Usmle Step 3 CCS cases part 3

Case 41[edit]

Location: office Presenting complaint: A 22-year-old woman presents with hirsutism.

Vitals: Pulse:80/min; BP: 122/82 mm Hg; Temp: 98.7 F, R.R: 16/min; Height:162.5cm; Weight: 90 kg (198 lbs).

History of present illness: A 20-year-old obese white female comes to the physician office with the complaint of male pattern body hair. She states that besides facial hair, hair is also present on her chest and on the lower abdomen. Her other complaints are amenorrhea for the last 4 months and obesity. She states that her menses have always been irregular since her first menses at the age of 14 years. She neither smokes nor drinks alcohol. She is not using any prescribed or recreational drugs. She has never been sexually active. She denies any other complaints. She is allergic to penicillin. FH: Father is healthy. Mother has a H/O DM. She does not use any recreational drugs. She is un-married. Review Of Systems are unremarkable.

How to approach this case? Important points to note in this young female are hirsutism, secondary amenorrhea, and obesity. These findings point towards the diagnosis of polycystic ovarian disease (PCOD). Other possible causes are hyperprolactinemia, late onset congenital adrenal hyperplasia, and androgen secreting tumors.

Diseases like Cushing’s syndrome and hypothyroidism also need to be ruled out as a cause of obesity. This patient is very stable and is coming for evaluation first time with you.

So, she needs complete physical examination. We also need to examine her skin for pattern of hair distribution, and genitalia for any evidence of virilization.

Ok first order the examination part: Complete physical examination (or) General, HEENT/Neck, Lymphadenopathy, Lungs, Heart, Abdomen, Pelvic exam, Extremities, Skin, and Neuropsychiatric.

Here are the results of your examination: Young obese female, not in acute distress. Hair are noted on the upper lip, chin, around nipples, and on linea alba.

Rest of the examination is normal.

Discussion: The most widely used criteria for the diagnosis of PCOS is: 1. Clinical or biochemical evidence of hyperandrogenism 2. Menstrual dysfunction (Fewer than 6-9 cycles per year) 3. Exclusion of other common causes of hyperandrogenism Many biochemical abnormalities are encountered in cases of PCOS. These include high serum androgens, high serum estrone with normal serum estradiol, high serum LH with normal serum FSH, and impaired glucose tolerance. Both total and free serum testosterone concentration is elevated. Finding of polycystic ovaries on USG is nonspecific for the diagnosis of PCOS.

Differential diagnosis: PCOS is a diagnosis of exclusion. PCOS and idiopathic hirsutism account for more than 95 percent cases of hyperandrogenism in females. Other causes are late-onset congenital adrenal hyperplasia, ovarian and adrenal tumors, drugs and hyperprolactinemia. In cases of hyperprolactinemia, menstrual dysfunction is prominent without any evidence of hyperandrogenism and serum prolactin levels are elevated. 24 hour urine cortisol, and 17-ketosteroids are indicated for suspected Cushing's syndrome. Late onset congenital adrenal hyperplasia is a rare disorder and can be ruled out by post-ACTH serum 17-hydroxyprogesterone levels.

In cases of androgen-secreting tumors, there are signs of virilization and serum LH concentration is low. Serum testosterone (>150 ng/dl) and serum dehydroepiandrosterone (>800ug/dl) levels are high in ovarian and adrenal tumors respectively.

Order routine labs: Urine testing for beta-HCG (as she has history of amenorrhea) Serum testosterone total and free Serum DHEAS Serum prolactin 24-hour urine cortisol 24-hour urine 17-ketosteroids Serum TSH Serum LH Serum FSH Pelvic ultrasound, routine Follow up visit when results are available.

Results of labs: Urine testing for beta-HCG: negative Serum testosterone total and free: total is 100ng/dl and free is 5ng/dl Serum DHEAS: normal Serum prolactin: 10ng/ml Serum cortisol: normal Serum TSH: 1microU/L Serum LH: 60 IU/L Serum FSH: 15 IU/L Pelvic ultrasound: Ovaries shows peripheral "strings of pearls" sign.

TREATMENT: All women with the diagnosis of PCOS should be initially evaluated for metabolic risk factors. The most common metabolic abnormality associated with PCOD is type 2 DM and impaired glucose tolerance. Measurement of weight, blood pressure, and fasting lipids are recommended in all patients. 2-hour glucose tolerance test with 75 g of oral glucose load is indicated in obese women with PCOD. Routine measurement of serum insulin levels is not indicated for various reasons. Weight reduction in obese females and use of drugs that decrease insulin resistance in both obese and non-obese reverse many abnormalities of PCOS. The drugs used for this purpose are metformin, troglitazone, and D-chiro-inositol.

Unopposed estrogen action may result in endometrial hyperplasia and endometrial Ca. To decrease this risk, OCPs are given and progestin present in them antagonizes the effect of estrogen. Another benefit of this therapy is inhibition of androgen production and increase in sex-hormone binding globulin levels. OCPs are therefore the treatment of choice for women who don’t want to conceive. Patients with PCOS who have evidence of DM should be treated with metformin. Metformin is preferable over thiazolidinediones for possible teratogenicty. OCPs are indicated in conjunction with metformin if they do not want to become pregnant. For hirsutism, hair is removed by shaving, electrolysis, laser treatment, and depilatories. Hair growth is slowed by an OCP alone or an OCP combined with antiandrogen. In cases of infertility, other possible causes of infertility are first ruled out by appropriate testing and only then ovulation induction is attempted. Clomiphene citrate is usually used for this purpose. Other agents include GnRH and exogenous gonadotrophins.

Patient’s with LDL of more than 160 without risk factors, or >130 with risk factors, >100 with known CAD should be treated with HMG-CoA inhibitor.

ORDER REVIEW: Fasting lipid profile Glucose tolerance test Counsel the patient/Patient education Weight reduction Low fat, low caloric diet Regular exercise OCPs Pap smear Follow up in 1 week with the results Primary Diagnosis: PCOD

Case 42[edit]

Location: Office Vitals: B.P: 140/88 mm Hg; P.R: 80/min; R.R: 17/min; Temp: 36.8C; Height: 150 cm; Weight: 80 kg.

C.C: A 52-year-old woman comes to you with the complaint of sleeplessness.

History of present illness: A 52-year-old African American woman comes to you with the complaint of sleeplessness for the past few weeks. She believes that her inability to sleep is due to episodes of excessive warmth, diaphoresis, and palpitations occurring while she’s trying to sleep. The episodes appear to be unrelated to any specific triggers, and last 3-5 minutes. These episodes occur during the daytime as well.

She gets comfort in cool environment during these episodes. She had similar symptoms three months ago, which ended spontaneously. She states that she has gained weight in the last couple of months. She has been having occasional episodes of urine incontinence associated with laughing for the last couple of months. She denies diarrhea, abdominal pain, cold intolerance, and feelings of guilt. However, she is irritable about these episodes. She hasn’t had a menstrual period for the last 12 months, which was preceded by a couple of months of irregular menstrual cycles. Menarche was at the age of 13. She had two episodes of gonorrheal cervicitis, which were adequately treated. She has been sexually active, with multiple partners, throughout her life. She felt pain during her last sexual intercourse. She has been feeling vaginal dryness for the last few months. She has never been tested for HIV. Her last pap smear one year ago was within normal limits. She has hypertension for which she takes hydrochlorothiazide. She has no known allergies. Her current medications include over the counter vitamins, and hydrochlorothiazide. There is no significant family history. She has been smoking 10 to 15 cigarettes/day for the last 16 years. She occasionally drinks alcohol on the weekends. She has not been sexually active for the last two years. She has never been married. Review of systems is unremarkable. How do you approach this case? This woman is most likely going through menopause. Her sleep difficulties are simply due to hot flashes. The diagnosis of menopause is established when amenorrhea is present for six months or more and symptoms like hot flashes, or vaginal dryness are exhibited. When there is some doubt, high FSH level confirms the diagnosis. LH levels are less helpful.

This patient has hot flushes, vaginal dryness, insomnia, urine incontinence, and 12 months of amenorrhea. You don’t need to order FSH, LH in the presence of symptoms such as amenorrhea, hot flushes, and vaginal dryness. In patients who have had a hysterectomy, elevated FSH is of diagnostic value.

When women develop symptoms of estrogen deficiency, estrogen replacement therapy should be started. Estrogen replacement therapy puts them at an increased risk for endometrial hyperplasia, and endometrial cancer. Therefore, endometrial thickness should be measured yearly by vaginal ultrasonography in those with endometrial thickness greater than 0.4 mm. Short-term effects of estrogen deficiency: The most frequent short-term effects of estrogen deficiency are hot flashes.

Estrogen is the most effective therapy. Hot flashes may cause inability to sleep that may result in irritability, depression, and other emotional, and psychological complaints. Urinary incontinence and UTI are associated with menopause. Urinary incontinence occurs due to the atrophy of urothelium resulting from estrogen deficiency. Systemic or topical estrogen may prove effective. Estrogen deficiency results in decreased vaginal lubrication, vaginal atrophy, vaginal dryness, and dyspareunia. Estrogen is used to treat dyspareunia.

Long-term effects of estrogen deficiency: Osteoporosis is a very important long-term effect of estrogen deficiency. Bone mineral density should be measured in women who are at risk for osteoporosis.

Onset of dementia may be delayed by estrogen replacement therapy. All postmenopausal women should be examined annually and risk factors for heart disease, osteoporosis, and breast cancers need to be determined.

This patient is stable. Order complete physical and rectal examination.

Order: Complete physical examination. Results of the examination: Completely normal physical exam Discussion The patient is going through menopause. However, she needs a couple of tests to ascertain her risk for colon cancer, breast cancer, cervical cancer, osteoporosis, and heart disease. She needs a sigmoidoscopy along with the fecal occult blood test to check the risk for colon cancer, as she is over 50 years old. Order: Pap smear Mammogram, bilateral, screening Fasting lipid Profile DEXA Scan Fecal Occult Blood Test (FOBT) Flexible Sigmoidoscopy Results: Mammogram: Normal Fecal Occult Blood Test: Negative Flexible Sigmoidoscopy: Negative Lipid Profile: Serum Cholesterol190 mg/dl (150-240) Serum Triglycerides 98 mg /dl (35-160) VLDL 26 mg/dl (<40) LDL 110 mg/dl (<160) HDL 40 mg/dl (30-70) Deal Energy X-ray Absorptiometry (DEXA Scan): The scan detected bone density over the hip, spine, and radius. The bone density was found to be 1.25 standard deviation less than expected for her age.

Impression: Osteopenia Review of orders: Hormone replacement therapy; combined estrogen and progestins PO Calcium Carbonate (Oral), continuous Vitamin D (Oral), continuous Advise for HIV testing by ELISA after appropriate counseling (Because she has a H/O STD) Consider counseling about the following Smoking cessation Limit alcohol Exercise program Use of seat belt Medication compliance Low salt diet (She has HTN) Discussion: If there are less than two risk factors (HTN, smoking, hyperlipidemia, DM, family history) in a woman, her LDL should be less than 160 mg/dl. If the risk factors are more than two, then her LDL should be less than 130 mg/dl. Estrogen is helpful for hot flashes and prevention of osteoporosis. In women who still have their uterus, estrogen must be combined with progestins. Calcium, vitamin D, and a good exercise program are all helpful in preventing osteoporosis.

Case 43[edit]

Location: Emergency Room C.C: A 42-year-old alcoholic male presents in a state of confusion.

Vitals: Pulse:102/min; B.P:160/88 mm Hg; Temp:99.90F; R.R:26/min.

History of present illness: A 42-year-old male, who chronically abused alcohol for the last 10 years, is brought to the ER in a state of confusion. His family reports that he has been having auditory hallucinations, tremors, nausea, fever, tachypnea, 2 episodes of non bloody vomiting, and insomnia for one day. He was seen on two previous occasions in the ER for alcohol intoxication. Further questioning reveals that he drank excessively three nights ago prior to the development of these symptoms. There is no complaint of headache or neck stiffness. He denies use of prescribed or recreational drugs. There is no history of fall or trauma. He has no known allergies. He is not taking any medication. SH: He is un-married and has no children. He lives with his parents. He has been drinking alcohol for twenty years. He used cocaine for some time 5 years ago, but quit. He smokes occasionally. Review Of Systems is unremarkable.

How to approach this case? Here we are dealing with an alcoholic patient who is most likely suffering from withdrawal/delirium tremens. Delirium tremens is a serous form of alcohol withdrawal, which is characterized by disorientation, hallucinations, tachycardia, high BP, fever, and diaphoresis. It typically occurs between 2 to 3 days after last drink. However, it may occur up to 7 days. Examination is performed to find out signs of alcohol related diseases like liver disease and pancreatitis as well as to rule out other causes of altered mental status (infection, trauma).

We will perform relevant examination, draw samples for labs and immediately start treatment in the emergency department. Order the physical examination: General Heart and Lungs Neuropsychiatric HEENT/Neck Abdominal Extremities Results of the examination: Significant findings on examination are tachycardia, tachypnea, hyperthermia, diaphoresis, tremor, ataxia, disorientation, and hallucination. His mucus membranes are dry. No neck stiffness or other meningeal signs present.

Mild hepatomegaly is present.

Patient is confused, disoriented, combative and abusive.

Heart and lungs are clear.

Pupils are equal and reacting to light. No papilledema.

No peripheral edema Emergency care: Pulse oxy, stat and continuous Supplemental oxygen, inhalation, continuous Cardiorespiratory monitoring, continuous Intravenous access IV normal saline bolus then continuous Blood glucose, stat (chronic use of alcohol may result in hypoglycemia due to decreased glycogen stores) NPO except meds EKG, 12 lead, stat IM thiamine, continuous PO folic acid 1 mg daily IV Lorazepam, continuous for moderate sedation Soft restraints Aspiration precautions Tests can be ordered once emergency measures are taken.

Labs: CBC, stat (as alcoholism cause hematological abnormalities like thrombocytopenia and macrocytosis, and also to look for evidence of associated infection which will cause elevation in WBC counts) BMP, stat Liver function tests (LFT), stat (for alcoholic liver disease) PT/INR, stat (associated live disease and its coagulopathy) PTT, stat (associated live disease and its coagulopathy) Serum magnesium, stat (hypomagnesemia may be associated with alcoholism) Serum phosphate, stat (hypophosphatemia may be associated with alcoholism) Draw blood for culture, stat (infection may be associated with DT) ABGs, stat (to exclude alcoholic ketoacidosis) Urine toxicology screen, stat Blood alcohol levels, stat Chest X-Ray, PA view (to rule out frequently associated chest infection and possibility of aspiration in a patient who has altered mental status) CT scan of head, stat (to rule out associated head injury) (Lumber puncture, stat (to exclude meningitis because you should not miss meningitis) – If you don’t suspect meningitis like in this cases, you don’t need to perform this.) Results: Labs are significant for macrocytosis (MCV of 110fL), and mild degree of hyponatremia (Na of 134 meq/L). Mg is low. Phosphate is low. Blood glucose is 50. Liver function tests (LFT) are nearly normal except mild hypoalbuminemia. CT scan of the head is WNL. Chest x-ray- shows no abnormalities. Blood alcohol levels are WNL. Urine toxicology is negative. Very mild elevation of PT is noted. ABG showed elevated pH and low PCO2.

Review orders: IV 50% glucose (after administration of thiamine) Discussion: Alcohol is a CNS depressant and sudden withdrawal from it causes hyperactivity of some parts of CNS especially of sympathetic nervous system. Minor withdrawal symptoms include tremors, insomnia, anxiety, headache, and diaphoresis. They usually occur within six hours of withdrawal and resolve within one to two days. Sometimes generalized tonic clonic seizures occur within 48 hours of withdrawal. Withdrawal may result in dehydration, hypokalemia, hypomagnesemia, and hypophosphatemia. Dehydration is due to diaphoresis, hypothermia, and tachypnea. Hypomagnesemia is most frequent with delirium tremens and may be a predisposing factor for alcohol withdrawal seizures. Hypophosphatemia results from malnutrition and may cause heart failure, and rhabdomyolysis.

Alcoholic hallucinosis is characterized by hallucinations occurring within 12 to 24 hours of alcohol withdrawal. These hallucinations are mostly visual.

Sensorium remains intact in cases of alcoholic hallucinosis.

Treatment of alcohol withdrawal syndromes: The patient must be reevaluated frequently and other similar conditions like trauma, infection, liver failure, metabolic abnormalities or drug overdose must be ruled out. CT scan and lumbar puncture are very important when patient presents with altered mental status, and fever. After excluding co-morbid diseases, symptomatic treatment is begun. Patient is placed in a quiet environment. His volume deficit is calculated and replaced. Patients with DT are kept under mechanical restraint. Multivitamins containing folate are given to all patients. Thiamine needs to be given before glucose to decrease the risk of precipitating Wernicke’s encephalopathy and Korsakoff’s syndrome. Deficiencies of electrolytes should be corrected. Patients at high risk need to be shifted to ICU.

The standard vitamin therapy: Thiamine 100 mg IM X 1 on admission, then Thiamine 50 mg orally once daily for 3-5 days Multivitamin one tablet once daily Folate 1 mg orally once daily DT is treated initially with lorazepam IV ( 2 - 4 mg IV q 1 hour prn, and then taper to q 2, 3, and 4 hours). Once the patient vitals are stable and can take oral medications chlordiazepoxide (Librium) protocal can be followed.

The standard Librium protocol: Day 1 Librium 50 mg po q 4 hours X 6 Day 2 Librium 50 mg po q 6 hours X 4 Day 3 Librium 25 mg po q 4 hours X 6 Day 4 Librium 25 mg po q 6 hours X 4 Oral chlordiazepoxide is given to patients with history of delirium tremens, seizures, or prolonged and excessive alcohol intake.

When do you give antipsychotics? Phenothiazines should not be used as they lower the seizure threshold. However, haloperidol is associated with low risk and may be used in combination with benzodiazepine for agitated patients. After acute treatment, all patients should be screened for alcohol dependence, and should be considered at risk for recurrent episodes of withdrawal. In-hospital evaluation is recommended, and long-term follow-up is crucial.

Order review: Place the patient in the ICU Continue IV lorazepam, Start chlordiazepoxide, PO continuous Haloperidol, IV, PRN (Only if the patient is agitated) Input/ output charts IV normal saline, continuous IV Multivitamins containing folic acid Replace phosphate Replace magnesium Vitamin K, IV one dose daily for 3 days if the PT and INR are elevated Brief history and physical for every 1 to 2hours until you see good improvement Once the patient has recovered fully, we do the following Order Review: Rehabilitation Alcoholics anonymous Counsel about safe sex practices, limit alcohol intake, smoking cessation, drive with seat belt, and safety plan.

44) Fatigue due to Ca Colon- Location: Office C.C: A 55-year-old white male presents with fatigue. Vitals: Pulse: 75/min; B.P: 110/75 mm Hg; Temp: 98.6 F; R.R: 16/min.

History of present illness: A 55-year-old white male presents to the outpatient clinic with the compliant of fatigue for the last one month. He says that he feels exhausted after doing his routine daily activities. He denies constipation, diarrhea, abdominal pain, melena or blood in the stools. He has no SOB, chest pain, palpitations, nausea, vomiting, fever, chills, or night sweats. He has had no change in his sleeping pattern, however he has decreased appetite and has lost 5 kg (11 lbs) over the last few months. He denies any bleeding per rectum or hematuria. He is happily married and has two sons. He denies any recent traumatic event. He has no known allergies. He has no symptoms of depression. He denies any IV drug abuse. He is not on any medication except multivitamin once daily. Mother has a H/O colon cancer. He has been smoking 10 cig/day for the last 25 years and drinks alcohol only on weekends. He is sexually active with his wife. He denies any stressors at home and work. He has never been tested for HIV. He does not have any history of STD. Review Of Systems is unremarkable.

How do you approach this case? This patient has presented with fatigue for the last one month. Physical examination in such cases is very important to exclude some specific causes.

Complete physical examination should be performed in all patients presented with fatigue. Order: General examination: To look for possible features of a psychiatric disorder like poor grooming, agitation as well as for evidence of pallor.

HEENT/Neck: Examination of neck for goiter is very important as hypothyroidism or hyperthyroidism may be the cause of his fatigue.

Lymph node examination: Lymphadenopathy may be a feature of chronic infection or malignancy.

Chest/lung examination: Chronic lung disease may cause fatigue.

Heart/CVS examination: Congestive heart failure may be a cause of fatigue.

Abdominal examination: This patient has abdominal complaints like pain, and constipation.

Rectal examination: In the presence of abdominal complaints, rectal examination should be performed.

Neurological examination: Neuromuscular causes may be responsible for fatigue.

Neuropsychiatric examination: Psychiatric causes may be responsible for fatigue. Results of PE: General: Pallor is noted on palms, and sclera. HEENT: thyroid gland is normal, no other abnormality found. Abdominal examination: completely normal. Rectal examination: Sphincter tone is normal with normal prostate, brown colored stools, and no palpable masses. No lymphadenopathy noted. Patient is alert and no neurological abnormality found. Rest of the examination is within normal limits. Discussion: Fatigue has very broad differential diagnosis. Medical and psychiatric illness accounts for up to two thirds of the causes of fatigue. The common causes include psychiatric (depression, anxiety), medications (Antidepressants, hypnotics etc.), endocrine and metabolic disorders (diabetes, hypo or hyperthyroidism, adrenal insufficiency, chronic renal failure, hepatic failure, etc.), neoplastic (Occult malignancy, severe anemia), cardiorespiratory (CHF, COPD, sleep apnea etc.), infections (EBV, HIV, TB etc.), rheumatologic diseases, and finally chronic or idiopathic fatigue syndrome. The general approach to a patient with chronic fatigue includes routine CBC with diff, ESR, basic metabolic panel, Liver function tests (LFT), serum CK, ESR, and TSH. Testing for PPD and HIV is considered in high-risk patients. The workup should also include the routine age appropriate screening (eg, FOBT, sigmoidoscopy, or mammography).

His exam is significant only for pallor. This is most likely a result of anemia.

Order review: CBC, with differential, routine Basic metabolic panel, routine TSH, routine Liver function tests (LFT), routine FOBT, routine Return to clinic with the results Result of Labs: CBC: Hemoglobin: 8g/dl Microcytic hypochromic cells Leukocytes and platelets normal in number and morphology BMP, TSH, and Liver function tests (LFT) are within normal limits. FOBT is positive. Order: Colonoscopy, routine Consult, GI procedures (Reason: colonoscopy) Results: Colonoscopy with biopsy confirms the presence of adenocarcinoma in the descending colon. Discussion: Once the diagnosis of colorectal cancer is diagnosed, staging should be performed. The role of preoperative CT of the abdomen and pelvis is controversial. MRI and PET scanning are not routinely recommended for preoperative staging. However, PET scanning is especially useful to detect occult metastasis in patient's with symptoms and raising CEA levels. CEA should not be used for screening purposes. However, it should be obtained in all patients before undergoing the surgery. Elevated CEA level after the surgery indicates residual or metastatic disease. Elevated CEA levels also has prognostic significance. Higher levels (>5ng/ml) are associated with worse prognosis. Order review: Oral iron sulphate, continuous CT scan of abdomen and pelvis with contrast, routine CEA level Refer the patient for colorectal surgery Primary Diagnosis: Colon cancer

45)

- Location
- Location: A nursery in a community hospital.

CC: Infant with jaundice.

History of present illness: You are called evaluate a 39-week white male infant who appears to be jaundiced.

The patient was born approximately 12 hours prior by vaginal delivery with vacuum assistance. Labor was slightly prolonged at 18 hours. The patient’s Apgar scores were 8 and 10 at 1 and 5 minutes. Points were removed for acrocyanosis and irritability. The patient took to the breast within about three hours after delivery, had good suck reflex and transitioned well to room temperature environment after being in the warmer for about four hours. Initial evaluation of the patient by the on-call resident was unremarkable other than a cephalohematoma over the posterior parietal and occipital areas from the vacuum-assisted delivery.

Maternal history: Mother is a 28-year-old Group B Streptococci (GBS) positive G2, P2, now L2 white female of Mediterranean descent who received regular prenatal care and had intrapartum antibiotic prophylaxis for her GBS positive status. She has no previous history of sexually transmitted diseases, had no infections during her pregnancy and had laboratory work revealing that she was Rh positive, blood group O. Mother’s other prenatal laboratories showed that she had positive rubella titers and positive IgG to toxoplasmosis. There is no history of smoking, IV drug use. Mother is not on any medications other than prenatal vitamins. FH: The patient has an 18-month-old sibling who had jaundice as an infant. Mother cannot recall how high her other child’s bilirubin level reached; however, she does note that her first child required phototherapy for two days prior to discharge. How to approach this case: Jaundice in an infant less than 24 hours old should always be presumed to be pathological. Therefore, you should look carefully for the etiology, including sepsis, hemolysis, polycythemia, and hemorrhages. You need to look at the infant to decide which etiology is highest on your differential and, in particular, to decide whether the child needs immediate antibiotics. You need to attend to details of the mother’s medical history (Group B strep status, TORCH exposure) and the delivery (prolonged, traumatic, vaginal vs. c-section, fetal distress intrapartum). Therefore, perform physical exam, including Review of vital signs (check for temperature instability; voiding) General appearance (lethargic? Arousable?) HEENT (cephalohematomas, caput succedaneum, corneal opacity?) Heart exam Lung exam Abdomen (hepatosplenomegaly?) Genitourinary (patent rectum) Neurological exam (tone, irritability, reflexes) Skin (ecchymoses) Check inputs/outputs Results: Vital signs are stable. Well-developed white male infant in no acute distress.

HEENT: There is mild scleral icterus and jaundice of the face. There is a 4 cm cephalohematoma over the posterior parietal occipital areas of the infant’s head that is soft and slightly ecchymotic. Mucous membranes are moist. Pupils have bilateral red reflex. Oropharynx is clear. The patient has a good suck reflex.

Neck is supple without any signs of meningismus. Anterior fontanel is open, flat and soft.

Cardiovascular and Lungs: normal.

Abdomen: soft, nondistended, nontender, no hepatosplenomegaly can be appreciated, no abdominal masses. Umbilicus: normal.

Extremities: normal. There is no acrocyanosis appreciated. Capillary refill is less than two seconds.

Neurologic: Good suck reflex. Moro reflex symmetric. Good tone. Appropriate level of irritability and able to be consoled.

GU: normal. The anus is patent and appropriately positioned. Review of nurse’s notes reveals that the patient has passed several meconium stools and voided one wet diaper. So far, this infant’s physical exam is reassuring. Your initial physical exam did not reveal any signs of sepsis: the patient had no temperature instability, had been eating well, had passed a stool and urine of normal color, and did not appear to be lethargic. Therefore, you can do some work up before initiating antibiotics. Order: Blood typing of infant and mother (mother’s is usually done already & on chart) Direct Coomb’s test, stat CRP stat and q 12 hr CBC with differential, stat Total and indirect bilirubin Inputs/outputs Vital signs q 4 hrs Discussion: This is a full-term infant who presents with jaundice in the first day of life. Because of the early onset of jaundice, hemolysis and sepsis must be ruled out. Other items in the differential include polycythemia and hemorrhages. Workup of this patient should be the initial physical exam to observe for signs of sepsis including in an infant signs of lethargy, vomiting, poor feeding, fever or temperature lability with a low temperature, lack of stooling, or abnormal-colored urine. History taking should focus on any possible maternal infections which might be transmitted to the infant, particularly TORCH infections including CMV, toxoplasmosis and rubella infection, and maternal GBS (Group B streptococcal infection) status. Eliciting any family history of hyperbilirubinemia is also helpful because there is some familial tendency for neonatal jaundice. Laboratory workup should begin by blood typing and direct Coombs’ testing on the infant. All infants who are born to mother’s with Type O blood group should routinely have direct Coombs’ testing to check for maternal fetal incompatibility and these children should be followed closely for evidence of jaundice from hemolysis. Laboratory work should also include C reactive protein for early assessment of infection, CBC, and initially a direct and total bilirubin. Results: Mother is group O blood group. The patient is Group B. The direct Coombs’ test was weakly positive. Initial CBC with differential is normal for age. CRP was normal. Total bilirubin was 5.6, direct bilirubin 0.3, indirect 5.2.

At this point the patient appears to have mild hemolysis secondary to ABO incompatibility with maternal blood with a weakly positive Coombs’ test. The patient needs to have his hemoglobin and hematocrit followed as well as his total bilirubin to observe for evidence of a continued climb in the bilirubin level or a significant drop in his hemoglobin and hematocrit.

Therefore, Order: Hemoglobin and hematocrit q 8 hr Total bilirubin q 8 hr Continue po feeding, breast milk May supplement with formula Vital signs q4 to watch for change in clinical status Results: 2nd CRP is normal. Hemoglobin and hematocrit remain stable. Total bilirubin increases to 8.4 and then to 13.4mg/dl Order: Transfer to NICU (Neonatal ICU) Phototherapy Erythromycin ointment for eyes while receiving phototherapy Start IV fluids at rate to ensure patient’s total fluid intake (oral and IV) is 1 ½ maintenance rate. D5 1/4NS Results: Total bilirubin levels fall with phototherapy Order review: Phototherapy discontinued D/C IV fluids Follow up total bilirubin q daily until stable. Discussion: At 12 hours of age, the patient’s total bilirubin is 5.6 which roughly corresponds to the rule of thumb for assessing clinical jaundice which corresponds to jaundice of the face with a bilirubin of approximately 5, jaundice of the midabdomen indicating a level of approximately 15 mg/dl and jaundice extending to the feet indicating a level of roughly 20 mg/dl. At this point, the patient does not meet criteria for phototherapy. One should consider phototherapy at levels of greater than 12 mg/dl for an infant 25-48 hours old. Definitely do phototherapy if the level is greater than or equal to 15 mg/dl and, if the patient has a level greater than 25 mg/dl, then exchange transfusion and intensive phototherapy is probably warranted. Q8H measurements of hemoglobin, hematocrit and total bilirubin would be appropriate. In addition, a second CRP level would be appropriate to monitor for signs of infection. Titers can be sent for CMV, toxoplasmosis and rubella as well, although usually this data is not available to the clinician in the first 24-48 hours of evaluation. If the patient’s clinical status should change and he should become lethargic or have difficulty feeding and you suspect sepsis, then empiric antibiotic therapy should be begun but urine cultures and a spinal would be appropriate.

By history, this patient also has an increased risk for hyperbilirubinemia secondary to his positive family history of a sibling who had neonatal jaundice requiring phototherapy. An infant with a sibling who developed a bilirubin level of greater than 12 has approximately a three times greater risk of developing jaundice than an infant with a negative family history. In addition, this infant obviously has an ABO incompatibility. One would suspect that the bilirubin level would continue to climb over the next 24 hours and this patient might indeed meet criteria for phototherapy. In the meantime, the patient should be continued to be monitored and the mother should be counseled to continue frequent breast-feeding to keep the baby well hydrated and to observe for any signs of infection.

The infant’s other risk factor for elevated jaundice includes his cephalohematoma which can be an increased source of bilirubin production as the hemorrhage reabsorbs. The patient did not meet criteria for polycythemia but this is another cause of early jaundice. For instance with “physiologic jaundice” the bilirubin level does not rise more than 5 mg/dl per 24 hours and it usually peaks on day three with a level no greater than 13 mg/dl. These children usually do not present with jaundice within the first 24-hours of life.

Likewise, breast-feeding jaundice which does present within the five days of life usually does not reach clinical levels within the first 24 hours. Breast milk jaundice is usually seen towards the end of the first week of life in an infant who is otherwise thriving. Jaundice which arises greater than one week from birth may indicate both breast milk jaundice but also other pathological mechanisms including liver disorder such as biliary atresia or metabolic disorder such has hypothyroidism, galactosemia or hereditary hemolytic disorder such has spherocytosis or G6PD deficiency which incidentally is an X-linked disease with variable phenotype. Jaundice that persists beyond the third week really should prompt one to investigate biliary causes as well as the metabolic and hereditary hemolytic diseases. Most forms of jaundice should resolve by two to three weeks of age and the vast majority of infants who do have jaundice have a physiologic or breast-feeding associated cause.

