Case Study : Bat bites and their treatment.

     A 15-year-old adolescent boy was cleaning some items in the shed in his backyard in afternoon,when he saw a bat in middle of the shed , the boy was administered to the ED (Emergency Department) With vital signs of 115/70 mm Hg BP, heart rate of 105 beats per minute , respiratory rate of 14 breaths per minute pulse oximetry of 99% on room air, and a temperature of 37.1°C (98.9°F) Inspection of the wound shows deep bite marks with a laceration close to the proximal interphalyngeal joint. The bat escaped after the boy was bitten and was not found.

What Is The Most Likely Diagnosis? 

     Unprovoked attack by a rabies-infected bat

    Analysis : The Bat shows abnormal behaviour ; It was active in the afternoon (while bats are nocturnal creatures) , and it bit the boy -while normal bats may bite when provoked , rabies infected bats are more likely to bite . The strange bat behaviour raises suspicions towards being infected by the rabies . 

Treatment And Considerations :

      Cleaning of the patient's wound should be the first priority , the medical service provider should keep in mind that the patient was bit close to the joint space of the proximal interphalengeal joint , take care of the possibility of retained teeth . The patient's tetanus status should be constantly checked . 

       In this patient’s case, postexposure prophylaxis for rabies and delayed primary closure to observe for infection are reasonable. Postexposure prophylaxis for rabies should include a combination of immediate, passive (rabies immunoglobulin) immunization and active immunization (human diploid cell vaccine). Tetanus vaccine should be administered if the patient has not received it within the last 5 years.

       The Animal Control agencies should be contacted to notify them of the loose animal so they deal with it , in order to avoid any further bite attacks .

5 Important issues in Clinical Problem Solving

 CLASSIC CLINICAL PROBLEM SOLVING 

There are typically five distinct steps that an emergency department clinician undertakes to systematically solve most clinical problems: 

 1. Addressing the ABCs and other life-threatening conditions 

 2. Making the diagnosis 

 3. Assessing the severity of the disease 

 4. Treating based on the stage of the disease 

 5. Following the patient’s response to the treatment

Definition of Azotemia

 AZOTEMIA: Presence of nitrogenous bodies, especially urea, in the blood that develops in urinary tract obstruction when overall excretion function is impaired

What to consider in Management of Acute Urinary Retention Case

Many disease processes, trauma, and medications can result in acute urinary retention  In elderly men, the most common cause is prostatic hypertrophy.

As with this patient, a thorough history and physical examination can help elucidate the etiology of the urinary retention. 

Passage of a urethral catheter to alleviate

the obstruction will bring about significant pain relief. 

Assessment of renal function is important, as is obtaining a urinalysis to rule out concomitant urinary tract infection. Imaging studies in the ED are rarely necessary for these patients, although

bedside ultrasound may help identify bladder distention or a clot in the bladder.

Depending on this patient’s renal function and physical status after drainage of his

bladder, he may require admission

Case Study Discussion : 65 years Man unable to urinate for 65 years

A 64-year-old man presents to the  (ED) because of an inability to urinate for the past 24 hours. 

In addition, he complains of an unintentional weight loss of 20 lb over the past 6 months , night sweats, and generalized fatigue. On examination, he is thin and in moderate distress. His BP is 168/92 mm Hg, heart rate is 102 beats per minute, temperature is 37.7°C (98.8°F),

and respiratory rate is 22 breaths per minute. The abdominal examination reveals

a tender mass in the suprapubic area. 

rectal examination, the prostate is firm, nontender, and somewhat irregular.

What is the most likely diagnosis

 How would you confirm the diagnosis

 What is the next step in treatment

 A 64-year-old man presents with an inability to void for the past 24 hours

and a tender mass in the lower abdomen. The patient has signs and symptoms

suggestive of prostate cancer, including unintentional weight loss, night sweats, a

decrease in energy, and an enlarged irregular firm prostate gland.

• Most likely diagnosis: Acute urinary retention likely due to prostate cancer.

• Confirming the diagnosis: Thorough history and physical examination including a rectal examination, urinalysis, electrolytes and renal function tests, along

with bedside ultrasound, if available. Prostate-specific antigen may help in the

diagnosis of neoplastic disease if results will be available in the ED.

• Next steps in treatment: Draining the bladder by inserting a urethral catheter

should relieve the patient’s pain; if not, a suprapubic catheter can be placed.

Treatment of the underlying disease process is also necessary.

Malignant causes of LBP , etiology , Clincal Picture , Diagnostics and Treatment

Aetiology

Common Cause metastatic  breast, prostate, lung 

May also be primary loke multiple myeloma, leukemia, lymphoma

Clinical Symptoms Analysis

Pain lasting longer than 1 month, worse at night, unrelieved by rest; unexplained

weight loss; 

mild tomoderate spinal tenderness

Diagnostic tools

CBC, ESR,

plain x-ray, CT,

MRI

Treatment in Emergency Departement 

intravenous dexamethasone

and  refer for radiation therapy

Spinal Infection , etiology , Clinical Picture , Diagnostics and Treatment

Etiology

Most commonly due

to Staphylococcus.aureus

Risk Factors

intravenous drug use

elderly, immunocompromised, alcoholism, recent bacterial

Signs and Symptoms

infection or back trauma

Back pain (even at rest/

night), fever, midline

cultures, tenderness

along spine.

Focal neurologic deficits as late finding

Diagnostics 

CBC, ESR,

 plain x-ray 

C.T

MRI - preferred

Treatment

Intravenous

antibiotics,

surgical drainage

and

decompression

Red Flag Signs and Symptoms of Low Back Pain LBP

 Patients younger than 18 years old or older than 50 years 

Significant trauma (or mild trauma in patients older than 50 years) 

Chronic steroid use 

Osteoporosis 

History of cancer Recent infection 

Immunocompromise 

History of intravenous drug use 

Pain worse at night, 

lasting longer than 6 weeks,

 or refractory to analgesics and rest 

Associated systemic symptoms (fever, unexplained weight loss, malaise, night sweats, diaphoresis, nausea, syncope) 

Acute onset Use of anticoagulants or coagulopathy 

Abnormal vital signs (including unequal blood pressures or pulse deficits) 

Neurologic deficits (including extremity weakness, numbness, paresthesias, loss of rectal sphincter tone, urinary retention)

Cauda Equina Syndrome Case Study , Cardinal Signs

A 57-year-old man 

  one month history of worsening low back pain 

 radiates down the back of both legs and suddenly increased yesterday.

 For the past 2 days,  have difficulty voiding

 skin around his anus feels numb when he wipes with toilet tissue. 

He denies prior trauma to or surgery on his back. 

- Most likely diagnosis: Cauda equine syndrome

Aetiology Central disk herniation multiple, involving bilateral nerve roots 

  the next diagnostic step MRI

Why Cauda Equina and not other causes of LBP because cardinal signs of Cauda equina syndrome are 

, urinary retention and overflow incontinence, decreased rectal tone, saddle anesthesia