Reversible neurological deficits in a chronic alcohol abuser: A case report of Wernicke's encephalopathy

The abuse of alcohol presents daily challenges for the emergency medicine physician. Wernicke's encephalopathy represents one of the metabolic complications associated with alcoholism. A classic presentation of Wernicke's encephalopathy is reported. The patient presented to the emergency department with the chief complaint of confusion, difficulty ambulating, and visual disturbances. Following administration of intravenous thiamine, the patient's symptoms spontaneously resolved. The pathophysiology, clinical presentation and therapy of this classic disorder are discussed.     

A Young Man Presenting with Acute Encephalopathy,Hemiparesis, and Headache

Background: Familial hemiplegic migraine (FHM) is a rare type of migraine. Correct diagnosis is challenging for emergency physicians (EPs) due to its variable clinical picture, as well as its lack of diagnostic biological markers. Objectives: To raise awareness among EPs regarding FHM's diverse clinical picture, and to highlight FHM's diagnostic criteria to facilitate an accurate and timely diagnosis of FHM in patients presenting to the emergency department (ED) with indicative symptomatology. Case Report: A 24-year-old male student presented to the ED complaining of dizziness, general weakness, and blurred vision that had developed the previous night. The initial physical examination revealed drowsiness, slow speech production, and slight weakness with paresthesia in all limbs. Detailed communication with the patient's aunt revealed that he had experienced several similar attacks since the age of 12 years, and that there was also an extensive family history of the same symptoms. In addition, 2 h after arrival, the patient experienced severe throbbing headache, vomiting, severe dysphasia, and the weakness shifted to the right side. A computed tomography scan of the brain showed no anomalies. He was admitted with a tentative diagnosis of FHM. Conclusion: A diagnosis of FHM should be considered if the patient's clinical features include headache and weakness, with a family history of similar symptomatology. However, atypical symptoms of FHM may present as recurrent episodes of unexplained encephalopathy. Crucial elements for making an accurate and timely diagnosis of FHM include a detailed knowledge of weakness-related diseases and an ability to consider FHM in the differential diagnosis, as well as obtaining a thorough family history with repeated neurologic assessments.     

Alcohol Use in the Elderly and the Risk for Wernicke-Korsakoff Syndrome

Two diseases linked with alcohol-related brain damage are Wernicke's encephalopathy (WE) and Korsakoff syndrome (KS) or psychosis, also referred to as Wernicke-Korsakoff syndrome (WKS). Thiamine deficiency is the underlying etiology for alcohol-related WKS. Persons older than 65 who have consumed alcohol at levels exceeding recommendations over a long period, even without a diagnosis of alcohol dependence, are at risk for WKS. Obtaining an alcohol-use history from people over 65 is essential to preventing WKS. The main purpose of this article is to provide the nurse practitioner with strategies for identifying persons over 65 at risk for alcohol-related thiamine deficiency, including screening for alcohol use and obtaining an alcohol-use history. This is followed by a review of the role and physiology of thiamine, laboratory tests that can be used to screen for thiamine deficiency, and prevention and early treatment.     

Lumbar disk disease

Back pain seems almost ubiquitous in our society. Every day, physicians hear complaints of backaches, yet diagnosis is often difficult because of the need to rely on the patient's subjective interpretation of the pain. The most difficult clinical decisions arise when the history and physical examination are compelling and seem diagnostic of disk disease yet corroborative tests fail to demonstrate evidence of disease. In this exhaustive review, the authors discuss the clinical findings necessary for accurate diagnosis and treatment of lumbar disk disease.     

Muscle contraction headache. Overview and update of a common affliction

Muscle contraction headache usually can be correctly diagnosed on the basis of a thorough patient history and physical examination, although diagnostic tests may be necessary to exclude structural or inflammatory disease. Often, symptoms are directly related to emotional conflicts. In most cases, the primary care physician can provide treatment, which includes understanding and emotional support. Pharmacologic therapy and biofeedback are effective in controlling symptoms. Depression should be suspected in patients with chronic headache. Referral for neurologic or psychiatric consultation should be considered if the diagnosis is unclear or therapy is unsatisfactory.     

