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Case1

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Location: Office

Presenting complaint: A 25-year old white female presents with burning micturition.

Vitals: Pulse: 80/min, B.P: 130/80 mm Hg, Temp:990F, R.R:14/min, Height: 67 inches (167.5 cm), Weight: 79 Kg (173.8 lbs).

HPI: A 25-year-old personal secretary at a local office presents with the complaints of three days of burning micturition, urgency, and frequency. She had to pass urine 10 times yesterday. She also complains of suprapubic discomfort. There is no vaginal discharge, fever, hematuria, or flank pain. She has no previous history of STD or UTI. ROS is unremarkable. She has no known allergies. Medications: None. SH: She is a personal secretary at a local office. She has been married for five years and has no children. She has been smoking 10 cigarettes for the last seven years and drinks alcohol on weekends. She is sexually active in a monogamous relation with her husband. They have not been practicing contraception. Her last menstrual period was 3 weeks ago.

How do you approach this case?

This young female has dysuria. Her dysuria may be due to acute pyelonephritis, acute cystitis, acute pelvic inflammatory disease, acute urethritis, or acute cervicitis. You should come up with the differential diagnosis of a dysuria in a young woman. Now, perform a focused physical examination on this patient.

Order physical examination:

Abdominal Genital/Pelvic exam

Here are the findings:

Suprapubic tenderness present Normal Pelvic examination

No Urethral and vaginal discharge No costovertebral angle tenderness

Small discussion:

This is probably a straightforward case of acute cystitis. The patient has no systemic signs of infection. So, she probably does not have acute pyelonephritis. A patient with pyelonephritis usually presents with a history of fever, chills, and flank pain. For acute uncomplicated pyelonephritis, oral ciprofloxacin for out-patients or IV ceftriaxone for hospitalized patients is appropriate therapy. The duration of treatment is usually 14 days. This patient is in a monogamous relationship with her husband and there is no history of vaginal discharge, so conditions like acute urethritis, cervicitis or acute PID are highly unlikely. A single oral dose of azithromycin or a 7-day course of doxycycline can be administered for chlamydial

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genital tract infections. For gonococcal genital tract infections, a single IM injection of ceftriaxone is the treatment of choice. Begin therapy for acute cystitis after confirming the diagnosis of acute cystitis by demonstrating pyuria on urine analysis. Cultures are generally not required for acute uncomplicated cystitis. Treatment with 3-day TMP-SMZ is appropriate.

The most important part of this case is whether your order pregnancy test or not. This patient is not using contraception and her LMP was 3 weeks ago. She might be a pregnant from the past 5-7 days. So, order serum pregnancy test before prescribing antibiotics.

ORDERS:

UA, stat

Pregnancy test, qualitative, stat

RESULT:

Serum pregnancy test is positive

Urine appearance

Turbid/ yellow

pH

5.6 (normal 4.1-8.0)

Specific Gravity

1.016 (normal 1.003-1.030)

Bilirubin

Negative

Ketones

Negative

Glucose

Negative

Blood

Negative

Leukocyte Esterase

Positive

Nitrite

Positive

Protein

Negative

Microscopic Analysis:

Epithelial cells

-

2

Bacteria 20-30/hpf

RBC/WBC Casts

-

WBC 30-40/hpf

RBC 3/hpf

Crystals

-

Mucus

-

Review order:

Amoxicillin therapy, oral, continuous (for 7 days)

Follow-up for prenatal assessment

Prenatal vitamin, oral, continuous

Consider counseling about the following:

Smoking cessation

Limit alcohol

Regular exercise

Use of seat belt

Medication compliance

Patient counseling

Primary Diagnosis:

Uncomplicated acute cystitis and Pregnancy

Treatment of uncomplicated cystitis:

Normal healthy women  3 day TMP-SMZ

Diabetic women, symptoms for >7 days, recurrent UTI, >65 yrs age group  7 day TMP-SMZ

Pregnancy  7-day amoxicillin; if the patient is allergic to penicillin – 7-day nitrofurantoin

Case2

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Location: office

Presenting complaint: A 75-year-old white male presents with forgetfulness.

Vitals: Pulse:75/min, B.P:110/75, Temp:98.6 F, R.R:16/min, Height:72 inches (180 cm), Weight:65kg (143 lbs).

HPI:

A 75-year-old white male is brought to the outpatient clinic by his son with the complaint of forgetfulness for the last two years. He reports that his forgetfulness was mild initially but it has gradually worsened and now he cannot continue his routine activities of daily life. He has also developed paranoid features and accuses his son of mixing poison in his food. He eats and sleeps well, does not take any recreational drugs, smoke or drink alcohol. He has been sexually inactive since the death of his wife 15 years ago. There is no history of CAD or stroke. An older sister has a history of dementia. He has no known allergies. He takes docusate for constipation. FH: Father died of MI at 68 and mother died of breast cancer at 55. His rest of the ROS are unremarkable.

How to approach this case?

This patient has presented with progressive memory loss, which is most likely due to dementia. Complete physical examination to detect some occult/atypical medical illness should be performed. Neurological examination is of special consideration, which may help us detect focal neurologic deficits due to stroke; rigidity or tremors due to Parkinson’s disease. Patient with Alzheimer’s does not present with motor deficits.

Perform the physical examination:

Complete physical exam except breast exam.

Results of the physical examination:

General

The patient is alert but appears poorly groomed.

HEENT

Thyroid gland is normal, no other abnormality found.

Abdominal examination

WNL

Rectal examination

Normal sphincter tone and prostate; brown colored stools with no evidence of occult blood; no palpable masses.

Chest/lungs

WNL

CVS

WNL

Lymph node examination

No lymphadenopathy

Neuropsychiatric examination

On Mini-mental state examination he can’t spell ‘world’ backwards, calculate, copy designs, recall objects or follow 3-stage commands.

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Discussion:

The major dementia syndromes include Alzheimer’s disease, Parkinson’s and Lewy body dementia, vascular dementia, frontal lobe dementia, and reversible dementia.

DSM-IV criteria for the diagnosis of Alzheimer’s disease:

Gradual impairment of cognitive function resulting in social or occupational dysfunction;

Impaired recent memory with one or more of the following: impaired executive function, impaired visual processing, impairment of skilled motor activities;

Absence of other psychiatric, neurologic or systemic diseases;

Occurrence of deficits not exclusively in the setting of delirium

Vascular dementia is suggested by the presence of abrupt onset of symptoms with stepwise deterioration, focal neurologic findings on examination, and presence of infarcts on CT scan.

If dementia is due to Parkinson’s disease, typical features like rigidity, tremor and bradykinesia will be evident. The recurrent graphic visual hallucinations and delusions are the most characteristic feature of associated dementia.

In frontal lobe dementia there is impairment of executive function, behavior is disinhibited, and cognitive function is normal or minimally abnormal. These patients don’t have insight of their problem.

Many causes of dementia are reversible and they include the followings: medication induced; metabolic disorders like vitamin B12 deficiency, thyroid problems, hyponatremia, hypercalcemia; alcohol related; hepatic, and renal dysfunction; normal pressure hydrocephalus, and CNS disorders like tumors and hematomas.

The American Academy of Neurology recommends routine non contrast CT/MRI of the head, vitamin B12 level, and TSH level in all patients with dementia. There are no clear evidence to support or refute ordering "routine" laboratory studies such as a CBC, BMP. and LFTs. Screening for neurosyphilis is done only when there is high index of suspicion. Test for HIV should be considered in a high-risk patient, but it is not a routine part of investigations.

