David is a 21-year-old college student who comes into the provider’s office with a complaint of headache.

As you watch this encounter, you will be asked to answer questions while the image on the screen freezes. These questions will engage you in practicing the skills of focused history taking, physical examination, and clinical reasoning as you develop your preliminary differential diagnosis.

You are expected to develop three diagnoses with supporting history and physical examination findings, and to list the diagnostic workup studies you would order.

You will have time to record your findings and receive feedback. You may go back to review the video again.

What are 3 potential diagnoses? Explain your rationale to support each diagnosis.

What symptoms does he offer?

Summarize how David describes his headache.

What other associated symptoms does he report?

David’s vital signs are:

BP 100/60

HR 100

RR 20

T 99.1

Are any of these vital signs abnormal or concerning? If so, why? If not, why not?

What areas of the assessment are important to complete at this time?

What abnormal assessment findings are identified?

Describe the Babinski reflex. Why is this important?

Describe the Brudzinski sign. Why is this important? What does a positive sign indicate?

Describe the Kernig sign. Why is this important? What does a positive sign indicate?

Now that you have obtained information and completed the assessment on David, what are 3 potential diagnoses? List in order of priority and give your rationale.

What are 3 diagnostic studies you will complete? List in order of priority. What is the purpose of each diagnostic study?

Mr. Jerry Smith, 59 y/o male, arrives via ambulance to the emergency department. He reportedly has a fever. EMS inserted a 22 g IV to the left hand and Normal Saline is infusing.

Hx- Paraplegia, HTN

EMS Vital Signs:

BP 140/80

HR 110

RR 16

SpO2 98% Room Air

Patient is met by the ED team. He reports a fever since the morning, staff gave him one ES Tylenol and he says “I think it helped a little”.

Currently the patient denies pain.

He has an indwelling urinary catheter.

He reports that his paraplegia starts at the level of his umbilicus.

What are the initial assessment findings by the nurse? Doctor Barker?

Are you concerned about this patient upon arrival to the ED? Please explain your rationale.

The nurse is attempting to insert an IV, but the patient has poor vascular access. After a couple attempts, the nurse was able to obtain some of the blood for labs.

What problems can this lead to?

Mr. Smith has reported that he was hospitalized for a UTI about one year ago. He has had the indwelling urinary catheter in place since his accident about 5 years ago. His current catheter has been in place for one month.

How often should a urinary catheter be changed?

How do you obtain a urine sample from the catheter?

Dr. Barker states the patient has SIRS criteria and has ordered the following:

CBC

CMP

Lactate

Blood cultures

Urinalysis and urine culture

Chest X-ray

What would you expect to find that is consistent with infection?

Since this is a small hospital, they utilize eICU nursing. The patient is started on Zosyn 3.375 Gm for the UTI and previous history of pseudomonas. They added Vancomycin one gram for antibiotic coverage for the sacral wound.

Staff still have not been able to obtain additional IV access, so Dr. Barker places an intraosseous line in the left humerus. The patient is given IV fluids at 30 mL/kg. The patient weighs 100kg. How much IV fluid should he receive? Over what period of time?

While monitoring the patient, the eICU nurse alerts the staff to a change in the patient’s mental status. After his IV fluids have infused his BP remains low.

Dr. Barker has ordered the patient to be transferred to the larger hospital. Additionally ordered Norepinephrine 4 mcg/min, and to titrate to keep the MAP > 65 mmHg.

Calculate the infusion rate for the Norepinephrine 4 mcg/min.

Available is 8mg in 250 mL % Dextrose.