Tuesday, February 7, 2023
This activity is intended for clinicians in primary care, emergency care, and infectious diseases.
The goal of this activity is to reinforce and highlight common concepts, situations, and presentations that clinicians will encounter on a regular basis in order to provide supportive continuing education that illustrates real-world conditions and situations.
Upon completion of this activity, participants will be able to:
As an organization accredited by the ACCME, Medscape, LLC requires everyone who is in a position to control the content of an education activity to disclose all relevant financial relationships with any commercial interest. The ACCME defines "relevant financial relationships" as financial relationships in any amount, occurring within the past 12 months, including financial relationships of a spouse or life partner, that could create a conflict of interest.
Medscape, LLC encourages Authors to identify investigational products or off-label uses of products regulated by the US Food and Drug Administration, at first mention and where appropriate in the content.
Medscape, LLC is accredited by the Accreditation Council for Continuing Medical Education (ACCME) to provide continuing medical education for physicians.
Medscape, LLC designates this educational activity for a maximum of 0.25 AMA PRA Category 1 Credit(s)™ . Physicians should only claim credit commensurate with the extent of their participation in the activity.
Medscape is accredited as a provider of continuing nursing education by the American Nurses Credentialing Center's Commission on Accreditation.
Awarded 0.25 contact hour(s) of continuing nursing education for RNs and APNs; none of these credits is in the area of pharmacology.
For questions regarding the content of this activity, contact the accredited provider for this CME/CE activity noted above. For technical assistance, contact [email protected]
There are no fees for participating in or receiving credit for this online educational activity. For information on applicability
and acceptance of continuing education credit for this activity, please consult your professional licensing board.
This activity is designed to be completed within the time designated on the title page; physicians should claim only those
credits that reflect the time actually spent in the activity. To successfully earn credit, participants must complete the
activity online during the valid credit period that is noted on the title page.
Follow these steps to earn CME/CE credit*:
processing....
 Figure 1. (Click to enlarge) |
 Figure 2. (Click to enlarge) |
A 30-year-old woman presents to the emergency department (ED) with malaise, diffuse myalgia, and a rash that has spread all over her body (see Figures 1 and 2). Her symptoms began the day before presentation and initially improved with ibuprofen. Her boyfriend, who has accompanied her to the ED, adds that she has been vomiting, has appeared to be in pain with movement, and has even had intermittent confusion during the night. She has developed a headache of moderate intensity that is diffuse, radiating to her neck, and worsens with movement. She does not have any photophobia or dizziness, and she has not experienced any seizures. She denies having any subjective fevers, abdominal pain, hematemesis, or diarrhea. She has not had any urinary complaints or low back pain. She denies having cough or shortness of breath. The patient's past medical history is only remarkable for trauma that occurred 3 months ago and resulted in rib fractures and blunt abdominal trauma. At that time, she underwent an exploratory laparotomy, with suture repair of liver lacerations and a right kidney laceration; she has been doing well since then. The patient does not have any chronic medical conditions and does not take any regular medications. She smokes cigarettes but denies heavy alcohol use or illicit drug use.
On physical examination, she appears drowsy and uncomfortable. Her oral temperature is 100.9°F (38.3°C). She is tachycardic and hypotensive, with a heart rate of 120 bpm and a blood pressure of 80/60 mm Hg. Her respiratory rate and oxygen saturation are normal (at 16 breaths/min and 99% while breathing room air, respectively). She grimaces in pain with movement of the joints, particularly with movement of her neck, which is limited. Her pupils are 3 mm and equally reactive. Her neurologic examination, including a cranial nerve inspection, is normal (except for her drowsy mental status). She has a nonpainful purpuric rash on her arms, trunk, and face consisting of patchy macules approximately 1-4 cm in diameter (see Figures 1 and 2). There is no cervical, axillary, or inguinal lymphadenopathy. Her lungs are clear and her heart sounds are normal, without any murmurs or gallops. She has a soft and nontender abdomen, with no splenomegaly. There is no midline spinal tenderness or costovertebral angle tenderness. There is no evidence of joint involvement, and no tenderness or swelling are noted. The remainder of the examination is unremarkable.
Laboratory studies show an elevated white blood cell (WBC) count of 17.6 × 103/µL (17.6 × 109/L), a hemoglobin of 13.6 g/dL (136 g/L), and a platelet count of 54 × 103/µL (54 × 109/L). Her creatinine is 3.3 mg/dL (291.7 µmol/L) and her blood urea nitrogen (BUN) is 57 mg/dL (20.4 mmol/L). The electrolyte concentrations and hepatic studies are normal. The patient's myoglobin and creatine kinase concentrations are elevated at 332 µg/L and 149 U/L (149 units/L), respectively. The C-reactive protein (CRP) is high at 22 mg/dL. Her partial thromboplastin time (PTT) is elevated at >120 seconds, with an international normalized ratio (INR) of 2.14. The d-dimer is markedly elevated at >10 µg/mL (10 mg/L). Her serum pregnancy test is negative. An arterial blood gas shows a pH of 7.3, a lactate of 64.9 mg/dL (7.2 mmol/L), a partial pressure of carbon dioxide (pCO2) of 35.4 mm Hg, a partial pressure of oxygen (pO2) of 318 mm Hg, and an oxygen saturation of 99.3% while using an oxygen mask at 10 L/min. Blood cultures are drawn and sent to the laboratory.