Thus, we will order the following tests

Order routine:

CBC with differential, routine

BMP (Na, K, Cl, Co2, BUN, Cr, Blood glucose, Ca), routine

LFT, routine

TSH, routine

Vitamin B12, serum, routine

Folic acid, serum , routine

CT scan of head, routine (non contrast)

Result of Labs:

CBC

WBC count of 8,000/micro-L with 85% neutrophils

BUN

11 mg/dL

Serum creatinine

5

0.7 mg/dL

Blood glucose 110mg/dL

Serum calcium 9.5 mg/dL

Serum TSH

Normal

Serum electrolytes

WNL

LFTs

WNL

CT scan of head

Moderate to severe cortical atrophy

So based on the history, examination and lab results, the most likely diagnosis in this patient is Alzheimer’s disease.

Order review:

Donepezil, oral, continuous (As cholinesterase inhibitors can improve cognitive function in patients with AD)

Vitamin E, therapy, continuous (Optional)

Olanzapine, oral, continuous for treatment of delusions in AD, atypical antipsychotics are preferred. The older low potency typical neuroleptics like chlorpromazine are highly sedating, and have anticholinergic side effects (May worsen memory). High potency neuroleptics like haloperidol are associated with high incidence of extra pyramidal side effects.

Counsel patient:

Advance directives

Patient counseling

No driving

Medical alert bracelet

Medication compliance

Also:

SSRI (Fluoxetine) antidepressants if depression is present

Buspirone if patient has anxiety

Temazepam is the drug of choice if the patient has sleep problems. Do not use short acting sedatives like triazolam as they exacerbate mental confusion.

Primary Diagnosis:

Alzheimer’s disease

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Case3

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Location: Emergency room

Vitals: Pulse: 80/min; B.P: 145/90 mm Hg; Temp: 98.8 F; R.R: 16/min; Height: 72 inches (180 cm); Weight: 72 Kg (158.4 lbs) .

CC: Severe chest pain

HPI: A 60-year old white male comes to E.R with a two- hour history of severe central chest pain that began while relaxing on the couch at home. The patient denies any exertional activity prior to the onset of symptoms. The pain is constant, 9/10 in severity, crushing in quality, and radiates to the left side of the jaw and left shoulder. There is associated nausea without vomiting. Over the past two months he has experienced several episodes of exertional chest pain while at work. The pain is usually relieved with rest. He did not seek any medical attention thinking that the pain was work related muscle spasms. Medical problems include hypertension for which he has been taking hydrochlorothiazide the past 10 years. He has no known allergies. FH: His father died of MI when he was 55. Mother is 85 yrs old and healthy. SH: He has been married for 34 years and has two sons. He is not sexually active. He has a 30-pack per year smoking history. He drinks moderate amounts of alcohol on weekends, but denies the use of recreational drugs. He is a truck driver. ROS: Denies headaches, vision changes, tinnitus, or vertigo. Denies muscle tenderness, joint pain, stiffness, or weakness. Rest of ROS is unremarkable.

How to approach this case?

This patient has come to the ED with chest pain of recent onset which has many causes and some of them may cause sudden death. Therefore, all such patients should be transported to ED immediately. Oxygen, IV access, cardiac monitoring, and EKG need to be done as soon as possible. Aspirin is given if MI is likely.

Therefore, we should order the following:

Order:

Pulse oximetry, stat

Oxygen inhalation, continuous

Aspirin, oral, continuous

Nitroglycerin, sub lingual, one time, stat (*Repeat every 5 minutes x 3 as needed for chest pain)

IV access, stat

Cardiac monitoring, continuous

Cuff, BP monitoring, continuous

EKG, 12 lead, stat

The history and physical examination complemented by selected tests such as chest X-ray, EKG, cardiac enzymes allow the physician to accurately diagnose most causes

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of chest pain, especially CAD. Therefore, we will also do the following

Physical Exam:

General appearance HEENT/Neck

Heart examination Lung examination Abdomen

Rectal exam (As this patient may require Heparin for CAD) Musculoskeletal (for possible DVT)

Results:

98% saturation on room air and 99% on 2-lit oxygen.

Physical exam is completely normal. Rectal exam shows hem negative stools. EKG shows normal sinus rhythm with 3 mm ST depression and T wave inversion in lead II, III and AVF.

Order:

FOBT, stat

Heparin, IV, continuous

Metoprolol IV, bolus x 3 (5 minutes apart)

Chest X-ray, PA, portable, stat

CK-MB, stat and every 8 hours x 2

Troponin-I, stat and every 8 hours x 2

CBC with diff, stat and daily

BMP, stat and daily

PT/INR, stat

PTT, stat

*Order brief history

Results:

Patient is still complaining of pain. His history, CAD risk factors such as smoking, HTN, family history, and the EKG findings of T wave inversion suggest the diagnosis of either unstable angina or non-Q wave infarction. In cases of unstable angina, troponins or CK-MB are not elevated but they are elevated in cases of non-Q wave infarcts. However, even in cases of non-Q wave infarcts, troponins levels may not be detectable at initial presentation. We will start heparin and anti-ischemic therapy in this patient.

Order review:

Shift to ICU

Nitroglycerin, IV, continuous (blood pressure should be monitored as hypotension may develop) or nitro paste, topical, continuous

EKG, 12 lead, stat (repeat this to see the EKG changes) Bed rest, complete

NPO, as this patient may require emergency catheterization Urine output

Metoprolol, oral, continuous Simvastatin, oral, continuous

Results:

Cardiac enzymes are within normal limits.

*Order brief history

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Results:

Now the patient is pain free; his second set of cardiac enzymes are negative.

Order review:

D/C intravenous nitroglycerine or nitro paste (once pain free)

Shift to ward after 24 hours and continue the above treatment.

Lipid panel, routine

LFTs (for baseline before you start statins), routine

Echocardiography, stat

Consult cardiology (for cardiac catheterization)

*Obtain TSH if the patient has abnormal lipids especially elevated triglycerides.

*Usually the case will end if you do this much. If it continue then follow...

Order review:

Patient counseling

Smoking cessation

Limit alcohol

Exercise program

Medication compliance

Relaxation techniques

Diet, low sodium

Diet, low cholesterol (fat)

Follow up visit at two to six weeks

His discharge medications should be (aspirin, metoprolol, statin, Sub lingual nitroglycerine, and +/- clopidogrel)

Diagnosis:

Unstable angina

Discussion:

The guidelines for the management of USA/NSTEMI are:

Bed rest with continuous ECG monitoring in patients with ongoing rest

pain.

NTG, sublingual, followed by intravenous administration, for the immediate relief of ischemia.

Aspirin should be given as early as possible. Clopidogrel is used in patients who are unable to take ASA because of allergic reactions or major gastrointestinal intolerance.

Pulse oximetry and/or ABG

Supplemental oxygen for patients with cyanosis or respiratory distress

IV Morphine when the chest pain is not immediately relieved with NTG or when acute pulmonary congestion and/or severe agitation is present.

IV beta-blocker followed by a oral dose provided there are no contraindications. The goal of the treatment is to bring the heart rate down to 60-70/min. If there are any contraindications for beta blockers and the patient is having continuous or frequently recurring, a nondihydropyridine calcium antagonist (e.g., verapamil or diltiazem) can be used as initial therapy in the absence of severe LV dysfunction or other contraindications.

Routine use of ACEI to all patients with USA/NSTEMI is a class II recommendation. However, an ACEI is used when hypertension persists despite treatment with NTG and a beta-blocker, in patients with LV systolic

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dysfunction and in diabetic patients.

