The image demonstrates the large chronic-appearing wound of the patient’s anterior chest as well as the visible fractured segments of the patient’s exposed sternum. The sternum is necrotic appearing concerning for a chronic process including osteomyelitis and malignancy. Purulent drainage is visible on the wound consistent with an infectious process.
Her physical exam was notable for multiple scattered tense vesicles on an erythematous base along the left and right lower extremities and right upper extremity. The lesions were excoriated and in different stages of evolution. No oral, mucosal, or conjunctival lesions were found. Physical exam was otherwise unremarkable.
At the conclusion of the simulation session, learners will be able to: 1) Obtain a relevant focused history including pregnancy history, medication use, and past medical history. 2) Develop a differential for fever and vaginal bleeding in a pregnant patient. 3) Discuss management of septic abortion, including empiric broad-spectrum antibiotics and obstetric consultation for source control with dilation and curettage (D&C). 4) Discuss expected laboratory findings of disseminated intravascular coagulation (DIC). 5) Discuss management of DIC, including identification of underlying etiology and supportive resuscitation with blood products. 6) Review the components of blood products. 7) Identify appropriate disposition of the patient to the intensive care unit (ICU).
Point-of-care ultrasound (POCUS) demonstrates a large, subcutaneous mass with areas of mixed echogenicity. The mass contains fluid-filled, anechoic areas with internal septations and absent doppler flow. The majority of the mass appears isoechoic to the surrounding tissues with a hyperechoic border. Computed tomography (CT) of his right thigh shows a 16 x 8.1 x 9.5 cm heterogenous, complex mass within his hamstring muscles, inferior to the femur. His lab work was significant for a white blood cell (WBC) of 17.3 (103/µL).
While still in the ED, MRI with and without gadolinium contrast of the brain, orbits, and cervical, thoracic and lumbar spine were obtained to evaluate for possible CNS lesions including encephalitis, myelitis, or demyelination. Imaging, however, demonstrated multiple unexpected findings: a T1 hypointense, T2 hyperintense and heterogeneously enhancing right adrenal mass measuring 2.7 x 2.1 x 3 cm (yellow asterisk) along with heterogenous enhancement at the clivus, C6, C7, T7, T8, T12, and L3 vertebral bodies (red asterisks). There were otherwise no significant intracranial signal or structural abnormalities and normal orbits.
After completing this simulated case, participants will be able to: 1) Obtain a detailed history that includes recent medications, medical, surgical, and social history to evaluate for HIT risk factors, 2) perform an adequate neurovascular exam including evaluation of motor function, sensation, skin color, pulses, and capillary refill, 3) order appropriate laboratory testing and imaging for diagnosis of thrombocytopenia and arterial occlusion, including bed side doppler or ultrasound, 4) discuss and recognize the symptoms of HIT and the contraindications of platelet and heparin administration in the emergency department, 5) avoid administration of heparin in the emergency department setting and recognize that platelets may worsen thrombus formation and lead to limb amputation, 6) select appropriate medications for treatment and determine appropriate disposition for a patient presenting with HIT, 7) demonstrate interpersonal communication with patient and family, 8) recognize that HIT with thrombosis is a potential complication in hospitalized patients and outpatient settings and is associated with high mortality rates.
The physical exam revealed globalized pallor of his skin as well as conjunctival pallor. Mucous membranes were found to be dry and pale with dried gingival hemorrhages apparent between teeth (image). Additionally, mild hepatosplenomegaly was noted. While in the ED, the patient’s urine was dark reddish-brown, which he then reported had been similarly discolored for the past 7 days.
By the end of this simulation, the participant will be able to: 1) create a thorough differential for the undifferentiated febrile, altered patient, 2) identify the signs and symptoms of blast crisis, 3) describe proper resuscitation of a patient in blast crisis, and 4) describe the indications, steps, and contraindications of performing a lumbar puncture.