Adapted from Rosens, chp 16.
Little Old Lady Workup (LOL)
Testing to consider in an elderly patient with altered mental status
ABG: hypoxia, CO2 retention, SOB
BMP/CMP: electrolyte abnormalities, hepatic encephalopathy
UA: infection, DKA, ingestion
PT/INT: hemorrhage, anemia, hypercoagulable
Lactate: ketotic state, ingestion, ischemia
TSH: thyroid storm, hypothyroid
Cardiac Enzymes: MI, ischemia, cardiogenic shock
CXR: infection, pneumothorax, CHF
CT head: hemorrhage, mass
MRI: edema, mass, ischemia
CTA: pulmonary emboli, aortic dissection
LP/CSF: infection, ICP
The Himmelfarb librarians have built an extensive reading list for internal medicine sub-specialties, from Cardiology to Infectious Disease. These are a great resource for studying up on both bread and butter as well as zebras.
Teaching Pearl: Bell's Palsy can be easily diagnosed by clinical examination, however the treatment varies depending on severity and the patient's own medical history. You should never prescribe steroids longer than antivirals, due to the possibility of a viral infection progressing while steroids are continued. Additionally, any patient who has a House-Brackmann score of IV or more, must go home with instructions and material to tape their eye shut at night, otherwise, they risk corneal abrasions and ulcers. You should also consider antivirals, and be sure to check their auditory canals for signs of herpetic skin lesions.
Can a CT read within 6 hours of headache onset can rule out SAH without the need for a lumbar puncture? This study found a 99% NPV of staff-read CTs in 11 non-academic centers with a 1/15,200 missed aneurysmal SAH. This study did not discuss the accuracy of resident or emergency medicine interpretations of CT scans.
A multicenter, retrospective study of 11 non-academic centers. Included patients older than 16, with acute-onset headache of known duration without focal deficits or altered mental status. To be included, patients had to undergo a CT in <6 hours from headache onset and a lumbar puncture >12 hours from headache onset. 760 patients were included with 52 positive CSF findings. On review of CT imaging, 51 were considered negative, and only one perimesencephalic nonaneurysmal SAH was found, and no readmissions due to SAH.
Adapted from a presentation by Ty Nichols, 12/2/2015
Dizziness can be difficult to assess in the ED given the vast range of etiologies and varying ways patients interpret their symptoms. Additionally, not all patients with emergency conditions will present with obvious focal deficits. A clinical decision making rule (HINTS) can help to more rapidly identify stroke patients to initiate acute therapies faster. The HINTS rule outperforms ABCD2 for stroke diagnosis in the ED when performed by qualified practitioners in patients with Acute Vestibular Syndrome.