Anticoagulation with LMWH or intravenous unfractionated heparin should be added to antiplatelet therapy with ASA and/or clopidogrel. Enoxaparin is the best studied of all. Heparin should be given for at least 2 days.

A platelet GP IIb/IIIa antagonist (Tirofiban or eptifibatide) should be administered, in addition to ASA and heparin, to patients in whom catheterization and PCI are planned.

Early invasive therapy is indicated for high-risk patients with UA. Patients with refractory ischemia, recurrent symptoms, ST segment depression, and hemodynamic instability are at high risks. These patients should be referred for angiography and revascularization. In the absence of these findings, either an early conservative or an early invasive strategy in hospitalized patients without contraindications for revascularization.

Role of statin therapy is conflicting. However, in the acute setting the mechanism of benefit from statin therapy probably involves anti-inflammatory effects rather than the lipid lowering. The other added benefit is, studies have shown that the long term compliance is better if the statins are started before the discharge.

Thrombolytic therapy is not indicated in the treatment of USA/NSTEMI and should not be used.

Case4

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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)

HPI:

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

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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. ROS are unremarkable.

Hospitalization/Procedures

Never

Other Medical Problems

None

Allergies

None

Current Medications

None

Vaccinations

See HPI

Family History

Father 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

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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 (or) Pregnancy test, serum, qualitative, stat

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

1.Blood type 2.Antibody screen 3.Rhesus type

4.CBC with differential 5.Basic metabolic panel 6.Pap smear

7.Rubella status 8.Syphilis screen 9.Urinary infection screen

10.Hepatitis B surface antigen 11.HIV counseling and testing 12.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,

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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 Rh type, routine

Atypical antibody titer

CBC with differential, routine

BMP, routine

Pap smear, routine

Rubella antibodies, routine

RPR, routine

Urinalysis, routine

Urine culture and sensitivity, routine

Hepatitis B surface antigen, serum

HIV test, ELISA, serum, routine

Transvaginal ultrasound, routine

Chlamydia, culture cervix, routine

Medications:

Vitamin, prenatal, oral, continuous

Iron sulfate, oral, continuous

Folic acid, oral (0.4 mg), continuous

High calorie diet

High fiber diet

Regular exercise

Patient education

Smoking cessation

Safety plan

Safe sex

No illegal drug use

No alcohol

Drive with seat belt

Follow up in 4 weeks

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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> 25years

Obesity

Family History of DM

Previous infant Wt > 4000 gm

Previous still born

Previous congenitally deformed child

Recurrent spontaneous abortions

Advise from 2nd Trimester:

Promotion of breast-feeding

Childbirth classes

Danger signs of pregnancy

Preterm labor education

Primary Diagnosis:

Pregnancy

Case5

Print

Location: Office

C.C: A 28-year-old white male presents with bleeding per rectum.

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Vitals: Pulse:76/min, B.P:120/70 mm Hg, Temp:98.5 F, R.R:16/min, Height:72 inches (180 cm), Weight:72 Kg (158.4 lbs).

HPI:

A 28-year-old white male presents with the complaint of having blood per rectum (BRBPR) for a week. His stools are streaked with blood. They are loose, watery, and contain mucus. He has mild colicky pain and a feeling of incomplete evacuation after defecation. He denies any history of nausea, vomiting, fever, weight loss, recent travel, or ill contacts with diarrheal illness. He has been smoking 20 cigarettes a day for the last seven years. He drinks alcohol occasionally and does not use illegal drugs. ROS are unremarkable. He has never been admitted to the hospital. He is not on any medications. He has no allergies. FH: Mother died at the age of 60 due to MI. An older brother has ulcerative colitis. Father is alive and healthy at the age of 65. SxH: Sexually active with his wife. He is a restaurant manager.

Approach to the patient:

Differential diagnosis of rectal bleeding include ulcerative colitis, Crohn's disease, infectious colitis, medication induced (NSAIDs, antibiotics), radiation colitis, ischemic colitis, internal hemorrhoid, anal fissure etc. The common infections include Campylobacter, Escherichia coli 0157:H7, Salmonella, Shigella etc. Consider CMV infections and Kaposi's sarcoma in an immunocompromised patient. C.difficle can sometimes present with bleeding per rectum. It should be considered in all patients who have been on antibiotics. NSAIDs can exacerbate the underlying IBD.

Whenever there is visible rectal bleeding in adults an evaluation, either in an inpatient or outpatient setting is necessary depending on the degree of risk. Low risk patients (e.g. self limited rectal bleeding in an otherwise healthy young patient is most likely due to an internal hemorrhoid) can be followed as outpatient.

High risk patients, such as those with acute abdomen, hemodynamic instability, or persistent bleeding need to be resuscitated and hospitalized. GI consult should be obtained as soon as possible. After assessing the stability of the patient, the next step is to determine the source of the bleeding. When the left colon is the source, the blood is usually bright red. Dark maroon bleeding or blood mixed with stool is probably from the right colon. Some times the source of the hematochezia is upper GI (in about 11% of patients) and therefore nasogastric lavage should be done in all cases to rule out an upper GI source.

In this patient, who is clinically stable, there is no need for resuscitation. This patient is stable, and he is a potential candidate to have ulcerative colitis. So he needs a thorough physical examination including rectal.

Order:

General, Skin, HEENT, Lungs, Heart, Abdomen, Rectal, and Extremities.

Results of your exam:

Physical examination is unremarkable except rectal examination, which is significant for blood stained stool.

*This patient is most likely suffering from ulcerative colitis based on his presenting complaints, family history and findings on examination. However, other similar conditions need to be ruled out.

Discussion:

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Typical history coupled with characteristic findings on endoscopy establish the diagnosis of UC, which is confirmed by a biopsy. The presence of ulcerative colitis, in a first-degree relative, is an extremely important clue. Flexible sigmoidoscopy documents the extent of inflammation as well as establishes the diagnosis. Colonic biopsy is particularly helpful when the findings on sigmoidoscopy are equivocal. A barium enema can confirm the diagnosis but is usually not necessary. Colonoscopy is usually not required unless the diagnosis is uncertain. The other problem with colonoscopy is it can cause perforation in a severely ill patient with extensive disease.

Order Routine:

CBC with differential, stat BMP, stat

Stool ova and parasites, routine Stool for white cells, routine Stool culture, bacterial, routine Liver function tests, routine ESR, stat

PT/INR, stat PTT, stat

Results of labs:

CBC with differential, an BMP are within normal limits. Stool for ova and parasites is negative.

Stool bacterial culture is pending. ESR is elevated at 60

LFTs are within normal limits.

PT, and PTT are within normal limits.

Order:

Consent for procedure

Flexible sigmoidoscopy, stat

Rectal biopsy , stat

Results:

Sigmoidoscopy, and rectal biopsy are consistent with the diagnosis of ulcerative colitis involving the rectum, and distal sigmoid colon.

Management of ulcerative colitis:

Treatment depends on the severity and extent of the disease.

Topical therapy with 5-ASA compounds is the treatment of choice (not steroid enemas) for mildly active proctitis or proctosigmoiditis. They are very effective in inducing and maintaining remission. For proctitis, 5-ASA suppositories are used and enemas are recommended for proctosigmoiditis. 5-ASA enemas are significantly superior in inducing remission and have less side effects compared with steroid enemas. Although the symptomatic improvement will be seen within a few days, treatment should be continued for at least four to six weeks. Doses should be tapered off during this time as complete healing takes place.