Case 46[edit]

Location: Outpatient clinic Vitals: Temperature of 36.3C; H.R: 95/min; R.R: 22/min; Blood pressure is 85/50 lying down and 77/46 mm Hg standing.

C.C: Swelling
History of present illness: The patient is a three-year-old white male who presents with his mother for evaluation of facial and scrotal swelling of ten days duration. Mother reports that the child had been well until one day prior to admission when she noticed the onset of swelling in his face. She also noted that he had scrotal swelling because he is almost potty trained. She notes some decrease in his urine output as well, although no change in color of the urine, other than becoming somewhat more concentrated. He has had no preceding diarrheal illness, sore throat, abdominal complaints, fevers, and rashes. Mother reports that the child has not complained of any pain syndrome. He does seem to be a little bit more tired than usual. Birth history is unremarkable. All of his immunizations are up to date. SH: He lives with his parents; two older siblings who are healthy, and have had no hospitalizations. There are no pets in the home. There are no smokers in the home. Risk for tuberculosis is low. Development has been normal. How to approach this case? Determine the nature and etiology of the "swelling", including whether it’s edema or something like hives. Examine the patient to decide whether he needs inpatient or outpatient management. Physical exam: General appearance HEENT/Neck Heart Lung Abdomen Genitourinary Extremities Skin CNS Results: General: well-developed, well-nourished white male in no acute distress. HEENT: remarkable for periorbital edema. Mucous membranes are slightly dry. Neck is supple without lymphadenopathy or thyromegaly. Pupils normal. Cardiovascular: Regular rate and rhythm without murmurs, rubs or gallops. Lungs: very faint rales at the bases and otherwise clear. Abdomen is soft, nontender, nondistended. There are normoactive bowel sounds. There is 1+ sacral edema. + fluid wave. GU: There is scrotal edema present. There is no tenderness to palpation and the cremasteric reflex is intact bilaterally. Extremities: Pulses are 2/4 in the radial, femoral, and dorsalis pedis areas. Hands and feet show 2+ pitting edema and are otherwise unremarkable. Neurologic is nonfocal and appropriate. Discussion: This is a three-year-old patient who is manifesting signs of generalized edema, most prominent in his face hands and scrotum. The leading diagnosis in this age frame for such marked edema is nephrotic syndrome secondary to minimal change disease. Order: Urinalysis, stat Basic metabolic panel, stat CBC with differential, stat Liver function tests (LFT) Lipid panel PT/INR, PTT Complement 3 and 4 levels Results: Urinalysis shows 4+ protein, no blood, no RBCs, specific gravity is 1.030, CBC shows a white count of 7, hemoglobin 12.6, hematocrit 36, and platelets 240.

Complete metabolic panel (Liver function tests (LFT) + BMP) reveals an albumin of 1.5, normal liver function tests, sodium 130, potassium 4.0, chloride 96, bicarbonate 20, BUN 10, creatinine 0.7, glucose 78, calcium 9.4, cholesterol level is 320 mg/dl. Serum albumin is 1.5 gm/dl. Serum protein is 3.7. PT, PTT are normal. Complement levels within normal. Patient has orthostatic hypotension and mild dehydration. Order: Admit to floor Inputs/outputs Vital signs q4; Continuous cardiorespiratory monitoring Nephrology consult Albumin 25% solution IV, 1 gr/kg body weight, infused over 8 hours Lasix (Furosemide), 1 mg/kg, administered halfway through the albumin infusion Complete metabolic panel q AM No salt added, high protein diet. Results: Patient responds with good diuresis to albumin and lasix therapy over 24 hours. Vital signs remain stable. Orthostasis resolves. Electrolytes and renal function remain stable. Order: Prednisone 2 mg/kg per day, may give in divided dose, po Vital signs q 12 hours Repeat albumin and lasix therapy. Results: Patient tolerates prednisone. Remains clinically stable. Order review: Discharge to home. Prednisone for 4-6 weeks. Follow up in 3-5 days. Discussion: The most likely cause of this patient’s clinical syndrome is a nephrotic syndrome. The patient is a three year old with generalized edema and screening laboratory tests indicate low protein as well as proteinuria. He therefore meets the diagnostic criteria for nephrotic syndrome which are: Generalized edema.

Hypoproteinemia, usually less 2 gm/dl, with a disproportionately low albumin level in relation to the globulin level.

Urine protein to urine creatinine ratio in excess of 2 on first morning void or a 24-hour urine protein that exceeds 50 mg/kg of body weight.

Hypercholesterolemia greater than 200 mg/dl.

In the vast majority of children in this age range the nephrotic syndrome is due to minimal change disease. This is the cause in approximately 76 percent of children in the one to 12 year age range who present with nephrotic syndrome in childhood. Other etiologies are focal segmental glomerulonephropathy, membranoproliferative glomerulonephropathy, membranous nephropathy and then other causes. For most children, clinical diagnosis is sufficient and renal biopsy is not warranted unless the child is not responsive to steroids as noted below. CLINICAL FINDINGS in nephrotic syndrome include facial edema frequently periorbital, pretibial edema as well as swelling of the scrotum or labia which may be prominent. These children also have reduced perfusion of their splanchnic capillary bed and may have abdominal pain. As a consequence of their low intravascular oncotic pressure, they may have hypotension as well as pleural effusions with tachypnea and chest pain. As noted in the diagnostic criteria, they do have hypercholesterolemia with increases in their VLDL and LDL because of changes in hepatic catabolism and enhanced synthesis, respectively. However, the disturbances in lipid metabolism usually do not cause any other clinical findings. By contrast, changes in the protein levels of their coagulation cascade does put them at increased risk for thrombosis. Their tendency to form thrombus is due to a combination of factors including hyperaggreatable platelets, increased fibrinogen concentrations, loss of antithrombin III, increased blood viscosity and decreased blood flow. Venous thrombosis can occur in the deep veins of the extremities and the cerebrocortial system and renal veins and the pulmonary venous system and it is a source of increased morbidity for these children. As a consequence, one should obtain initial coagulation studies upon admission. Laboratory analysis also shows reduced immunoglobulins, particularly IgG. This low level of IgG in combination with the steroids which are the primary treatment for nephrotic syndrome puts the children at increased risk for development of infections. Peritonitis is one of the more serious complications of nephrotic syndrome. The causative organisms in children are streptococcus pneumoniae and Escherichia coli. One should consider peritonitis in any child who presents with significant abdominal complaints and paracentesis should be performed to identify the organism and confirm the diagnosis. For children in whom thrombosis is a serious consideration, one can start heparin therapy at a dose of 50 units/kg intravenously and 100 units/kg every four hours IV for maintenance therapy. Human nephrotic syndrome is supportive and aimed at increasing the intravascular oncotic pressure, decreasing third spaced fluid maintaining fluid balance, monitoring nutrition and treating any concomitant infection. Usually the typical approach is to give the patient intravenous albumin 1 gm/kg of a 25% solution for example and infuse it continuously over 8 to 12 hours under close supervision for the development of heart failure. Loop diuretics like Lasix can then be administered halfway through the albumin infusion or after it at a dose of 1-2 mg/kg IV and this effectively reduces third spaced fluids and pulls interstitial fluid into the vascular space. Prednisone is begun on patients at a dose of 60 mg/M2 or 2 mg/kg and the daily dose is maintained for four to six weeks. It is advisable to obtain a tuberculosis screen test prior to initiating the steroid therapy. Most children will begin to show a decrease in their urine protein excretion after about seven to ten days following the initiation of steroids. If the child is stable with just mild to moderate edema, no pulmonary edema and has good diuretic response, then they do not need to stay in the hospital until their protein excretion is reduced and instead most of them can be discharged within two to three days. Fluid balance in the hospital setting is important and should be monitored closely during the initial diuresis. Patient should be given a high quality, high protein diet to improve their growth and because they have an increased protein need to regenerate their albumin. They should have a no salt added diet to discourage further edema formation. About 85-90% of children treated in fashion will have a satisfactory response and obtain remission. The mortality in minimal change nephrotic syndrome is approximately 2% with the majority of deaths due to peritonitis or thrombus formation and these complications can occur even under ideal treatment circumstances. The other 98% of children who develop this syndrome are likely to have a good response to steroids and return to a normal state of health. About two-thirds of them experience at least a single relapse and another third go on to have a series of relapses over the course of many years. For children who remain symptom free for over two years without any medications, their prognosis is the best and they are considered recovered. Primary diagnosis: NEPHROTIC SYNDROME

CASE NO - 47[edit]

Location: Emergency Room. Vital signs: Temperature 38.6C; heart rate 156/min; respirations 62 per minute; blood pressure is 75/43m Hg; Weight 3.0 kg. C.C: Poor feeding, and decreased responsiveness.
History of present illness: The patient is a six-day-old female, brought to the Emergency Room by her mother because of difficulty arousing the baby for feedings, decreased intake and generally seeming less responsive according to the mother. Mom did not take patient’s temperature. She has noticed that there are a decreased number of wet diapers from usual of around eight per day to only four since the same time the day prior to being seen. The baby shows some increased somnolence and when she is awake she seems to be more irritable. Mother notes that during breast-feeding the patient’s sucking seems somewhat diminished. The patient has had no episodes of emesis or diarrhea, other than her usual loose yellow stools from breast-feeding. Mother has witnessed no cyanosis, episodes of apnea, gross hematuria, or seizure-like activity. BIRTH HISTORY: The patient was a 3.210 kg female born at 38-weeks gestation to a G2, P2, now L2, GBS positive, Rh positive 25-year-old nonsmoking mother who was in good health throughout the pregnancy and received regular prenatal care including intrapartum antibiotics. Birth was via spontaneous vaginal delivery with labor lasting approximately 14 hours and delivery occurring without complications. The patient’s Apgar scores were 9, one point taken off for color, and 10 at one and five minutes, respectively. The patient was discharged home after 48 hours with the mother. The discharge weight was 3.002 kg. SOCIAL: The patient lives with parents and a three-year-old sibling. Father smokes in the house. There is no previous history for the mother of any elicit or IV drug use. The baby is being breast-fed on demand approximately every two to three hours for the first approximately four days of life. Each breast-feeding sitting lasting about 20 minutes. Mother reports that the baby is now feeding every three to four hours and only staying at the breast for about ten minutes before falling off to sleep. The baby did receive a hepatitis B immunization prior to discharge from the hospital. How to approach this case? In an infant less than one month old presenting with decreased responsiveness, the suspicion for sepsis should be high, but the differential is broad and includes trauma (e.g., shaken baby), congenital abnormalities, and parental misinterpretation. Physical exam: Pulse Oximetry, stat General appearance HEENT/neck Heart Lung Abdomen Neuro Musculoskeletal Skin Results: General: Well-developed, well-nourished white infant sleeping in her mother’s arms. Pulse oximetry 91% on room air. HEENT: Normocephalic, atraumatic. Anterior fontanel is open, flat and soft. Mucous membranes are slightly dry. Pupils are equal, round and reactive to light. Red reflex is present bilaterally. Nares show mild flaring and are patent. Tympanic membranes are within normal limits. Oropharynx is clear. Neck flexion and extension are within normal and do not elicit irritability. Cardiovascular: Regular rate and rhythm without murmurs, rubs or gallops, S-1 and S-2 auscultated. Lungs are clear bilaterally. There are mild subcostal and suprasternal retractions. Abdomen is soft, nontender, and nondistended with normoactive bowel sounds. No hepatosplenomegaly appreciated. Umbilicus is without erythema or discharge around the umbilical stump. Extremities: Pulses are 2/4 in the radial, femoral, dorsalis pedis areas. Capillary refill is between 2 and 3 seconds with no evidence of cyanosis, edema or clubbing of the extremities. GU shows normal female genitalia. At this point in the evaluation, one has a six-day-old infant with a fever of 38.6 and some evidence of respiratory compromise with diminished peripheral O2 saturation and tachypnea with retractions. Orders: Supplemental oxygen to keep saturations >94% Place IV CBC with differential, stat Basic metabolic panel or chemistry panel, stat Blood cultures, urine cultures, and, given this patient’s age, CSF cultures. CSF for protein, glucose, cell count, and Gram stain. Chest X ray should be obtained to evaluate for pneumonia.

CRP is also useful to evaluate acute infectious processes but is nonspecific. Results: Chest X ray - Diffuse reticular nodular pattern bilaterally with slight hyperinflation, and a very small right pleural effusion.

CBC: White count 16, hemoglobin 13.7, hematocrit 38, platelets 221, the differential shows 68% neutrophils with 5 band neutrophils, 10% lymphocytes.

Chemistry panel shows sodium of 135, potassium 3.9, chloride 99, CO2 20, Bun 7, creatinine 0.3, calcium 10.1, glucose 71, CRP elevated at 2.7. Blood cultures were obtained and pending. Urinalysis - Specific gravity of 1.028, 1-4 white blood cells, 0 red cells, negative nitrate, negative esterase. Urine cultures still pending.

Lumbar puncture was performed. CSF cell count, glucose and protein were within normal limits. Gram stain no organisms, no neutrophils. Culture is still pending. Order: Admit to floor Continuous cardiorespiratory monitoring. Vitals signs q4 Diet no oral if respiratory rate is greater than 60 IVF D5 ¼ NS at maintenance rate Ampicillin 100 mg/kg/day divided q 8 hr Cefotaxime 150 mg/kg/day divided q 8 hr Inputs/outputs CBC with diff, BMP q daily Results: Blood culture grows out gram-positive cocci in chains. (The likelihood of Group B strep infection is very high.) Order: Continue monitoring. Examine the patient for every 2 to 4 hours until you see some improvement, then every 8 to 12 hours Change diet to po when respiratory rate is < 60 and no significant respiratory distress. Wean oxygen for saturations >94% Results: Patient’s oxygenation improves and she’s weaned to room air. Respiratory rate normalizes; work of breathing normalizes. Patient tolerates po and maintains hydration status. Blood culture—group B strep. Sensitive to amoxicillin. Order: Discharge home Change antibiotic to amoxicillin 50-80 mg/kg/day divided q 8 Discussion: This patient presents with signs and symptoms suggestive of a respiratory process; however, given her age and other nonspecific findings, the possibility of urinary tract or CSF infection or generalized sepsis is still in the differential and therefore one would want to begin empiric antibiotics to cover for the most likely organisms to infect this infant. For a child of this age with respiratory symptoms, the most likely etiologies are E. coli and Group B strep infections. Other causes of respiratory compromise with infectious etiologies include Haemophilus influenza, streptococcus pneumoniae, Group B strep, Listeria, and anaerobes. For many infants, the only indication that their infection is respiratory in nature is tachypnea which may at first be missed. Oftentimes these infants do not have typical rales or sounds of consolidation on auscultation. Depending on how old the infant is, hyaline membrane disease and transient tachypnea of the newborn are differential considerations for the infant in the first 24-48 hours of life who exhibits respiratory symptoms. Blood cultures obtained on newborns with respiratory illnesses frequently will grow out the offending organism. This patient has a risk factor for Group B strep infection because her mother was Group B strep positive. Despite the fact that the mother received intrapartum antibiotics, it is still possible for this infant to have a Group B strep infection. Likewise, for maternal histories in which the Group B strep screening is negative, it is still possible that the infant has GBS infection since screening is not 100% sensitive. Empiric antibiotic coverage should be done as soon as possible after culture fluids are obtained. One regimen is ampicillin 100 mg/kg/d divided every 12 hours for infants who are less than 1.2 kg or every eight hours for infants who are greater than 1.2 kg and cefotaxime (Claforan) 100 mg/kg/d divided every 12 hours or 150 mg/kg/d divided every eight hours for infants who are greater than 1.2 kg and greater than seven days old. Gentamicin can be added as well or used as an alternative treatment when there is no evidence for meningitis. Infants should be treated at least ten days and possibly 14-21 days if they have a gram-negative infection. An infant of this age with respiratory symptoms should be admitted and monitored closely for worsening respiratory compromise with decreased oxygenation and increased work of breathing. In an infant who does not respond to empiric antibiotic therapy but still has respiratory symptoms, then CMV (cytomegalovirus) pneumonia should be considered. If there is a maternal history of herpes simplex virus infection, particularly a primary infection, then that etiology should also strongly be considered and acyclovir begun. Primary diagnosis: Group B streptococcal pneumonia

CASE NO-48[edit]

Location: Emergency Room. Vital signs: B.P: 108/75 mm Hg; HR 88/min; RR: 8/min; Temp. 36.5C. CC: altered mental status, stumbling
History of present illness: The patient is a seven-year-old boy brought in by his parents after he came home from a playmate’s house and his parents found him to be confused and stumbling; he then became less responsive with garbled speech and somnolence. He had been previously well with no recent infections, no sick contacts. He had gone to school that day and come home appearing to be normal at that time. He then went to a schoolmate’s house and returned home several hours later with the above symptoms. SOCIAL HISTORY: He attends second grade at a suburban school. He lives with his parents and two other siblings. His development has been normal.

His immunizations are up to date. Review Of Systems: no headache, fevers, vomiting, diarrhea, photophobia, joint complaints, rashes, urinary complaints, no seizure activity. How to approach this case? This child has suffered an acute change in mental status. Initial management should focus on the ABCs. He needs a brief focused physical exam to guide the differential. Order: Pulse oximetry, stat Supplemental oxygen Continuous cardiorespiratory monitoring Finger stick glucose IV lock Urine toxicology screen Narcan (naloxone), IV Physical exam: General appearance HEENT/neck Heart Lung Abdomen Musculoskeletal Neuro Results: O2 sat 94% on room air. General: well-developed, well-nourished seven-year-old boy; he appears diaphoretic and cool. Neuro: He mumbles a response that cannot be understood and will not open his eyes to command; he localizes to painful stimuli.

HEENT/Neck: Pupils 3mm bilaterally and responsive. Neck supple, no adenopathy: mucous membranes tacky. He has the odor of alcohol on his breath. Heart: regular without murmurs. Lung: respirations are shallow and slow. Abdomen: normal. Musculoskeletal: There is no evidence of trauma.

There is no change in level of responsiveness after Naloxone. Finger stick glucose is 48 mg/dl. Order: D50, 1 ampule, IV IVF Normal saline bolus 500cc, then at maintenance Blood alcohol level (BAL) Serum toxicology panel Basic metabolic panel, stat CBC with differential, stat Accuchecks q 1 hour until stable Results: BAL is elevated. Urine toxicology screen positive for ethanol. Serum toxicology panel positive for ethanol only. BMP is normal. CBC with diff is normal. Accuchecks normalize. Order: Admit to observation unit/floor. Continuous cardiorespiratory monitoring. IVF D5 ½ NS with 20 meq/L KCL at maintenance NPO until awake BMP in AM Repeat blood alcohol level in 12 hours. Result: Patient becomes more responsive after 4 hours and is fully awake and back to his baseline by the next morning. Repeat BAL is within normal limits. Order: Discharge home. Patient education on drug use/toxicity. Screen for abuse and domestic violence prior to discharge. Discussion: This is a school-aged child who presents with altered mental status and hypoglycemia. He had a depressed mental status with shallow and slow respiratory rate and hypoglycemia. This presentation along with helpful information obtained during the physical exam, such as the smell of alcohol, can direct the clinician to look for ethanol intoxication as the cause of this patient’s syndrome. Typically children get hypoglycemia and it is not necessarily related to the dose or blood level of the ethanol. They have a depressed CNS secondary to ethanol as a CNS depressant. EVALUATION involves ruling out trauma, infectious processes (particularly CSF infections), sepsis, or other drug intoxication, and then beginning supportive care with detection and maintenance of the airway. IV fluids are given for fluid balance, correction of any electrolyte imbalances and correction of hypoglycemia. Most children respond well to supportive therapy and their prognosis for a full recovery is excellent in the absence of prolonged hypoglycemia and respiratory arrest.

Case 49[edit]

Location: Emergency room Vitals: B.P: 100/60 mm of Hg; P.R: 112/min, regular; Temperature is 98.60C; R.R: 34/min.

C.C: Shortness of breath and chest pain.
History of present illness: A 65-year-old white female, with a past medical history of ovarian carcinoma treated with chemotherapy, presents to the emergency room with the sudden onset of severe shortness of breath associated with right-sided chest pain. The patient reports that while watching the baseball game she suddenly noticed severe shortness of breath. The pain is constant, 7-8/10 in severity, increases with deep breaths, and non-radiating. She is nauseated but denies any vomiting.

She denies any fever, chills, cough, and hemoptysis. She denies orthopnea, PND, exertional chest pain, or shortness of breath. There is no H/O leg swelling, or claudication symptoms. PMH is significant for ovarian cancer treated with TAH + BSO, followed by chemotherapy. She is disease free for the past 3 years. SH: She smoked 1 PPD for 30 years. Drinks alcohol occasionally. She is allergic to penicillin. FH: Father died from acute MI at the age of 60. Mother died from breast cancer at the age of 65. Review Of Systems: Her Review Of Systems is unremarkable. How would you approach this case? Based on history the most probable diagnostic possibilities are – MI, pulmonary embolism, aortic dissection, tension pneumothorax, acute heart failure, and acute pericarditis. All of these are associated with very high mortality. Always stabilize the patient first. Once the patient is stable you have to do really focus examination and the most important investigations. Order: Airway, breathing, and circulation is maintained in this patient. Pulse oximetry, stat and continuous Oxygen, nasal canula, continuous Elevate the patient head Intravenous access, stat Continuous cardiorespiratory monitoring Aspirin 325 mg, sublingual, one dose Sublingual nitroglycerine is not indicated in this patient, as his B.P is borderline. Order focused physical exam: Lungs Heart Results: Pulse oximetry showed oxygen saturations of 85% on room air and 87% on four liters. Lungs are clear to auscultation (excludes tension pneumothorax). Heart exam is remarkable for loud pulmonic component of S2. Patient is still having shortness of breath. Review orders: Check the blood pressure on both arms (we excluded heart failure by physical exam) 12 lead EKG, stat Portable Chest X-Ray, PA view, stat CK-MB, stat Troponin T or I, stat ABG, stat IV NS, 250 cc bolus, stat IV NS, 100 cc/hr, continuous Results: EKG showed sinus tachycardia, RVH, and new onset right bundle branch black. Chest X-Ray is within normal limits. Blood pressure is equal in both arms. ABG, showed PAO2 of 60, PACO2 of 37, and PH of 7.5 CK - MB, and Troponin I or T are within normal limits. Review orders: V/Q scan, stat D-dimer, stat Results: V/Q scan: Intermediate to high probability for PE D-dimer is elevated. Review orders: Stat aPTT, one time Stat PT/INR, one time CBC with diff, stat Basic metabolic panel, stat FOBT (Fecal Occult Blood Testing), stat Start IV heparin, bolus IV heparin, continuous aPTT, after 6 hours Review orders: aPTT is 35 PT is 14 and the INR is 0.9 CBC with differential: Mild leukocytosis but no bandemia, Hb is 14, Platelets count: 250,000 BMP is completely normal. Review orders: Perform detailed physical exam and interval history Results: Patient is slightly better on oxygen Review orders: Admit the patient to floor Continue cardiorespiratory monitoring (telemetry) Maintain oxygen saturations >90-92% with high flow oxygen (100% Non-rebreather mask) NPO except medications Vitals: Q 2 hours Complete bed rest Strict inputs and outputs Continue IV fluids Daily CBC with diff aPTT for every 6 hours (adjust the heparin drip to a goal aPTT of 55-70) Perform brief history and physical exam for every 2 to 4 hours until you see clinically significant improvement. Next day, review order: Consider weaning oxygen Stop IV fluids if the BP is stable Start regular diet Change vitals to Q 8 hours D/C continuous cardiorespiratory monitoring Start Coumadin (warfarin), once daily (for a female of reproductive age always rule out pregnancy before you give warfarin i.e. order a pregnancy test).

Daily aPTT/PT/INR Check the platelet count and Hb (CBC with diff), as heparin is associated with thrombocytopenia and bleeding. Discharge the patient: Once the INR is above 2, plan discharge (goal is 2-3) D/C heparin on 4th or 5th day Anticoagulation teaching Patient education Follow-up in 2 days for PT/INR checked.

Continue warfarin for 12 months, monitor INR twice weekly. During follow up look for any sites of bleeding. (In general, menstruation is not a contraindication of warfarin. If patient wants to become pregnant D/C warfarin and start heparin.) No smoking Discussion: Pulmonary embolism should be suspected in any patient presents with sudden onset of SOB, and chest pain.

Findings suggestive of PE: D-dimer is positive. D-dimer is a very sensitive assay for ruling out PE.

Normal D-dimer essentially excludes PE. But the positive D-dimer may be a false positive. ABG: Increased A - a gradient, low PO2, low PCO2, and respiratory alkalosis.

A-a gradient is more sensitive than PO2 alone.

EKG: Right ventricular hypertrophy & new onset RBBB.

Chest –X-ray may be normal. Some times a wedge shaped consolidation may be seen in the middle and lower lobes (Hampton’s hump).

This patient clearly has risk factors for a hypercoagulable state (ovarian carcinoma). Based on history and physical examination and the results of the V/Q scan this is a pulmonary embolism. V/Q scans of low to intermediate probability warrant further investigations and deep vein thrombosis should be ruled out with a duplex of the lower extremities. Otherwise venous ultrasound of the legs is indicted in patients with suspected PE and leg symptoms. If the Doppler is negative, continue the investigation with a either CT angio or pulmonary angiogram, the gold standard diagnostic test for pulmonary thromboembolism. A negative result by pulmonary angiogram essentially excludes pulmonary thromboembolism as the diagnosis. If the V/Q is highly probable for pulmonary embolism treatment should be started without further investigations. The treatment of choice is low molecular weight heparin. Low molecular weight heparin is associated with a lower risk of thrombocytopenia and hemorrhage and it appears to be as effective as unfractionated heparin in the treatment of venous thromboembolism. Failure to achieve therapeutic heparin levels within 24 hours is associated with a five-fold increase risk of clot propagation and increase in mortality. However, FDA has not approved LMWH for he treatment of PE. So, we usually continue with unfractionated heparin. All patients should be followed with regular platelet counts. Thrombolytic therapy with streptokinase or t-PA may accelerate resolution of emboli compared with standard heparin therapy. However, at one week and one month after diagnosis, there is no difference in outcome compared with heparin and warfarin. The major disadvantage of the thrombolytic therapy compared with heparin is its greater cost and a significant increase in major hemorrhagic complications like stroke .

Current evidence supports the use of thrombolytic therapy for patients at high risk despite heparin therapy or for those in whom thromboembolism may be life saving. Thrombolytic therapy is absolutely contraindicated in any patient with active intimal bleeding or stroke within the past two months, or patients who have had major surgical procedures or trauma within six weeks. Placing an IVC filter is routinely used for patients who have contraindications for anticoagulation or in patients with recurrent pulmonary thromboembolism from the pelvis or lower extremities despite adequate medical therapy. However, placement of IVC filter does not guarantee prevention of emboli as clots may form above the filter. IVC filters are also associated with a two-fold increased recurrence of venous thrombosis in the first two years following the placement. How long do you treat with warfarin? Occurrence of PE in the setting of reversible risk factors such as use oral contraceptive pills, immobilization, or surgery should be treated with 3 to 6 months of warfarin therapy. If the first episode of thromboembolism occurs in the setting of underlying malignancy, anticardiolipin antibody, and antithrombin deficiency patient should be treated with at least 12 months of warfarin therapy.

Patient's with first episode of idiopathic thromboembolism should be treated for at least 6 months with warfarin. 3 months of therapy is inadequate in this patient group.

Patients with recurrent thromboembolism or a continuing risk factor should be treated indefinitely.

Case 50[edit]

Location: Office Vitals: Temp: 38.1C; P.R: 82/minute; B.P: 128/80; R.R: 16/min. C.C: Pain and swelling of the first metatarsophalangeal joint.

History of present illness: A 43-year-old, previously healthy, white male presented to your office with a two-day history of excruciating pain in the right metatarsophalangeal joint. The pain was sudden in onset, stated overnight, 8-9/10 in severity, and was aggravated by moving the joint. Today he noticed some swelling and pain in the right knee. The patient denies any trauma. The patient also has a mild fever, and body aches. He denies any history of morning stiffness, tick bites, or rashes. The patient has had similar pain two months ago for which he took over-the-counter ibuprofen and it relieved the pain. Past medical history: Nothing significant. SH: He smokes one to two packs of cigarettes a day and drinks alcohol on the weekends. The patient is sexually active with his wife and does not use any type of contraception. He denies any prior H/O STDs, or urethral discharge. FH: Significant for osteoarthritis in his mother. How would you evaluate this patient? This is a 33-yr old, previously healthy, male presented with acute onset of severe pain in the right metatarsophalangeal joint as well as some knee pain, with a similar episode around 2 months ago. Discuss the differential diagnosis: Gout – Involvement of the metatarsophalangeal joint is very classic for gout.

Pseudogout can be present with pain in the metatarsophalangeal joint.

Septic arthritis - When any patient presents with swelling, redness, pain in the joint, accompanied by fever and chills, always consider septic arthritis.

Sometimes rheumatoid arthritis is a part of the differential diagnosis because monoarticular rheumatoid arthritis can present with pain and swelling in any joint.

Order examination: Focus the physical examination on the: General HEENT/Neck Lymphnode exam Heart Lungs Abdomen Extremities Genitourinary Skin Neurological Results: The extremities reveal a warm, tender, erythematous joint with extensive soft tissue swelling; erythema extending to the knee and below the first metatarsophalangeal joint. Skin examination is within normal limits and did not reveal any rash. Rest of the exam is within normal limits.

Now, how would you approach this patient? Here you have a patient with painful, swollen, tender, erythematous right metatarsophalangeal joint. If you get any patient like this, always the first step is to get aspiration of the fluid from the joint space. The fluid should be tested for viscosity, WBC count with a differential, gram stain, culture & sensitivity, and microscopy, which may reveal crystals. Also, obtain an urinalysis that may show some uric acid crystals. Do routine labs for a complete blood count with a differential as well as a basic metabolic profile. At the same time, obtain serum uric acid levels. Get an X ray of the joint. While waiting on the aspiration and lab results, start the treatment. The treatment of choice is nonsteroidal anti-inflammatory drugs. Typically, indomethacin is the best drug. Order: CBC with, diff, stat BUN, stat Creatinine, stat PT, stat PTT, stat Serum uric acid X-ray of the joint Indomethacin, oral, continuous If you have a patient with a history of gastrointestinal bleeding, acid peptic disease, or peptic ulcer disease, you can start Cox 2 inhibitors like celecoxib or rofecoxib instead of nonsteroidal anti-inflammatory drugs like indomethacin. Results: Normal PT/PTT. CBC with diff showed a WBC count of 12,000/ml with 80% polymorphs; no bands are noted. BMP is within normal limits. Serum uric acid level is 20 Order review: Aspiration of the joint, stat Fluid should be sent for gram stain, microscopy, and cell count.

Results: Synovial fluid analysis did not reveal any organisms. The WBC count is 10,000 per micro liter and most of the cells are polymorphs. Microscopy reveals negative birefringent monosodium urate crystals.

