Steroids in Pediatric Asthma

lungAsthma exacerbation is a common complaint seen in the emergency department. The cornerstone of treatment consists of short acting beta agonists (albuterol), respiratory anticholinergics (ipratropium bromide), and steroids. Lets talk about steroid treatment in children with mild to moderate asthma who will likely be discharged to home. Continue reading

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Clinical evaluation of meningitis

An 18 year old female college freshman presents to the Emergency Department with fever for 8 hours, headache and diffuse myalgias.  Her maximium temperature has been 102.8° F (39.3 C) and she has vomited five times.  She is mildly tachycardic, with a heart rate of 110.  Physical exam demonstrates tenderness of the paraspinal musculature of the neck and back with absence of Kernig’s and Brudzinski’s signs, and is otherwise nonfocal.  After symptomatic treatment with acetaminophen, ondansetron and fluid, she is no longer tachycardic and is tolerating oral fluids, though still feels somewhat ill.  She asks about the possibility of meningitis, but would prefer not to undergo lumbar puncture if not necessary. Continue reading

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Methotrexate Toxicity

A 43 year old woman with a history of depression, anxiety and severe chronic pain resulting from rheumatoid arthritis was found down in her house, surrounded by empty pill bottles with a suicide note present.  Time of ingestion was unknown and was potentially as much as 72 hours prior to discovery.  Family members reported that her medicines include acetaminophen/oxycodone, methadone and lorazepam.  The patient was intubated due to depressed mental status and poor respiratory drive, and N-acetylcysteine therapy was initiated for her elevated acetaminophen level and evidence of early hepatotoxicity.  On hospital day 3, her white blood cell count was noted to be low, with platelets on the lower end of normal.  She required initiation of hemodialysis for acute renal failure.  This trend continued, and on hospital day 5, her white blood cell count was 0.1 (x103 per microliter) with a platelet count of 9.  She developed significant lower GI hemorrhage requiring transfusion of 4 units PRBC and platelets.  Family members were asked to provide all the pill bottles found at the scene, and methotrexate was noted to be present in addition to the above listed medications.  The patient’s methotrexate level on hospital day 5 was 0.29 micromol and the Poison Control Center was consulted. Continue reading

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Fever in unvaccinated children

An 11 month old male is brought into the ED by his mother with fever as high as 104.5° Fahrenheit (40.3 C) and vomiting for the last 12 hours.  He has made fewer-than-usual wet diapers today and has vomited after nearly every feeding.  He is not in day care.  He was born via uncomplicated spontaneous vaginal delivery at 39 weeks, was circumcised at birth, has no known medical problems, no medications or medication allergies, and has never had surgery.  When asked about his vaccination status, his mother states “Oh, we don’t do vaccines in my home.”
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