Oral therapy with sulfasalazine or with newer 5-aminosalicylates is the treatment of choice for moderately active proctosigmoiditis. Newer 5- aminosalicylates like mesalamine are more costly but have fewer side effects. Folic acid supplementation should be given to patients on sulfasalazine. Steroids are used when these 5-aminosalicylates compounds fail to induce

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remission. Steroids should not be used for maintenance of remission. Immunomodulator drugs like azathioprine or 6-MP are used when patient becomes steroid dependent or he is refractory to steroids.

Patients with severe disease need to be hospitalized and resuscitated with IV fluids and electrolytes. They are kept NPO and given parenteral nutrition. It’s very important to monitor the patient for complications that might develop. Abdominal examination, vital signs, and plain abdominal films are used for this purpose. IV steroids are the most important treatment modality. Role of antibiotics is controversial in this patient population. However, many physicians consider giving broad spectrum antibiotics if the patient has fever, leukocytosis, or any indication of sepsis. Surgery is considered for refractory cases.

Antidiarrheal agents like loperamide may be used for symptomatic treatment of diarrhea, and anticholinergic agents for abdominal cramps. Antidiarrheal agents need to be avoided in severely ill patients.

Antidepressants or anxiolytics may be required in some cases. Dietary counseling is important in all cases.

ORDER REVIEW:

5-ASA, rectal, continuous Loperamide, oral, continuous Dicyclomine, oral, continuous Dietary consult, routine

Counseling:

Patient counseling No alcohol

No smoking Safe sex Seat belts use

Regular exercise No illegal drug use

Medication compliance

Primary Diagnosis:

Ulcerative colitis, mild case involving rectum and distal sigmoid colon

Case6

Print

Location: Office

17

Presenting complaint: A 28-year-old man presents with two months of abdominal pain, and altered bowel.

Vitals: Pulse:72/min, B.P:130/75 mm Hg, Temp:98.70F, R.R:17/min, Height:70 inches (175 cm), Weight:70 Kg (154 lbs)

HPI:

A 28-year-old white male presents with the complaints of abdominal pain and altered bowel habits for the last three months. The pain is colicky in nature. It is located in the lower abdomen. The pain does not radiate, is 5/10 in severity, worsens postprandially, and relieves with defecation. For the last three months he has been suffering with diarrhea alternating with constipation. For the last three days, he has been having diarrhea. Stools contain mucus but not blood. Symptoms occur during the day and do not interfere with his sleep or work. His weight and appetite are normal. He is not taking any prescribed or recreational drugs. He smokes 10 cigarettes per day for the last 10 years and drinks alcohol only on weekends. He is currently sexually active with his wife and always uses condoms. He has no other medical problems or known allergies. He is not on any medications. FH: No H/O IBD or colon cancer in the family. SH: Married for 5 years and has a 2 year old daughter. Works at a local university. ROS are unremarkable.

How to approach this case?

This patient has alternating diarrhea and constipation. This may be due to infectious causes like amebiasis or giardiasis, which are very rare. Irritable bowel syndrome is another possible cause. Bowel obstruction may present with alternating diarrhea and constipation. Colon cancer may also present in this manner, but is unlikely in a 28 year old with no family history of bowel cancer.

Order:

A complete physical examination, including rectal, is appropriate in this setting.

Results:

Completely normal physical examination

Now, order the following:

CBC with differential, routine

BMP, routine (diarrhea is associated with electrolyte abnormalities) TSH, routine

FOBT, routine ESR, routine

Stool ova and parasites , routine Stool for white cells, routine Stool cultures, bacterial, routine 72-hour stool fat, routine

*Schedule an appointment in one week.

Results of labs:

WBC count is 8,000/micro-L, hemoglobin is 15.6g/dL, and platelet count is 200,000/micro-L

Serum TSH is 1 micro-U/L BMP is normal

FOBT is negative

Stool does not contain any ova, parasites, or white cells.

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Stool culture – No growth 72 hour fecal fat is WNL.

Order review:

Lactose free diet High fiber diet

Loperamide, orally, continuous Biofeedback, routine

Counseling:

Patient counseling Reassurance Relaxation exercise No smoking

No alcohol Safe sex Seat belt use

No illegal drug use

Counseling about cessation of cigarette smoking, limitation of alcohol intake, safe sex practices, and driving with seat belt

Follow up visit in 2 weeks

Discussion:

Clinical features:

Irritable bowel syndrome is a diagnosis of exclusion. Abdominal pain and altered bowel habits are the most characteristic features of this entity. Abdominal pain is crampy, located in lower abdomen, aggravated by stress, and relieved by defecation. Patients with IBS have diarrhea, constipation or diarrhea alternating with constipation. Stools contain mucus but no blood. Clinical features that suggest disease other than IBS include fever, weight loss, bloody diarrhea, large volume diarrhea, nocturnal diarrhea, nocturnal pain, anorexia and anemia.

Diagnosis:

When a clinical presentation is typical of IBS, only a few investigations are ordered. They include CBC and routine chemistry panel in all; thyroid hormones, and stool for ova, parasites, and leukocytes in patients with diarrhea; and flexible sigmoidoscopy in patients over 40, and in patients who have persistent diarrhea. When all the fore mentioned studies are normal, symptomatic treatment is started and patient is reevaluated after 4-6 weeks. If symptoms progress, more detailed studies are warranted.

Treatment:

A lactose free diet and high fiber diet are considered. A diet that produces gas is discouraged. Anticholinergic drugs for abdominal pain and loperamide for diarrhea are given on a 'as needed basis'. Prokinetic drugs may be used for constipation. Benzodiazepines are used only in cases of acute situational anxiety. Behavioral treatment is a consideration for patients who have some sort of stressor.

PRIMARY DIAGNOSIS:

IBS

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Case7

Print

Location: Emergency room

Presenting complaint: A 65-year-old male presents with a chief complaint of severe breathlessness.

Vitals: Pulse: 88/min , regular, B.P: 120/70 mm Hg, Temp: 100.5 F, R.R: 25/min , Height: 72 inches (180 cm), Weight: 72 Kg (158.4 lbs).

HPI:

A 65-year-old white male, with a two-year history of COPD, presents to the ER with an acute onset of severe breathlessness, wheezing, and chest tightness. He also states that his cough has become more severe the past two days and the sputum production has increased in quantity and become yellowish. Other complaints include fever and malaise. He denies any chest pain and does not use supplemental oxygen at home. He continues to smoke 2-5 cigarettes/day. He does not drink alcohol or use illegal drugs. He has no allergies. His current medications are albuterol 2 puffs as needed for SOB. He has no other medical problems. Vaccinations are up to date. He was admitted once in the hospital for exacerbation of COPD.

REVIEW OF SYSTEMS:

Skin

No complaints

HEENT

No vision changes, epistaxis, or sore throat

Musculoskeletal

Easily fatigued, chronic left knee pain

Cardio respiratory

Frequent productive cough, wheeze, and dyspnea

Genitourinary

No history of STD or UTI.

Neuropsychiatric

Not asked

Abdominal

Occasional heartburn, denies nausea, vomiting, or diarrhea

How to approach this case?

Based on his history, this is most likely an exacerbation of COPD.

Features suggestive of COPD exacerbation include increase in the severity of

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dyspnea, and a change in the color and quantity of sputum. To assess the severity of exacerbation, ABGs and pulmonary function tests are performed.