Approach to the Agitated Emergency Department Patient

Background

Acute agitation is a common occurrence in the emergency department (ED) that requires rapid assessment and management.

External Monitoring-Induced Pacemaker-Driven Tachycardia: A Case Report

A 55-year-old African-American woman with a history of end-stage renal disease secondary to systemic lupus erythematosus, dual-chamber pacemaker placement secondary to sick sinus syndrome, and a previous subarachnoid hemorrhage presented via ambulance to our Emergency Department (ED) from an outside hospital with the report of altered mental status, hyperkalemia, and hypoglycemia. In the ED, the patient's initial physical examination revealed a stable, normal heart rate. Reassessment after placement of external monitoring devices found the patient to be tachycardic at approximately 132–135 beats/min, with minimal variation in rate. The patient was also tachypneic during this episode, up to a respiratory rate of 38 breaths/min. When misplaced external monitoring device leads were removed during pacemaker interrogation, the patient's heart rate dropped to the 70s. Reapplication of the external monitoring leads replicated the tachycardia. With permanent repositioning of the leads in the ED, the tachycardia did not return. The placement of the leads was determined to have caused a plethysmography-induced pacemaker-driven tachycardia.     

Black urine due to urobilinogen in a patient with alcoholic pellagra

Objectives

Systemic exposure to drugs, chemicals and foods can cause abnormally colored urine. Food exposures are typically benign, but urine discoloration due to chemicals or drugs may indicate a potentially dangerous condition. Discolored urine can also be caused by medical problems. This brief report reviews the laboratory findings leading to lactic acidosis and elevated urine urobilinogen in an alcoholic patient with pellagra.

Design and methods

A 66-year-old male, found unconscious in his hotel room, was brought to the emergency department (ED). Upon arrival he had hypothermia, a diffuse rash and altered mental status. During ED evaluation, a urinary catheter was placed and demonstrated black urine. Medical history noted chronic alcoholism, malnutrition, and poor self-care.

Results

Evaluation in the hospital suggested that his rash and neurologic changes were a result of malnutrition and vitamin deficiency. A thorough biochemical workup demonstrated that elevated urobilinogen was likely causing the patient's black urine. Serum niacin concentration was undetectable. His dermatitis improved with multivitamins, thiamine, and niacin as well as topical steroids. His mental status returned to baseline and he was discharged to a skilled nursing facility following a brief hospital stay.

Conclusions

The patient's abnormal laboratory results were explained by his alcoholism and poor nutrition. Furthermore, urine color returned to normal with decreased concentration of urobilinogen, after vitamin supplementation and supportive medical care.     

Common emergent pediatric neurologic problems

Although there are a variety of neurologic disease processes that the emergency physician should be aware of the most common of these include seizures, closed head injury, headache, and syncope. When one is evaluating a patient who has had a seizure, differentiating between febrile seizures, afebrile seizures, and SE helps to determine the extent of the work-up. Febrile seizures are typically benign, although a diagnosis of meningitis must not be missed. Educating parents regarding the likelihood of future seizures, and precautions to be taken should a subsequent seizure be witnessed, is important. The etiology of a first-time afebrile seizure varies with the patient's age at presentation, and this age-specific differential drives the diagnostic work-up. A follow-up EEG is often indicated, and imaging studies can appropriate on a nonurgent basis. Appropriate management of SE requires a paradigm of escalating pharmacologic therapy, and early consideration of transport for pediatric intensive care services if the seizure cannot be controlled with conventional three-tiered therapy. Closed head injury frequently is seen in the pediatric emergency care setting. The absence of specific clinical criteria to guide the need for imaging makes management of these children more difficult. A thorough history and physical examination is important to uncover risk factors that prompt emergent imaging. Headaches are best approached by assessing the temporal course, associated symptoms, and the presence of persistent neurologic signs. Most patients ultimately are diagnosed with either a tension or migraine headache; however, in those patients with a chronic progressive headache course, an intracranial process must be addressed and pursued with appropriate imaging. Syncope has multiple causes but can generally be categorized as autonomic, cardiac, or noncardiac. Although vasovagal syncope is the most common cause of syncope, vigilance is required to identify those patients with a potentially fatal arrhythmia or with heart disease that predisposes to hypoperfusion. As such, all patients who present with syncope should have an ECG. Additional work-up studies are guided by the results of individual history and physical examination.     

