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Robodoc's Trauma Puzzle # 2

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  • Robodoc's Trauma Puzzle # 2

    29 year old man involved in single vehicle rollover on freeway. Brought in full spinal precautions by paramedics as level I trauma. Patient is confused, combative and perseverating on arrival. No history is obtainable.

    On exam: BP= 95/60, P=112, R=28, SaO2=94% room air
    Primary Survey intact
    Secondary trauma survey = thin asthenic pale man who appears older than stated age of 29. No visible or palpable trauma to head, neck, torso or extremities. GCS = 12 (E3,V4,M5)

  • #2
    Would give IV fluids & insert Foley to get urine drug screen ASAP. Check BG/give 1 amp D50W if not done in field. Head CT, though I suspect money is on drug screen, given lack of overt evidence of trauma.
    - Sue

    End the chaos - kill the butterflies!

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    • #3
      Field accucheck not performed; On arrival in Trauma suite: fingerstick Glucose = 55mgm%; NA=128, chlor 89, K=2.9, BUN = 30 Creatinine = 1.8; WBC= 2.8K Hgb/Hct = 7.6 & 22.4 with 55K and macrocytic indices; CT brain = negative; CT C-spine negative; CT abdomen/pelvis negative; UA = specific gravity = 1.015 otherwise normal; UDS = positive for THC. Patient refuses foley. 1 amp D50 given IV without change in mental status - patient remains confused and intermittently uncooperative. Recheck fingerstick glucose is now 225 mgm%. Patient vomits x 1 yellowish bilious material that is gastrocult negative. 2 liters IV normal saline given bolus. BP = 92/50; P = 66; R= 24

      Where do we go from here?
      Ragster

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      • #4
        Does he have any long bone fractures?
        Bigdoc

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        • #5
          Wait, he's immunosuppressed. What's the temp? Is this guy septic too? Does he have AIDS dementia or other CNS infection?

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          • #6
            No long bone fractures. Rectal temp = 103.4 degrees F. Tylenol ordered. Blood cultures x 2 and urine culture ordered. Patient seizes just as "significant other" arrives in ED to provide additional history.

            Interested? What next?
            Ragster

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            • #7
              Stop seizure and LP?

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              • #8
                Sounds like underlying hematologic path like AIDS, post-chemo, or undiagnosed lymphoma. Agree with need to control seizures, but wonder about intracranial pressure as well as febrile seizure.

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                • #9
                  Once again, I didn't fool ya'all with this case! Significant other (male partner) advises docs of patient's positive HIV/AIDS. Patient actually had been complaining to SO for several days of fever and headache and decided to drive self to hospital ED (not trauma center) for eval. PAtient on retroviral therapy with a T4 count of 150 - viral load not known. Retrovirals probably explain macrocytic changes on CBC. LP performed revealing crytococcal CNS disease. Patient actually did well (short term) once condition recognized and treated. MVC was "red herring" and probably resulted from ALOC or seizure from primary infectious problem.

                  Case serves to illustrate the importance of basic vitals - in this case overlooked temperature - which can be critical to formulating appropriate ddx.
                  Ragster

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                  • #10
                    Thanks, Ragster. Good series of exercises, a bit of work to put together.

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