CXR is done to rule out disorders that mimic COPD exacerbation. ECG is done to detect RVH, arrhythmia and ischemia. CBC is performed to detect polycythemia or bleeding. Serum chemistry may point towards some metabolic cause of COPD exacerbation. Sputum gram staining, culture, and sensitivity are indicated when COPD exacerbation with a purulent sputum fails to respond to empiric antibiotic treatment.

PaO2 of < 60 mm Hg and/or SaO2 <90 on room air indicates respiratory failure. PaO2 <50 mm Hg, PaCO2 >70 mm Hg, and pH <7.30 indicate a life-threatening respiratory failure and requires mechanical ventilation with ICU management.

A PEF <100 L/min or an FEV1 <1.00 L also indicates a severe exacerbation.

Start with the physical examination:

General

HEENT

Neck

Heart examination Lungs examination Abdomen Extremities

Results of your examination:

The patient is in obvious respiratory distress, sitting upright and using his accessory muscles of respiration.

Increased AP diameter of chest, decreased air entry on both sides, and generalized bilateral rhonchi and wheezing.

Heart exam: Regular rate, and rhythm,; loud P2 but no murmurs. There is no edema, calf tenderness, or Jugular venous distension. Rest of the examinations is within normal limits.

Routine Orders:

Sit upright (Head elevation)

Pulse oximetry, stat and continuous Oxygen inhalation, continuous

IV access, stat

Cardiac monitor, continuous FEV1, stat and every hour PEFR, stat and every hour EKG, 12 lead, stat

CXR, PA, lateral, stat ABG, stat

Lab results:

PEFR: 0.9L/min FEV1: 0.85L

Oxygen saturation: 86% on room air and 94% on 2-litre oxygen via nasal cannula

CXR shows hyperinflation of both lung fields and a small infiltrate on the right lower lobe EKG is within normal limits.

Start treatment:

Nebulized albuterol, continuous

Nebulized ipratropium, continuous

Prednisone, IV, continuous

Levofloxacin, oral, continuous

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CBC, with differential, stat

BMP, stat

Lab results:

ABG:

pH: 7.38

PaO2: 53

PaCO2: 53 mm Hg

CBC shows WBC count of 12,000/micro-L with 8% bands. BMP are normal

Patient is feeling better and his pulmonary function has improved now after 4 hours of therapy.

Review orders:

Shift to floor/ward Ambulate as tolerated Urine output

Vitals Q 4 hours Regular diet

Serum theophylline levels if patient is on theophylline

Pulmonary toilet (suction upper airway): If the patient is having lot of secretions and is unable to clear them

Diuretics are given in cases of cor pulmonale Phlebotomy (> 50 hematocrit)

Low sodium diet in cases of cor pulmonale

Discontinue the cardiac monitor if the patient's vitals are stable and the acute episode is over

DISCUSSION:

Pharmacological agents used to treat acute exacerbation of COPD include inhaled beta-adrenergic agonists, inhaled anticholinergics, antibiotics, and steroids.

Inhaled beta-adrenergic agonists like albuterol are the main stay of treatment for acute exacerbation of COPD and are given via a nebulizer or MDI.

Anticholinergic bronchodilators like ipratropium are sometimes used along with beta-agonists when more bronchodilation is required.

Even though there is no clear evidence, parenteral corticosteroids may be used in hospitalized patients for severe exacerbation.

Methylxanthines like theophylline are used for patients who fail with inhaled bronchodilators. It may improve dyspnea, airway function, mucociliary clearance, and central respiratory drive. However, theophylline has narrow therapeutic window and may cause tachyarrhythmias.

Antibiotics are indicated when COPD exacerbation is caused by infection. Empiric treatment is done with levofloxacin, amoxicillin, TMP-SMZ or doxycycline. Gram staining and culture of sputum is required in refractory cases.

Adequate oxygenation must be maintained by giving supplemental oxygen with goal arterial oxygen tension of >55-60 mmHg and the oxygen saturation of above 88-90%.

Noninvasive positive pressure ventilation (NIPPV) should be tried initially in selected patients with respiratory failure. However, it is contraindicated in patients with hemodynamic instability (eg, hypotension, serious cardiac arrhythmias).

Criteria to use NIPPV include moderate to severe dyspnea, PaCO2 of > 45 mmHg or pH of < 7.35 or RR of >25/minute.

Review order:

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Patient is asymptomatic and his pulmonary function tests have reached his personal best after 2 days of inpatient therapy.

Discharge:

Send the patient home

Follow-up visit at 2 weeks

Smoking cessation

Alcohol, advice the patient to limit intake

Counsel patient, no illicit drugs

Patient counseling

Oxygen therapy at home (when PaO2 is less than 55 mm Hg or SaO2 is less than 88 percent, oxygen therapy and cessation of cigarette smoking improves prognosis) Oral Levofloxacin for total of 10 days

D/C nebulization of albuterol and ipratropium (Switch to metered dose inhalers) Ipratropium inhalation, continuous

Albuterol inhalation, continuous Influenza vaccine Pneumococcal vaccine

Primary diagnosis:

Acute exacerbation of COPD

Case8

Print

Location: office

Presenting complaint: A 40-year-old female with complaints of insomnia, easy fatiguability, and feelings of worthlessness presents to the outpatient medicine clinic.

Vitals:

Pulse:75/min, B.P:110/75mm Hg, Temp:98.6 F, R.R:16/min, Height:72 inches (180 cm), Weight:55kg (121 lbs).

HPI:

A 40-year-old female comes to the clinic with the complaint of insomnia, easy fatiguability, and feeling worthless. She states that she has been “feeling low” for the last two months. She no longer finds pleasure in any of her normal activities. She can’t sleep. There is loss of appetite. Her weight has decreased by 20 pounds in two months. The patient has feelings of guilt, hopelessness, and inability to concentrate. She is finding it difficult to continue her job as a librarian and has decided to take a leave of absence. Prior to the onset of symptoms, she was doing well, both at home and in the office. She is married, has two children, and her

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husband is very loving. Because of her lack of interest in sex, they have been sexually inactive for the past two months. Generally, the patient has always been in good health. She doesn’t smoke, drink alcohol, or use drugs. She has a history of cluster headaches. Her last cluster headache was six years ago. ROS are unremarkable. FH: Mother is 65 and has HTN. Father is 70 and healthy. Vaccinations are up-to-date. She is not on any medications. She has no known allergies.

How do you approach this case?

This patient has classic clinical features of depression. A number of medical conditions may present with depression, including stroke, diabetes, dementia, cancer, hypothyroidism, chronic fatigue syndrome (see Fatigue below), fibromyalgia, systemic lupus erythematosus (SLE), coronary heart disease, corticosteroid use, anxiety and panic disorders, hypercalcemia, Sjögren's syndrome, increased bone loss, and seizure disorders in older adults.

Perform a complete physical and psychiatric examination. An assessment of the presence of suicidal ideation is essential in all depressed patients.

Physical examination:

Complete physical examination

Results of PE:

General: Well developed, well nourished, middle aged female, in no acute distress. HEENT, lungs, heart, abdomen, and the rectal exam is completely normal. No lymph nodes palpable. Neuro/psychiatric examination: Neurological examination is non- focal. She is alert and oriented though her speech is somewhat slow. She expresses feelings of worthlessness and lack of energy. She denies having delusions or hallucinations. There are no suicidal ideations. Her cognitive functioning is normal.

How would you approach this patient?

In cases of depression, limited laboratory testing that may help rule out associated disorders includes measurement of thyroid function (TSH), serum electrolytes/basic metabolic panel, folate, vitamin B12, and an electrocardiogram.