Taking a history of the patient with diplopia

The diagnosis and treatment of adult diplopia is challenging. Having a thorough and complete history of the patient can make this difficult process easier. This article describes the most important questions to ask when taking the history of a patient with diplopia and explains why a particular question is essential. Tips of what to search for in the patient's answers are also provided.     

Postobstructive Pulmonary Edema in a 40-Year-Old Man after Suffocation by a Swimming Pool Cover

Background

Postobstructive pulmonary edema (POPE) is a form of sudden onset, noncardiogenic pulmonary edema that can occur after the relief of an upper airway obstruction.

Objective

Since POPE is an uncommon diagnosis made in the emergency department (ED), this case is presented to increase emergency physicians' awareness of the etiology, pathophysiology, and management of this type of edema.

Case Report

This is a case of bilateral POPE in a 40-year-old man with no history of cardiac or pulmonary disease who experienced near suffocation due to the vacuum effect of a swimming pool cover. On presentation to the ED, the patient's symptoms included bilateral pleuritic pain over the anterior chest, shortness of breath, and inspiratory cough. He was tachycardic and tachypneic, with an oxygen saturation of 92% on room air. Pertinent physical examination findings included shallow breathing and right-sided rhonchi. The initial arterial blood gas on room air demonstrated a PaO₂/FiO₂ ratio of 304 mm Hg. Cardiac enzymes and the electrocardiogram result were normal. The patient's chest radiograph was interpreted as having marked bilateral pulmonary edema. The patient was admitted to the Medicine Intensive Care Unit and placed on noninvasive positive pressure ventilation (NIPPV). The patient was clinically asymptomatic and was discharged after 72 h.

Conclusions

Emergency physicians should consider the diagnosis of POPE in a symptomatic patient if there is evidence of pulmonary edema immediately after a history of hanging, suffocation, strangulation, choking, naloxone administration, or other forms of upper airway obstruction. Rapid initiation of NIPPV with or without diuretics, steroids, or fluid restriction can lead to symptom resolution within 24 to 48 h.     

Iatrogenic magnesium overdose in a patient with suspected acute myocardial infarction

A case of iatrogenic, parenteral overdose of magnesium sulfate in a patient with suspected acute myocardial infarction is presented. A 73-year-old man presented with a history and physical examination consistent with suspected acute myocardial infarction and congestive heart failure. During the patient's treatment in the emergency department (ED), the physician ordered 2 g magnesium sulfate intravenously. The nurse mistakenly administered “two amps” (two 25-g single-dose vials) of magnesium sulfate intravenously. The patient developed bradycardia, hypotension, and apnea during the infusion. Although the use and inadvertent misuse of magnesium salts in obstetrics is well known, iatrogenic overdose in a patient with cardiac indications for magnesium has not been previously reported. Personnel responsible for the administration of medications in the ED must be educated about the dosing regimens and adverse effects associated with magnesium.     

The evaluation of children and adolescents with headache

Headache can be caused by primary entities (as in migraine or tension-type headache) or the pain may result from secondary causes, such as brain tumors, idiopathic intracranial hypertension, chronic meningitis, hydrocephalus, drug intoxications, paranasal sinus disease, or acute febrile illnesses (eg, influenza). To determine the nature of a child’s headache, the evaluation begins with a thorough medical history, followed by methodic physical examination with measurement of vital signs and complete neurologic examination. The diagnosis of primary headache disorders such as migraine and tension-type rests principally on clinical criteria as set forth by the International Headache Society (). Clues to the presence and identification of secondary causes of headache are uncovered through this systematic process of history and physical examination. The performance of ancillary diagnostic testing rests upon information or concerns revealed during the history and physical examination.     

Evaluating adolescents with fatigue

Although most adolescents who complain of fatigue do not have a serious medical illness, the complaint cannot be dismissed without further investigation. If the diagnosis remains uncertain after a careful history and a thorough physical examination, laboratory tests, including complete blood count, erythrocyte sedimentation rate, urinalysis and an Epstein-Barr antibody profile, may be considered next. If the etiology is still unclear, sequential visits often provide clues for the physician and reassurance for the family.     