The presence of negatively birefringent monosodium urate crystals is pathognomonic of acute gouty arthritis. Based on these investigations, the most probable diagnosis of this patient is acute gouty arthritis. Treatment: Usually NSAIDs, that is indomethacin, is the drug of choice for acute gouty arthritis. Often, the clinical response will be seen within 12-24 hours. If NSAIDs or Cox 2 inhibitors are contraindicated, colchicine is the drug of choice. Colchicine is very effective in treating acute gouty arthritis but the incidence of side effects like diarrhea, abdominal cramps, nausea, and vomiting often limit its usefulness. Glucocorticoids are usually reserved for patient's who have contraindications for both NSAIDs as well as colchicine for example in patients with renal failure. If the patient does not respond to NSAIDs and colchicine and the patient is having monoarticular arthritis, then intra-articular triamcinolone can be used to treat a single inflamed joint. Allopurinol should not be prescribed in acute gouty arthritis. It is primarily used for the prevention of acute gouty arthritis. The patient should be advised not to take aspirin, diuretics, excessive amounts of alcohol, and foods rich in purines. The serum uric acid level should be lowered if arthritic attacks are frequently occurring or if there is any renal damage or if there is persistent elevation of serum or urine uric acid levels. Allopurinol is highly effective for hyperuricemia. If the patient is having a history of tophi, concomitant use of a glycosuric agent like probenecid or sulfapyrazone should be used. If an acute attack occurs during the treatment with allopurinol it should be continued at the same dosage while other agents are used to treat the acute attack. The use of glycosuric drugs is limited to patients who have low uric acid levels. A 24-hour measurement of creatinine clearance as well as urine uric acid levels should be obtained before you start glycosuric drugs. Glycosuric drugs are ineffective when the GFR is less than 50 ml/minute. They are not recommended for patients who already have high levels of urine uric acid i.e. about 800 mg for a period of 24 hours because of the risk of urate stone formation. Patients should also be advised to take high fluid intake and urine should be alkalinized with sodium bicarbonate.

Pseudogout: If you find a calcium pyrophosphate crystals deposited in the bone, or positively birefringent crystals in the fluid aspiration, the most likely diagnosis is pseudogout. As in acute gouty arthritis, the treatment of choice for most patients is a brief course of high dose nonsteroidal anti-inflammatory drugs. The maintenance therapy of choice is colchicine rather than allopurinol or glycosuric agents, which have no role in treating pseudogout. Patients who have contraindications for nonsteroidal anti-inflammatory drugs, use oral corticosteroids as the treatment of choice.

Case 51[edit]

Location: Emergency room Vital signs: B.P: 140/80 m Hg; P.R: 70/min; R.R: 18/min; Temp: 36.0C.

C.C: Headache
History of present illness: A 50 yr old white female presents to E.R for sudden onset of severe headache developed over the past two hours. She took ibuprofen without any relief. She describes the pain all over her head, but more on the left temporal region. Pain is 10/10 in severity, constant, non-radiating, associated with nausea, but no vomiting. She also noticed some visual changes and photophobia. She denies any fever, chills, and weakness or numbness of face or extremities. There is no loss of consciousness. She says that she's been having tension headaches for the past few years but describes this as "completely different and the worst headache in my life". PMH: depression, chronic tension headaches. Allergies: None. SH: Quit smoking, alcohol, and excessive caffeine intake. Lives with husband. FH: No FH of aneurysms or stroke . Medications: Fluoxetine 20 mg Po QD and Ibuprofen 400 mg TID PRN. How do you approach this patient? This is a 50 yr old WF who has a H/O depression and chronic tension headaches presented with completely different, sudden onset severe headache associated with nausea and visual changes.

D.D: Migraine headaches Subarachnoid hemorrhage/Stroke Temporal arteritis Acute congestive glaucoma Tensions headache (less likely) Sinusitis (less likely) Order physical exam: General HEENT/Neck CNS Results: Patient is in severe pain. HEENT: PERRLA, EOMI (extra ocular muscles intact).

Neck stiffness is present. Mild tenderness over the left temporal area is present. No sinus tenderness. No papilledema. No visual field defects noted.

CNS: Completely normal.

Order: Intravenous access IV analgesia ESR, stat CT head without contrast, stat Discussion: Indications for CT head in patients with headache are: Occurrence of severe new onset headache even in a patient with H/O chronic headache and previously normal CT Sudden onset of severe headache in any patient of >50 yr. age Presence of focal neurological findings Results: ESR is WNL CT head demonstrate no evidence of acute stroke . No midline shift. Impression: Completely normal study.

Patient is still in mild pain Order: PT/INR, stat PTT, stat Results: PT/INR and PTT are within normal limits.

Order: Lumbar puncture, stat Results: Xanthochromic supernatant is noted on LP Order: Admit in ICU Continuous cardiorespiratory monitoring NPO Complete bed rest Strict ins and outs Neuro checks Q 1 hour CBC with diff, stat BMP, stat and daily EKG, 12 lead, one time (for baseline) Transcranial Doppler (For baseline) Neurosurgery, consult, stat IV fluids, NS 1000 ml bolus, followed by 50-100 cc/hr Acetaminophen with codeine po Q 4 to 6 hours prn for pain Stool softener (Docusate), twice daily Nimodipine 60 mg po QID for 21 days Omeprazole 20 mg po QD Pneumatic compression devices After you finish the orders perform complete physical examination Discussion: Based on the above findings, the most likely diagnosis in this patient is subarachnoid hemorrhage (SAH). SAH can occur even with normal CT scan. If the index of suspicion is very high, such as in patients with neck stiffness or other meningeal signs, lumbar puncture should be performed. Lysis of RBC and subsequent conversion of Hb to bilirubin occurs over a period of time and turns the CSA yellow. Presence of this xanthochromic supernatant is classic for SAH.

ST, T wave changes similar to cardiac ischemia may be seen on ECG. Serum electrolytes should be obtained at the time of admission and at least once daily, as they are more prone to develop hyponatremia ('cerebral slat wasting syndrome') in the first two weeks. Vasospasm remains the leading cause of morbidity and mortality in these patients. Transcranial Doppler (TCD) ultrasound assessment of the proximal middle, anterior, posterior cerebral arteries, and basilar artery flow is very helpful in predicating the vasospasm. Treatment: Patients should be placed in ICU, and kept NPO, with complete bed rest. Stool softeners and mild laxatives are useful to prevent straining. Control the headache with acetaminophen plus codeine. Stress ulcer prophylaxis should be given with either H2 blockers or PPIs. Patients should have pneumatic compression stockings applied to prevent the DVT. Management of blood pressure is important in patients with SAH. Uncontrolled hypertension causes more bleeding. On the other hand, decreased blood pressure can cause cerebral hypoperfusion resulting in infarction. The goal is to keep the systolic blood pressure 120-140 mm Hg. IV labetalol is the drug of choice if the blood pressure is high. Cerebral hypoperfusion is treated with IV NS bolus, and vasopressors.

Patients with uncontrolled blood pressure should have intra arterial and central venous line. The use of prophylactic antiepileptic medications in patients with SAH is highly controversial. Hyponatremia should not be treated with free water restriction. IV NS with salt supplements are enough to treat hyponatremia.

However, sometimes 3% hypertonic saline may be needed. Because of the risk of 'central pontine myelinolysis', hyponatremia should be corrected slowly. Acute hydrocephalus is a complication of SAH. Patients should be frequently examined, and if necessary ventriculostomy should be performed. Once the medical management has been established and the patient is stable, a standard 4-vessel angiogram should be performed. Further management is beyond the level of this exam.

Case 52[edit]

Hyperthyroidism- Location: Office Vital signs: B.P: 148/90 mm Hg; P.R: 110/min, regular; R.R: 24/min; Temp: 37.0 C. C.C: Rapid heart beat and palpitations.
History of present illness: A 48-year old white female presents to your office for evaluation of recent onset of rapid heartbeat and palpitations. They occur without warning, are regular in rhythm, and resolve spontaneously. She also reports that she has lost 12 pounds, during the last two months, despite a good appetite. She says she’s having trouble getting to sleep. She denies any constipation, diarrhea, blood in the stools, or melena. She denies any heat or cold intolerance. She has noticed decreased duration of her menstrual cycles recently, and thinks she’s reaching menopause. She denies any chest pain, dizziness, syncope, leg swelling, shortness-of-breath, orthopnea, or PND. PMH: No H/O heart disease, HTN, or DM.

Nothing significant except an anxiety disorder. She has no known allergies. FH: There is no family H/O sudden death. SxH: The patient is sexually active with husband. They use condoms as contraception. SH: She denies smoking, alcohol, or IV drug abuse. Medications: None. Review Of Systems: Unremarkable. How would you evaluate this patient? Complete physical examination Results: On exam she has rapid speech. Her hands are warm and moist. Mild diffuse nontender enlargement of the thyroid is noted. Rest of her exam is completely normal. Orders: CBC with diff, stat BMP, stat ECG, 12 lead, stat Serum TSH Serum Free T3, and T4 Results: CBC with diff is within normal limits BMP is within normal limits EKG showed sinus tachycardia TSH is low - 0.08 µU/mL T3 and T4 are elevated Review order: 24-hour radioiodine uptake Follow-up with the results Results: Radioiodine uptake is increased Review order: Propranolol, oral, continuous Methimazole, oral, continuous Follow up in 4 weeks. Advise to stop methimazole 4 days prior to follow up. Review order: CBC with diff Stop Methimazole Radioiodine, one time Follow up in one month Discussion: A 48-year old white female presented with palpitations, weight loss (despite having a good appetite), difficulty sleeping, and menstrual problems. This is one of the classic presentations of hyperthyroidism. The combination of weight loss and good appetite is classic for hyperthyroidism.

Approach of a patient with palpations: A complete history and physical examination should be performed in all hemodynamically stable patients. There are no evidence-based guidelines to direct the laboratory workup on patients with palpitations. We routinely obtain 12 lead ECG, CBC with diff, BMP, and TSH levels. Identify common causes like anemia, electrolyte imbalance, and thyroid abnormalities. If the initial approach does not establish the definitive diagnosis, further evaluation is indicated. Patients are classified as either low risk or high risk depending on the risk factors. High-risk patients: Patients with H/O syncope or dizziness.

Patients with a family history of sudden death, arrhythmias, or long QT syndrome. Any patient with underlying organic heart disease, which include scarring from prior MI, cardiomyopathy, significant valvular disease, and HOCM.

These patients are at high risk of developing ventricular tachycardia so should be evaluated with either ambulatory monitoring or an inpatient electrophysiological study. Low-risk patients: Patients with no family or personal history of arrhythmias.

No H/O dizziness or syncope.

No underlying organic heart disease.

These patients should be reassured. However, ambulatory monitoring (24-hour Holter monitor) is indicated if the ECG shows sustained arrhythmia.

Hyperthyroidism: The most cost affective approach to a patient with suspected hyperthyroidism is to obtain serum TSH levels. A patient with normal TSH is very unlikely to have hyperthyroidism. However, it is reasonable to obtain a simultaneous free T3 and T4 if the index of suspicion is very high. If the TSH is less than 0.1 ml and free T4 is elevated, hyperthyroidism is confirmed. If the TSH, free T4, and T3 are elevated, a TSH producing pituitary tumor should be suspected and MRI of the brain should be ordered. Once the diagnosis of hyperthyroidism has been established, the underlying cause should be determined. Basically, hyperthyroidism is categorized into two broad classifications: Graves' disease and toxic multinodular goiter.

Postpartum thyroiditis, iodine induced, or factitious hyperthyroidism.

Often, Graves disease is diagnosed on clinical grounds (diffuse goiter, ophthalmopathy) alone. Measurement of TSH receptor–stimulating autoantibodies (TSI), is not routinely recommended for the diagnosis of Graves disease.

However, a 24-hour radioiodine uptake is necessary to confirm Graves disease and to exclude other possibilities (it will be elevated in the first group and decreased in the second group). Once the diagnosis is made, treatment should be started. Sub acute and postpartum thyroiditis are usually transient and require only symptomatic treatment. Radioiodine is the treatment of choice for people over 20 years old. Obtain a pregnancy test before you take a radioiodine uptake because it is contraindicated in pregnancy. Radioiodine causes destruction of the thyroid and often associated with a small risk of thyrotoxicosis. So, all elderly and patients with cardiac problems should be pretreated with antithyroid drugs for at least one month. Antithyroid drugs must be stopped 3 to 5 days prior to the radioiodine treatment to achieve optimum iodine uptake. Ophthalmopathy may be aggravated by radioiodine treatment. So, physicians often start tapering course of steroids at the time of radioiodine treatment if the patient has evidence of ophthalmopathy. Symptoms of hyperthyroidism can be seen upto 2 to 3 months after the treatment of radioiodine. Either antithyroid drugs or beta blockers can be used to control the symptoms during this period. Patients should be followed at 4-6 week intervals with clinical examinations, and the free T4 level (not TSH).

If symptomatic hyperthyroidism persists after six months, radioiodine uptake should be repeated. Antithyroid drugs are primarily used in pregnancy, when radioactive iodine is contraindicated or in a patient of less than 20 years old. Propylthiouracil is the drug of choice in pregnancy. These are associated with granular cytopenia, so always obtain a baseline CBC with differential before starting the treatment.

PTU is also associated with hepatotoxicity so, baseline Liver function tests (LFT) are important.

Finally, surgery is indicated in pregnant patients who do not respond to propylthiouracil therapy. Euthyroid state is usually achieved in two to four months. Follow the patient in six weeks with free T4 levels. Beta-blockers (eg, propranolol or atenolol) can be used if the patient is tachycardic, anxious, sweating, or having tremors. If beta-blockers are contraindicated, such as in symptomatic bronchial asthma patients, verapamil can be given.

Case 53[edit]

LOCATION- Location: Outpatient Clinic, Pediatrics. Vital signs: Normal. C.C: 2-1/2-year-old girl with abdominal pain and constipation.

History of present illness: The patient is a 2-1/2-year-old Hispanic female who presents today for evaluation of abdominal pain, constipation and anorexia that had been present for approximately eight weeks. She arrives with her parents who report that her symptoms started slowly at first with some anorexia and then slowly they began to notice that she was constipated more frequently and had complaints of abdominal pain. The parents note that the patient’s stools are normal in appearance, other than being somewhat hard and round. She has had no episodes of rectal bleeding or melena. She had no complaints of nausea and has not been vomiting. The patient has not had regular medical care but has received immunizations at a local health department. The family lives in a house built in the 1930s. They have been remodeling the home over the past year and a half including tearing down walls and refinishing the flooring. The house still has its original windows. The father works in the construction business and mainly does the initial demolition prior to putting up a new structure. Mother stays home and watches the patient.

They have a school age child who is six years of age. There are no pets in the house. They have city water. The patient herself has never had trouble with constipation or anorexia prior to this time. The patient’s gross motor development has been normal up until this point and she has been meeting her developmental milestones. The patient spends all of her time at home. She does not go outside of the home for day care. How to approach this case: This is a 2-1/2-year-old child presenting with anorexia, abdominal pain, and constipation. The differential diagnosis is rather broad and constipation is an exceedingly common problem in the pediatric population. However, this child has some red flags that might make one want to pursue a slightly different course in the workup of her constipation symptoms. First, she has not had routine health check-ups so she has not had a screening hemoglobin level to identify iron deficiency anemia nor has she presumably had a screening lead level to identify children who are high risk of lead poisoning. Both of these studies should be obtained on this patient as part of her constipation workup.

Orders: Complete physical exam Results: General: The patient is well developed and well nourished, in no acute distress. HEENT: Slightly pale conjunctivae, otherwise normal. Cardiovascular, and Lungs: Normal. Abdomen: Bowel sounds are present but slightly diminished. Belly is soft, nontender, and slightly distended with stools felt in the left lower quadrant. Extremities are normal. Neurologic: Nonfocal and appropriate for age.

The patient is a 2-1/2-year-old with constipation so one would want to at least treat that problem. Orders should include a bowel regimen to improve the constipation symptoms. Hypercalcemia and occult urinary tract infection may present with constipation. Orders: Fingerstick lead level (Unfortunately this is not available in CCS software; So you can directly obtain 'blood lead, quantitative'), CBC with differential, routine Basic metabolic panel, routine Calcium level, routine Milk of magnesia 10 cc QD, Docusate 20 mg QD, Urinalysis, Follow up appointment in three to five days to review laboratory studies and see if improved.

Results: Fingerstick lead of 70 mcg/dl, Hemoglobin is 10.7, hematocrit is 33, MCV is slightly low at 76 cl/cell.

U/A - WNL Discussion: This patient has an elevated fingerstick lead. The current guidelines indicate that any level over 9 is considered elevated. The patient also has a mild decrease in her MCV and her hemoglobin and hematocrit are slightly decreased suggesting microcytic anemia. Both iron deficiency and lead poisoning can induce a microcytic anemia. As the first test to follow up with the patient’s elevated fingerstick lead level, one should obtain a venous blood lead level.

Order: Venous blood lead level.

Results: 54 mcg/dl.

Discussion: This patient has an elevated blood lead level at a level sufficiently high to warrant treatment. Treatment is aimed at assessing the patient’s environment to see what sources of lead may be contaminating the patient’s environment; changing the child’s behaviors, particularly hand-mouth behavior which can contribute to the ingestion of lead dust; ensuring that the child has adequate nutrition, particularly calcium and iron to decrease lead absorption; and lowering the patient’s whole body lead level through chelation therapy. In general, chelation therapy is warranted when the blood lead level is greater than 45 mcg/dl. Monotherapy is indicated up to 69 mcg/dl; greater than 69 mcg/dl warrants two-drug chelation therapy.

Orders: Home inspection for sources of lead - Type 'Lead paint assay at home' Dietary recommendations to increase calcium in the diet to approximately 1 gram of calcium per day. This may be obtained either through milk and other dairy products or calcium-fortified orange juice as well as recommendations for iron therapy since the patient has iron deficiency or simply add an iron-containing multivitamin if the patient does not have iron deficiency. Serum iron, ferritin, and TIBC Succimer (DMSA) chelation therapy, oral continuous Liver function tests, erythrocyte protoporphyrin - baseline prior to succimer therapy Follow up in one month If inspection reveals the home as the source of lead poisoning, then lead abatement (Type, 'Lead abatement agency') within the home is also a necessary part of this patient’s plan, and the patient should be removed from the home while the abatement is occurring and while the family is remodeling.

Succimer, also known as DMSA, is the first drug of choice for children who have elevated lead levels in the 45-100 mcg/dl range, at a dosage of 350 mg/M2 per dose every eight hours orally for five days and every 12 hours for another 14 days. Toxicities associated with succimer include GI distress, rashes, elevated liver function tests and depressed white blood cell count. Therefore when ordering succimer further orders include CBC and hepatic panel. One should obtain these at baseline as well.

Results: Patient has completed the chelation therapy without any side effects.

Iron studies were normal.

Baseline liver functions were normal.

Erythrocyte protoporphyrin level was elevated.

Her constipation has improved and she no longer needs the milk of magnesium or docusate.

Orders: Repeat lead level, (Type blood lead, quantitative) CBC, Erythrocyte protoporphyrin today.

Discussion: Exposure to lead can cause subtle cognitive defects in children. Currently the accepted level for the threshold of concern is a blood lead level greater than 9 mcg/dl. Because of increased public awareness of the toxicities associated with lead, screening programs that routinely screen for lead as well as anemia have been able successfully to identify children who have increased exposure to lead and possible toxicity from it. Patient populations who are at increased risk of high lead levels include immigrant families, particularly Hispanic ones, who may use ceramic ware glazed with lead paint; children who live in poverty; who are younger than six years of age; who are African-American; or who dwell within a city. Children can have increased exposure if they live in a house or spend considerable time in a structure built before 1950 when use of lead-based paint was prevalent. Children whose family members work in areas that may have elevated lead levels (including metal refineries, battery recycling plants, maintenance workers on bridges and boats, and demolition workers) may receive “second hand” dust exposure from contaminated clothing. Other sources include window blinds, zippers, painted furniture and mineral supplements, particularly ones that have been brought to this country from a country in which lead levels are not vigorously monitored. Lead dust is a particular problem for children as it usually accumulates in places such as windowsills where paint along the window is frequently rubbed with the release of dust particles; toddlers who, because of their developmental stage, tend to mouth objects including windowsills, toys, and their hands become exposed to this dust.

Because of monitoring, most children present with asymptomatic lead poisoning that is noted on screening laboratory tests. The fingerstick lead level is the initial screening test; however, because of contamination problems, this level is frequently higher than a venous blood level and therefore any fingerstick screen that is elevated should be followed up in 48 hours with a venous blood lead level. Erythrocyte protoporphyrin levels may be elevated and can be followed to see a response to chelation.

It is felt that GI symptoms occur at approximately 50 mcg/dl; however, some data suggest that nearly half of children who have blood level levels in the 20-45 mcg/dl range may also have GI symptoms which may be misinterpreted.

Encephalopathy secondary to lead poisoning usually does not occur unless the level is exceedingly high such as over 100 mcg/dl and this will be an indication for prompt chelation therapy. As noted above, chelation therapy is recommended for levels greater than 45 mcg/dl with monotherapy being recommended for levels between 45 and 69. There are currently four different chelating agents available in the United States for lead poisoning. They are succimer, calcium edetate, BAL/dimercaprol, and D-penicillamine. Children who undergo chelation therapy can expect to have their blood lead level rebound about four to six weeks post chelation, presumably due to the release of lead from bone stores. Those children who have levels above 100 mcg are likely to have a rebound blood lead level greater than 45 mcg/dl which would warrant a second round of chelation therapy. Those children who have levels greater than 45 will generally have a rebound in their level to about two-thirds of what it had been prior to chelation therapy, and they may or may not warrant further chelation therapy. Therefore, it is important to do follow up blood lead level measurements on these children.

Order review: Follow up appointment in one 4-6 weeks with erythrocyte protoporphyrin level and a blood lead level. Repeat chelation if still warranted.

Continue multivitamin with iron. Continue calcium supplementation in the diet.

Primary diagnosis: Lead poisoning. Note: You may get a case of lead poisoning with a different presentation. For example, child may present with fatigue, lethargy, not doing well in school; and on exam he has pallor. You order a CBC, which shows microcytic anemia and basophilic stippling etc.

Case 54[edit]

Location: Outpatient Clinic.

Vital signs: Blood pressure:137/79 supine, 124/68 erect; Heart rate: 85/min, regular; Respirations: 16/min; Temperature 38.8C.

C.C: Cough.

History of present illness: The patient is a 65-year-old white male with a past medical history significant for COPD with a 60-pack-year smoking history. He continues to smoke cigarettes occasionally, although he has recently cut back. He presents with a five-day history of increasing cough, increased sputum production and fever up to 38.7 for the last two days. He has dyspnea on exertion and currently has some mild dyspnea. He’s had decreased appetite, poor PO intake and a ten pound weight loss over the past two months. Review Of Systems: He denies any chills, hemoptysis, chest pain, pleuritic chest pain, abdominal symptoms/pain, diarrhea, constipation, blood per rectum, or melena. He denies any neurologic symptoms. The rest of his review of systems is negative. He had a similar illness approximately seven to eight weeks ago which was treated with cefuroxime and azithromycin, and the patient reports that after that course of treatment he got better and has been well for the past three weeks until the last five days when he had return of the cough, increased sputum production and fever. FH: Nothing significant.

Medications: Takes albuterol puffs as needed. Allergies: None How to approach this case: The patient is an elderly man with a significant history of COPD now presenting with a second pneumonia in the course of about two months. He needs an evaluation right now of his O2 saturation, physical exam, and then an exploration into the etiologies behind his recurrent pneumonia. The suspicion for malignancy is very high given his 60-pack-year smoking history, the weight loss noted in the review of systems, and the recurrence of a pneumonia, particularly if the pneumonia is in the same place as the prior one. Orders: Pulse oximetry Results: O2 saturation 90% on room air Order: Physical exam: HEENT/Neck, lungs, heart, abdomen, and extremities, Results: General: Elderly white male in no acute distress with temporal wasting. HEENT shows a clear oropharynx with upper and lower dentures. There is no neck lymphadenopathy. Temporal wasting is present. Conjunctivae are slightly pale. Cardiovascular is normal. Lungs: Decreased breath sounds throughout with rales present on the right upper lung fields posteriorly and decreased breath sounds in the right upper lung anteriorly. Increased anterior posterior distance on the chest with barrel chest habitus, and mild supraclavicular retractions.

Abdomen: Slightly obese but otherwise normal. Extremities: There is bilateral tenderness of wrists, with nails more curved longitudinally and base of nail bed fluctuant in all fingers. Right index finger and middle finger show nicotine staining.

Discussion: The patient has hypertrophic osteoarthropathy noticed on examination. It is characterized as chronic proliferative periostitis of long bones, clubbing of fingers and synovitis. It is more related with squamous and adenocarcinoma of the lungs. Symptoms of this condition may occur before the actual manifestation of lung carcinoma. As a No.1 killer Cancer in USA, it remains very important to know the different manifestations of lung carcinoma. This patient’s finding of hypertrophic osteoarthropathy is significant for lung carcinoma in the context of his recurrent pneumonia and dyspnea.

Orders: Shift to hospital ward. Begin supplemental oxygen therapy at 2 lpm by nasal cannula (Type oxygen inhalation) Intravenous access IV fluids at 100 cc an hour with normal saline Urine outputs, Q 4 hours Vitals: Every 4 hours Pulse oximetry every 4hours Activity: Bed rest with bathroom privileges Chest X-Ray, PA and lateral, stat Blood cultures, stat Coughed sputum sample for gram stain, culture and cytology. CBC with differential, stat Basic metabolic panel, stat Begin antibiotic therapy with Levofloxacin (Levaquin) orally or IV after cultures obtained Albuterol and ipratropium nebulized treatments Q6 H and albuterol Q2H PRN for shortness of breath.

Results: Chest X ray shows an infiltrate in the right upper lobe with some elevation of the transverse/minor fissure anteriorly. There are no effusions. There is evidence of hyperinflation and chronic lung changes. Whenever Ca lung is suspected on the basis of clinical features and initial diagnostic tests, we need to perform advanced imaging procedures and other tests to establish the tissue diagnosis of lung cancer. CT scan of chest is done for mediastinal and pleural extension of the suspected lung tumor. For tissue diagnosis of the lung Ca following diagnostic modalities are available: Sputum cytology Biopsy of suspicious lymph nodes Flexible fiberoptic bronchoscopy: Biopsy specimens are taken when any endobronchial lesion is noted Pleural biopsy if pleural effusion is present Mediastinoscopy and anterior mediastinotomy when there is suspicion of mediastinum involvement by the tumor Transthoracic FNA biopsy under CT or fluoroscopic guidance when a peripheral pulmonary nodule is present Order review: Spiral CT scan of the chest Arrange for bronchoscopy Consult Pulmonary Medicine/cardiovascular surgery for bronchoscopy CBC/diff with basic metabolic panel daily Continue supplemental oxygen therapy Results: The patient undergoes bronchoscopic examination the following day. He tolerates the procedure well. Broncho Alveolar Lavage (BAL) samples are sent for cytology, gram stain, culture, AFB smear, and fungal culture. The patient continues to show slight improvement in his oxygen saturations and overall function with the levofloxacin therapy. His IV fluids can be discontinued. His supplemental oxygen can be weaned to room air.

Results of the bronchoscopy showed an endobronchial lesion in the takeoff of the right superior bronchus. The area was biopsied and brushed. Cytology reveals malignant cells consistent with a bronchogenic carcinoma and cytology reveals small cell carcinoma of the lung. Order: Pulmonary Function Tests (PFT) Liver Function Tests (LFT) Serum calcium , stat CT of the abdomen and pelvis MRI brain with and without contrast Bone scan Consult oncology Consult radiation oncologist Quit tobacco use Supplement diet with high protein nutritional shakes Consider changing albuterol/ipratropium nebulizer to MDI (Metered dose Inhalers)

Primary diagnosis: Bronchogenic carcinoma presenting as obstructive pneumonia Discussion: Lung cancer incidence is about 3-5 per 1000 persons per year and the majority of patients are symptomatic at presentation. Local symptoms include cough (70%), hemoptysis (40%), dyspnea (40%), chest pain, hoarseness, superior vena cava obstruction, and wheezing. Systemic symptoms include weight loss, anorexia, weakness, and fever. Signs on exam include bone pain, hepatic dysfunction, lymphadenopathy, and neurological or cranial nerve involvement. Almost all patients diagnosed have constitutional symptoms, such as the case above. Lung cancers typically metastasize to bone, liver, lymphnodes, brain, and soft tissue. Unfortunately, screening with chest radiography and sputum cytology in patients at risk has not been found to decrease cancer mortality although it may detect disease at an earlier stage.

Work up of suspected cases includes bronchoscopy for cytology and visualization, as well as High Resolution CT (HRCT) of the chest. If small cell lung cancer is found, then an MRI or CT of the brain, CT of the abdomen and pelvis, and bone scan should be performed in all patients because of the high incidence of micro/macro metastasis by the time of diagnosis. Bone marrow aspiration/biopsy is warranted in patients of SCLC (small cell carcinoma of the lungs) when there is cytopenia or increased LDH. This workup is also indicated in patients of NSCLC in whom involvement of the specific organs is suspected.

PFT’s with diffusion capacity, spirometry, and oxygen saturations should be obtained early on. After staging has been completed, about 30-40% of patients will have limited stage disease and 60-70% will have extensive disease.

Case 55[edit]

CHIEF COMPLAINT- Location: Emergency room Vitals: B.P: 110/70 mmHg; P.R:100/minute; Temperature: 1020F; R.R: 15/minute.

C.C: Fever and chills.

History of present illness: A 54-year-old retired businessman is brought into the emergency room. Family members report that he has had a mild fever, chills, and body aches, for two days. However, this morning the patient exhibited a high-grade fever with chills, rigors, altered mental status, and a severe headache. He is nauseated and had non-bloody vomiting. The patient denies any neck pain, sensory changes in his extremities, weakness, seizures, or visual changes. His bowel and bladder functions are intact. PMH: Significant for hypertension the last ten years and has been taking atenolol 50 mg. once daily. SH: He denies smoking or drinking alcohol. He has no known allergies. FH: Nothing significant. Review Of Systems: No H/O head trauma. Rest is unremarkable.

How would you approach this patient? This is a 54-year old male with a two to three day history of high-grade fever with chills, severe headache, vomiting, and altered mental status. The most likely diagnosis is either meningitis or encephalitis. It is difficult to differentiate encephalitis from meningitis, on clinical grounds alone. All patients should be treated as having meningitis, until proven otherwise.

Order physical examination: HEENT/Neck CNS Heart Lungs Abdomen Extremities Skin Results: On general examination the patient appears alert, awake, and oriented to time, place, and person. The patient appears mildly confused, and sleepy. He appears very ill. The only positive findings on exam are neck stiffness and Kernig sign.

No focus of infection or other abnormalities are found. Fundoscopy did not reveal any papilledema.

Orders: Pulse oximetry, stat and every two hours Intravenous access IV NS, 100 cc/hr NPO except medications Hold his atenolol Complete bed rest DVT prophylaxis (Type 'Pneumatic compression stockings') Vitals Q 2 hours Urine output every two hours Head elevation Blood cultures, stat Urinalysis, stat Urine culture and sensitivity, stat CBC with diff, stat and Q day BMP, stat and Q day PT/INR, stat PTT, stat Phenergan, IV PRN for vomiting Acetaminophen, oral, PRN for headache and fever Once the blood cultures are obtained: IV ceftriaxone, continuous IV vancomycin, continuous Lumbar puncture, stat Send the CSF for cell count, protein, glucose, Gram stain, Fungal stain, culture, and sensitivity Results: Gram stain of the CSF shows Gram positive cocci CBC showed elevated white count with left shift BMP is normal PT/INR/PTT is within normal limits Review orders: Change the antibiotic according to the organism and sensitivities. Do not forget to stop the initial or unnecessary antibiotics. Order interim history and focused physical exam every four hours until you see improvement, then Q12 hours. Once the mentation is improved start clear liquids, then advance the diet. Order 'out of bed to chair'. D/C daily CBC with diff, and BMP when no longer required. Discussion: Basically, this patient is showing signs and symptoms of meningitis. He needs to be hospitalized immediately because of his altered mental status. The patient should be kept NPO. Start IV with normal saline because the patient is on NPO and his diastolic blood pressure is 70, in spite of having a history of hypertension. Blood should be drawn immediately and sent for CBC with a differential, BMP, blood cultures, and coagulation studies (PT, INR and PTT to rule out the possibility of DIC and to obtain his baseline coagulation studies).