Other tests may be ordered based on the findings of history and physical examination include:

1.ANA when SLE is suspected

2.HIV testing and VDRL in cases of high risk sexual behavior

3.Urine and blood toxicology screening in cases of suspected substance abuse

4.Dexamethasone suppression test for suspected Cushing’s disease

5.Cosyntropin stimulation test for suspected Addison’s disease

Order review:

In this case, no associated medical illness is suspected based on history and examination.

Routine Orders:

CBC with differential, routine BMP, routine

TSH, serum, routine EKG, 12 lead, routine

Vitamin B 12, serum, routine

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Folate, serum, routine

Result of Labs:

EKG: normal rate, rhythm and axis, no evidence of ischemia or hypertrophy. Serum TSH: 1microU/mL

BMP: Na is 140 meq/L, K is 4.0 meq/L, Cl is 100 meq/L; calcium, CO2, BUN, creatinine, B 12 and Folate are normal.

Discussion:

Based on the history and examination, this patient is likely suffering from major depression. There are four major types of depression: adjustment disorder with depressed mood; depressive disorders; bipolar disorders; and mood disorders secondary to illness and drugs.

These need to be differentiated from grief and bereavement, which are normal responses to a loss.

The DSM-IV criteria for major depression:

At least five of the following symptoms should present for a period of two-weeks. One of the symptoms must be depressed mood or loss of interest. The symptoms should not be the result of an organic factor or substance. The disturbance should not occur within 2 months of the loss of a loved one.

1.Depressed mood most of the day

2.Markedly diminished interest or pleasure in almost all activities nearly every day (anhedonia)

3.Significant weight loss or weight gain

4.Insomnia or hypersomnia

5.Psychomotor agitation or retardation

6.Fatigue or loss of energy nearly every day

7.Feelings of worthlessness and/or excessive or inappropriate guilt

8.Impaired concentration or indecisiveness

9.Suicidal ideation

A history of a prior manic episode in addition to these criteria suggests the diagnosis of bipolar disorder.

Dysthymia is defined as mild, chronic depression which lasts for at least two years or longer. It is characterized by poor appetite, insomnia, low energy or fatigue, low self-esteem, impaired concentration, and anhedonia. Long-term psychotherapy is frequently helpful.

Mild to moderate major depression is treated with either psychotherapy or pharmacotherapy. Patients with moderate to severe depression should be treated initially with either pharmacotherapy or ECT.

SSRIs are the drugs of choice. Patients should have a follow-up appointment at least every one to two weeks for six to eight weeks during the initiation phase of treatment. Patients with severe depression should be seen weekly. Less severely ill patients should be seen every 2 weeks.

Patients with associated anxiety symptoms and difficulty sleeping should be offered a short acting benzodiazepine like lorazepam for 1-2 weeks with tapering doses.

Patients with suicidal behavior and severe functional impairment should be admitted in the hospital and treated with ECT.

When to obtain a psychiatry consultation?

Psychiatric consultation is needed

When the first line medication produce no improvement in 6-8 weeks period

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Patients with severe suicidal ideation

Patients with associated psychiatric or medical or substance abuse disorders

When to add antipsychotics?

If the patient experiences the associated psychotic symptoms with depression, a small dose of atypical antipsychotics like resperidol can be added.

As this patient has moderate to severe depression and she does not reveal any history of suicidal ideation, psychotic symptoms and anxiety, we can treat her with antidepressants alone.

Order review:

Fluoxetine, oral, continuous

Counseling:

Suicide contract

Seat belt use

Patient education

No smoking

No alcohol

Seat belts use

Regular exercise

No illegal drug use

Follow up visit after 10 days

Primary Diagnosis:

Major depression

Case9

Print

Location: Emergency room

Presenting complaint: A 55-year-old male presents with recent onset confusion, blurry vision and headache.

Vitals:

Pulse:75/min, B.P:215/150 mm Hg, Temp:98.8 F, R.R: 16/min, Height:72 inches (180 cm), Weight:72 Kg (158.4 lbs)

HPI:

A 55-year-old white male comes to the E.R with a 2-hour history of confusion, blurred vision, headache, nausea, one episode of vomiting, and breathlessness. He was doing his routine office job when symptoms developed. The headache started this morning, was 1-2/10 in severity but now it is 6-7/10. He denies weakness,

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sensory disturbances, dysphasia, dysarthria, leg swelling, chest pain or palpitations. Bowel and bladder functions are intact. Diagnosed 5 years ago with hypertension, he was prescribed atenolol, however he is poorly compliant. There is no history of DM, CAD or hyperlipidemia. He has a 25-pack-year smoking history and rarely drinks alcohol. He has no known allergies. FH: Mother is 80 and is hypertensive, father died of MI at 65. One brother is diabetic. SH: Married 30 years, has two sons and one daughter. He is a business executive. SxH: he is sexually active with his wife and does not use condoms. ROS are unremarkable.

How to Approach this case:

This hypertensive male presents with recent onset of confusion, blurred vision and headache. He is most likely suffering from hypertensive encephalopathy, a hypertensive emergency. Other possible causes include subarachnoid hemorrhage, intra-parenchymal brain hemorrhage, acute MI or migraine. Hypertensive emergency or hypertensive crisis is characterized by very high blood pressure with impairment of end organs like CNS, heart or kidney. CNS manifestations include confusion, blurring of vision, headache, weakness and fatigue. CVS involvement results in congestive heart failure, angina, MI or aortic dissection. Renal manifestations are hematuria and/or proteinuria and impaired renal function.

Immediate examination is crucial in this patient,

Order:

General, HEENT/Neck, Heart, Lungs, Abdominal, Extremities, Neuropsychiatric.

Results:

Patient is disoriented and neurological examination is otherwise non-focal. Fundoscopy shows arteriolar narrowing and AV nicking. There is mild papilledema, and soft exudates. There is no neck stiffness. CVS examination is significant for S4 gallop. Lungs are clear to auscultation bilaterally. Abdominal examination is normal. Extremities show no evidence of edema.

Order:

IV access, stat

Oxygen inhalation, continuous Pulse oximetry, stat and continuous Cardiac monitor, continuous Continuous BP cuff

12 Lead EKG, stat

*Before starting treatment, rule out the possibility of stroke. Treating high BP is detrimental in patients with stroke especially those who with increased intracranial pressure, i.e. papilledema. First order CT scan of the head without contrast.

STAT Order:

CT scan of head, stat ( without contrast to look for edema, hemorrhage, infraction)

Results:

CT is negative for stroke. Pulse oximetry is 97% on 2 lit. Vitals are same as before.

12 lead EKG has evidence of Left ventricular hypertrophy.

Now start treatment:

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Nitroprusside, IV, continuous (monitor the patient for hypotension)

After starting treatment, order basic labs to assess the end organ involvement. CBC with differential, stat (for microangiopathic hemolytic anemia)

BMP, stat (for possible renal involvement) Urinalysis, stat (for possible renal involvement)

CXR-PA view, stat (to look for the evidence of pulmonary edema) *Shift the patient to ICU

Order:

NPO

Bed rest, complete Urine output

Order review:

BP is under control and patient is symptom free. Always check the BP frequently (in the exam) as continuous infusion of nitroprusside can cause hypotension and try to wean nitroprusside and add an oral agent.

