronic database (SYMPHONY Version 2.29). The collected information included age, sex, country of origin, residential postcode, main language spoken at home, arrival mode, arrival time, presenting symptoms, a registered nurse-allocated triage urgency score that categorised the presentation as being an emergency (triage scores of 1 or 2), urgent (triage score of 3) or semi and non-urgent (triage scores of 4 or 5) and length of stay in the ED. The final main acute diagnosis reached on discharge from the ED was also collected together with the discharge destination. Among admitted patients, three possible admission departments were recorded: CCU, ICU and medical ward. The medical ward was used to categorise all adult hospital departments that did not have intensive specialised care. The admitting ward of patients transferred to another public or private hospital was also recorded and accounted for in this analysis. All diagnoses were identified using ICD-10-AM codes.
This study utilised a large population-based dataset that included all emergency non-traumatic chest pain presentations in three Victorian hospitals that serve uniquely different sub-populations. The study population was limited to those presenting with emergency non-traumatic chest pain. This has subsequently minimised elective admissions, such as for coronary angioplasty where the highest rates are reported in the more affluent. Compared to the latter, patients coming from socioeconomically disadvantaged backgrounds often wait longer for, and have less access to, a coronary angioplasty consistently observed in the US, UK, and Australia [5, 38]. The admitting ward of patients transferred to other hospitals was also captured in this analysis; for example, if patients coming from higher SES locations chose to be transferred to other private hospitals.
To our knowledge, this study is the first to report dose-response relationships between geographic-based socioeconomic disadvantage and higher admission rates to specialised care units in a population-based representative sample of patients presenting with emergency chest pain. The relationship between socioeconomic disadvantage and cardiovascular morbidity is complex and multifactorial. Not every individual exposed to lower socioeconomic disadvantage develops disease and our results cannot infer causal relationships but our findings add to the accumulating evidence supporting a direct association between socioeconomic disadvantage and increased morbidity.
Chest x-ray has been one of the most used tests to evaluate for hypervolemia. Radiographic sings of volume overload include dilated upper lobe vessels, cardiomegaly, interstitial edema, enlarged pulmonary artery, pleural effusion, alveolar edema, prominent superior vena cava, and Kerley lines. However, up to 20 % of patients diagnosed with heart failure had negative chest radiographs at initial emergency department evaluation. Additionally, these radiographic sings can be minimal in patients with late-stage heart failure [24].
RM: Dr. Mehta received the M.B.B.S. degree (1976) from the Government Medical School in Amritsar, India, and the M.D. (1979) and D.M. (1981) degrees from the Post Graduate Institute of Medical Education and Research in Chandigarh, India. He subsequently completed a nephrology fellowship at the University of Rochester in Rochester New York and obtained his boards in internal medicine (1986) and Nephrology (1988). He is a Professor of Medicine in the Division of Nephrology and Associate Chair for Clinical Affairs in the Department of Medicine at the University of California, San Diego (UCSD) where he directs the Clinical nephrology and dialysis programs. He is also the Chair of the International Society of Nephrology 0by25 initiative, founding member of the Acute Dialysis Quality Initiative. His research interests are in the field of acute kidney injury (AKI) and he has directed several clinical studies in the management of patients with AKI including comparing different types of renal replacement therapies, conducting several large multicenter observational studies of AKI, evaluating different predictive models for outcomes in AKI, investigating the role of cytokine removal by dialysis membranes in sepsis and AKI, and evaluating techniques for determining the amount of excess fluid in dialysis patients.
1) To examine whether blood lactate levels are predictive for in-hospital mortality in patients in the acute setting, i.e. patients assessed pre-hospitally, in the trauma centre, emergency department, or intensive care unit. 153554b96e
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