Immediately after ordering these investigations, intravenous antibiotics should be started which are mostly empirical. The use of prior imaging studies, like a CT scan of the brain, is not necessary to proceed with a lumbar puncture. In a patient with a normal level of consciousness, without any focal neurological signs, a lumbar puncture can be safely performed even without prior imaging studies. We recommend starting intravenous antibiotics, even before obtaining a lumbar puncture. Antibiotic therapy for several hours, prior to lumbar puncture, will not significantly alter the CSF, WBC count, glucose concentration, or the results of culture. However, blood cultures should be obtained prior to starting antibiotics. CSF should be sent for gram stain, culture and sensitivity, protein, glucose, and cell count with a differential. If the patient has a history of seizures, with focal neurological signs, herpes simplex should be considered and empirical IV acyclovir should be started along with IV antibiotics. In all HIV patients, CSF should be sent for cryptococcal antigen assay to rule out cryptococcal meningitis. In acute bacterial meningitis, the CSF, WBC count will be elevated and red blood cells will be absent unless there is a traumatic tap. Glucose is usually low (less than 40 mg/dl) and the protein is elevated (more than 40 mg/dl). Gram stain is usually positive in 70-90% of untreated patients and culture is positive in around 80% of cases. The use of empirical antibiotics depends on the patient's age and risk factors.

In infants of less than three months, cefoxitin plus ampicillin should be given. Cefoxitin covers most of the gram negatives and ampicillin is to cover Listeria meningitis. Dexamethasone has been indicated for H. influenza meningitis. Immunocompetent children of more than three months to adults age of less than 50 years should receive a third generation cephalosporin, preferably ceftriaxone plus vancomycin. Adults of more than 50 years of age and individuals with alcoholism or other debilitating illnesses should receive ceftriaxone plus vancomycin plus ampicillin (to cover Listeria). Meningitis, which develops after head trauma, or neurosurgical procedures, or in patients with neutropenia, should receive vancomycin plus ceftazidime.

Ceftazidime covers gram-negative organisms, preferably Pseudomonas. Once the organism has been identified on gram stain, antibiotics should be directed against a specific organism. If you find gram-negative bacilli on the gram stain, ceftriaxone again is the drug of choice. If you find a Pseudomonas on the gram stain and the culture, the drug of choice is IV ceftazidime. If you find gram-positive cocci in clusters (staphylococcus), IV nafcillin is the drug of choice. First generation cephalosporins should not be used for staphylococcus infections because they do not have high permeability into the CSF. IV vancomycin is the drug of choice for Penicillin allergic patients and methicillin resistant Staph aureus. If the Gram stain shows Haemophilus influenza, IV ceftriaxone is the drug of choice. If the patient is having meningococcal meningitis, the patient should be placed in respiratory isolation and the patient can be tested for terminal component complement deficiencies (C6-C9). If you identify Listeria monocytogenes and the patient is an immunocompromised or undergoing dialysis, IV ampicillin plus IV gentamicin should be given for at least three to four weeks. Usually the period of antibiotic doses is in between 10-14 days of intravenous antibiotics. Primary diagnosis: Bacterial meningitis

Case 56[edit]

Vitals- Location: Office Vitals: B.P: 140/80 mm Hg; P.R: 88/min; R.R: 18min; Temperature: 38.1C.

C.C: Pain and swelling of the right leg.

History of present illness: A 38-yr old white female, who is otherwise healthy, presents to office with two to three day history of pain and redness of the right leg. The pain continues despite applying heat and elevating the legs. There is a mild fever today. She denies any trauma, tick or insect bites, joint pains, or prior episodes of similar problems. She has no other medical problems except menstrual abnormalities. Her gynecologist placed her on oral contraceptive pills. FH: Her mother has a H/O rheumatoid arthritis. SH: She smokes less than half a pack of cigarettes per day. Drinks alcohol on the weekends. SxH: Sexually active with her husband. Review Of Systems: unremarkable.

How do you approach this case? Consider differential diagnosis: Deep vein thrombosis Cellulitis/Lymphangitis Superficial thrombophlebitis Rupture of the Bakers cyst Hematoma Order physical examination: General HEENT/Neck Lungs Heart Abdomen Extremities Skin Results: Exam is remarkable for a palpable cord, edema, warmth, and superficial venous dilation of the right lower extremity. There is no source of infection noted on careful examination of foot. Rest of the exam is unremarkable.

Order: Transfer to ER Pulse oximetry, stat Compressive ultrasonogram of the right leg (Type 'Venous doppler, lower leg'), stat D-dimer, stat CBC with diff, stat Results: Pulse oximetry shows 95% on room air USG shows deep vein thrombosis of the popliteal vein CBC shows Hb of 14, WBC of 12,000 with no bandemia, and platelet count of 220,000.

Order: Rectal exam FOBT, stat PT/INR, stat PTT, stat D/C Oral contraceptive pills Results: Rectal exam is normal FOBT is negative PT is 13.6; INR is 0.9 PTT is 24 Order: LMWH (Enoxaparin), stat and Q 12 hours, sub cutaneously Acetaminophen and oxycodone for pain as needed Anticoagulation teaching (Type 'patient education') No smoking Discharge to home with follow up in office next day Review: Brief physical exam and interim history Coumadin/warfarin (5 to 7.5 mg) oral, continuous PT/INR, every day until the INR is therapeutic Appointment with anticoagulation clinic to follow PT/INR (Option is not available in software, so you have to follow every day with PT/INR) Platelet count, in day 3 and 5 of heparin treatment Discussion: DVT is classified into proximal vein and calf vein thrombosis. This classification is important because proximal vein thrombosis is often associated with embolic phenomena (Board question).

Even though contrast venography is the gold standard test for diagnosis of DVT, it is not recommended for screening purposes because it is invasive, associated with patient discomfort, and technically difficult.

The two commonly used noninvasive tests for the diagnosis of DVT are compression ultrasonography and impedance plethysmography. Studies have shown that compression ultrasonography was superior to impedance plethysmography in guiding therapeutic strategy in patients with DVT. However, impedance plethysmography is the preferred test for the evaluation of suspected recurrent DVT because it normalizes more quickly after a previous episode than compression ultrasonography.

Measurement of D-dimers is useful in excluding thromboembolic phenomena because of its high negative predictive value. However, the presence of elevated D-dimer alone cannot establish a diagnosis of DVT. D-dimers should be correlated with clinical probability, and noninvasive tests in guiding the diagnosis.

Simple DVT can be managed as an outpatient. Low molecular weight heparin (LMWH) is the treatment of choice for acute DVT. Enoxaparin is the most commonly used LMWH. Warfarin can be started within 24 hours. PT/INR should be measured daily until the therapeutic range (2.0 to 3.0) is reached. Heparin is stopped in day five or six if the INR is therapeutic for at least two consecutive days. A platelet count should be obtained on day three and five to monitor HIT (heparin induced thrombocytopenia). Heparin should be stopped if there is a >50% reduction in platelet count or a total count of less than <100,000/µL.

How long should you treat DVT? Patients with reversible risk factors (surgery, oral contraceptive pills) – 3 months Idiopathic first time DVT – 6months Recurrent idiopathic DVT, and patients with continuing risk factors (malignancy, inherited thrombophilia) – 12 months or more

Case 57[edit]

Presenting Complaints- Location: Office Vital signs: P.R: 72/min; B.P: 136/80 mm Hg; Temperature: 98.6 F; R.R 20/min; Height: 130 cm; Weight 60 kg. C.C: A 53-year-old woman comes to you with the complaint of abdominal distention

History of present illness: A 53-year-old African American comes to you with abdominal distention. She noticed it one week ago. Her symptoms started with the complaint of anorexia, early satiety, and abdominal discomfort the past several weeks. She is very worried something is terribly wrong inside her stomach. Her other complaints include exertional shortness of breath and orthopnea. She never had postmenopausal bleeding, jaundice, fever, pruritus, or abdominal pain. She has never received a blood transfusion nor traveled outside USA. Her bowel movements and bladder function are normal. She has no history of contact with a jaundice patient. She had her menarche at age 13 and menopause at age 51. Her family history is significant for breast cancer in her mother at age 65. She has been smoking less than half a pack of cigarettes per day since 30 years. During that same amount of time, she generally has a couple of beers per week. She denies any IV drug abuse. She has had a total of four sexual partners in her life. She has no known allergies. Review Of Systems is unremarkable. Order physical emanation: General HEENT/Neck Lymph nodes Breast Lungs Heart Abdomen Rectal Extremities Skin Results: There is no lymphadenopathy. No JVD. Lungs: There are decreased breath sounds, and a dullness to percussion note is noted at the right base. Abdomen: Bowel sounds present. Abdomen is nontender. Rebound tenderness is negative. Flank and shifting dullness is present. Pelvic exam: Eternal genitalia are healthy. Solid, fixed, irregular right adnexal mass is palpable. Rest of the exam is unremarkable. Review order: Admit to floor/ward Pulse oximetry, stat and Q 12 hours Vitals, Q 12 hours Regular diet CBC with diff, stat Comprehensive metabolic panel, stat Abdominal ultrasonogram Pelvic ultrasonogram Chest - X ray, PA and lateral U/A, stat FOBT PT/PTT Results: Pulse oximetry showed 93% on room air. CBC showed Hb of 11, WBC of 9,000 with normal differential, and a platelet count of 190,000. Comprehensive metabolic panel is WNL. Chest X-Ray shows mild to moderate right sided pleural effusion. USG showed solid, irregular right ovarian mass, and ascites. U/A is WNL and FOBT is negative. PT/PTT are WNL Review order: Paracentesis, diagnostic (consider 'therapeutic' if the patient has respiratory distress at rest) Send fluid for cell count and diff, protein, glucose, and cytology CT of the abdomen CT chest, spiral Bilateral mammogram PAP smear CA 125 levels After results place a consult for Gynecologic oncology Medical oncology CCS do not have options for surgical/gynecologic oncology. So, just type 'oncology' and 'general surgery' or 'gynecology' Discussion: This patient has the main complaint of abdominal distention. Presence of flank dullness is the single most significant finding to make the clinical diagnosis of ascites. However, at least 1500 ml of fluid should be present to get the flank dullness. The common causes of ascites include, cirrhosis (most common), cancer, heart failure, nephrotic syndrome, tuberculosis, dialysis, and pancreatitis. The most cost effective imaging modality to confirm the diagnosis of ascites is an ultrasonogram. The other advantage of USG over CT is it is noninvasive and does not require contrast. Appropriate ascitic fluid analysis is required in all patients, to confirm the ascites and diagnose the underlying cause. Abdominal paracentesis is a very safe procedure and can be done even in patients with advanced liver disease. There are no clear coagulation parameters beyond which the procedure should be avoided. However, it is contraindicated in patients with active bleeding secondary to DIC. Fluid should be sent for cell count with differential, protein, glucose, and cytology. Gram stain, culture, AFB staining, amylase, and bilirubin levels are indicated for individual patients based on the clinical suspicion. Ascitic fluid pH, lactate, and 'humoral tests of malignancy' such as fibronectin, cholesterol etc. are useless and not indicated. The presence of solid, fixed, irregular pelvic/ovarian mass associated with ascites is almost always malignancy until proven otherwise. USG examination and abnormal tumor markers (CA 125) usually differentiates between malignant and benign tumors. However, the definitive diagnosis usually requires surgery for histological examination. Surgery is also necessary for proper staging and cytoreduction/debulking. Preoperative evaluation should include complete pelvic examination, PAP smear (cervical cytology), and CT of the abdomen and chest. Exclude other potential primary sites (breast and GI tract), which can give metastatic disease to the ovaries. If the FOBT is positive, a colonoscopy should be performed. If a patient has any symptoms suggestive of upper GI malignancy, an endoscopy should be performed. A bilateral mammogram should be performed, especially when there is a palpable lump. Patients who have irregular menses or postmenopausal bleeding should have an endocervical curettage and endometrial biopsy to exclude the presence of endocervical or endometrial cancer that may be metastatic to the ovary. Bone scan, liver-spleen scan, and brain imaging are not required unless the patient has signs and symptoms suggestive of involvement of these organs. CA 125 levels are elevated in more than 80% of patients with epithelial tumors. When a germ cell tumor is suspected (solid pelvic mass in a premenarchal or adolescent female), the other associated tumor markers are helpful. Alpha-fetoprotein - endodermal sinus tumor Lactate dehydrogenase - dysgerminoma Human chorionic gonadotropin - non gestational choriocarcinoma Is screening of general population recommended? No method is recommended for screening of ovarian malignancy. Pregnancy and oral contraceptives significantly decrease the risk of ovarian cancer probably by decreasing the number of ovarian cycles.

Case 58[edit]

History of present illness- Location: Emergency room Vitals: B.P: 130/70 mm Hg; P.R: 90/min; R.R: 20/min; Temperature: 37.8C.
History of present illness: A 63 year old nursing home resident is brought to emergency room complaining of colicky abdominal pain. Nursing home staff reports that for several hours he has been complaining of nausea, abdominal distention, and a colicky type of left lower quadrant abdominal pain. He says the pain is continuous and severe, with a superimposed colicky component. He has had no bowel movements the past three days. He has never had abdominal surgery. His other medical problems include schizophrenia, for which he is on haloperidol as needed. He is allergic to sulfa. Family history is nothing significant. SH: He denies smoking and alcohol.

How do you approach this patient? Consider differential diagnosis: Bowel obstruction, -carcinoma Pseudo-obstruction (ileus) Giant sigmoid diverticulum Constipation

Order physical examination: General appearance Lungs Heart Abdomen Rectal Extremities Results: Examination reveals a tympanitic/distended abdomen. Bowel sounds are diminished.

There is no rigidity or rebound. Mild to moderate tenderness is present. Rectal examination shows only an empty rectal ampulla.

Order: Intravenous access NPO IV NS@100 cc/hr CBC with diff, stat - Leukocytosis (in some cases Leukocytosis may be absent) SMA -7 or BMP, stat ( to evaluate any electrolyte abnormality) X-ray of Abdomen, stat Results: CBC showed mild leukocytosis SMA -7 is WNL Supine radiograph of abdomen shows a markedly distended loop of sigmoid colon with a convex superior margin projecting into the right upper abdomen.

Impression: Sigmoid volvulus. Order review: NG tube suction GI consult (reason for consult: evaluation and decompression of sigmoid volvulus) Sigmoidoscopy (decompression and untwisting of the sigmoid loop with placement of long soft tube) Rectal tube

Decision about changing patient's location: Admit to ward Continue IV fluid Monitor patient for 2-3 days after decompression for persistent abdominal pain and bloodstained stools, signs that may herald ischemia and indicate the need for surgical intervention. Consult General surgery- Emergency surgery is reserved for patients in whom tube decompression fails or for those in whom signs of ischemia are suggested.

After patient is stabilized, move patient home with office follow-up in 5-7 days.

Educate patient and family: Console patient to seek medical care if nausea, vomiting, rectal bleeding, or abdominal pain reoccur. Console on low fat, high fiber diet.

Final Diagnosis: Sigmoid Volvulus Explanation: Sigmoid volvulus is commonly seen in elderly patients who are institutionalized and debilitated from neurological and psychiatric diseases. Typically, patients present with left lower quadrant abdominal pain, nausea, abdominal distension, and constipation; Vomiting is less common and occurs late. The pain is usually continuous and severe, with a superimposed colicky component. Failure to diagnose and treat at the initial presentation causes colonic ischemia, gangrene, and perforation. Physical examination reveals a distended, tympanitic abdomen, and a palpable mass may be present. Bowel sounds are usually absent.

Rectal examination shows empty rectal ampulla. Severe pain, tenderness, rigidity, and rebound tenderness suggest peritonitis resulting from ischemia/perforation.

In approximately 60% of patients, diagnosis of sigmoid volvulus can be made by using plain abdominal radiographic findings. Supine radiograph of abdomen shows a markedly distended loop of sigmoid colon with a convex superior margin projecting into the right upper abdomen. Also, dilated gas-filled lumen, can result in a coffee bean–shaped structure; i.e. the coffee bean sign. If diagnosis is questionable, a barium enema will confirm diagnosis but is contraindicated in suspected perforation. The management of sigmoid volvulus involves relief of obstruction and the prevention of recurrent attacks. Sigmoidoscopy is the initial procedure of choice in patients with viable bowel. Sudden decompression is successful in 70-90% of cases. Many physicians subsequently place a rectal tube in situ. This non-operative approach is only a temporary measure, which allows further medical assessment, preoperative care, and bowel preparation.

Case 59[edit]

Loaction:Emergency room History of present illness Emergency room Vital signs: B.P: 130/70 mm Hg; H.R: 80/min; R.R: 18/min; Temperature: 38.7ºC.
History of present illness: A 50-year old lady, with a history of chemotherapy post a successful breast surgery, came to the ER with a fever. Patient was diagnosed with breast cancer three months earlier. She underwent surgery that was followed by two cycles of combination chemotherapy. She was advised to come back to the office immediately if she developed any fever. She denies any cough, cold, headache, neck stiffness, SOB, chest pain, diarrhea, abdominal pain, blood in the stools, ulcers, or burning urination. Her other medical problems include reflux disease and osteoarthritis. She takes lansoprazole QD, and acetaminophen as needed. She denies smoking, alcohol, and IV drug abuse. Family history is nothing significant. She is allergic to sulfa drugs, and codeine. Review Of Systems is unremarkable.

(Patient with history of chemotherapy and fever should make you think about possible infection secondary to immunocompromised status. First step is to get a good history and physical exam.) Order physical examination: General appearance Skin - check for skin lesions Lymphnodes HEENT/Neck- evidence of fungal infection. Chest/Lung- evidence of respiratory infection i.e. decreased breath sounds, rales, rhonchi. Lungs are the most frequent site of infection in immunocompromised patients. Heart/CVS Abdomen Extremities Neuro/Psych.- mental status evaluation looking for meningism or focal deficits Note: Digital rectal exam is not routinely performed as trauma of these frail mucosal areas can precipitate infection. However, we generally inspect the peri anal areas for any focus of infection. If there is suspicion for prostatitis or perirectal abscess, it can be performed after the broad-spectrum antibiotics have been administered. Results: Completely normal physical exam Order: Continue lansoprazole Intravenous access CBC with differential, stat Urinalysis, urine culture & sensitivity, and Gram stain, stat Blood culture, stat Sputum Gram stain, and cultures (if the patient has symptoms) Comprehensive metabolic panel, stat Chest X-Ray, PA, and lateral, stat Ceftazidime, IV, continuous Treatment: Admit to floor Regular diet Activity - As tolerated Nursing - Vitals Q 4 hours Acetaminophen, oral, as needed (Do not give continuously, as you have to monitor whether he is responding to antibiotics or not) CBC with diff, daily Consider PT/PTT for baseline if there is a risk of developing DIC. Consider use of Neupogen (G-CSF) - Not in this patient Re-examine the patient in six hours, obtain interim history, then see the patient Q 12 hours and monitor. Consider changing the antibiotics according to the culture and sensitivities During discharge: After 3 days D/C IV antibiotics Start oral antibiotics D/C daily CBC with diff Educate patient and family: Console patient to avoid people with cold/flu Console patient to seek medical help if a fever develops Final Diagnosis: Febrile neutropenia secondary to chemotherapy Discussion: Fever in a neutropenic patient is a medical emergency. Febrile neutropenia is defined as a single temperature of >38.3ºC (101.3ºF), or a sustained temperature >38ºC (100.4ºF) for more than one hour. However, patients who are on corticosteroids may not develop fever. Neutropenia is defined as an absolute neutrophil count (ANC) <500 cells/mm3. Disruption of the skin and mucosal barrier resulting from the chemotherapy often results in seeding of bacteria into the blood stream (bacteremia) and the most common site of mucositis is in gastrointestinal tract. Chemotherapy also results in impaired immunologic function. The frequently identified organisms in febrile neutropenic patients are Gram negatives, particularly P. aeruginosa. But there has been a recent increase in Gram positive infections for several reasons. Although GI tract has abundant anaerobic organisms, anaerobic coverage is not indicated in the initial empirical antibiotic regimen. Anaerobic coverage is indicated if there is any evidence of necrotizing mucositis, periodontal abscess, perirectal abscess/cellulitis, intraabdominal or pelvic infection, typhilitis (necrotizing neutropenic colitis), or anaerobic bacteremia. Evaluation should include CBC with diff, basic metabolic panel, Liver function tests (LFT), blood cultures, urine Gram stain and cultures, sputum Gram stain and cultures, and Chest X-Ray. Lumbar puncture is not routinely indicated unless the clinical features suggestive of meningitis present. Other tests are indicated if the patient has localizing signs or symptoms. For example, patients with diarrhea should be evaluated with: Stool for Gram stain, culture, Clostridium difficile toxin, and ova and parasites. All central lines and catheters should be inspected carefully and may need to be removed if clinically infected and infection not responding to appropriate antibiotics. We generally repeat the blood culture if the fever persists for more than 48 hours. Chest x-ray should also be repeated for persistent pulmonary symptoms. The findings on Chest X-Ray may be subtle or absent even in a patient with pneumonia. It is important to remember that the absence of neutrophils on sputum Gram stain, blood smear, or CSF does not exclude the presence of infection. Treatment: The empirical antibiotic choice should cover the Gram negative organisms especially Pseudomonas. The following are the commonly used regimens. We usually prefer monotherapy. Monotherapy: Cefepime, ceftazidime, imipenem, or meropenem.

Double coverage: Aminoglycoside + extended spectrum antipseudomonal penicillin.

When should I consider vancomycin? In general, vancomycin is added if there is no response to the above monotherapy in 2-3 days. The addition of vancomycin to the initial empiric antibiotic regimen should be considered in patients who present with hypotension, mucositis, skin or catheter site infection, history of MRSA colonization, or recent quinolone prophylaxis. When to add antifungal therapy? Antifungal therapy with amphotericin B should be considered at five to seven days of neutropenia in patients with persistent fever. When to use G-CSF: The benefit of colony stimulating factors as an adjuvant to antibiotic therapy in an uncomplicated febrile neutropenic patents is not proven and is not indicated. However, it is considered in patients with predictive poor outcome such as patients with ANC <100/µL, uncontrolled primary disease, pneumonia, hypotension, multiorgan dysfunction, or invasive fungal infection. General approach to the therapy: What is the initial antibiotic choice? Does the patient need vancomycin? If yes, order vancomycin + ceftazidime. If no, order ceftazidime or aminoglycoside + extended spectrum antipseudomonal penicillin.

If patient became afebrile in three days: change to oral antibiotics, either cefixime or quinolone.

If patient is still febrile after three days: stop the vancomycin if added initially and cultures are negative; add vancomycin, if not administered initially, obtain repeat cultures, and Chest X-Ray.

Duration of therapy: If the source of the infection is identified, antibiotics should be continued for the standard duration (14 days for Staph aureus bacteremia). If the source is unknown, then the following approach is indicated: If the patient is afebrile in 3 days and the ANC is >500, stop antibiotics after 7 days; If the patient is afebrile and the ANC is less than 500 continue antibiotics.

Case 60[edit]

Location: Emergency Room. Vitals signs: Temperature 38.9; heart rate 72; blood pressure 125/78 m Hg; respirations 14 per minute;
History of present illness: The patient is a 35-year-old white female who presents with the sudden onset of pain in the right upper quadrant of her abdomen for approximately eight hours. She has nausea and emesis and reports that the pain began earlier that morning after she had had breakfast and this became more severe over the past eight hours and now is a constant severe pain in her right upper quadrant. Pain is worsened by taking deep breaths. Her PAST MEDICAL HISTORY is remarkable for prior attacks, approximately one year ago with epigastric and right upper quadrant severe continuous pain that had occurred about one-half hour after she had eaten at a picnic. The pain at that time radiated to her scapula and improved within several hours of onset. She reports that she did not seek medical care at that time. The patient is currently on oral contraceptive pills. She has two children. The FAMILY HISTORY is positive for gallstones in her mother and older sister. REVIEW OF SYSTEMS is positive for elevated temperature and chills over the last two hours, decreased appetite. She denies any other abdominal symptoms. Other review of systems is negative.

How do you approach this patient? Order physical exam: General HEENT/Neck Heart Lungs Abdomen Extremities Rectal Genitourinary Results: General: She is a well-developed, slightly obese white female in moderate distress. HEENT: Unremarkable. Sclerae are anicteric. Cardiovascular: Unremarkable. Lungs: Clear to auscultation but respirations are shallow. Extremities are normal. Abdomen: Obese. There is tenderness to palpation and percussion over the right upper quadrant. Mild guarding in the right upper quadrant. The patient has as positive Murphy’s sign with deep inspiration. She has slightly diminished bowel sounds. There is no shifting dullness and no tenderness in other quadrants. Rectal exam is heme negative. GU exam reveals a normal paracervix without evidence of cervicitis.

How to approach this case: The patient is a female, slightly obese, of childbearing age. She has had a previous history of what sounds like biliary colic which was not subsequently treated with cholecystectomy. Her current symptoms are quite suspicious for recurrent gallbladder disease and physical exam is also consistent with gallbladder etiology. The differential diagnosis for RUQ pain, however, could include routine biliary colic, acute peptic ulcer perforation, acute pancreatitis, acute appendicitis, acute hepatitis, gastric outlet problems, lower lobe pneumonia, lung abscess, liver abscess, pyelonephritis, renal colic, or more severe disease such as ascending cholangitis or MI. Fitz-Hugh-Curtis syndrome is also a possibility which is why a GU exam should be performed to look for evidence of cervicitis.

Orders: Intravenous access IV NS (normal saline) at 100 cc per hour Pulse oximetry, stat NPO NG, aspiration (If the patient has vomiting) CBC with diff, stat Comprehensive metabolic panel, stat Serum amylase, and lipase U/A Beta HCG, serum stat Abdominal X-ray, stat PT/PTT, stat Note: A Chest-X-ray will rule out pneumonia and an ECG is indicated if the patient has any risk factors for CAD. Amylase and lipase should be ordered to exclude pancreatitis. Renal disease is excluded by sending urine for microscopy. Results: O2 saturation 98% on room air. CBC shows a white count of 17,000 with left shift, hemoglobin 14.5, hematocrit normal, platelets normal. Comprehensive metabolic panel shows normal electrolytes. A BUN slightly elevated at 25, creatinine 0.8, normal glucose and calcium. Coagulation studies are normal. Alkaline phosphatase is mildly elevated. Bilirubin is normal. ALT and AST are elevated three times normal values. Amylase is mildly elevated. Lipase is normal. Abdominal X ray reveals a nonspecific gas pattern. No air under the diaphragm/intestinal obstruction is identified. No gallstones are identified. Urinalysis is within normal limits. Pregnancy test is negative.

Note: Mild elevation of amylase, and upto 5 fold elevation of serum aminotransferases is seen in some patients with uncomplicated cholecystitis.

However, elevation of serum total bilirubin and alkaline phosphatase are not common in uncomplicated cholecystitis, and should raise the suspicion for complications such as cholangitis and choledocholithiasis. Interim exam: The patient is hemodynamically stable. She still has nausea and vomiting and would like something for her pain control and nausea.

Review orders: Compazine IM for the nausea and emesis.

IV Morphine or Fentanyl for pain management. Ultrasound of the abdomen. Obtain surgical consult Begin IV antibiotics with cefuroxime or a combination of ampicillin and gentamicin Continue IV fluids with normal saline. Change setting to inpatient management (Floor/ward) Vitals Q 4 hours Activity - Bed rest with bathroom privileges CBC with diff, next day Comprehensive metabolic panel, next day Results: Ultrasound of the right upper quadrant reveals numerous echogenic foci within the gallbladder with thickening of the gallbladder wall and dilatation of the cystic duct.

INTERIM EXAM the next morning shows the patient is afebrile. She has some improvement in the pain in the right upper quadrant which she rates as a 4 out of 10 in severity. Her basic metabolic panel shows a decrease in the BUN to normal range, normal electrolytes, normal glucose, her CBC shows a decrease in her white count to 10, hemoglobin 13, platelets normal, differential segmented neutrophils 80%, no band neutrophils, lymphocytes 10%.

ORDERS: Continue IV antibiotics and IV fluids. Continue NPO status. PRN pain orders with Morphine/Fentanyl, PRN nausea and vomiting orders with Compazine.

Results of the Surgery consult indicate that one should continue medical management. The patient will be scheduled for laparoscopic cholecystitis in 24-48 hours after she is afebrile.

Primary diagnosis: Acute cholecystitis.

Discussion: Gallbladder disease is a relatively common occurrence and over 95% of cases of acute cholecystitis are due to gallstone disease, about 80% of gallstones are cholesterol gallstones and the other 20% are pigment gallstones. Gallstone disease is usually considered to have four stages. The first two stages are asymptomatic in which one has lithogenic bile that is prone to stone formation because of super saturation of the bile with cholesterol and nucleation and crystal growth. The second stage is asymptomatic gallstone disease. Many patients will have gallstones that remain asymptomatic for their entire lives. Stage three is symptomatic gallstones which may be heralded by episodes of biliary colic. In the case described above, the patient appears to have had an episode of biliary colic the year prior. Approximately two-thirds of patients will experience and additional attack of biliary colic within two years of their first attack. Recurrent episodes of biliary colic even without acute cholecystitis are is an indication for cholecystectomy. The fourth stage of gallstone disease is that some complications for the gallstones including acute cholecystitis, choledocholithiasis and more chronic forms including chronic cholecystitis, choledochoduodenal fistula with gallstone ileus and gallbladder adenocarcinoma. Obstructive jaundice, acute pancreatitis, and ascending cholangitis are other acute forms of the severe complications of gallstone disease. Diagnosis: Gallstones are best visualized with ultrasonography which shows echogenic foci within the gallbladder and may also include a sonic shadow. There also may be evidence of gallbladder thickening and dilatation of ducts. Ultrasound is highly sensitive, specific, and noninvasive and a relatively inexpensive test for evaluating for gallstone disease. Other tests include HIDA scans which stands for hepatobiliary immunodiacetic acid radionucleide scan. This test looks for patency of the cystic duct and common bile duct. Injected IV dye is taken up into the liver and rapidly excreted into the bile. If one fails to visualize the gallbladder or ducts on subsequent scans, then it is suggestive of obstruction of the cystic or common bile duct. HIDA scan is usually performed if the USG findings are equivocal and the clinical suspicion for cholecystitis is high. ERCP is the gold standard for examining the biliary tree and can reveals stones or narrowing and stenosis of the common bile duct which might not be detectable by other means. Oral cholecystography: It has no role in the diagnosis of acute cholecystitis since it cannot show gallbladder wall edema and requires days to complete. Management: In more than 90% of patients acute symptoms resolve with conservative treatment.

Typical nonoperative treatment include: 1. NG tube aspiration. 2. IV fluid administration with NS and correction of electrolyte abnormalities. 3. Broad-spectrum IV antibiotics mainly to cover gram-negative enteric organisms and anaerobic organisms which may play a role in acute cholecystitis and ascending cholangitis. Even though the second generation cephalosporins such as cefuroxime is frequently used, cephalosporins do not cover Enterococcus. We recommend a combination of ampicillin and gentamicin as empiric antibiotic.

Aminoglycosides cover E. coli, other gram-negative bacilli, and also act synergistically with ampicillin against the Enterococcus. 4. IV analgesia.

Once the patient is afebrile, and the other inflammatory signs are subsided, NG tube can be discontinued and the clear fluids followed by a fat free diet is administered. Cholecystectomy may either be performed on the next available schedule or can be done later when the inflammation is completely resolved.

Case 61[edit]

Location: Emergency Room.

Vital signs: Temperature 39.3C; heart rate 112/min, regular; blood pressure 112/70 mmHg; respirations 12 per minute;
History of present illness: The patient is a 39-year-old white male who presents with a two-day history of increasing fevers and chills with a temperature up to 39.2 the previous evening.