Review article: Best practice management of common knee injuries in the emergency department (part 3 of the musculoskeletal injuries rapid review series)

Knee injuries are a common presentation to the ED and are often difficult to assess and definitively diagnose due to the patient's acute pain, effusion and guarding. The quality of ED care provided to patients with fractures or soft tissue injuries of the knee is critical to ensure the best possible outcomes for the patient. This rapid review investigated best practice for the assessment and management of common knee injuries in the ED. Databases were searched in 2017, including PubMed, CINAHL, EMBASE, TRIP and the grey literature, including relevant organisational websites. Primary studies, systematic reviews and guidelines were considered for inclusion. English‐language articles published in the past 12 years that addressed the acute assessment, management, follow‐up plan or prognosis were included. Data extraction of included articles was conducted, followed by quality appraisal to rate the level of evidence where possible. The search revealed 2250 articles, of which 54 were included in the review (n = 8 primary articles, n = 28 systematic reviews, n = 18 guidelines). This rapid review provides clinicians managing fractures and soft tissue injuries of the knee in the ED, a summary of the best available evidence to enhance the quality of care for optimal patient outcomes. There is consistent evidence to support undertaking a thorough history and physical examination, including the application of special tests and clinical decision rules for imaging. In the undifferentiated knee injury, expedited follow up and further imaging is recommended to improve patient outcomes and cost‐effectiveness.     

Emergency department management of the acute headache

Headache is a common complaint of patients seeking care at an emergency department (ED). A survey of more than 16,755 walk-in patients at an ED showed that 323 (1.9%) had a chief complaint of migraine (1). Almost one sixth of these patients had used the ED more than once. In fact, migraineurs used the ED and other health care providers 2 to 5 times more than nonmigraineurs (2). Fortunately, headaches associated with significant morbidity and mortality occur infrequently (3). The ED physician must be able to address the patient's need for pain management and establish the correct diagnosis for the headache while also ruling out any possibility of organic disease or life-threatening illness. Potential problems include ensuring appropriate follow-up and avoidance of narcotic habituation.     

Priapism

The evaluation of priapism is unfamiliar to many emergency physicians. Rapid assessment and treatment are essential in the hope of preserving sexual function. A thorough history and physical examination reveal an underlying vascular or neurologic etiology in most cases. Treatment generally consists of adequate oxygenation, hydration, and analgesia, with early urologic consultation.     

Cardiovascular evaluation of adolescents and young adults. Salient aspects of the examination

Cardiac findings in adolescents and young adults are usually normal, and most murmurs and other abnormalities that are found are benign. However, the primary care physician needs to obtain a complete personal and family history and perform a thorough physical examination to rule out cardiovascular disease and its precursors. Of primary concern are a personal or family history of syncope, family history of sudden death, and several pathologic murmurs such as those caused by mitral valve prolapse and hypertrophic cardiomyopathy. The physician may need to reassure the patient until a definitive diagnosis is made and can also provide accurate information on cardiac disease prevention.     

Rheumatic disorders in adults under 50. Guidelines for differential diagnosis

Rheumatic disorders are not uncommon in patients between 20 and 50 years of age, and the differential diagnosis may be difficult. However, after a careful history and thorough physical examination, the cause usually becomes apparent. Laboratory findings alone should not be relied on for diagnosis. Because the impact on younger adults may be devastating and the potential disability may be present for many years, these patients represent an important challenge for any practicing physician.     

Diagnostic Procedures in Uropediatric Problems

The author discusses signs and symptoms suggestive of urinary tract disease, stressing the importance of suspicion when the patient fails to respond to therapy for vague general symptoms seemingly unrelated to renal disease. No routine schedule of tests should be followed. A thorough knowledge of the function and the advantages and disadvantages of each test is necessary to determine its usefulness in the particular problem presented.

The patient's physician and the urologist should cooperate in early diagnosis and care of urinary tract lesions to prevent irreparable damage to renal function.