*Shift the patient to the ward/floor

D/C cardiac monitor, oxygen, pulse oxy, NPO, bed rest

Vitals Q 6 hours

Metoprolol or hydrochlorothiazide, oral, continuous Low salt diet

*Once the blood pressure is controlled with oral antihypertensive agents, the patient can be sent home with the following orders

Order review:

Lipid profile, routine Patient counseling Regular exercise Medication compliance Smoking cessation

Alcohol, advice patient to limit intake Seat belt use

No illegal drugs

Discussion:

Diastolic blood pressure of more than 120 is considered as hypertensive crisis. The presence of end organ damage further classifies it as hypertensive emergency and lack of end organ damage classifies it as hypertensive urgency.

The most common cause of hypertensive crisis is inadequately treated essential hypertension. The other common causes include renovascular hypertension and renal parenchymal diseases and rarely form pheochromocytoma or primary hyperaldosteronism.

Careful physical exam to differentiate hypertensive urgency from emergency should be done. The main components of the exam are funduscopy, CVS, CNS and BP in both upper extremities and at least one lower extremity.

Basic labs, which include CBC with peripheral smear, U/A, BUN, Cr, EKG, and CXR, should be ordered.

Treatment:

In hypertensive emergency blood pressure should be lowered within

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one hour to limit the end organ damage. In hypertensive urgency the aim is to reduce the diastolic blood pressure to about 100-105 mm hg with in a period of 2-6 hours. The maximum initial fall should not be more than 25 mm Hg. More aggressive reduction of BP decreases the blood pressure below the auoregulatory range and may cause ischemic events like stroke. Once the goal is reached, the patient should be switched to oral medications. The diastolic pressure should be lowered to 85-90 over a period of 2-3 months.

IV nitroprusside is the drug of choice for hypertensive crisis. It acts within seconds and it has a very short half-life. The patient BP should be monitored with intra-arterial line. Prolonged infusion i.e. >48 hrs may cause cyanide toxicity, especially in patients with renal insufficiency. It is not a first line medication in pregnant women. The other good alternatives to nitroprusside are IV labetalol and hydralazine. Hydralazine is the drug of choice in pregnant patients.

IV phentolamine is the drug of choice in pheochromocytoma.

Esmolol is an IV beta-blocker and is effective in acutely lowering BP when used in conjunction with a vasodilator. Myocardial ischemia is an important indication for its usage.

Management of hypertension varies in certain situations:

Rapid reduction for blood pressure is detrimental in patents with cerebrovascular accident. These patients can be differentiated from hypertensive emergency by the abrupt onset of focal neurological findings.

Patients with acute pulmonary edema are best treated with combination of nitroprusside or nitroglycerine and loop diuretic. Drugs like hydralazine or beta-blockers or labetalol should be avoided.

Patients with acute coronary syndromes are best treated with IV nitroglycerine or IV labetalol or IV nitroprusside.

Aortic dissection: The primary goal is to decrease both the systemic BP and cardiac contractility. The best regimen is a combination of IV nitroprusside and an IV beta-blocker either a labetalol or metoprolol. Nitroprusside alone should not be used without a beta-blocker.

Rebound hypertension secondary to abrupt withdrawal of short acting sympathetic blockers such as clonidine is best treated by re-administration of the discontinued drug and if necessary with IV phentolamine.

The rare causes include 1. Pheochromocytoma 2.Cocaine intoxication 3. Interaction of MAOI and tyramine containing foods can also cause hypertensive crisis. This is best treated with IV phentolamine.

Case10

Print

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Location: Emergency room

Presenting complaint: A 7-month-old boy presents with severe breathlessness of sudden onset

Vitals:

Pulse: 100/min, B.P: 80/55 mm Hg, Temp: 98.70F, R.R: 40/min, Weight: 6.8 kg (15lbs), Height: 53 cm

HPI:

A 7-month-old boy is brought to the ER with severe cough, stridor, and breathlessness. His 6-year-old brother went to school leaving peanuts near him. Mom found the child in respiratory distress and rushed him to the hospital. There is no family history of asthma. The infant was healthy prior to this incident. Developmental milestones are being achieved at the appropriate ages. He has no allergies. Vaccinations are up-to-date. FH: Father is 32 and healthy; mother is 28 and has DM. He has one elder brother who is healthy. ROS are unremarkable.

How to approach this case:

This child presents with acute dyspnea due to upper airway obstruction. Stridor is one of the important clinical signs of upper airway obstruction. There are a number of causes of upper airway obstruction in the pediatric population. Etiologies vary according to the age of the patient. Careful history, and examination as well as lateral and PA chest X-rays should be done in all such patients.

First

General examination HEENT/Neck Chest/lungs

CVS

Results of PE

General examination: The baby is crying, and in obvious respiratory distress. est/lungs: The child is tachypneic with nasal flaring, suprasternal, and intercostal retraction. Inspiratory stridor is noted. Air entry is reduced, and percussion note is resonant bilaterally.

VS: Normal S1 and S2. No murmurs, rubs, or gallops. Pulses are normal. No jugular venous distension. Blood pressure is equal in both arms.

Review orders:

Oxygen inhalation, stat IV access, stat

Pulse oximetry, stat and continuous Cardiac monitoring, stat CXR-PA/lateral views, portable, stat X-ray neck lateral views, portable, stat CBC with differential, stat

Results of Labs:

CBC: normal.

CXR PA and lateral views: No abnormality found.

Pulse oxymetry: oxygen saturation is 91 percent on room air, and 97% on 2-lit oxygen.

Cardiac monitoring: no abnormality of rate or rhythm.

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Discussion:

This child has sudden and dramatic onset of symptoms. He had peanuts in the vicinity before he developed symptoms. Based on these findings, symptoms are most likely due to aspiration of a foreign body. The next step in this case would be bronchoscopy, which will confirm the diagnosis and aid in the removal of aspirated foreign body. Before bronchoscopy, IV steroids and IV antibiotics may be used to help reduce the chances of edema and infection. Other important causes of upper airway obstruction include croup, laryngitis, epiglottitis, retropharyngeal abscess, angioedema, peritonsillar abscess, and laryngeal papilloma. Croup is common in children aged 6 months to three years and it develops insidiously as an upper respiratory tract infection. Patients with croup have a characteristic barking cough. Laryngitis occurs in children aged greater than five, the voice is hoarse, and there is no stridor. Epiglottitis is more frequent in children aged 2-6 years. There is a short prodrome, drooling is noted, and the patient feels better when leaning forward. Patients with retropharyngeal abscess are usually younger than 6 years, and they do not have stridor. The voice is muffled and they are found to be drooling. Angioedema can occur at any age, onset is sudden, and clinical features of stridor, retractions of intercostal muscles, and facial edema are found. Peritonsillar abscess occurs in children greater than 10 years of age, onset is gradual but with sudden worsening, and there is no stridor. Laryngeal papilloma is encountered in patients of ages 3 months to 3 years, onset is chronic and voice is hoarse.

The majority of foreign bodies are not visible by plain films. So, a normal radiograph can never rule out aspirated foreign body in a highly suspicious patient like this.

STAT orders:

IV methylprednisolone, one dose

IV cefazolin, one dose

Bronchoscopy, stat (It will ask you surgery consult. Reason: Confirmation and removal of aspirated foreign body by bronchoscopy)

Primary Diagnosis:

Foreign body aspiration

Case11

Print

Location: Office

Presenting complaint: A 40-year old female patient presents with lump in her left breast.

Vitals: BP

:130/80 mm Hg, Pulse:86/min, Temp:

98.70F, R.R:16/min,

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Height:162.5cm, Weight:55 kg (12lbs).