He complains of anorexia, diffuse joint pains, and back pain. He also has some myalgias and has noted several painful spots on his fingers. He denies any chest pain, SOB, palpitations, cough, abdominal pain, headache, and seizures. He is feeling nauseated but no vomiting. His REVIEW OF SYSTEMS is positive for a history of recent IV drug use. His past medical history is significant for personality disorder, tobacco abuse, and alcohol abuse. SH: He smokes 2 PPD for the past 15 years, drinks alcohol almost everyday. He admits using IV drug abuse from the past 5 years. He was tested for HIV, and Hepatitis B and C recently for pre-employment and were negative. He is allergic to sulfa. He is not on any medication. How do you approach this case? Order physical exam: General HEENT/Neck Lungs Heart Abdomen Extremities Skin Results: General: The patient is an ill-appearing white male who appears his stated age.

HEENT: Oropharynx is clear, except for some palatal petechiae. Pupils are equal, round and reactive to light. Conjunctivae show a small hemorrhage. Funduscopic examination is unremarkable. Neck: Supple; no lymphadenopathy, thyromegaly or bruits. Cardiovascular: Tachycardic, soft holosystolic murmur heard at the left lower sternal border, increased by inspiration and decreased by expiration. Lungs: Clear to auscultation bilaterally. Abdomen is soft, nontender, nondistended. No hepatosplenomegaly appreciated. Extremities: The other arm shows two recent needle tract marks. There is a fine petechial rash noted of the bilateral lower extremities below midtibia. Several digits on the feet have splinter hemorrhages. In addition, the digits of the hand show several splinter hemorrhages. There are two palpable painful small violaceous nodules on the digits of the right hand. Review order: Pulse oximetry, stat Intravenous access CBC with differential, stat BMP, stat PT/PTT Blood cultures, stat U/A Chest -X-ray, PA and lateral ECG, 12 lead Results: O2 saturation 97% on room air. CBC with differential shows a white count 18 with 89% polymorphonuclear leukocytes, 10 band neutrophils, 12 lymphocytes, hemoglobin 12, hematocrit 35.5, platelets 309. X ray of the chest shows 2 very small wedge shaped infiltrates with cavitation. Normal electrolytes, BUN 25, creatinine 0.9. PT/PTT are WNL. EKG shows sinus tachycardia. U/A is WNL. Order: IV vancomycin, continuous IV Gentamicin, continuous Acetaminophen, one time and prn for fever IV NS at 100 cc/hr Admit to floor/ward Vitals Q 4hours Pulse oximetry Q 4 hours Urine outputs Q 4 hours Bed rest with bathroom privileges NPO TEE (Transesophageal echocardiogram) CBC with diff, next morning BMP, next morning Check "Call me with the next available result" Results: Preliminary blood culture results show staphylococcus aureus, methicillin sensitive growing in 4 out of 4 bottles. Basic metabolic panel: Normal electrolytes and renal function. Results of transesophageal echocardiogram reveals a vegetation on the tricuspid valve approximately 5 mm in length. There is no evidence of perivalvular disease.

Review orders: D/C Vancomycin Start IV Nafcillin Daily CBC with diff, Daily BMP Daily blood cultures until sterile and once after the completion of antibiotic course (4 to 6 weeks) to document the cure Examine the patient next day Interim exam: The patient’s temperature down trends with a T-max of 37.8 on first day of admission. He is hemodynamically stable. Order review: D/C daily CBC D/C daily BMP The patient is continued on the nafcillin and gentamicin for five days. He is then switched to nafcillin alone (D/C gentamicin after 5 days). Arrangements are made for a long-term IV line to be placed for continued IV antibiotic therapy for a total of four to six weeks. Patient education Smoking cessation Advise not to drink alcohol No illicit drugs Primary diagnosis Right sided infective endocarditis from MSSA Discussion: Early cases of infective endocarditis may be difficult to diagnosis if there is a concomitant infection elsewhere in the body. His physical exam had several findings suspicious for an endocarditis infection including splinter hemorrhages, also nodes on his hands on the pulp of his fingers, petechiae of the lower extremities and on the palate, conjunctival hemorrhages.

'Duke criteria' for the diagnosis of IE: Major: 1. Positive blood cultures 2. Positive echocardiogram for IE Minor: 1. Predisposing factors such as IV drug abuse 2. Fever of >38C (>100.4F) 3. Evidence of embolic phenomena 4. Evidence of immunologic phenomena such glomerulonephritis, Osler's nodes etc. 5. Equivocal blood cultures 6. Equivocal echo findings Presence of 2 major or one major and 3 minor or 5 minor criteria is required for the diagnosis of IE.

What 'empirical' antibiotic should I use? 1. In a patient with H/O IV drug abuse, the antibiotic choice should cover MRSA (methicillin resistant staphylococcus aureus) and gram-negative organisms i.e.

Vancomycin and gentamicin. 2. Blood culture-negative native valve endocarditis is treated with ceftriaxone and gentamicin.

3. Blood culture-negative prosthetic valve endocarditis is treated with ceftriaxone ad gentamicin plus vancomycin. When should I obtain CVTS (cardiovascular thoracic surgeon) consult? The indication for cardiac surgery in patients with infective endocarditis is not fully agreed upon. However, some of the indications include, moderate to severe heart failure secondary to valvular dysfunction or partially dehisced unstable prosthetic valve, prosthetic valve endocarditis with Staph aureus or Staph epidermidis or relapse of the prosthetic valve after prosthetic valve endocarditis after appropriate antimicrobial therapy, and large (>10 mm) hypermobile vegetations, which can potentially cause septic embolism. In patient’s with suspected infective endocarditis one should aim therapy at the most likely organism. Staph aureus is the most common organism isolated in this setting of IV drug use. The patient should be screened for other signs of endocarditis including a urinalysis which may show hematuria, chest X ray which in this case was suspicious for septic pulmonary emboli which can be seen more often in the setting of tricuspid valve endocarditis in IV drug users. Transesophageal echocardiography has become an important mode of helping to diagnose infective endocarditis and help guide management. There are a number of complications of infective endocarditis, especially with left sided disease that should be monitored for vigilantly. These are mainly embolic in nature and include CNS embolus with stroke -like syndromes or subtle neurologic defects.

Emboli to the kidney may cause focal glomerulonephritis which induces hematuria or renal failure may ensure secondary to diffuse proliferative glomerulonephritis. One may see arrhythmias including various degrees of heart block and pericarditis, myocarditis or myocardial abscess. Heart failure as noted above in the indications for surgery is also a potential major complication of infective endocarditis. This patient managed to avoid most of the complications possibly because of early presentation and early treatment of his endocarditis. In patients in whom one suspicious of major complications, it could be appropriate to obtain CT scans of the head, chest, abdomen, and pelvis looking for other sites of embolic disease or infarction. One should monitor as well renal function for evidence of kidney failure secondary to glomerulonephritis or infarction or emboli. The patient should receive four to six weeks total of antimicrobial therapy directed at the results of the blood cultures obtained. In this case with Staph aureus optimal therapy is with the penicillinase resistant penicillin, nafcillin, 2 grams IV Q4H. He also received gentamicin for three to five days initially. In patient’s intolerant to nafcillin an appropriate substitute antimicrobial therapy would be cefazolin with or without gentamicin. In patients who have allergies or who have methicillin resistant Staph aureus, vancomycin would be the agent of choice.

Case 62[edit]

Location: Office Vitals: B.P: 130/76 mm Hg; H.R: 130/min, irregularly irregular pulse; Temp: 38.3C; R.R: 18/min.

History of present illness: A 60 yr white female who has known H/O CAD, S/P CABG presents to your office with 2-day H/O dizziness, light-headedness, and palpitations. She describes the palpitations as irregular, and almost continuous. She denies any chest pain, angina, SOB, orthopnea, PND, or syncope. She also felt little warm since one day. She denies any cough, URI symptoms, dysuria, abdominal pain, and leg swelling. Her Review Of Systems is positive for frequency of urination. PMH: She had undergone 3 vessel CABG 3 years ago after an acute anterior wall MI. Her other medical problems include HTN, Type II DM, hypercholesterolemia, osteoarthritis, COPD, and gout. Allergies: She has no allergies. SH: She quit smoking after her CABG.

She occasionally drinks alcohol. She lives with her husband at home. FH: Father died at the age of 70 with MI. Mother died at the age of 68 from stroke . She has one brother and one sister both have HTN, and DM. Meds: She takes ASA 81mg po qd, simvastatin 20 po qhs, lisinopril 5 mg po qd, SL NTG prn, glyburide 5 mg po QD, metformin 850 mg po bid, albuterol puffs prn, and acetaminophen with codeine for osteoarthritis. How do you approach this patient? Order physical exam: General HEENT/Neck Lungs Heart Abdomen Extremities Rectal exam with FOBT Results: HEENT/Neck is WNL. There are few rales and decreased breath sounds noted at left lower base. Heart exam is WNL. Abdomen is WNL. No edema or JVD noted. Hem negative for stools.

Order review: Pulse oximetry, stat Intravenous access 12 lead EKG, stat Results: 94% on room air EKG showed atrial fibrillation with rapid ventricular response at a ventricular rate of 120-140/min. There are Q waves in anterior leads, consistent with old MI. LVH pattern is noted. Order review: Cardizem IV, bolus CBC with diff, stat BMP, stat Chest X-Ray, PA and lateral, stat CK MB, and troponin T/I , stat and Q 8hours x 2 U/A, stat Liver function tests (LFT), stat TSH, stat Free T4, routine PT/INR/aPTT, stat Order review: Admit to floor/ward Telemetry Vitals Q 4 hours Pulse oximetry Q4 hours Order 'old records' Diet: Consistent carbohydrate diet Activity: Bed rest with bathroom privileges Labs: HbA1C, stat Accuchecks QID(4 times a day) 2D-echo, routine Meds: Continue all home medications: ASA 81mg po qd, Simvastatin 20 po qhs, lisinopril 5 mg po qd, SL NTG prn, glyburide 5 mg po QD, metformin 850 mg po bid, albuterol prn, and acetaminophen with codeine for osteoarthritis Start Cardizem (diltiazem), IV drip, Start Heparin, IV, continuous PTT every 6 hours Daily CBC with diff Call me when lab results available Results: CBC with diff showed a WBC count of 12,000 with 3% bands. Hb is 13.5. Platelet count is 230,000. BMP showed a Na: 140, K: 4.0, CL: 102, Co2: 22, BUN: 20, Cr: 1.0. Chest X-Ray showed small left pleural effusions unchanged from previous 1 yr X-ray. TSH is 1.5. Free T4 is WNL. Liver function tests (LFT) are WNL. HbA1C is 7.2. U/A showed positive esterase, 50 WBC, and many bacteria. Urine culture is pending. PT/INR is 14.0/0.98. PTT is 30. First set of cardiac enzymes - negative. 2D -echo showed normal LV function with an EF of 50%, mildly dilated left atrium, normal valves, and mild hypokinesis of the anterior wall. Findings unchanged from previous echo. No LV/LA thrombus notified.

Order review: Urine culture and sensitivity Bactrim PO QD (TMP-SMZ) Examine the patient in 2 hours After 2 hours: Interim history Monitor telemetry strip: HR is now 90-100/min; patient is still in atrial fibrillation Repeat EKG: HR is now 90-100/min; patient is still in atrial fibrillation.

Call me when needed.

Examine the patient in next 6 hours Again order interim history and monitor telemetry strip Once the HR is less than 80 D/C Cardizem drip Start Cardizem PO, continuous Next day Start Coumadin po continuous Daily PT/INR Examine next day: Check CBC, PT/INR, telemetry strip Once the PT/INR is above 2.0, D/C IV heparin Discharge the patient Patient education Out patient follow up in 3 days with repeat CBC, PT/INR Discussion: The principle issues in managing a patient with atrial fibrillation with rapid ventricular response include: 1. Rhythm control or rate control 2. Anticoagulation to prevent systemic embolization 3. Correcting the underlying abnormality Rhythm control: It is indicated in: 1. acute atrial fibrillation (less than 48 hours duration), 2. Hemodynamically unstable patient, 3. patients with acute coronary syndromes, 4. Patients with severe heart failure. It can be done by either DC cardioversion or pharmacologic cardioversion. DC cardioversion is particularly indicated in unstable patients. In stable patients, and patients with a reversible underlying problem can be dealt with either electrical or chemical cardioversion. The commonly used drugs for rhythm control include dofetilide, ibutilide, and to a lesser degree amiodarone. Amiodarone is particularly useful in patients with left ventricular dysfunction. Without chronic antiarrhythmic therapy, only 20-30% of patients who are successfully cardioverted remains in NSR for more than one year. The 2 commonly used medications for the maintenance therapy are amiodarone (patient with left ventricular dysfunction) or sotalol (in patients with CAD).

Rate control: The 3 most commonly used AV nodal blockers for the rate control are beta-blockers, calcium channel blockers, and digoxin. Digoxin is particularly indicated in patients with heart failure or hypotension. In most other situations digoxin is less effective than a beta-blocker or calcium channel blocker. The choice between a CCB or beta-blocker depends upon physician preference, and the patient presentation. Beta-blocker is preferred in patients with H/O angina, acute MI. The use of calcium channel blockers is preferred in patients with chronic lung disease. In most situations Cardizem (diltiazem) is the preferred drug as it is easy to administer in the form of IV drip and the dose can be titrated for a goal heart rate. Patients who fail to respond with pharmacologic treatments require EP study and radiofrequency AV nodal-His bundle ablation.

Choosing between Rate and rhythm control: Until recently, rhythm control has been the preferred method over rate control for patients presenting with the first few episodes of atrial fibrillation. The thought was controlling the rhythm causes low frequency of embolic events.

However, the 2 major clinical trials (AFFIRM, and RACE) have demonstrated no significant difference between the 2 groups in terms of embolic events, functional status, or quality of life. Thus, both rate and rhythm control are acceptable approaches and both require anticoagulation. There is a growing support for rate control.

Anticoagulation: There are 3 situations where you should consider anticoagulation: 1. Chronic AF, 2. Recurrent AF, 3. Prior and after cardioversion.

AF of more than 48 hours or unknown duration requires at least 3 to 4 weeks of warfarin prior to and after cardioversion. The target INR is 2.5(2.0-3.0).

Patients with recurrent or chronic AF should be treated with long-term anticoagulation even if they are in sinus rhythm. Patients who have underlying rheumatic valvular disease, severe LV dysfunction, or recent thromboembolism should receive anticoagulation even if the duration of AF is less than 48 hours.

Patients with AF of less than 48 hours duration without concurrent valvular disease, or severe LV dysfunction, or H/O thromboembolism are treated with cardioversion under IV heparin coverage but without long term coumadin. The other alternative approach for cardioversion to avoid prior prolonged anticoagulation is TEE guided cardioversion.

When should I admit a patient with AF? Low risk patients (patients without valvular disease, or severe LV dysfunction) with AF of less than 48-hour duration and uncomplicated clinical status can be cardioverted and discharged from the ER. Hospitalization is necessary in high risk and hemodynamically unstable patients. Searching for the underlying cause: The common causes of new onset AF include heart failure, acute coronary syndromes, PE, HTN, hyperthyroidism, and infections. Serum TSH and free T4 should be checked in all patients even if they do not have symptoms of hyperthyroidism as there is a 3 fold increase of AF in patients with subclinical hyperthyroidism (Low TSH and normal free T4). If the AF is caused by an underlying problem, cardioversion should be postponed until the condition has been successfully treated. However, anticoagulation should be started.

Case 63[edit]

Location: Emergency room Vital signs: B.P 80/40 mm Hg; P.R: 130/min; R.R: 30/min C.C: Chest pain from a severe motor vehicle accident (MVA).
History of present illness: A 61 year old man involved in a motor vehicle accident (MVA), brought to the ER immediately. He complains of severe chest pain, 10/10, and non radiating. He also C/O shortness of breath. Chest wall impacted the steering wheel. No other history is available. How do you approach this patient? Order: Intravenous access Pulse oxy, stat Oxygen, inhalation Order general, lungs, and heart exam Results: Patient is in severe chest pain, his extremities are turning blue. Lungs are CTA B/L. There is a 15 cm JVD. S1, S2 muffled. No murmurs heard. Pulse oxy shows 88% on room air. Order review: IV NS bolus, and continue at 150 cc/hr Elevate the patient legs Continuous cardiac monitoring Pericardiocentesis, stat Results: Patient started improving His BP came upto 100/60 mm HG HR decreased to 90/min Order review: Stat EKG, 12 lead Chest -X ray, portable Transthoracic Echocardiogram (TTE), stat Pericardial fluid for cell count, stat ABG, stat CVTS (Cardiovascular thoracic surgeon) consult, stat Results: 12 lead EKG shows sinus tachycardia, low-voltage QRS complexes, and electrical alternans. Chest x-ray showed globular heart with air fluid level in pericardial cavity. TTE - Revealed fluid in the pericardial cavity. Impression: Cardiac tamponade If the CVTS doesn't want to operate, then the patient management will be as follows: Shift the patient to ICU Continue continuous cardiac monitoring Swan-Ganz catheter, stat Diet - NPO Complete bed rest Place a Foley catheter Urine output Q 2 hours Pneumatic compressions of the legs CBC with diff, stat Basic metabolic panel, stat PT/aPTT, stat Continue NS @ 150 cc/hr Gastric prophylaxis - Omeprazole (20mg) orally, once daily Type and screen for 2 units of blood Acetaminophen + codeine for pain, continuous (actually as needed in real life) Note: Transfuse blood if the Hb is less than 8 in a patient with no active bleeding, less than 10 in actively bleeding patient. Each unit of blood will increase the Hb approximately 1 gm%. Next day: D/C Foley catheter Repeat TTE Repeat Chest -X-ray Note: If you do this much, your case will end in the exam. Further management is complicated, it is based on the patient condition, CVTS recommendations, etc. Explanation: Cardiac tamponade is a life threatening condition and should be diagnosed and treated emergently. The diagnosis of tamponade is primarily clinical. Myocardial rupture in patients with trauma usually manifests itself as cardiac tamponade.

The classic description of cardiac tamponade is Beck’s triad: Hypotension (100%), distended neck veins, and muffled heart sounds. The other useful findings are tachycardia, elevated central venous pressure, pulsus paradoxus, and cyanosis of the head, neck, arms, and upper chest. Tamponade should be suspected in any patient with chest injury whose hypotension do not respond to fluids or out of proportion to the apparent blood loss. Differential diagnosis in patients with trauma should include tension pneumothorax (decreased breath sounds, deviated trachea, hyperresonance to percussion), right ventricle contusion/failure, superior vena cava obstruction, ruptured tricuspid valve, and aortic dissection. Pulmonary embolism, pericarditis, and cardiogenic shock should be considered in patients without trauma.

Emergency pericardiocentesis is a potentially life-saving procedure performed in the ED. Emergent thoracotomy is indicated when the patient does not respond to pericardiocentesis and has rapidly deteriorating vital signs or cardiac arrest.

After pericardiocentesis, intrapericardial catheter is left in place and attach it to a closed drainage system. Drain should be checked regularly for reaccumulation of fluid. Pericardial fluid should be sent for cell count initially and periodically (Q 24 hours) to diagnose an impending bacterial catheter infection, which could be catastrophic. If the WBC count rises significantly, the pericardial catheter must be removed immediately. A Swan-Ganz catheter is very useful to monitor the central venous pressure and it can be left in place for continuous monitoring and to assess the effect of reaccumulation of pericardial fluid. Patients should have a repeat echocardiogram and chest x-ray within 24 hours.

The ComputerUSMLE step 3 General information: This section is intended for those preparing for the USMLE Step 3 examination.

We have tried to put all of the important information into one place, so it’s easily accessible for you.

First of all, don't believe those who say the Step 3 is easy. It may be easy for AMG for a variety of reasons, but not so for IMGs. The exam is difficult, but doable. You should plan ahead and study as much as you can. How much time you need depends on your situation. If you have taken step-2 a few years ago and have not studied since, you probably need more time. If, on the other hand, you completed your step 2 a few weeks or months ago, then you need less time. Most applicants study between two-four months.

After figuring out your timetable, you need to get a few good sources to study. There are lots of books, CDs, and study courses available for step 3.

Obviously, you won’t have enough time to read all of them. You should select a couple of sources and stay with them. Most books or CDs give you the same information in different styles or formats, but the material is basically the same. You need some reference books to look things up. CMTD and Washington manuals are pretty good sources.

CCS: The Computer Based Case Simulations (CCS) currently comprises about 25% of the Step 3 examination. At this time, it consists of ten cases with 20- 25 minutes assigned to each case.

Examinees manage the case without prompting, using a variety of diagnostic and treatment options. As simulated time passes, the patient's status will change based on the response to your management decisions. Acute cases may need to be managed in a short period of time, while patients with chronic problems will require management over weeks or months of simulated time.

Each case begins with a brief description of the patient's appearance and reason(s) for the visit. You may be following patients in both inpatient and outpatient settings. To do well on this part of the Step 3, it is imperative that you practice with the USMLE's CCS software. You can download the software at www.usmle.org You will be judged on the actions taken, their sequencing, and timing. One measure of your score will be whether the patient was subjected to unnecessary testing or therapy. Also, an important consideration and evaluation will be whether the patient was placed at serious risk as a result of your action or failure to act. Evaluation emphasizes process rather than outcome.

Case 64[edit]

CASE 64 - Location: Emergency Room Vitals: BP: 90/60 mm Hg; HR: 124/min; RR: 24/min; Temp: 98.4F C.C: Sudden onset abdominal pain
History of present illness: A 55 years old white obese female is brought to the ER with abrupt onset of epigastric pain. The pain started 5 hours ago, is steady, boring and severe in nature and radiates to the back. It is made worse by lying supine and is better by sitting and leaning forwards. The patient also has nausea and vomiting. She denies any fevers or bowel or bladder problems. She has a past history of episodic right upper quadrant pain and fatty food indigestion, for which she never sought any medical advice. She has no allergies and is not taking any medications. The patient does not smoke and denies any alcohol use. Family history is non-contributory. Rest of the review of systems is unremarkable.

How would you approach this patient? The initial approach should be to take some general resuscitative measures, a delay in which might be life threatening. Simultaneously, think of a differential diagnosis and order the relevant tests to rule in and rule out the disease process and its etiology. Remember you always need a thorough physical examination before establishing a diagnosis.

Order No. 1: Intravenous access, stat Start IV fluids: Normal Saline, bolus Make NPO Continuous BP monitoring Pulse Oximetry, stat EKG, 12 lead, stat Results for Order No. 1: Oxygen Saturation is 95% on room air EKG shows sinus tachycardia without evidence of ischemia or infarction Order physical exam: General appearance HEENT/Neck Examination of CVS Examination of lungs Examination of Abdomen Examination of Rectum FOBT Extremities Skin CNS Results of Physical Examination: General appearance: Obese female, ill looking, diaphoretic, restless. HEENT - Normal; No JVD. Lungs are clear to auscultation and percussion bilaterally; Cardiovascular - S1 S2 normal, no murmurs, rub or gallop. Abdomen is soft, tenderness is present in the epigastric area but there is no rigidity, rebound or guarding; bowel sounds are hypoactive, no organomegaly or free fluid. Rectal - Normal sphincter tone, no hemorrhoids or fissures, stool is heme negative. Extremities - no edema, clubbing or cyanosis, no calf tenderness, peripheral pulses feeble.

Meanwhile the nurse tells you that the pain is worse Order No. 2: Continue NPO IV NS, continuous Continuous BP monitoring IV Fentanyl or Meperidine, continuous Serum amylase, stat Serum lipase, stat Liver function tests (LFT), stat Erect abdominal X-ray, portable CBC with differential, stat BMP, stat Calcium, stat Call me when the lab results available Results for Order No. 2: BP - 94/70 mm Hg Amylase - 500 IU/L; Lipase -160 IU/L Hgb -13 g/dl, WBC - 14,000/ uL, Platelet - 250,000/mm3, leftward shift in differential count BUN - 30, Creatinine-1.1, Sodium -131 meq/L, Potassium - 3.6 meq/L, Chloride -101 meq/L, Bicarbonate - 26 meq/L, Calcium -10.1 mg % LFT- Total bilirubin - 6.0 mg %, Direct bilirubin - 4.5 mg %, ALT - 35 IU/L, AST - 40 IU/L, Alkaline phosphatase - 190 IU/L X-ray abdomen - No air under the diaphragm, no dilated bowel loops Discussion: Differential Diagnosis: This is a patient with acute epigastric pain. Your differential diagnosis should include acute gastritis, perforated duodenal ulcer, acute pancreatitis and acute cholecystitis. Important point here is the description of pain that radiates to the back, is made worse by lying supine and is better by sitting and leaning forwards. This is typical of acute pancreatitis and may also be seen with a perforated duodenal ulcer. Confirming the diagnosis: The diagnosis of acute pancreatitis is confirmed by elevated amylase and lipase with the latter being more specific. These enzymes rise to three times their baseline values within 24 hours in 90 % cases. Besides, you need to order CBC, differential count, BMP, calcium, LFT to look for etiology and assess the severity of the disease that will guide you in the management of the patient. The severity of acute pancreatitis is assessed using the “Ranson’s Criteria” which are not discussed here. A plain X-ray of the abdomen would help in ruling out air under the diaphragm and perforated duodenal ulcer that is high on the list of differential diagnosis.

An ultrasound imaging the liver, gall bladder and biliary tract is a useful initial investigation in patients with suspicion of gallstone pancreatitis and an abnormal LFT. However, ultrasound is a very poor modality for imaging the pancreas. On the other hand, the CT scan of the abdomen can miss gallstones and duct stones but has the advantage of visualizing the pancreas very nicely. It may be ordered when there is a doubt in the diagnosis or when you suspect complications such as necrotizing pancreatitis, pancreatic abscess or pancreatic pseudocyst (discussed in brief later on). Remember, that ultrasound and CT scan of the abdomen are not routinely indicated for establishing the diagnosis of acute pancreatitis but may be useful when indicated; although many may argue for ordering both these tests in most cases of pancreatitis.

Discussion - The above patient results suggest that the patient has acute pancreatitis with hypovolemia and prerenal azotemia.

Likely Etiology: The two most important causes are gallstones and alcohol. The past history of right upper quadrant pain and the LFT results suggest possibility of gallstones pancreatitis in this obese female. Besides, other causes to remember include hypertriglyceridemia (triglycerides>1000 mg %), viral infections (e.g. mumps), drugs (e.g. valproic acid, estrogen, thiazide diuretics, azathioprine, didanosine) and following ERCP. Establishing the etiology is important because unlike other causes where management is conservative, the latest recommendation for gallstone pancreatitis is early ERCP, biliary sphincterotomy and stone extraction. Many a times etiology is not established and is believed to be secondary to “occult biliary microlithiasis.” Order No. 3: Continue NPO Continue IV fluids Continuous BP monitoring Ultrasound of liver, gall bladder and biliary tract, stat Results for order No. 3: BP - 100/70 Ultrasound - multiple gallstones and dilated common bile duct Meanwhile the patient continues to have pain but it is better than before Order No. 4: Continue NPO Continue IV fluids Continuous BP monitoring PT/aPTT, stat (preoperative preparation) Gastroenterology consult for ERCP: Reason: Gallstone pancreatitis; requires possible intervention with ERCP. Please evaluate and treat.

If the case still continues, order: Examine the patient 6 hours later Order, repeat CBC with diff, BMP, Calcium next day. Management: In most patients, acute pancreatitis is a mild disease associated with only edema of the pancreatic tissue subsides spontaneously within five to seven days. These patients are managed conservatively. 1. They are kept NPO and put on IV fluids. In severe cases patients may be severely hypovolemic with prerenal azotemia, requiring massive amount of IV fluids for resuscitation. Correction of electrolytes especially hypocalcemia is important.

2. Pain control is achieved using narcotics like morphine, meperidine and fentanyl. Contrary to the previous belief, there is no data to suggest that morphine increases the sphincter of Oddi pressure and may aggravate acute pancreatitis or cholecystitis.

3. Nasogastric suction is reserved for patients with protracted nausea and vomiting or ileus and is not required routinely.

4. If the acute pancreatitis is secondary to gallstones (especially with total bilirubin >5 mg % or evidence of acute cholangitis), urgent ERCP and biliary sphincterotomy within 72 hours of presentation can improve outcome by reducing biliary sepsis. If this patient had no gallstones or the LFT was normal then it would be appropriate to manage just conservatively.

5. Acid suppression is necessary only in severely ill patient in ICU settings where the risk of stress ulcer gastrointestinal bleeding is high.

Once the pain subsides, the patient can be started on clear liquids and diet advanced as tolerated.

Complications: a) Necrotizing Pancreatitis is a more severe form of pancreatitis that usually develops in the second week, requiring CT scan of the abdomen for diagnosis. It is associated with increased mortality and morbidity secondary to multisystem organ involvement including pulmonary (ARDS) and renal (ATN). The necrotic tissue is usually sterile but may get infected. A CT guided aspiration may be needed to confirm infection if patient has persistent fever, leukocytosis, and multisystem organ failure. In addition to the routine measures discussed above these patients require enteral feedings or TPN and antibiotics if infection is present. The antibiotic of choice is Primaxin (imipenem). Further a percutaneous drainage procedure or major surgical debridement may be needed in very sick patients with infected necrotic tissue.

b) Pseudocyst is suspected in presence of severe pain or persistently elevated amylase levels. These are diagnosed with CT scan of the abdomen. Asymptomatic, nonenlarging pseudocysts of less than 6 cm can be followed clinically with serial imaging studies.

Final Diagnosis: Acute Pancreatitis, secondary to gallstones

Case 65[edit]

65 - Location: Office visit Vitals: BP: 120/80 mm Hg; HR: 84/min; RR: 14/min; Temp: 98.8F C.C: “I am not feeling well, can’t eat anything and my urine has become dark yellow”
History of present illness: A 34 years old white male photographer comes to the office complaining of ill health for last 1 week. His symptoms began with low-grade fever, generalized body aches and fatigue. He has been nauseated; apetite is poor, with occasional loose stools and vomiting. He has not had any fever for last 2 days but his urine has become dark yellow in color and the stools seem to be very light colored. He also complained of right upper quadrant dull ache. He denied any hematemesis, malena, weight loss or dysuria. There is no history of jaundice or blood transfusion in the past. He has no allergies and is not taking any medications. The patient was a heavy smoker but has developed distaste for cigarettes since his illness started. He denied any alcohol use. He had been to Mexico on an assignment 3 weeks ago. He is married, lives with his wife and daughter. He is heterosexual, with only one sexual partner. Family history is non-contributory. Rest of the review of systems is unremarkable.

How would you approach this patient? A patient with non-specific constitutional symptoms and dark yellow colored urine suggests that this could a patient with jaundice. His vital signs and history suggest that he can be managed as an outpatient and does not need admission. Before ordering any tests, order a complete physical examination to confirm your suspicion. This will also help you in formulating a differential diagnosis and ordering the relevant tests.

Order physical exam: Complete physical examination Results of Physical Examination: General appearance: Well built male, ill looking, not in distress. HEENT: Icteric sclera present; No JVD. Lungs are clear to auscultation and percussion bilaterally; cardiovascular: S1 S2 normal, no murmurs, rub or gallop. Abdomen is soft; tenderness is present in the right upper quadrant, but there is no rigidity, rebound or guarding; normal bowel sounds; liver is enlarged about 2 cm below the right costal margin, tender to palpation, firm in consistency with a smooth edge and surface; no splenomegaly or free fluid. Rectal: Normal sphincter tone, no hemorrhoids or fissures, stool is heme negative. Extremities: no edema, clubbing or cyanosis, no calf tenderness; peripheral pulses are full. Skin: no palmar erythema, no spider angioma. CNS: normal, no asterixis. Rest of the examination is within normal limits.

Order No. 1: Liver function tests (LFT), stat CBC with differential, stat Peripheral smear, stat Reticulocyte count, stat BMP, stat PT, stat Call me when the lab results available Results for Order No. 1: LFT: Total bilirubin - 6.0 mg %, Direct bilirubin - 4.0 mg %, ALT - 980 IU/L, AST - 700 IU/L, Alkaline phosphatase - 190 IU/L, Protein- 7.4 g/dl, albumin-3.8 g/dl. PT= 13.2 sec, CBC: Hgb- 15 g/dl, WBC - 9,000/ uL, Platelet - 250,000/mm3, normal differential count Peripheral smear: normal; Reticulocyte count: normal BMP: BUN - 18, Creatinine-1.1, Sodium -138 meq/L, Potassium - 3.8 meq/L, Chloride -105 meq/L, Bicarbonate - 26 meq/L, Discussion: Differential Diagnosis: The etiology of jaundice can be divided into three broad categories - hemolytic, hepatocellular and obstructive. The hemolytic jaundice is characterized by a triad of anemia, mild jaundice and splenomegaly but the hyperbilirubinemia is unconjugated (predominantly indirect bilirubin). The peripheral smear may show some abnormal cells suggestive of hemolysis and reticulocyte count is elevated. This patient has jaundice with conjugated hyperbilirubinemia (predominantly direct acting bilrubin) narrowing the possibility to hepatocellular and obstructive pathology. The significant elevation of aminotransferases and only mild elevation of alkaline phosphatase in this patient makes the possibility of obstructive jaundice (e.g. stones, strictures or cancer) less likely. This implies that this patient most likely has a hepatocellular cause. The causes of acute hepatocellular jaundice would include infections (mainly viral), drugs (e.g. acetaminophen), toxins (e.g. mushroom), alcohol and ischemic. Remember that in acute alcoholic hepatitis the AST/ALT ratio is >2:1, but transaminases are never >300.

This patient’s recent visit to Mexico (developing nation), incubation period of 2 weeks after return from Mexico, onset with fever during the anicteric phase, fever resolving with onset of jaundice and aversion to cigarettes suggest viral hepatitis A. Hepatitis A is the most common form of acute viral hepatitis in the USA and worldwide. He does not have risk factors for hepatitis B or C. Remember, that although feco-oral route is the most common mode of hepatitis A infection, homosexual men and IV drug users are also at an increased risk. Its incubation period varies from 15 to 50 days. Confirming the diagnosis: The diagnosis of acute viral hepatitis can be confirmed by ordering anti-HAV antibodies. These are of two types- IgM and IgG. Both the antibodies may be present in the serum soon after the onset of illness. But the presence of the IgM anti-HAV antibody confirms the diagnosis of hepatitis A. The IgM antibody peaks during first week and disappears within 3-6 months. The presence of IgG anti HAV antibody in the absence of IgM indicates a previous exposure, non-infectivity and immunity against recurring hepatitis A infection.

Order No. 2: Anti-HAV antibodies (IgM and IgG) *Could also order a Hepatitis B (HBsAg, IgM anti-HBc ab), Hepatitis C (Hep C antibody) screening panel if risk factors were present. Bed rest with bathroom privileges, Antiemetics PRN (Phenergan, oral, continuous because there is no PRN (as needed) option in software) Diet, advance No alcohol, No acetaminophen or hepatotoxic drugs (these are 2 not available in software) May send the patient home, repeat appointment once the results available Results for order No. 2: Patient comes for return visit the next day IgM anti HAV antibody positive IgG anti HAV antibody positive Order: Interim history and brief focused physical exam Results: Patient feels weak, continues to have poor appetite; vitals stable Patient questions about prophylaxis for his wife and daughter (May not happen in real exam) Order No. 3: May send the patient home again and schedule appointment for 3 days LFT in 3 days PT in 3 days Rest at home, activity as tolerated Antiemetics PRN Diet, advance No alcohol, acetaminophen or hepatotoxic drugs Hepatitis A Immune globulin and Hepatitis A Vaccine for wife and daughter (May not happen in real exam) Results for order No. 3: Patient comes for a return visit LFT- Total bilirubin - 8.0 mg %, Direct bilirubin -5.0 mg %, ALT - 1500 IU/L, AST - 1300 IU/L, Alkaline phosphatase - 210 IU/L PT- 14.0 sec, INR=1.36 Patient still feels weak, continues to have poor appetite but vitals stable Order No. 4: May send the patient home LFT in 3 days PT in 3 days Rest at home, activity as tolerated Antiemetics PRN Diet as tolerated No alcohol, acetaminophen or hepatotoxic drugs Repeat appointment with lab results Results for order No. 4: Patient comes for a return visit LFT- Total bilirubin - 5.0 mg %, Direct bilirubin -3.0 mg %, ALT - 800 IU/L, AST - 700 IU/L, Alkaline phosphatase -190 IU/L PT- 14.0 sec, INR=1.36 Patient feels better, nausea is less and appetite improved; vitals stable If the case still continues, order: Examine the patient 3 days later Order, repeat LFT and PT in 3 days Discussion: Hepatitis A causes a self-limiting acute hepatitis. There are no chronic or carrier forms of hepatitis A.

Given the generally benign nature of hepatitis A, most patients can be treated at home with symptomatic and supportive therapies. No specific antiviral treatment is available. Intake of alcohol, acetaminophen and other potentially hepatotoxic substances should be avoided. Remember that conjugated hyperbilirubinemia is seen in viral hepatitis and do not be fooled by light colored stools. These are acholic stools because of cholestatic phase seen in infectious hepatitis causing a picture similar to obstructive jaundice. Do not be scared by high and rising levels of aminotransferases. The aminotransferases may be as high as 5000 IU/L and may show a rising trend for couple of weeks before starting to resolve. Recovery occurs in 3-16 weeks, although LFT may be impaired till one year. Encephalopathy and coagulopathy point towards hepatic failure and the need for admission.

Does this patient need vaccination? No, since Hepatitis A infection leads to life-long immunity.

Case 66[edit]

Final Diagnosis: Acute Hepatitis A Case 66 - Location: Emergency Room Vitals: BP: 100/60 mm Hg (supine), 80/50 mm Hg (sitting); HR: 124/min; RR: 24/min; Temp: 98.4F C.C: Black colored stools
History of present illness: A 55 years old white male is brought to the ER with a history of black colored, sticky, foul smelling stools for 48 hours. He decided to seek medical help after he vomited out bright red blood about an hour ago and felt weak and light headed. He has had six episodes of black stools in the last 24 hours. The patient has had history of epigastric pain for the last 1 month that occurs mostly on an empty stomach and is relieved with food and antacids. He denies history of fissures, hemorrhoids, jaundice or weight loss. He also has chronic low backache for six months. He has no allergies and has been taking over the counter ibuprofen on regular bases. The patient has been smoking one pack of cigarettes per day for the last 30 years. He also drinks beer regularly on weekends and parties. Family history is non-contributory. Rest of the review of systems is unremarkable.

How would you approach this patient? This is a patient with melena and hematemesis, who is hemodynamically unstable as is obvious from the hypotension, orthostasis and tachycardia. The initial approach should be to take the general resuscitative measures, a delay in which might be life threatening. Simultaneously, think of a differential diagnosis and order the relevant tests to rule in and rule out the disease process and its etiology. Remember you always need a thorough focused physical examination before establishing a diagnosis.

Order No. 1: Intravenous access, stat- 2 large (18 G) IV bore needles Start IV fluids: Normal Saline, bolus Make NPO Continuous BP, HR monitoring Pulse Oximetry, stat Results for Order No. 1: BP- 100/70 mm Hg; HR- 116/min Oxygen Saturation is 95% on room air Order focused physical exam: General appearance HEENT/Neck Examination of CVS Examination of lungs Examination of Abdomen Examination of Rectum FOBT Extremities Skin Results of Physical Examination: General appearance: Well built, pale looking, anxious male. HEENT: Pale conjunctiva, anicteric sclera, dry mucous membranes; no JVD. Lungs are clear to auscultation and percussion bilaterally; Cardiovascular: Tachycardia, S1 S2 normal, no murmurs, rub or gallop. Abdomen is soft, mild tenderness in the epigastric area but there is no rigidity, rebound or guarding; bowel sounds are normal, no organomegaly or free fluid. Rectal: Normal sphincter tone, no hemorrhoids or fissures, stool is black colored and heme positive. Extremities: no edema, clubbing or cyanosis, no calf tenderness, peripheral pulses feeble. Skin is normal.

Order No.2 CBC with differential, stat BMP, stat Liver function tests (LFT), stat PT/aPTT, stat EKG, 12 lead, stat IV Pantoprazole (Protonix), continuous Discontinue his ibuprofen Results for Order No. 2: CBC: Hgb -7.0 g/dl, Hct- 21% WBC - 11,000/ uL, Platelet - 250,000/mm3, normal differential count BMP: BUN - 32, Creatinine-1.1, Sodium -138 meq/L, Potassium - 3.8 meq/L, Chloride -103 meq/L, Bicarbonate - 26 meq/L, Calcium -10.1 mg % LFT: Total bilirubin - 1.0 mg %, Direct bilirubin – 0.3 mg %, ALT - 30 IU/L, AST - 28 IU/L, Alkaline phosphatase - 100 IU/L PT=18 sec, INR=1.63 aPTT=38 sec; control=35 sec EKG shows sinus tachycardia without evidence of ischemia or infarction Order No. 3: Continue NPO Stop IV NS Start packed RBC transfusion - 3 Units 4 Units fresh frozen plasma (FFP) Hb and Hematocrit every 6 hours PT after FFP transfusion Continue Protonix infusion Continuous BP monitoring Admit in ICU Call me when the lab results available Results for Order No. 3: BP – 110/70 mm; HR- 100/min After 3 Units of PRBC and 4 Units FFP Hgb-10 g/dl; Hct-30% PT=14.5 sec, INR=1.45 Patient feels better Order No. 4: Gastroenterology Consult for EGD Continue NPO Restart IV NS, continuous H and H every 6 hours Continue Protonix infusion Continuous BP monitoring Call me when the lab results available Results for Order No. 4: EGD- clean based ulcer in the first part of duodenum. Biopsy taken Hgb-10.2 g/dl; Hct- 30.6 % BP- 120/80; HR- 90/min Order No. 5 Discontinue NPO Stop IV NS Starts clears and advance to regular diet as tolerated H and H every 6 hours Stop IV Protonix Start Protonix, oral Continue BP monitoring Results of order No. 5: Patient is tolerating regular diet Hgb-10.0 g/dl; Hct- 30.0 % BP- 128/80; HR- 74/min Biopsy is positive for inflammation, ulceration, no malignant cells Tissue is negative for Helicobacter pylori Order No.6 Discharge the patient home after overnight watch Send home on protonix for 4-8 weeks, make follow-up appointment in 2 weeks Patient education Recheck Hb and Hematocrit with return visit Start Ferrous sulfate, continuous (Optional) Avoid NSAIDs (Type - No aspirin) Stop smoking Stop alcohol Discussion: Differential Diagnosis: Hematemesis and malena suggest upper gastrointestinal (UGI) hemorrhage. UGI bleed by definition is bleeding proximal to the ligament of Treitz. Remember that while presence of hematemesis always suggests UGI bleed, not all patients with UGI bleed have hematemesis. Malena most often is seen with an UGI bleed but may also be seen sometimes with proximal lower GI bleeding. It is in this situation (i.e. malena with no hematemesis) that a nasogastric tube placement and aspiration will be useful. Presence of fresh blood or coffee ground aspirate will suggest fresh or old UGI bleed respectively. The nasogastric tube can then also be used for lavage with tap water to clear the stomach before esophagogastroduodenoscopy (EGD). A negative finding on nasogastric lavage does not rule out an upper GI bleed as bleeding might have stopped or may have been distal to the gastric pylorus. However, a bilious lavage rules out with certainty an upper GI bleed. A nasogastric tube was not put in this patient, as there was a definite history of hematemesis.

Hematochezia (bright red bleed per rectum) is seen more commonly with a lower GI bleed but may sometimes be seen with an UGI bleed if it is severe and rapid. The elevated BUN with normal creatinine is another pointer towards UGI bleed.

The most common causes are peptic ulcer disease (stomach or duodenum), gastric erosions and esophageal varices. The less common ones include Mallory Weiss tear (suspect in an alcoholic, with severe retching and vomiting), neoplasm, esophagitis, and arterio-venous malformations. This patient with his history of pain that is relieved with food and use of ibuprofen is certainly a candidate for duodenal ulcer. Other risk factors include smoking and alcohol use.

Management: Hemodynamic stabilization is more important before an EGD.

1. All patients with UGI bleeding should have two large bore (18 G or larger) peripheral IV lines.

2. Patient should be resuscitated with blood transfusions to keep a hematocrit greater than 30%. If coagulopathy is present, transfusion with FFP and administration of Vitamin K is needed to keep the INR below 1.5. Platelet transfusions may be needed for platelet counts of less than 50,000/ mm3. Calcium levels should be monitored as multiple transfusions may lead to hypocalcemia requiring specific therapy.

3. Once the patient is stabilized the investigation of choice is an EGD that offers diagnostic and therapeutic options. This patient had a duodenal ulcer, which is the most common cause of UGI bleed. The endoscopic appearance of the ulcer predicts the risk of rebleeding and mortality. Since this patient had a clean based ulcer that carries a very little risk of rebleeding, he could resume a normal diet and be discharged within 24 hrs, as his hemoglobin was stable. Flat spots or adherent clots on EGD need observation on a general floor for 2 to 3 days. Patients with visible vessels or actively bleeding ulcers can be treated with local epinephrine injections. These lesions are associated with the highest risk for rebleeding and such patients need to be monitored in the ICU after the EGD. They should be discharged only after 3 days of stabilization. If during this period of observation rebleeding occurs then a repeat urgent EGD is needed. Such patients might need surgery if recurrent bleeding continues to occur after two endoscopic treatment attempts.

4. IV proton pump inhibitors (PPI) have been shown to reduce recurrent bleeding after endoscopic management of bleeding ulcers and may be continued for 72 hrs after EGD. At the time of discharge the patient should be put on an oral PPI for 4-8 weeks. Repeat EGD on an outpatient basis should be performed in patients with gastric ulcer to ensure healing and exclude underline malignancy. However, repeat EGD is unnecessary in patients with duodenal ulcers.

5. If the biopsy is positive for H.pylori, the patient should receive triple drug therapy for eradication of the organism. NSAIDs, smoking and alcohol need to be stopped to promote healing and prevent recurrence.

6. In patients with known cirrhosis and portal hypertension the most likely source of bleeding is esophagogastric varices. Once these patients are hemodynamically stabilized, octreotide should be started. Besides EGD is performed and sclerotherapy and band ligation of the varices can be done to stop bleeding. If octreotide and EGD intervention do not stop bleeding then a balloon tamponade (for e.g. with a Sengstaken-Blakemore or Minnesota tube) should be instituted and transjugular intrahepatic portosystemic shunt (TIPS) should be attempted to decrease portal pressure. The TIPS procedure has replaced surgery because of the significantly lower mortality rate. Once the patient has stopped active bleeding he can be discharged on a nonselective beta blocker (for e.g. nadolol or propranolol).

Final Diagnosis: Upper gastrointestinal hemorrhage, secondary to duodenal ulcer

Case 67[edit]

Case 67 - Location: Emergency Room Vitals: BP: 104/70 mm Hg (supine), 80/50 mm Hg (sitting); HR: 120/min; RR: 24/min; Temp: 98.4F C.C: Bright red blood per rectum
History of present illness: A 65 years old white female is brought to the ER with a one day history of passing bright red blood with bowel movements. She has had three episodes with moderate amount of fresh blood mixed with stools, with no anal pain. Her stools are soft in consistency and there is no history of fissures or hemorrhoids in the past. She felt weak and light headed. There was no history of nausea, vomiting or abdominal pain. She denied any hematemesis, melena, diarrhea, constipation, jaundice or weight loss. Her past medical history is significant for type II diabetes mellitus, hypertension and hyperlipidemia. She has never had a colonoscopy in the past. She has no allergies. Her medications include glyburide, simvastatin and lisinopril. The patient does not smoke or consume alcohol. Her mother died of colon cancer at the age of 60 years. Rest of the review of systems is unremarkable.

How would you approach this patient? This is a patient with hematochezia, who is hemodynamically unstable as is obvious from the hypotension, orthostasis and tachycardia. The initial approach should be to take the general resuscitative measures, a delay in which might be life threatening. Simultaneously, think of a differential diagnosis and order the relevant tests to rule in and rule out the disease process and its etiology. Remember you always need a thorough focused physical examination before establishing a diagnosis.

Order No. 1: Intravenous access, stat - 2 large (18 G) IV bore needles Start IV fluids: Normal Saline, bolus Make NPO Continuous BP, HR monitoring Pulse oximetry, stat Results for Order No. 1: BP - 100/70 mm Hg; HR- 124/min Oxygen Saturation is 97% on room air Order physical exam: General appearance HEENT/Neck Examination of CVS Examination of lungs Examination of Abdomen Examination of Rectum FOBT (not required if u see a fresh bleeding) Extremities Skin Results of Physical Examination: General appearance: Pale looking, anxious female. HEENT: Pale conjunctiva, anicteric sclera, dry mucous membranes; no JVD. No palpable lymph nodes. Lungs are clear to auscultation and percussion bilaterally. Cardiovascular: Tachycardic, S1 S2 normal, no murmurs, rub or gallop. Abdomen is soft, non tender, no rigidity, rebound or guarding; bowel sounds are normal, no organomegaly or free fluid. Rectal: Normal sphincter tone, no hemorrhoids or fissures, blood in rectum. Extremities: no edema, clubbing or cyanosis, no calf tenderness, peripheral pulses feeble. Rest of the exam is unremarkable.

Order No.2 CBC with differential, stat BMP, stat Liver function tests (LFT), stat PT/aPTT, stat EKG, 12 lead, stat Blood Typing and Cross-match - in preparation for transfusion Nasogastric tube placement and aspiration Anoscopy, stat Discontinue her glyburide, simvastatin and lisinopril Results for Order No. 2: BP - 100/70 mm Hg; HR- 124/min CBC: Hgb -7.5 g/dl, Hct- 22.5 %, WBC - 12,000/ uL, Platelet - 450,000/mm3, normal differential count BMP: BUN - 25, Creatinine -1.0, Sodium -135 meq/L, Potassium - 3.7 meq/L, Chloride -104 meq/L, Bicarbonate - 25 meq/L LFT: Total bilirubin - 1.0 mg %, Direct bilirubin – 0.4 mg %, ALT - 31 IU/L, AST - 30 IU/L, Alkaline phosphatase - 110 IU/L PT=17 sec, INR=1.60; aPTT=39 sec, control=35 sec EKG shows sinus tachycardia without evidence of ischemia or infarction Nasogastric aspirate – bilious with no blood Anoscopy - no anal fissures; no external or internal hemorrhoids; no ulcerations in distal part of rectum Order No. 3: Continue NPO Stop IV NS Start packed RBC transfusion - 3 Units 4 Units fresh frozen plasma (FFP) H and H every 6 hours PT after FFP transfusion Continuous BP monitoring Discontinue NG tube Complete bed rest Apply pneumatic compressions for DVT prophylaxis Accuchecks every 6 hours (use regular insulin as needed, based on blood sugar levels) Admit in ICU Examine the patient 6 hours later: order interim history and focused physical exam (make sure you listen lungs as they may develop fluid overload with all the IV infusions).

Results for Order No. 3: BP – 110/70 mm; HR- 100/min After 3 Units of PRBC and 4 Units FFP Hgb-10.5 g/dl; Hct-30% PT=14.5 sec, INR=1.45 Patient feels better; exam looks fine Order No. 4: Gastroenterology consult for colonoscopy (Reason: 65 yr old with Hematochezia, no prior Colonoscopy; Please evaluate for the source of bleeding). Continue NPO Restart IV NS, continuous (if the lungs are clear) H and H every 6 hours Start bowel preparation for colonoscopy - 4 liters of polyethylene glycol (Golytely, Colyte) given over two hours Continuous BP monitoring Call me when the lab results available Results for Order No. 4: Colonoscopy - Multiple diverticuli in sigmoid and descending colon. Biopsy taken Hgb-10.2 g/dl; Hct- 30.6 % BP - 120/80; HR- 90/min Order No. 5 Discontinue NPO Stop IV NS Start clears and advances to high fiber diet as tolerated H and H every 6 hours Continue BP monitoring Results of order No. 5: Patient is tolerating low roughage diet Hgb-10.0 g/dl; Hct- 30.0 % BP - 128/80; HR- 74/min Biopsy is positive for diverticulosis, no inflammation or ulceration; no malignant cells Order No.6 Discharge the patient home after overnight watch High fiber diet Restart her home medications D/C DVT prophylaxis Avoid nuts and fruits with seeds (No option in software) Follow up appointment in one week with repeat Hgb and hematocrit.

Discussion: Differential Diagnosis: LGI bleed by definition is bleeding distal to the ligament of Treitz. Most patients with bright red blood per rectum or hematochezia have a LGI bleed, but about 10% are the result of a brisk UGI bleed. Thus patients with hematochezia should have a nasogastric tube lavage to exclude an upper gastrointestinal hemorrhage. An EGD instead of the usual colonoscopy may be needed to establish the cause of hematochezia in case the nasogastric aspirate shows blood.

The most common causes are diverticulosis, angiodysplasia, polyps and colon cancer in a patient above 65 years. All these conditions are painless, except colon cancer, which sometimes may be associated with abdominal pain. This patient is at a high risk of colon cancer because of a positive family history. Another important cause to consider in this patient is ischemic colitis since she has multiple risk factors for vascular disease. However, ischemic colitis is most often associated with abdominal pain. Also remember, that diverticular bleed usually do not occur in the presence of diverticulitis. Other less common causes include inflammatory bowel disease (ulcerative colitis, crohn’s disease), vasculitis (Polyarteritis nodosa, Wegner’s granulomatosis), radiation colitis, and infectious colitis (Ecoli, salmonella, CMV).

Management: 1. Hemodynamic stabilization is more important before a colonoscopy. Hemodynamically unstable patients should be admitted in the intensive care unit. Presence of shock, orthostatic hypotension, a 6% drop in hematocrit or blood transfusion requirement of two or more units suggests hemodynamic instability.

2. All patients with GI bleeding should have two large bore (18 G or larger) peripheral IV lines.

3. Patient should be resuscitated with blood transfusions to keep a hematocrit greater than 30%. If coagulopathy is present, transfusion with FFP and administration of Vitamin K is needed to keep the INR below 1.5. Platelet transfusions may be needed for platelet counts of less than 50,000/ mm3.

4. Calcium levels should be monitored as multiple transfusions may lead to hypocalcimia requiring specific therapy.

5. Nasogastric tube lavage should be done. If it shows no blood or has copious bile then the investigation of choice once the patient is stabilized, is colonoscopy. Colonoscopy can localize the site of bleeding, allow tissue biopsies and therapeutic interventions like injection sclerotherapy and electrocautery. However, a good bowel preparation is needed for good visualization of the colon. If nasogastric aspirate shows blood then an EGD is recommended as the initial investigation of choice. If EGD is negative, then go ahead with colonoscopy.

What if the colonoscopy is normal but the patient continues to have hematochezia? Order a tagged red blood cell scan (radionuclide imaging study) — Radionuclide scanning is a highly sensitive technique that can detect bleeding occurring at a rate of 0.1 to 0.5 mL/minute. However, it cannot localize the site of bleeding and requires presence of active bleeding at the time of the test. If the tagged RBC scan is positive, one must proceed with angiography.

Angiography detects blood loss as low as 0.5 mL/minute. The procedure is 100 percent specific and is performed to accurately localize the site of bleeding, especially if surgical management is needed. It also permits control of bleeding using vasopressin infusion or embolization via the catheter. However, it is an invasive procedure and needs to be performed during active bleeding.

*Remember that angiography is reserved for patients in whom colonoscopy cannot localize the site of bleeding or is not feasible.

When should I get surgery consult? A surgical consultation is needed for continued severe bleeding with high transfusion requirements. A blind surgery performed without localizing the site of bleeding carries a higher risk of rebleeding. Hence, if feasible a tagged RBC scan and angiography should be done before proceeding for surgery. Final Diagnosis: Lower gastrointestinal hemorrhage, secondary to diverticulosis.

Case 68[edit]

Location: Emergency Room Vitals: BP: 80/50 mm Hg; HR: 40/min; RR: 24/min; Temp: 98.4F C.C: Lightheadedness
History of present illness: A 55 years old male victim of a motor vehicle accident is brought to the ER by ambulance. He was a unrestrained driver of a car that hit a tree due to poor visibility on that foggy night. The patient complains of mild generalized body ache, severe chest pain and lightheadedness. He remembered his chest having struck against the steering wheel. However, there was no history of head injury, headache or loss of consciousness. He did not complain of respiratory distress. The patient was feeling uncomfortable with the Miami-J collar put by the EMS team around his neck at the site of the accident. He has no allergies and denied being on any medication. Rest of the review of systems is unremarkable.

How would you approach this patient? This is a victim of motor vehicle accident, who is hemodynamically unstable as is obvious from the hypotension and bradycardia. The initial approach should be to take the general resuscitative measures, a delay in which might be life threatening. Simultaneously, think of reasons for hypotension and bradycardia in an accident victim and order the relevant tests. Remember you always need a thorough physical examination to rule out serious injuries and decide which body parts to image.

Order No. 1: Intravenous access, stat- 2 large (18 G) IV bore needles Start IV fluids: Normal Saline, bolus Continuous BP, HR monitoring Pulse oximetry, stat Results for order No 1: BP- 80/50 mm Hg; HR- 34/min Oxygen Saturation is 95% on room air Order examination: General Heart Lungs Results of the exam: General appearance: Well-built, white male, in severe pain, holding on to his chest with his right hand. Lungs are clear to auscultation and percussion bilaterally; Cardiovascular – Bradycardia, variable intensity of S1 and S2; no murmurs, rub or gallop.

Order No 2: EKG, 12 lead, stat Chest-X ray, PA portable X-ray cervical spine, stat IV Fentanyl or Ketorolac, bolus Results of Order No 2: EKG shows complete heart block, ventricular escape rhythm with a rate of 40/min, QRS duration of 140 msec. No evidence of ischemia or injury except nonspecific ST/T changes.

Chest X-Ray: Fracture of the left 3rd and 4th ribs. No pneumothorax or effusion. Heart and mediastinum are normal in size and configuration. X-ray cervical spine: Normal Order No 3: Atropine 0.5 mg IV stat Put patient on transcutaneous pacemaker Consult Cardiology, stat (for transvenous pacemaker placement) Consult Orthopedics, stat (to rule out cervical spine injury and get rid of Miami-J collar) Make NPO CBC with differential, stat BMP, stat PT/aPTT, stat Results of Order No 3: CBC: Hgb -13.0 g/dl, Hct - 39% WBC – 9,200/uL, Platelet - 250,000/mm3, normal differential count BMP: BUN - 19, Creatinine-1.1, Sodium -138 meq/L, Potassium - 3.8 meq/L, Chloride -103 meq/L, and bicarbonate - 26 meq/L. PT=13 sec, INR=1.23; APTT=33 sec; control=35 sec Order No 4: Check the BP and HR Result of Order No 4: Transcutaneous pacemaker paces at rate of 80/min, BP-90/60 Patient’s lightheadedness and chest pain is better Order examination of: HEENT/Neck Abdomen Extremities Skin CNS Results of Physical Examination: HEENT: Normocephalic, atraumatic, PERLA, EOMI, pink conjunctiva, anicteric sclera, moist mucous membranes, no ear or nose bleed; Neck- Miami J collar on; Abdomen is soft, no tenderness, rigidity, rebound or guarding; bowel sounds are normal, no organomegaly or free fluid. Extremities - no edema, clubbing or cyanosis, no calf tenderness, peripheral pulses feeble. Neurological exam-awake, alert oriented, moves all four limbs with no focal neurological deficits.

Order No. 5: Continuous HR and BP monitoring Continue NPO Continue NS CK and MB, stat Troponin T, stat Echocardiogram, stat Results for Order No. 5: CK- 500; MB-11 Troponin T- 0.500 Echocardiogram: EF=55 - 60, no wall motion abnormalities, all valves are normal, no pericardial effusion Cardiologist takes the patient to the cardiac cath lab for a temporary transvenous pacemaker insertion.

If case continues further, may need permanent pacemaker insertion. Discussion: The most important cause of hypotension in a trauma victim is hemorrhage. The first step in management would be to start IV fluids and send a CBC to look for the amount of blood loss. If there is no overt bleeding one must look for an occult collection in the chest and abdomen, for which you need to do imaging studies. Normally, patients develop tachycardia in response to hypotension secondary to hypovolemia. The bradycardia accompanying the hypotension and the normal hemoglobin in this patient should make you suspicious of an etiology other than bleeding.

The EKG confirms the diagnosis of complete heart block (CHB). CHB is a third degree AV block the diagnosis of which is made by AV dissociation with a slow ventricular escape rhythm of around 40 beats/min. The atria may be in sinus rhythm or in fibrillation but the ‘P’ waves do not bear any relationship with the QRS complexes. However, it is also important to establish the etiology of CHB since it aids in the further management. The most important causes are fibrosis or degeneration of the conduction system and ischemic heart disease. The others include drugs (beta blockers, calcium channel blockers, digitalis, amiodarone), metabolic abnormalities (hyperkalemia), valvular heart disease, and cardiomyopathy (amyloid, sarcoid, hypertrophic cardiomyopathy).

Remember, trauma is an uncommon cause of CHB. Absence of ST-T changes suggestive of ischemia in EKG and no wall motion abnormalities excluded the possibility of acute coronary syndrome. The elevated CK, MB and Troponin T were probably secondary to myocardial contusion. The patients was not on any heart rate lowering drugs, his electrolytes were normal and Echo further ruled out any valvular abnormalities, cardiomyopathy or pericardial effusion.

The only modality of treatment for complete heart block is pacing. Atropine is only of little benefit and may sometimes transiently improve the heart rate and the blood pressure. These days the life packs are equipped with pads for transcutaneos pacing. But these should be used only as a bridge for the transvenous pacing. The transvenous pacing may be a temporary pacing to begin with. In this patient, if the CHB persists for the next couple of days, a permanent pacemaker can be placed.

Patients with second-degree atrioventricular blocks who are asymptomatic and hemodynamically stable may be managed without a pacemaker. However, a complete heart block even in the absence of symptoms warrants a pacemaker, since you are not sure when the patient may become unstable.

Another important thing is to avoid medications that would cause bradycardia and hypotension. This patient has rib fracture and a lot of chest pain. Use of morphine may worsen his hemodynamic parameters. So, ketorolac or fentanyl would be better options for pain control in these patients.

Final Diagnosis: Motor vehicle accident with complete heart block (secondary to myocardial contusion)

Case 69[edit]

Case 69 - Location: Emergency Room Vitals: BP: 100/60 mm Hg; HR: 104/min; RR: 30/min; Temp: 100.4F C.C: Generalized bodyache and weakness
History of present illness: A 80 years old white male is brought to the ER by his son. His son found him lying in the woods on a hot sunny day. It seemed that the patient had gone for a stroll last evening and fell down. He was unable to get up, shouted for help but could not get any. He had been lying on the ground for the last 24 hours till his son found him. The patient complained of severe bodyache. He felt very weak and was thirsty. He denied having lost consciousness. He did not pass urine for the past 24 hours. There was no history of head injury or seizures. He has no allergies and is not taking any medications. The patient does not smoke and denies any alcohol use. Family history is non-contributory. Rest of the review of systems is unremarkable.

How would you approach this patient? This is an 80 years old man who had a fall and had been lying on the ground for more than 24 hours on a hot sunny day with no help. He is hemodynamically stable. The generalized bodyache is a hint towards possible muscle injury and should be a guide for ordering further diagnostic tests. Remember you always need a thorough physical examination to rule out serious injuries and decide which body parts to image.

Order No. 1: Intravenous access, stat Pulse oximetry, stat Results for order No 1: Oxygen Saturation is 95% on room air Order examination: Complete Results of the exam: General appearance: Well-built, in dirt laden clothes, appears extremely dry and weak. HEENT-normal; Neck- no JVD; Respiratory - Clear to auscultation bilaterally; Cardiovascular- Tachycardia, S1 S2 normal, no murmur, rub or gallop; Abdomen-soft, non-distended, non-tender, normal bowel sounds, no organomegaly; Extremities- no edema, clubbing or cyanosis, no calf tenderness, peripheral pulses feeble; Neurological- awake, alert, oriented, no focal neurological deficit

Order No 2: Start IV fluids: Normal saline, bolus Insert Foley’s catheter, stat CBC with differential, stat BMP, stat EKG, 12 lead, stat Urinanalysis Results for order No 2: The nurse reports that the patient could give her only 5 cc of dark brown urine CBC: Hgb -13.0 g/dl, Hct - 39% WBC – 13,200/uL, Platelet - 250,000/mm3, normal differential count BMP: BUN – 45mg%, Creatinine-2.6 mg%, Sodium -134 meq/L, Potassium – 5.5 meq/L, Chloride - 92 meq/L, and bicarbonate - 17 meq/L. Calcium- 8.0 mg% EKG shows sinus tachycardia Urine dipstick- positive for blood; Urine microscopic- no RBC, no WBC, reddish-gold pigmented casts

Order No 3: CPK, stat Ionized calcium, stat Serum magnesium, stat Serum phosphorus, stat Serum uric acid, stat Urine myoglobin, stat PT/INR, stat APTT, stat Admit in floor Vitals Q 2 hours Urine output, hourly Activity as tolerated IV NS, continuous Results of Order No 3: CPK- 10,500 IU/L 10 cc urine in Urobag Ionized calcium- 0.99 mmol/L Serum magnesium- 1.8 meq/L Serum phosphorus-5.5 mg/dl Serum uric acid- 8.5 mg/dl Urine myoglobin- positive PT- 14.2 sec, INR-1.40; APTT-35 sec

Order No 4: Inform in 4 hours Result of Order No 4: BP-110/80 mmHg, HR-104/min Urine output- 75 ml/hr

Order No. 5: Stop 0.9% Saline Start 0.45% Saline (with mannitol and Soda bicarbonate added to it) Monitor urine pH every 1 hour Titrate the mannitol - bicarbonate drip for urine pH> 6.5 and Urine output of >300 mL/hr Check CPK in 4 Hours Check BMP in 4 Hours Check Magnesium and phosphorus in 4 Hours

Result of Order No 5: CPK- 9000 IU/L BMP: BUN-38mg%, Creatinine-2.1 mg%, Sodium -138 meq/L, Potassium –5.0 meq/L, Chloride -101 meq/L, and bicarbonate - 21 meq/L. Calcium- 8.2 mg% Serum Magnesium- 1.4 meq/L Serum Phosphorus- 5.0 mg/dl BP-130/80 mm Hg; HR-96/min Urine pH-7.2 Urine output- 1300 cc in last 4 hours Nurse says that the patient is feeling better Order No. 6: Stop mannitol-bicabonate diuresis Start 0.45% saline, continuous Check BMP, every six hours Check serum magnesium every 6 hours Check serum phosphorus every 6 hours Check CPK, every 12 hours

Discussion This is a case of rhabdomyolysis. Prolonged immobilization and compression of muscles lead to ischemic muscle damage. The hot climate and dehydration contributed to the myoglobin induced acute tubular necrosis. This resulted in acute renal failure with anion gap metabolic acidosis and the electrolyte abnormalities seen with rhabdomyolysis.

Rhabdomyolysis is a syndrome resulting from skeletal muscle injury with release of myoglobin and creatine phosphokinase (CPK) into the plasma. The myoglobinuria, acid urine pH and renal hypoperfusion resulting from hypovolemia leads to precipitation of heme proteins and acute tubular necrosis.

Etiology: 1. Traumatic causes: Crush syndrome, burns, electrocution, 2. Non-traumatic causes: • Muscle hyperactivity- strenuous physical exercise, seizures, delirium tremens • Muscle compression- prolonged immobilization, coma • Muscle ischemia- acute arterial occlusion • Malignant hyperthermia, neuroleptic malignant syndrome, hypothermia • Infections- Viral including HIV, bacterial, etc.

• Drugs - alcohol, heroin, cocaine, amphetamines, zidovudine, statins • Metabolic disorders- hypocalcaemia, hypokalemia, hypophosphatemia, hypothyroidism, hyperthyroidism, diabetic ketoacidosis • Metabolic myopathies- e.g. Carnitine palmitoyltransferase deficiency. These should be suspected in patients with recurrent episodes of rhabdomyolysis after exertion.

• Others- carbon monoxide, snake bite Remember that inflammatory myopathies like polymyositis and dermatomyositis very rarely give rise to rhabdomyolysis and acute renal failure. Diagnosis: The most common complaint is muscular pain, which is very non-specific. Moreover, a comatose patient will not complain. Dark brown urine may be the only visible sign. Suspect rhabdomyolysis in a patient with renal failure, who has blood present on urine dipstick but no RBC on microscopic examination. This is because the myoglobin in the urine causes the urine dipstick to be falsely positive for blood. Plasma creatinine concentration rises more rapidly with rhabdomyolysis (up to 2.5 mg/dL per day) than with other causes of acute renal failure. In contrast to other forms of acute tubular necrosis, FENa is less than 1 percent.

The diagnosis of rhabdomyolysis is made by measurement of CPK. It begins to raise 2 to 12 hrs after the injury and reaches its peak value 1 to 3 days after injury. The peak may range from several hundred IU/L to over 200,000 IU/L in a full blown crush syndrome. Therefore, CPK should be measured daily for at least 3 days to follow extent of muscle damage. If the serum CPK remains elevated despite treatment, ongoing muscle injury, necrosis and/or compartment syndrome should be sought.

Myoglobin is also released from the injured muscle. It increases before CPK and decreases more rapidly owing to its clearance by kidneys and metabolism to bilirubin. Therefore, remember that a normal serum myoglobin and absence of myoglobinuria does not exclude the diagnosis of rhabdomyolysis.

Various electrolyte abnormalities result from rhabdomyolysis. These can be better understood by grouping them into two categories 1. Influx from Extracellular compartment into muscle cells- water, sodium, chloride (hypovolemic shock), calcium(hypocalcemia) 2. Efflux from injured muscle cells- potassium(hyperkalemia), purines (hyperuricemia), phosphate (hyperphosphatemia), lactic acid (metabolic acidosis), myoglobin(myoglobinuria, nephrotoxicity), thromboplastin (DIC), creatine kinase, creatinine (increased serum creatinine–to-urea ratio) Management: 1. Fluid replacement is the mainstay of therapy. Use normal saline and initiate at 1.5 L/hr. The aim is to wash off the myoglobin from the renal tubules, establish a good urine output and prevent or limit acute tubular necrosis. While on one hand many electrolyte abnormalities can precipitate rhabdomyolysis, the syndrome itself can lead to various metabolic derangements. Hence one needs to monitor the BMP and electrolytes very closely for the initial 2 days.

2. Forced alkaline diuresis using mannitol and bicarbonate is recommended by some. Alkalinization of urine prevents precipitation of myoglobin in the tubules. However, this should be used once the BP is stable and a urine output is established using isotonic saline.

One has to be careful during such large volume fluid replacement as there is always a risk of fluid overload.

Final Diagnosis: Rhabdomyolysis due to prolonged immobilization

Case 70[edit]

Case 70 - Location: Emergency Room Vitals: BP: 120/80 mm Hg; HR: 112/min; RR: 28/min; Temp: 101 F C.C: Fatigue and right upper quadrant abdominal pain
History of present illness: A 74 years old white male presents to the ER with a 3 days history of fatigue and right upper quadrant abdominal pain. His pain is a dull in character, moderate intensity, poorly localized with no radiation to back or shoulder. It increases with deep inspiration. He denies any fever, cough or sputum production but complains of profuse sweating off and on. He has poor appetite with some nausea but no vomiting. There is no history of bowel or bladder problems. The past medical history is significant for type II diabetes mellitus. He has no allergies and is taking glipizide for his diabetes. The patient denies any tobacco or alcohol abuse. There is no history of sick contacts. He is a widower and lives alone. Family history is non-contributory. Rest of the review of systems is unremarkable.

How would you approach this patient? This is a 74 years old patient with acute onset right upper quadrant pain and non-specific constitutional symptoms. First think of a differential diagnosis of right upper quadrant pain. The possibilities are: acute cholecystitis, cholangitis, choledocholithiasis, hepatitis, pyelonephritis, appendicitis and pneumonia. The absence of dysuria, back pain and normal urine color make the possibility of hepato-biliary and renal pathology a little less likely but not impossible. Moreover, absence of fever, cough and sputum point against the diagnosis of pneumonia. In such a situation one should perform a good physical examination to narrow down the list of differential diagnosis and order relevant tests.

Order No. 1 Pulse Oximetry, stat Results of Order No.1 Oxygen Saturation- 89 % on room air Order No. 2 Start oxygen by nasal canula @ 4 L/min Order physical exam: General appearance HEENT/Neck Examination of heart Examination of lungs Examination of abdomen Examination of extremities CNS Skin Results of Physical Examination: General appearance: Well built male, toxic looking, tachypneic. HEENT: Anicteric sclera, No JVD.

Lungs: crackles over the right lung base, no rhonchi or rub; Cardiovascular: Tachycardic, S1 and S2 are normal, no murmurs, rub or gallop. Abdomen is soft, non-tender, no rigidity, rebound or guarding; normal bowel sounds; no organomegaly or free fluid. Extremities: No edema, clubbing or cyanosis, no calf tenderness, peripheral pulses palpable. Skin: No rash. CNS- normal.

Order No. 3: X-ray Chest, PA and lateral stat EKG, 12 lead, stat CBC with differential, stat BMP, stat LFT, stat Results for Order No. 3: X-ray Chest- Right lower lobe infiltrate suggestive of right lower lobe pneumonia, normal cardiac size, no pleural effusion Hgb -13.5 g/dl, WBC – 16,500/ uL, Platelet - 350,000/mm3, Differential count: 90 % polymorphs, 8% lymphocytes, 20 % bands BUN - 18, Creatinine-1.1, Sodium -138 mEq/L, Potassium - 3.8 mEq/L, Chloride -105 mEq/L, Bicarbonate - 26 mEq/L, Calcium -10.1 mg % LFT – Completely normal EKG – Sinus tachycardia Order No. 4: Admit the patient on regular floor Blood cultures, 2 sets, stat Sputum Gram stain, stat Sputum cultures, stat Start antibiotics after drawing blood cultures - Levofloxacin/gatifloxacin or Ceftriaxone + azithromycin, IV continuous Acetaminophen, PRN for fever and pain Check Vitals every 4 hours Pulse Oximetry, Q 2 hours Bed rest with bathroom privileges Pneumatic compression for DVT prophylaxis Diabetic diet Plenty of oral fluids Acu checks, QID (4 times a day) Continue his oral glipizide Pneumovax and Influenza vaccination if not received earlier Review after 12 hours Order interim history and focused physical exam Results for Order No. 4: Vitals: BP: 120/80 mm Hg; HR: 96/min; RR: 20/min; Temp: 99 F Oxygen saturation- 100% on 4L/min of oxygen by nasal canula Order No. 5: Continue same treatment CBC/differential after 24 hours Call me with the results Results for Order No. 5: After 24 hours, the nurse reports that patient feels better. No nausea; feels stronger and wants to eat Vitals: BP: 120/80 mm Hg; HR: 80/min; RR: 16/min; Temp: 98 F Oxygen saturation- 95% on room air Blood cultures - no growth after 24 hours Hgb -13.0 g/dl, WBC – 11,500/ uL, Platelet - 350,000/mm3, Differential count: 82 % polymorphs, 8% lymphocytes, and 10% bands Blood sugar - stable on diet and oral hypoglycemics If case continues- Stop IV antibiotics; plan to send patient home on oral antibiotics for 7-10 days. Make a follow-up in one week.

Discussion: This is a case of community-acquired pneumonia (CAP) with an atypical presentation. With an abnormal chest x-ray, normal Liver function tests (LFT) and a benign abdominal examination, no abdominal imaging studies are needed in this patient.

Certain important points to remember regarding CAP: 1.Pathogens: The most common pathogens are Streptococcus pneumoniae and Hemophilus influenzae. Staphylococcus aureus, gram-negative bacilli and Moraxella catarrhalis are less common organisms causing CAP. Atypical agents including Legionella, Mycoplasma pneumoniae and Chlamydia pneumoniae although not very common need to be considered when choosing a broad-spectrum antibiotic for empiric treatment of CAP.

2.Clinical Presentation: Cough, sputum production, dyspnea, fevers and sweats are the typical symptoms. However fatigue, headaches, nausea, vomiting, diarrhea and abdominal pain are some of the non-specific and atypical symptoms. Elderly patients (> 75 years) have fewer symptoms of CAP.

3.Diagnostic studies: Chest X-Ray is a must for diagnosis of CAP. CBC/Diff, basal metabolic profile , sputum cultures, blood cultures, and pulse oximetry (or ABG) are recommended before starting antibiotics. The role of routine sputum Gram stain and sputum cultures is controversial. These labs may support the diagnosis, identify the pathogen and help in making treatment decisions, regarding the need for admission. Blood cultures are positive in only 11% cases of CAP with Streptococcus pneumoniae accounting for 67% of the positive cultures. In case Legionnaire’s disease is suspected (hyponatremia, immunocompromised, no response to Beta-lactam antibiotics) then urine should be tested for Legionella antigen.

4.Choice of antibiotics: For a patient being admitted in the general medical floor/ward: a. Fluoroquinolone alone - levofloxacin or gatifloxacin; Do not use ciprofloxacin b. 2nd /3rd generation Cephalosporin (e.g. Ceftriaxone) + Macrolide (e.g. Azithromycin) *Remember, the cephalosporins are not effective against atypicals like legionella, mycoplasma and Chlamydia; hence, it should be combined with a macrolide. Levofloxacin alone also covers atypical organisms.

For uncomplicated pneumonia in the out patient setting: a. Azithromycin or Doxycycline alone Duration of antibiotics depends upon the pathogen being suspected and treated. In general it varies from 7-10 days. However, it may be 10-14 days for Mycoplasma and Chlamydia and 14-21 days for Legionella. 5.Decision to admit: Various guidelines and scoring systems have been developed to help in deciding whether to admit the patient or not. However, these are difficult to remember off hand. The following major points are poor prognostic factors in patients with CAP. The presence of any of these may necessitate admission.

a. Age greater than 65 years b. Coexisting disease: Diabetes, renal failure, heart failure, chronic lung disease, chronic alcoholism, immunosuppression, and neoplastic disease.

c. Clinical findings: RR >30 breaths/min, Systolic BP<90mm Hg or Diastolic BP< 60 mm Hg, d. Temperature>38.3 C, altered mental status, extarpulmonary site of infection (meningitis, septic arthritis).

e. Laboratory tests: WBC <4000/mm3 or >30,000/mm3; Pao2<60 mmHg; renal failure; multilobar involvement on chest radiograph; pleural effusion; Hct<30%.

Case 71[edit]

Case 71 - Location: Office.

Vital signs: Pulse: 88/min, BP: 130/80 mmHg, Temperature: 100.0F, RR: 22/min, Height: 72”, Weight: 64kgs.

History of present illness: A 32-year-old previously healthy male who is an immigrant from INDIA presents to your office with 6 weeks history of fatigue, low-grade fever and dry cough. Recently he noticed increasing cough with yellowish sputum since 1 week. He says his appetitive is decreased, and have unintentional loss of around 10 lbs of weight during this period. He denies and shortness of breath or hemoptysis. He has been smoking 1 pack per day cigarettes since 10 years, but denies alcohol intake. He has no other medical problems. Family history is nothing significant. He has no known allergies. Rest of the review of systems is unremarkable. He is sexually active in a monogamous relationship with his wife and uses condom always. His immunizations are uptodate.

How do you approach this case? This is a 32-year-old INDIAN male with 6 weeks history of fatigue, low-grade fever, dry cough and weight loss. The possible diagnosis in this may be due to pulmonary tuberculosis (most likely), fungal infections, HIV, carcinoma of lung (age is little atypical), chronic bronchitis, and bronchiectasis. Chronic cough may be due to postnasal drip, asthma, GERD, medications (ACE inhibitors), and some rare causes. However, fever and weight loss makes postnasal drip, asthma, GERD, and medications unlikely.

Order physical examination: Complete examination

Findings on exam: General appearance: Thin built male appears comfortable. HEENT: Normal conjunctiva, anicteric sclera, wet mucous membranes; there is no JVD or lymphadenopathy. Lungs: Distant hollow breath sounds and posttussive rales are heard over the right upper lobe. Decreased breath sounds and dullness to percussion is noted at the base of right lung. Cardiovascular, abdomen, and CNS examination is completely normal. Extremities: No edema, clubbing or cyanosis, no calf tenderness; peripheral pulses are full.

Order labs: CBC with diff, routine BUN, routine Serum creatinine, routine Chest x-ray, PA and lateral views, routine Sputum examination for gram’s stain, and AFB Sputum culture and sensitivity ESR, routine EKG 12 Lead, routine

See me with the lab results available

Here are the results: CBC: Hb: 13gm%, Hct: 40%, WBC: 12,000/Cmm with normal differential, Platelets: 230,000/cmm. Peripheral smear: Normal BUN: 10mg/dL; serum creatinine: 0.9 mg/dL. Chest x-ray: Right apical cavity with mild pleural effusion and right hilar adenopathy. Sputum examination: AFB is positive for rod shaped bacilli suggestive of Mycobacterium tuberculosis.

Culture and sensitivity results are pending. EKG: Normal sinus rhythm.

Review of orders: LFT, routine Serum uric acid, routine Ophthalmology consult. Reason: Assessment of visual acuity and other abnormalities before starting ethambutol.

Results: Liver function tests (LFT) are within normal limits. Serum uric acid is normal Ophthalmology consultation: Normal ocular study

Order review: Tab INH, oral, continuous*6months Tab Pyridoxine oral, continuous*6months Tab Rifampin oral, continuous*6 months, Tab Pyrazinamide oral, continuous*2 months Tab Ethambutol, oral, continuous*2months Smoking cessation counseling Regular diet Medication compliance

Change location to home and fix appointment after 15days. Then order brief history and focused examination.

Order review: Continue same medication. Fix appointment each month and check LFT. Repeat Chest X-Ray in one month to see pleural effusion is coming down or not.

Primary diagnosis: Pulmonary tuberculosis

Discussion: Tuberculosis is not uncommon in USA because of the immigrants from disease prevalent countries (INDIA, China, Africa). It is also common among populations like malnourished, homeless, in those living in overcrowded situations and in immunocompromised patients. Tuberculosis is caused by acid-fast bacilli Mycobacterium tuberculosis. The most common variant is the pulmonary form. In patients with impaired CMI, active primary tuberculosis occurs with pulmonary and constitutional symptoms like fatigue, decreased appetite, weight loss, fever, night sweats and cough. Once the pulmonary form occurs, the disease spreads to other parts of the body by hematogenous spread. Atypical presentation occurs especially in elderly and HIV positive patients.

The disease is mainly diagnosed by chest x-ray, which often shows apical or right middle lobe infiltrates (cavity) with or with out pleural effusion, and sputum examination for AFB; ESR will be elevated but it has no diagnostic value. Patients usually have positive PPD test. Positive PPD is not diagnostic in symptomatic patients as it indicates both active and latent infection. Culture of mycobacterium is possible but takes several weeks and treatment can be started without the results.

The standard treatment involves administration of 4 medications (INH, Rifampin, Pyrazinamide and Ethambutol) for 2 months followed by 4 months of 2 drugs (INH and Rifampin). The main cause of treatment failure is non-adherence, which can be improved by patient education and directly observed therapy (DOT) by a health care worker. Inpatient therapy is not usually required unless patient is not reliable, incapable of self-care. Inpatient therapy should be in an isolated room with good ventilation until 3 consecutive smears are negative for bacilli.

All the antitubercular drugs cause hepatic impairment, in addition INH causes pyridoxine deficiency leading to central and peripheral neuropathy, which can be prevented by oral pyridoxine. Monitoring of liver function tests should be individualized. Even though there is no specified interval by CDC, it is recommended that patients should be seen by a physician atleast once monthly and measure liver function tests. Ethambutol causes visual acuity disturbances and optic neuritis; hence many physicians obtain ophthalmology consultation before treatment. Rifampin causes orange discoloration of body fluids; pyrazinamide causes hyperuricemia leading to joint pains but most often it is asymptomatic. Many physicians recommend a baseline testing of uric acid before starting pyrazinamide. Routine follow-up measurement of serum uric acid is not required unless patient has a history of gout or receiving medications that alter uric acid metabolism such as loop diuretics. All drugs are safe in pregnancy except streptomycin and special consideration to be taken while using pyrazinamide in pregnant patients, as teratogenicity is not clearly defined.

Therapy in HIV positive patients is similar to HIV negative patients except for a longer duration with DOT and to watch out for drug interactions. All cases should be reported to public health authorities.

Note: All patients should have a baseline CBC with diff, BUN, serum creatinine, Liver function tests (LFT), chest-x ray and serum uric acid.

Case number 72[edit]

Case number - Location: Office

Vital signs: Pulse: 110/min; BP: 110/60 mmHg, Temperature: 103.4F, RR: 20/min, Height: 70”, Weight: 165LB.

History of present illness: A 28-year-old, previously healthy, Hispanic male presents with 3-day history of burning micturition. He also has discomfort and pain in perineum, lower abdomen and back along with fever, chills, and nausea. He states that he needs to strain to pass urine. He passed moderate amount of urine few hours ago. He denies nocturia or increased frequency; even though he had not had vomitings he feels very nauseous and did not eat form past 24 hours. He has no other known medical problems. He has no known drug allergies. He is sexually active with his wife and do not use contraception. He denies multiple sexual partners, previous STDs and illicit drug use. He denies smoking and alcohol. Family history is nothing significant.

How do you approach this case? This young man has dysuria, perineal discomfort and fever. The differentials to keep in mind are acute prostatitis, acute cystitis, acute urethritis, acute epididymitis and pyelonephritis.

Order physical exam: Complete physical examination

Here are the findings: Gen: A 28-year-old male patient in moderate pain and appears ill. HEENT, Neck, Lungs, Heart, Neuro exam is completely normal. Abdomen is non-distended, bowel sound are active; supra pubic tenderness is present; there is no costo vertebral angle tenderness; bladder is not distended. DRE revealed exquisitely tender, diffusely enlarged boggy prostate (avoid message and repeating DRE). External genitalia appear normal without any ulcerations or urethral discharge.

Discussion: Presence of perineal discomfort, clinical finding of exquisitely tender, diffusely enlarged boggy prostate on digital rectal exam makes acute prostatitis the most probable diagnosis.

Orders Change the location to ward. Intravenous access. CBC with diff, stat BMP, stat Urine complete analysis, stat Urine Gram stain, stat Urine culture and sensitivity, routine Blood cultures, stat Vital signs Q8Hrs Regular diet Bed rest with bathroom privileges

Here are the results: CBC: Hb: 14mg%, WBC: 17,000/cmm with 6% bands.

BMP: Na: 135meq, K: 4.0 meq, HCO3: 24meq, Cl: 100meq, BUN: 16 mg/dL, S.Creatinine: 0.8mg/dl, Blood sugar: 100 mg/dL. Urine analysis: Urine appearance cloudy/yellow pH 6 (Normal 4.1-8) Specific gravity 1.026(Normal 1.003-1.030) Bilirubin Negative Ketones Negative Glucose Negative Blood Negative RBC Negative Casts None Esterase Positive Nitrite Positive Proteins Trace Bacteria Too numerous to count WBC 50+

Urine for gram staining shows Gram-negative bacilli Urine C/S results pending Blood cultures pending

Order: Ampicillin, IV, continuous*1-2 days until patient is afebrile Gentamycin, IV, continuous*1-2 days until patient is afebrile NS at 100 cc/hour, continuous Acetaminophen, PO, continuous Promethazine, IV, PRN for vomiting

Click call me if needed; advance the clock for 8 hours

Obtain brief history, and do focused physical exam; check his vital signs. If everything is ok advance the clock for 16 hours; again obtain brief history, and do focused physical exam; check his vital signs.

Order: Once patient is afebrile, D/C IV medications (Double click on the medication and choose delete) Order CBC with diff and urine analysis after 24hours of treatment. Tab Ciprofloxacin, PO, Continuous. D/C IV fluids and Promethazine

Results: Blood cultures after 24 hours shows no growth Urine culture is growing >100,000 colonies of Lactose fermenting gram-negative rods. Sensitivities are pending (It takes 2 days).

Counseling: Patient education Regular diet Medication compliance Safe sex practice Seat belt while driving

Discharge the patient (change location to home) once afebrile and fix an appointment to see in 7 days.

Order the following with next appointment: Brief history Focused physical examination

Available lab results: Urine C/S reveals E. coli, sensitive to ampicillin, cefazolin, gentamycin, azithromycin and ciprofloxacin.

Order: Urine analysis, stat Change antibiotic depending on C/S results*4 weeks

Primary diagnosis Acute bacterial prostatitis

Discussion: Annually 2 million cases of prostatitis cases are documented in USA. Prostatitis occurs in young and middle aged men. The common forms of presentation are acute bacterial, chronic bacterial and chronic abacterial prostatitis, the common being acute bacterial prostatitis.

The most common organism is E. coli. Pseudomonas may be the causative organism in case of diabetics; chlamydia and gonorrhea is common in high-risk patients such as patients with multiple sexual partners who don’t practice safe sex. The organisms ascend up to prostate through urethra precipitated by trauma, dehydration and bladder catheterization. The common presenting symptoms are faver, malaise, irritating voiding symptoms, supra pubic and perineal pain or discomfort. There may be obstructive symptoms because of edematous prostate in which ‘suprapubic’ drainage may be necessary to drain the bladder, avoiding bladder catheterization through urethra, which predisposes to bacteremia. Most of the time it is confused and treated as cystitis. The striking examination finding will be tender diffusely enlarged boggy prostate on DRE, which is done by gentle fashion avoiding prostatic message, as it will be painful and also to avoid bacteremia. Urinanalysis is always the first step along with Gram stain of urine to guide the antibiotic therapy. Positive urine/blood cultures and leukocytosis support the diagnosis. PSA may be elevated but is not diagnostic and if elevated, should be repeated after infection resolves; if remains elevated biopsy should be done to rule out malignancy.

Patients with sepsis like picture (altered mental status, hypotension) and who cannot take oral antibiotics secondary to nausea and vomiting should be aggressively treated with IV antibiotics, IV fluids and if needed vasopressors. The most cost affective regimen will be IV ampicillin and gentamycin (get BUN and Creatinine before you start Gentamycin) empirically before the culture results available. Once patient is afebrile, oral antibiotics can be used. Either Bactrim (TMP+SMX) or ciprofloxacin are the oral antibiotics of choice. Once the culture results are available patient should be maintained on appropriate antibiotics for 4 weeks to prevent complications such as prostatic abscess or septicemia. Patient should be seen on regular visits with urine analysis. If treated appropriately chances of acute prostatitis going for chronic form and abscess is rare.

Measles

Meningococcal Infections

Rocky Mountain Spotted Fever

Systemic Lupus Erythematosus peptic ulcer disease (stomach or duodenum), gastric erosions and esophageal varices. The less common ones include Mallory Weiss tear (suspect in an alcoholic, with severe retching and vomiting), neoplasm, esophagitis, and arterio-venous malformations. This patient with his history of pain that is relieved with food and use of ibuprofen is certainly a candidate for duodenal ulcer. Other risk factors include smoking and alcohol use.

Management: Hemodynamic stabilization is more important before an EGD.

7. All patients with UGI bleeding should have two large bore (18 G or larger) peripheral IV lines.

8. Patient should be resuscitated with blood transfusions to keep a hematocrit greater than 30%. If coagulopathy is present, transfusion with FFP and administration of Vitamin K is needed to keep the INR below 1.5. Platelet transfusions may be needed for platelet counts of less than 50,000/ mm3. Calcium levels should be monitored as multiple transfusions may lead to hypocalcimia requiring specific therapy.

9. Once the patient is stabilized the investigation of choice is an EGD that offers diagnostic and therapeutic options. This patient had a duodenal ulcer, which is the most common cause of UGI bleed. The endoscopic appearance of the ulcer predicts the risk of rebleeding and mortality. Since this patient had a clean based ulcer that carries a very little risk of rebleeding, he could resume a normal diet and be discharged within 24 hrs, as his hemoglobin was stable. Flat spots or adherent clots on EGD need observation on a general floor for 2 to 3 days. Patients with visible vessels or actively bleeding ulcers can be treated with local epinephrine injections. These lesions are associated with the highest risk for rebleeding and such patients need to be monitored in the ICU after the EGD. They should be discharged only after 3 days of stabilization. If during this period of observation rebleeding occurs then a repeat urgent EGD is needed. Such patients might need surgery if recurrent bleeding continues to occur after two endoscopic treatment attempts.

10. IV proton pump inhibitors (PPI) have been shown to reduce recurrent bleeding after endoscopic management of bleeding ulcers and may be continued for 72 hrs after EGD. At the time of discharge the patient should be put on an oral PPI for 4-8 weeks. Repeat EGD on an outpatient basis should be performed in patients with gastric ulcer to ensure healing and exclude underline malignancy. However, repeat EGD is unnecessary in patients with duodenal ulcers.

11. If the biopsy is positive for H.pylori, the patient should receive triple drug therapy for eradication of the organism. NSAIDs, smoking and alcohol need to be stopped to promote healing and prevent recurrence.

12. In patients with known cirrhosis and portal hypertension the most likely source of bleeding is esophagogastric varices. Once these patients are hemodynamically stabilized, octreotide should be started. Besides EGD is performed and sclerotherapy and band ligation of the varices can be done to stop bleeding. If octreotide and EGD intervention do not stop bleeding then a balloon tamponade (for e.g. with a Sengstaken-Blakemore or Minnesota tube) should be instituted and transjugular intrahepatic portosystemic shunt (TIPS) should be attempted to decrease portal pressure. The TIPS procedure has replaced surgery because of the significantly lower mortality rate. Once the patient has stopped active bleeding he can be discharged on a nonselective beta blocker (for e.g. nadolol or propranolol).

Final Diagnosis: Upper gastrointestinal hemorrhage, secondary to duodenal ulcer

Case 73[edit]

Location: Emergency Room Vitals: BP: 104/70 mm Hg (supine), 80/50 mm Hg (sitting); HR: 120/min; RR: 24/min; Temp: 98.4F C.C: Bright red blood per rectum
History of present illness: A 65 years old white female is brought to the ER with a one day history of passing bright red blood with bowel movements. She has had three episodes with moderate amount of fresh blood mixed with stools, with no anal pain. Her stools are soft in consistency and there is no history of fissures or hemorrhoids in the past. She felt weak and light headed. There was no history of nausea, vomiting or abdominal pain. She denied any hematemesis, melena, diarrhea, constipation, jaundice or weight loss. Her past medical history is significant for type II diabetes mellitus, hypertension and hyperlipidemia. She has never had a colonoscopy in the past. She has no allergies. Her medications include glyburide, simvastatin and lisinopril. The patient does not smoke or consume alcohol. Her mother died of colon cancer at the age of 60 years. Rest of the review of systems is unremarkable.

How would you approach this patient? This is a patient with hematochezia, who is hemodynamically unstable as is obvious from the hypotension, orthostasis and tachycardia. The initial approach should be to take the general resuscitative measures, a delay in which might be life threatening. Simultaneously, think of a differential diagnosis and order the relevant tests to rule in and rule out the disease process and its etiology. Remember you always need a thorough focused physical examination before establishing a diagnosis.

Order No. 1: Intravenous access, stat - 2 large (18 G) IV bore needles Start IV fluids: Normal Saline, bolus Make NPO Continuous BP, HR monitoring Pulse oximetry, stat Results for Order No. 1: BP - 100/70 mm Hg; HR- 124/min Oxygen Saturation is 97% on room air Order physical exam: General appearance HEENT/Neck Examination of CVS Examination of lungs Examination of Abdomen Examination of Rectum FOBT (not required if u see a fresh bleeding) Extremities Skin Results of Physical Examination: General appearance: Pale looking, anxious female. HEENT: Pale conjunctiva, anicteric sclera, dry mucous membranes; no JVD. No palpable lymph nodes. Lungs are clear to auscultation and percussion bilaterally. Cardiovascular: Tachycardic, S1 S2 normal, no murmurs, rub or gallop. Abdomen is soft, non tender, no rigidity, rebound or guarding; bowel sounds are normal, no organomegaly or free fluid. Rectal: Normal sphincter tone, no hemorrhoids or fissures, blood in rectum. Extremities: no edema, clubbing or cyanosis, no calf tenderness, peripheral pulses feeble. Rest of the exam is unremarkable.

Order No.2 CBC with differential, stat BMP, stat Liver function tests (LFT), stat PT/aPTT, stat EKG, 12 lead, stat Blood Typing and Cross-match - in preparation for transfusion Nasogastric tube placement and aspiration Anoscopy, stat Discontinue her glyburide, simvastatin and lisinopril

Results for Order No. 2: BP - 100/70 mm Hg; HR- 124/min CBC: Hgb -7.5 g/dl, Hct- 22.5 %, WBC - 12,000/ uL, Platelet - 450,000/mm3, normal differential count BMP: BUN - 25, Creatinine -1.0, Sodium -135 meq/L, Potassium - 3.7 meq/L, Chloride -104 meq/L, Bicarbonate - 25 meq/L LFT: Total bilirubin - 1.0 mg %, Direct bilirubin – 0.4 mg %, ALT - 31 IU/L, AST - 30 IU/L, Alkaline phosphatase - 110 IU/L PT=17 sec, INR=1.60; aPTT=39 sec, control=35 sec EKG shows sinus tachycardia without evidence of ischemia or infarction Nasogastric aspirate – bilious with no blood Anoscopy - no anal fissures; no external or internal hemorrhoids; no ulcerations in distal part of rectum

Order No. 3: Continue NPO Stop IV NS Start packed RBC transfusion - 3 Units 4 Units fresh frozen plasma (FFP) H and H every 6 hours PT after FFP transfusion Continuous BP monitoring Discontinue NG tube Complete bed rest Apply pneumatic compressions for DVT prophylaxis Accuchecks every 6 hours (use regular insulin as needed, based on blood sugar levels) Admit in ICU Examine the patient 6 hours later: order interim history and focused physical exam (make sure you listen lungs as they may develop fluid overload with all the IV infusions).

Results for Order No. 3: BP – 110/70 mm; HR- 100/min After 3 Units of PRBC and 4 Units FFP Hgb-10.5 g/dl; Hct-30% PT=14.5 sec, INR=1.45 Patient feels better; exam looks fine

Order No. 4: Gastroenterology consult for colonoscopy (Reason: 65 yr old with Hematochezia, no prior Colonoscopy; Please evaluate for the source of bleeding). Continue NPO Restart IV NS, continuous (if the lungs are clear) H and H every 6 hours Start bowel preparation for colonoscopy - 4 liters of polyethylene glycol (Golytely, Colyte) given over two hours Continuous BP monitoring Call me when the lab results available

Results for Order No. 4: Colonoscopy - Multiple diverticuli in sigmoid and descending colon. Biopsy taken Hgb-10.2 g/dl; Hct- 30.6 % BP - 120/80; HR- 90/min Order No. 5 Discontinue NPO Stop IV NS Start clears and advances to high fiber diet as tolerated H and H every 6 hours Continue BP monitoring Results of order No. 5: Patient is tolerating low roughage diet Hgb-10.0 g/dl; Hct- 30.0 % BP - 128/80; HR- 74/min Biopsy is positive for diverticulosis, no inflammation or ulceration; no malignant cells Order No.6 Discharge the patient home after overnight watch High fiber diet Restart her home medications D/C DVT prophylaxis Avoid nuts and fruits with seeds (No option in software) Follow up appointment in one week with repeat Hgb and hematocrit.

Discussion: Differential Diagnosis: LGI bleed by definition is bleeding distal to the ligament of Treitz. Most patients with bright red blood per rectum or hematochezia have a LGI bleed, but about 10% are the result of a brisk UGI bleed. Thus patients with hematochezia should have a nasogastric tube lavage to exclude an upper gastrointestinal hemorrhage. An EGD instead of the usual colonoscopy may be needed to establish the cause of hematochezia in case the nasogastric aspirate shows blood.

The most common causes are diverticulosis, angiodysplasia, polyps and colon cancer in a patient above 65 years. All these conditions are painless, except colon cancer, which sometimes may be associated with abdominal pain. This patient is at a high risk of colon cancer because of a positive family history. Another important cause to consider in this patient is ischemic colitis since she has multiple risk factors for vascular disease. However, ischemic colitis is most often associated with abdominal pain. Also remember, that diverticular bleed usually do not occur in the presence of diverticulitis. Other less common causes include inflammatory bowel disease (ulcerative colitis, crohn’s disease), vasculitis (Polyarteritis nodosa, Wegner’s granulomatosis), radiation colitis, and infectious colitis (Ecoli, salmonella, CMV).

Management: 1. Hemodynamic stabilization is more important before a colonoscopy. Hemodynamically unstable patients should be admitted in the intensive care unit. Presence of shock, orthostatic hypotension, a 6% drop in hematocrit or blood transfusion requirement of two or more units suggests hemodynamic instability.

2. All patients with GI bleeding should have two large bore (18 G or larger) peripheral IV lines.

3. Patient should be resuscitated with blood transfusions to keep a hematocrit greater than 30%. If coagulopathy is present, transfusion with FFP and administration of Vitamin K is needed to keep the INR below 1.5. Platelet transfusions may be needed for platelet counts of less than 50,000/ mm3.

4. Calcium levels should be monitored as multiple transfusions may lead to hypocalcimia requiring specific therapy.

5. Nasogastric tube lavage should be done. If it shows no blood or has copious bile then the investigation of choice once the patient is stabilized, is colonoscopy. Colonoscopy can localize the site of bleeding, allow tissue biopsies and therapeutic interventions like injection sclerotherapy and electrocautery. However, a good bowel preparation is needed for good visualization of the colon. If nasogastric aspirate shows blood then an EGD is recommended as the initial investigation of choice. If EGD is negative, then go ahead with colonoscopy.

What if the colonoscopy is normal but the patient continues to have hematochezia? Order a tagged red blood cell scan (radionuclide imaging study) — Radionuclide scanning is a highly sensitive technique that can detect bleeding occurring at a rate of 0.1 to 0.5 mL/minute. However, it cannot localize the site of bleeding and requires presence of active bleeding at the time of the test. If the tagged RBC scan is positive, one must proceed with angiography.

Angiography detects blood loss as low as 0.5 mL/minute. The procedure is 100 percent specific and is performed to accurately localize the site of bleeding, especially if surgical management is needed. It also permits control of bleeding using vasopressin infusion or embolization via the catheter. However, it is an invasive procedure and needs to be performed during active bleeding.

*Remember that angiography is reserved for patients in whom colonoscopy cannot localize the site of bleeding or is not feasible.

When should I get surgery consult? A surgical consultation is needed for continued severe bleeding with high transfusion requirements. A blind surgery performed without localizing the site of bleeding carries a higher risk of rebleeding. Hence, if feasible a tagged RBC scan and angiography should be done before proceeding for surgery. Final Diagnosis: Lower gastrointestinal hemorrhage, secondary to diverticulosis.

Case 74[edit]

Location: Emergency Room Vitals: BP: 80/50 mm Hg; HR: 40/min; RR: 24/min; Temp: 98.4F C.C: Lightheadedness
History of present illness: A 55 years old male victim of a motor vehicle accident is brought to the ER by ambulance. He was a unrestrained driver of a car that hit a tree due to poor visibility on that foggy night. The patient complains of mild generalized body ache, severe chest pain and lightheadedness. He remembered his chest having struck against the steering wheel. However, there was no history of head injury, headache or loss of consciousness. He did not complain of respiratory distress. The patient was feeling uncomfortable with the Miami-J collar put by the EMS team around his neck at the site of the accident. He has no allergies and denied being on any medication. Rest of the review of systems is unremarkable.

How would you approach this patient? This is a victim of motor vehicle accident, who is hemodynamically unstable as is obvious from the hypotension and bradycardia. The initial approach should be to take the general resuscitative measures, a delay in which might be life threatening. Simultaneously, think of reasons for hypotension and bradycardia in an accident victim and order the relevant tests. Remember you always need a thorough physical examination to rule out serious injuries and decide which body parts to image.

Order No. 1: Intravenous access, stat- 2 large (18 G) IV bore needles Start IV fluids: Normal Saline, bolus Continuous BP, HR monitoring Pulse oximetry, stat Results for order No 1: BP- 80/50 mm Hg; HR- 34/min Oxygen Saturation is 95% on room air Order examination: General Heart Lungs Results of the exam: General appearance: Well-built, white male, in severe pain, holding on to his chest with his right hand. Lungs are clear to auscultation and percussion bilaterally; Cardiovascular – Bradycardia, variable intensity of S1 and S2; no murmurs, rub or gallop.

Order No 2: EKG, 12 lead, stat Chest-X ray, PA portable X-ray cervical spine, stat IV Fentanyl or Ketorolac, bolus Results of Order No 2: EKG shows complete heart block, ventricular escape rhythm with a rate of 40/min, QRS duration of 140 msec. No evidence of ischemia or injury except nonspecific ST/T changes.

Chest X-Ray: Fracture of the left 3rd and 4th ribs. No pneumothorax or effusion. Heart and mediastinum are normal in size and configuration. X-ray cervical spine: Normal

Order No 3: Atropine 0.5 mg IV stat Put patient on transcutaneous pacemaker Consult Cardiology, stat (for transvenous pacemaker placement) Consult Orthopedics, stat (to rule out cervical spine injury and get rid of Miami-J collar) Make NPO CBC with differential, stat BMP, stat PT/aPTT, stat Results of Order No 3: CBC: Hgb -13.0 g/dl, Hct - 39% WBC – 9,200/uL, Platelet - 250,000/mm3, normal differential count BMP: BUN - 19, Creatinine-1.1, Sodium -138 meq/L, Potassium - 3.8 meq/L, Chloride -103 meq/L, and bicarbonate - 26 meq/L. PT=13 sec, INR=1.23; APTT=33 sec; control=35 sec

Order No 4: Check the BP and HR Result of Order No 4: Transcutaneous pacemaker paces at rate of 80/min, BP-90/60 Patient’s lightheadedness and chest pain is better Order examination of: HEENT/Neck Abdomen Extremities Skin CNS Results of Physical Examination: HEENT: Normocephalic, atraumatic, PERLA, EOMI, pink conjunctiva, anicteric sclera, moist mucous membranes, no ear or nose bleed; Neck- Miami J collar on; Abdomen is soft, no tenderness, rigidity, rebound or guarding; bowel sounds are normal, no organomegaly or free fluid. Extremities - no edema, clubbing or cyanosis, no calf tenderness, peripheral pulses feeble. Neurological exam-awake, alert oriented, moves all four limbs with no focal neurological deficits.

Order No. 5: Continuous HR and BP monitoring Continue NPO Continue NS CK and MB, stat Troponin T, stat Echocardiogram, stat Results for Order No. 5: CK- 500; MB-11 Troponin T- 0.500 Echocardiogram: EF=55 - 60, no wall motion abnormalities, all valves are normal, no pericardial effusion Cardiologist takes the patient to the cardiac cath lab for a temporary transvenous pacemaker insertion.

If case continues further, may need permanent pacemaker insertion.

Discussion: The most important cause of hypotension in a trauma victim is hemorrhage. The first step in management would be to start IV fluids and send a CBC to look for the amount of blood loss. If there is no overt bleeding one must look for an occult collection in the chest and abdomen, for which you need to do imaging studies. Normally, patients develop tachycardia in response to hypotension secondary to hypovolemia. The bradycardia accompanying the hypotension and the normal hemoglobin in this patient should make you suspicious of an etiology other than bleeding.

The EKG confirms the diagnosis of complete heart block (CHB). CHB is a third degree AV block the diagnosis of which is made by AV dissociation with a slow ventricular escape rhythm of around 40 beats/min. The atria may be in sinus rhythm or in fibrillation but the ‘P’ waves do not bear any relationship with the QRS complexes. However, it is also important to establish the etiology of CHB since it aids in the further management. The most important causes are fibrosis or degeneration of the conduction system and ischemic heart disease. The others include drugs (beta blockers, calcium channel blockers, digitalis, amiodarone), metabolic abnormalities (hyperkalemia), valvular heart disease, and cardiomyopathy (amyloid, sarcoid, hypertrophic cardiomyopathy).

Remember, trauma is an uncommon cause of CHB. Absence of ST-T changes suggestive of ischemia in EKG and no wall motion abnormalities excluded the possibility of acute coronary syndrome. The elevated CK, MB and Troponin T were probably secondary to myocardial contusion. The patients was not on any heart rate lowering drugs, his electrolytes were normal and Echo further ruled out any valvular abnormalities, cardiomyopathy or pericardial effusion.

The only modality of treatment for complete heart block is pacing. Atropine is only of little benefit and may sometimes transiently improve the heart rate and the blood pressure. These days the life packs are equipped with pads for transcutaneos pacing. But these should be used only as a bridge for the transvenous pacing. The transvenous pacing may be a temporary pacing to begin with. In this patient, if the CHB persists for the next couple of days, a permanent pacemaker can be placed.

Patients with second-degree atrioventricular blocks who are asymptomatic and hemodynamically stable may be managed without a pacemaker. However, a complete heart block even in the absence of symptoms warrants a pacemaker, since you are not sure when the patient may become unstable.

Another important thing is to avoid medications that would cause bradycardia and hypotension. This patient has rib fracture and a lot of chest pain. Use of morphine may worsen his hemodynamic parameters. So, ketorolac or fentanyl would be better options for pain control in these patients.

Final Diagnosis: Motor vehicle accident with complete heart block (secondary to myocardial contusion)

Case 75[edit]

Location: Emergency Room Vitals: BP: 100/60 mm Hg; HR: 104/min; RR: 30/min; Temp: 100.4F C.C: Generalized bodyache and weakness
History of present illness: A 80 years old white male is brought to the ER by his son. His son found him lying in the woods on a hot sunny day. It seemed that the patient had gone for a stroll last evening and fell down. He was unable to get up, shouted for help but could not get any. He had been lying on the ground for the last 24 hours till his son found him. The patient complained of severe bodyache. He felt very weak and was thirsty. He denied having lost consciousness. He did not pass urine for the past 24 hours. There was no history of head injury or seizures. He has no allergies and is not taking any medications. The patient does not smoke and denies any alcohol use. Family history is non-contributory. Rest of the review of systems is unremarkable.

How would you approach this patient? This is an 80 years old man who had a fall and had been lying on the ground for more than 24 hours on a hot sunny day with no help. He is hemodynamically stable. The generalized bodyache is a hint towards possible muscle injury and should be a guide for ordering further diagnostic tests. Remember you always need a thorough physical examination to rule out serious injuries and decide which body parts to image.

'Order' No. 1: Intravenous access, stat Pulse oximetry, stat Results for order No 1: Oxygen Saturation is 95% on room air

'Order' examination: Complete Results of the exam: General appearance: Well-built, in dirt laden clothes, appears extremely dry and weak. HEENT-normal; Neck- no JVD; Respiratory - Clear to auscultation bilaterally; Cardiovascular- Tachycardia, S1 S2 normal, no murmur, rub or gallop; Abdomen-soft, non-distended, non-tender, normal bowel sounds, no organomegaly; Extremities- no edema, clubbing or cyanosis, no calf tenderness, peripheral pulses feeble; Neurological- awake, alert, oriented, no focal neurological deficit

'Order' No 2: Start IV fluids: Normal saline, bolus Insert Foley’s catheter, stat CBC with differential, stat BMP, stat EKG, 12 lead, stat Urinanalysis Results for order No 2: The nurse reports that the patient could give her only 5 cc of dark brown urine CBC: Hgb -13.0 g/dl, Hct - 39% WBC – 13,200/uL, Platelet - 250,000/mm3, normal differential count BMP: BUN – 45mg%, Creatinine-2.6 mg%, Sodium -134 meq/L, Potassium – 5.5 meq/L, Chloride - 92 meq/L, and bicarbonate - 17 meq/L. Calcium- 8.0 mg% EKG shows sinus tachycardia Urine dipstick- positive for blood; Urine microscopic- no RBC, no WBC, reddish-gold pigmented casts

'Order' No 3: CPK, stat Ionized calcium, stat Serum magnesium, stat Serum phosphorus, stat Serum uric acid, stat Urine myoglobin, stat PT/INR, stat APTT, stat Admit in floor Vitals Q 2 hours Urine output, hourly Activity as tolerated IV NS, continuous Results of Order No 3: CPK- 10,500 IU/L 10 cc urine in Urobag Ionized calcium- 0.99 mmol/L Serum magnesium- 1.8 meq/L Serum phosphorus-5.5 mg/dl Serum uric acid- 8.5 mg/dl Urine myoglobin- positive PT- 14.2 sec, INR-1.40; APTT-35 sec Order No 4: Inform in 4 hours Result of

'Order' No 4: BP-110/80 mmHg, HR-104/min Urine output- 75 ml/hr Order No. 5: Stop 0.9% Saline Start 0.45% Saline (with mannitol and Soda bicarbonate added to it) Monitor urine pH every 1 hour Titrate the mannitol - bicarbonate drip for urine pH> 6.5 and Urine output of >300 mL/hr Check CPK in 4 Hours Check BMP in 4 Hours Check Magnesium and phosphorus in 4 Hours Result of

'Order' No 5: CPK- 9000 IU/L BMP: BUN-38mg%, Creatinine-2.1 mg%, Sodium -138 meq/L, Potassium –5.0 meq/L, Chloride -101 meq/L, and bicarbonate - 21 meq/L. Calcium- 8.2 mg% Serum Magnesium- 1.4 meq/L Serum Phosphorus- 5.0 mg/dl BP-130/80 mm Hg; HR-96/min Urine pH-7.2 Urine output- 1300 cc in last 4 hours Nurse says that the patient is feeling better

'Order' No. 6: Stop mannitol-bicabonate diuresis Start 0.45% saline, continuous Check BMP, every six hours Check serum magnesium every 6 hours Check serum phosphorus every 6 hours Check CPK, every 12 hours

Discussion

This is a case of rhabdomyolysis. Prolonged immobilization and compression of muscles lead to ischemic muscle damage. The hot climate and dehydration contributed to the myoglobin induced acute tubular necrosis. This resulted in acute renal failure with anion gap metabolic acidosis and the electrolyte abnormalities seen with rhabdomyolysis.

Rhabdomyolysis is a syndrome resulting from skeletal muscle injury with release of myoglobin and creatine phosphokinase (CPK) into the plasma. The myoglobinuria, acid urine pH and renal hypoperfusion resulting from hypovolemia leads to precipitation of heme proteins and acute tubular necrosis.

Etiology: 1. Traumatic causes: Crush syndrome, burns, electrocution, 2. Non-traumatic causes: • Muscle hyperactivity- strenuous physical exercise, seizures, delirium tremens • Muscle compression- prolonged immobilization, coma • Muscle ischemia- acute arterial occlusion • Malignant hyperthermia, neuroleptic malignant syndrome, hypothermia • Infections- Viral including HIV, bacterial, etc.

• Drugs - alcohol, heroin, cocaine, amphetamines, zidovudine, statins • Metabolic disorders- hypocalcaemia, hypokalemia, hypophosphatemia, hypothyroidism, hyperthyroidism, diabetic ketoacidosis • Metabolic myopathies- e.g. Carnitine palmitoyltransferase deficiency. These should be suspected in patients with recurrent episodes of rhabdomyolysis after exertion.

• Others- carbon monoxide, snake bite Remember that inflammatory myopathies like polymyositis and dermatomyositis very rarely give rise to rhabdomyolysis and acute renal failure. Diagnosis: The most common complaint is muscular pain, which is very non-specific. Moreover, a comatose patient will not complain. Dark brown urine may be the only visible sign. Suspect rhabdomyolysis in a patient with renal failure, who has blood present on urine dipstick but no RBC on microscopic examination. This is because the myoglobin in the urine causes the urine dipstick to be falsely positive for blood. Plasma creatinine concentration rises more rapidly with rhabdomyolysis (up to 2.5 mg/dL per day) than with other causes of acute renal failure. In contrast to other forms of acute tubular necrosis, FENa is less than 1 percent.

The diagnosis of rhabdomyolysis is made by measurement of CPK. It begins to raise 2 to 12 hrs after the injury and reaches its peak value 1 to 3 days after injury. The peak may range from several hundred IU/L to over 200,000 IU/L in a full blown crush syndrome. Therefore, CPK should be measured daily for at least 3 days to follow extent of muscle damage. If the serum CPK remains elevated despite treatment, ongoing muscle injury, necrosis and/or compartment syndrome should be sought.

Myoglobin is also released from the injured muscle. It increases before CPK and decreases more rapidly owing to its clearance by kidneys and metabolism to bilirubin. Therefore, remember that a normal serum myoglobin and absence of myoglobinuria does not exclude the diagnosis of rhabdomyolysis.

Various electrolyte abnormalities result from rhabdomyolysis. These can be better understood by grouping them into two categories 3. Influx from Extracellular compartment into muscle cells- water, sodium, chloride (hypovolemic shock), calcium(hypocalcemia) 4. Efflux from injured muscle cells- potassium(hyperkalemia), purines (hyperuricemia), phosphate (hyperphosphatemia), lactic acid (metabolic acidosis), myoglobin(myoglobinuria, nephrotoxicity), thromboplastin (DIC), creatine kinase, creatinine (increased serum creatinine–to-urea ratio)

Management: 3. Fluid replacement is the mainstay of therapy. Use normal saline and initiate at 1.5 L/hr. The aim is to wash off the myoglobin from the renal tubules, establish a good urine output and prevent or limit acute tubular necrosis. While on one hand many electrolyte abnormalities can precipitate rhabdomyolysis, the syndrome itself can lead to various metabolic derangements. Hence one needs to monitor the BMP and electrolytes very closely for the initial 2 days.

4. Forced alkaline diuresis using mannitol and bicarbonate is recommended by some. Alkalinization of urine prevents precipitation of myoglobin in the tubules. However, this should be used once the BP is stable and a urine output is established using isotonic saline.

One has to be careful during such large volume fluid replacement as there is always a risk of fluid overload.

Final Diagnosis: Rhabdomyolysis due to prolonged immobilization

Case 76[edit]

Location: Office Presenting complaint: A 24-year-old married female presents with nausea and vomiting Vitals: Pulse:82/min, Temp:98.6 F,R.R:15/min, B.P:130/70 mm Hg,Height:162cm, Weight:62 kg (136.4lbs)
History of present illness: A 24-year-old Asian female presents with complaints of nausea and vomiting for the last several days. She feels more nauseated in the morning and also complains of breast pain. Her last menstrual period was 7 weeks ago and before that her menstrual periods have always been regular with a 28-29 day cycle. She was married 8 months ago, is sexually active with her husband, and has never been pregnant. The patient denies abdominal pain, fever or vaginal discharge. She has been a one pack per day smoker since her teenage years. She is not on any medications, does not drink or use recreational drugs. The patient migrated to the United States 5 years ago and does not recall her vaccination history. There is no history of sexually transmitted disease, but she has never been tested for STDs. Recently, she has been experiencing some constipation, other wise her bowel and bladder functions are regular. She is doing well at her office where she works as a secretary and has no emotional stresses. Review Of Systems are unremarkable.

Hospitalization/Procedures Never Other Medical Problems None Allergies None Current Medications None Vaccinations See HPI Family HistoryFather is healthy at 55; mother is healthy at 45. Maternal grandmother died of breast cancer at 60. She has one older sister who is healthy.

Social history See HPI Recreational history Attending social events and watching movies

How to approach this case? This young sexually active female has presented with nausea, vomiting and amenorrhea, which are most likely due to pregnancy. Therefore do complete physical examination, which should include abdominal, breast and genital examination to look for signs of pregnancy and order a pregnancy test. Here are the results: Breast examination: Mild breast tenderness bilaterally.

Abdominal examination: Normal Pelvic examination: Bluish discoloration of vulva and vagina present; no vaginal discharge; no vaginal or cervical lesions, uterus is globular and soft; no adnexal masses or adnexal tenderness noted.

Rest of the examination is within normal limits. Labs: Urinary beta-HCG, routine The "gold standard" for diagnosis of pregnancy is the detection of the beta subunit of human chorionic gonadotropin (hCG) by immunologic techniques in blood or urine. When performed in a clinical laboratory, the sensitivity and specificity for both blood and urine pregnancy tests are between 97 and 100 percent. Results: Urinary beta-HCG: positive

Discussion: There are many signs of pregnancy, which can be grouped into presumptive, probable and positive categories. Presumptive signs are associated with skin and mucous membrane changes. The dark discoloration of vulva and vagina noted in this woman is called Chadwick’s sign. Probable signs are associated with changes in uterus. Globular shape and softer consistency of uterus is one of the probable signs. Positive signs of pregnancy are the detection of fetal heart sounds and the recognition of fetal movements. Doppler techniques enable us to detect fetal heart sounds as early as 9 weeks of gestation while the stethoscope can detect at 16 weeks. Recognition of fetal movements by an observer is possible at 20-24 weeks.

Positive pregnancy testing coupled with findings on history and examination is suggestive of pregnancy. Next, confirm her pregnancy by ultrasound and start antenatal care. Ultrasound will also help us determine gestational age.

A standard panel of laboratory tests should be obtained on every pregnant woman at the first prenatal visit. Additional testing of women at risk for specific conditions can augment this panel. The initial laboratory tests recommended by the American College of Obstetricians and Gynecologists are Blood type Antibody screen Rhesus type CBC with differential Basic metabolic panel Pap smear Rubella status Syphilis screen Urinary infection screen Hepatitis B surface antigen HIV counseling and testing Chlamydia Additional laboratory tests commonly performed in at-risk individuals include: Gonorrhea Tuberculosis Red cell indices to screen for thalassemia Hemoglobin electrophoresis to detect hemoglobinopathies (e.g. sickle cell, thalassemias) Hexosaminidase A Cystic fibrosis carrier testing Serum phenylalanine level Toxoplasmosis screen Hepatitis C antibodies The first prenatal visit is a good time to discuss the patient's responsibilities and the expected course of pregnancy and delivery. Patients should be given information regarding the general plan of management for the pregnancy.

Number and frequency of prenatal visits Recommendations for nutrition, weight gain, regular exercise (limited), rest, and sexual activity Routine pregnancy monitoring Listeria precautions Toxoplasmosis precautions Abstinence from alcohol, cigarettes, and illicit drugs Information on the safety of commonly used nonprescription drugs Recommendation to continue wearing seat belts during pregnancy Potential problems related to plans for travel, work outside of the home, or hobbies Childbirth classes and breastfeeding recommendations Confidentiality issues Therefore, we will do order the following in this patient Order Routine: Blood type and antibody screen Atypical antibody titer CBC with differential Basic metabolic panel Pap smear Rubella antibodies RPR Urinalysis Urine culture and sensitivity Hepatitis B surface antigen, serum Anti-HIV by ELISA, serum Transvaginal ultrasound Chlamydia, culture cervix

Medications: Vitamin, prenatal, oral Iron sulfate, oral Folic acid, oral (0.4 mg) High calorie diet Regular moderate exercise Patient education Smoking cessation Safety plan Safe sex No illegal drug use No alcohol Drive with seat belt Follow up in 4 weeks U/A and Urine culture are very important because 5-10 % of pregnant patients may have asymptomatic bacteriuria and untreated patients may develop pyelonephritis.

Follow up visits: Every 4 weeks until 28 weeks Every 2 weeks between 28 to 36 weeks Every week between 36 to delivery Follow up visits: Complete physical examination Wt. Measurement Vitals especially BP Complete urinalysis Fundal measurement Fetal heart rate (110—160/min=N) measurement Glucose screening: In the United States all pregnant women will get 50 gm 1 hr glucose tolerance test between 24-28 wks gestational age. Results >135 is abnormal. If the patient has risk factors, she should be screened at 1st prenatal visit.

Indications for glucose screening on 1st prenatal visit: Age> 25 years Obesity Family History of DM Previous infant Wt > 400 gm Previous still born Previous congenitally deformed child Recurrent spontaneous abortions Advise from 2nd Trimester: Promotion of breastfeeding Childbirth classes Danger signs of pregnancy Preterm labor education

Primary Diagnosis: Pregnancy

Abbreviations[edit]

Partial list of medical abbreviations and acronyms

@ “At”
> “More than”
< “Less than”
/ Slash mark Never use with numbers
& And “And”
+ Plus or and “Plus” or “and”
˚ Hour (used next to an hour — 2˚) “hr” or “hour”
a ¯ Before
ABG Arterial blood gas
ac Before meals
ad lib As desired
AMT Amount
APAP ** Acetaminophen
ASA Aspirin
ASAP As soon as possible
BG Blood glucose
BID Twice (two times) a day
BP Blood pressure
BS Bowel sounds
c ¯ With
cc Cubic centimeters “ml”
CC chief complaint
C/O or c/o Complaint of
CBG Capillary blood glucose
CHF Congestive heart failure
COPD Chronic obstructive pulmonary disease
CP Chest pain/cerebral palsy
CVA Cerebrovascular accident (stroke)
D/C “Discontinue” or “discharge”
DM Diabetes mellitus
DOB Date of birth
ER Emergency or emergency room
F Female
Fx Fracture
FH family history
GI Gastrointestinal
H/A Headache
hs At bedtime (hour of sleep) “Bedtime”
Hx History
HPI History of present illness
HTN Hypertension
IU International unit “Units”
lb Pound
L Left
IM Intramuscular
IV Intravenous
M Male
mcg Microgram(s) – Don’t not use periods after each letter
mg Milligram – Do not use periods after each letter
ml Milliliter – Do not use periods after each letter
MI Myocardial infarction (heart attack)
MS Multiple sclerosis or morphine sulfate List full name of disease or use complete drug name
MSO4 Morphine sulfate Use complete drug name
NC Nasal cannula
NKDA No known allergies
NPO Nothing by mouth
N/V Nausea/vomiting
N/V/D Nausea/vomiting/diarrhea
O2 Oxygen
OT Occupational therapy
OTC Over-the-counter
oz Ounce
p¯ After
pc After meals
per By or through
PO or po By mouth or orally
PR pulse rate, or per rectal
PRN As necessary or needed
PT Physical therapy
q6pm Every evening at 6 PM but sometimes mistaken for every 6 hours (any hour that might be listed) “Daily at 6 PM” or “6 PM daily”
q1d Daily but mistaken for four times a day “Daily”
QD or qd Each day or daily “Daily”
QH or qh Every hour
qhs At bedtime “Nightly” or “bedtime”
QID or qid Four times a day
QOD Every other day “Every other day”
R Right
Rx Prescription medicine
s¯ Without
SL Sublingual
SOB Shortness of breath
SQ or sq Subcutaneous “Subcut” or “subcutaneous”
ss Sliding scale or ½ Spell out “sliding scale”;
one half or ½
Sx Symptom
TB Tuberculosis
TID or tid Three times a day
U Unit “Unit”
UA Urinalysis
URI Upper respiratory infection
UTI Urinary tract infection
V/S Vital signs
wt Weight
tab Tablet

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