HPI:

A 40-year-old white female presents with mass in the upper outer quadrant of her left breast. She first noted this mass two months ago, the mass is painless and its size does not change pre or post-menstrually. There is no nipple discharge. She does not give a history of breast lumps. There is no family history of breast cancer. She is a 10-pack year smoker and drinks alcohol socially. She is married and uses oral contraceptives. The patient denies recreational drug use. Her age at menarche was 13 and her menses have always been regular. LMP was 10 days ago. She is gravida 2, para 2, one at the age of 23 and the other at 27. Both deliveries were spontaneous vaginal. Her mother is 65 and is diabetic; her father is 70 and has angina. The rest of her ROS are unremarkable.

How to approach this case:

This 40-year old female has presented with a lump in her breast. Careful examination of breasts and lymph nodes especially supra clavicular and axillary should be performed when any woman presents with a breast lump.

First order the physical examination:

General examination HEENT/Neck

Heart examination Lung examination Abdomen examination Breast examination Lymphnode examination

Here are the results of examination:

General, HEENT/Neck, heart, lung, and abdomen examination is WNL.

Breast examination: There is a 2 cm size solid, mobile, firm, non-tender mass with distinct margins, located in the left upper and outer quadrant. There is no nipple discharge. There are no skin changes.

Lymphnode examination: There is no palpable lymphadenopathy.

Discussion:

Based on the history and examination, this patient most likely has benign breast disease. There are multiple causes of benign breast disease.

Fibroadenoma: Typically a 15-30 yr old female presents with firm, painless, mobile, (breast mouse) and well-circumscribed lumps.

Fibrocystic changes: Multiple and bilateral cystic breast swellings, which are noted to be particularly painful and tender premenstrually.

Papillomas: C/O bloody nipple discharge (Non-bloody nipple discharge is usually benign).

Duct ectasia: Presents with fever, greenish cheesy discharge, pain, and tenderness. Mastitis: Patients complain of the sudden onset of pain, fever, chills, and local erythema, tenderness, and induration.

Breast cancer: Consider risk factors first - elderly age, family history of breast cancer, early menarche, late pregnancy, nulliparity, and late menopause. On examination you have to look for the characteristics of cancerous lesion (Single, hard, immobile lumps with irregular borders and a size of more than 2cm).

Diagnosis:

The best way of making the diagnosis is by using a combination of physical

32

examination, mammography, and fine needle aspiration cytology/biopsy (triple diagnosis). Interpretation should be followed as.

If all three, suggest a benign lesion - Follow the patient with 3 to 6 monthly physical exam for 1 year to make sure the mass is not enlarging.

If all three, suggests malignancy - Refer to definitive therapy.

If any one of the three suggests malignancy - Perform excisional biopsy.

Women younger than age 35:

Mammogram is not useful in this age group, as the breast tissue is very dense. However, it can be done in very high-risk patients.

If you find a lump and appears to be cystic, perform FNAB/FNAC. If the aspirated fluid is non-bloody, the patient can be reassured and followed in four weeks to check for recurrence. If it recurs then the patient should be referred to surgical specialty. If the fluid is bloody, send it for cytology.

If the mass is not cystic, obtain an ultrasound. If ultrasound shows a solid mass, the patient should undergo biopsy (Core biopsy or excisional biopsy).

Women age 35 and older:

The only difference from the above age group is all these patients should undergo bilateral mammogram along with clinical exam.

Management is similar to the above group.

Upto 15% of palpable breast cancers will not be visualized by mammogram. So, a negative mammogram doesn't eliminate the need for biopsy in a patient with palpable mass.

We will follow triple diagnostic approach here, and will perform mammography and FNAB.

Order Review:

Mammography, routine

FNA, breast, routine (Software will ask you general surgery consult)

*Schedule an appointment in one week

Results:

Mammography and FNAB are consistent with the diagnosis of fibroadenoma. In this patient, the fibroadenoma is small; therefore it does not need to be excised. The patient can be followed every three to six months for one year to assess the size of the mass.

Order review:

Reassure the patient

Follow up visit at 3 months

Screening of cervical cancer by Pap smear

Counsel the patient

Patient counseling

Contraception advise

Safe sex

Smoking cessation

Limit alcohol intake

Safety plan

Seat belt use

Regular exercise

Diagnosis:

Fibroadenoma of the left breast

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Case12

Print

Location: Emergency room

Vital signs: BP:90/60 mmHg, HR:128/min regular, Temp:100.0° F, R.R:30/min rapid and shallow

C.C: Vomitings and abdominal pain.

HPI:

A 20-yr-old woman presents to E.R with 5 episodes of vomiting, abdominal pain, weakness and increasing drowsiness of one-day duration. During the last 2 months she has noticed increased thirst and increased urination. The abdominal pain is diffuse, 4-5/10 in severity, constant, non-radiating and there are no aggravating or relieving factors. Vomiting is non-bloody. She has no other medical problems. She has no known drug allergies. She is not on any prescription or over the counter medications. She is not a smoker or alcoholic, and denies IV drug abuse. She has a family history positive for Type 1 Diabetes Mellitus. Her father, and paternal uncle and grandfather are all diabetics.

Review of systems:

She denies weight changes, fever, chills, night sweats, diarrhea, constipation, skin, hair, or nail changes, blurry vision, acute bleeding, easy bruising, indigestion, dysphagia, changes in bowel movements, bloody stools, burning on urination, recent travel, ill contacts, vaginal discharge or itch, pregnancy, heat or cold intolerance, drug or alcohol use. Last menstrual period ended four weeks ago, was normal in flow and duration.

How do you approach this case?

First quickly examine the patient General

HEENT

Neck

Heart

Lungs Abdomen Extremities

Here are the results of the exam:

General: Patient is in mild to moderate abdominal pain and appears very distressed. HEENT: Very dry mucus membranes, no JVD, EOM are intact. Rest is unremarkable. Lungs: Clear to auscultation B/L.

Heart: Completely normal except tachycardia.

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Abdomen: Soft, non tender, normal bowel sounds and no guarding or rigidity. Extremities: No edema, calf tenderness, but week peripheral pulses.

Discussion:

Now, make a mental checklist of differential diagnosis, i.e.

Abdominal pathology like appendicitis, gastroenteritis, pancreatitis, acute intestinal obstruction etc.

Menstrual symptoms or pregnancy related complications

DKA (Based on the family history and presenting clinical features) Nonketotic Hyperosmolar state

Alcoholic ketoacidosis Drug intoxication

Order the following stat:

Pulse oximetry, stat and continuous Oxygen, inhalation, continuous

IV access, stat Cardiac monitor, stat

Normal saline, 0.9% NaCl, continuous, stat (This patient is severely dehydrated. She is hypotensive and tachycardic. So, she needs IV fluids.)

Finger stick glucose, stat

Results:

Pulse oxymetry showed 96% on room air

Finger stick glucose shows 600mg/dL

Order:

Urine pregnancy test, stat

CBC with differential, stat

BMP, stat

Calcium, serum, stat

EKG, 12 lead, stat

Serum amylase, stat

Serum lipase, stat

UA, stat

ABG, stat

Serum osmolality, stat

Serum ketones, qualitative, stat Regular insulin, IV, continuous Phenergan, IV, one time (for nausea) Discontinue oxygen

Ok here are the results:

Urine pregnancy test is negative

WBC 10,000/µL and normal differential

Sodium is 129, Potassium is 5.0, Chloride is 90, Co2 is 14, calcium is 8.0, and a blood sugar of 600mg/dL

EKG sinus tachycardia, nothing concerning Serum Amylase - mildly elevated

Serum Lipase WNL

UA showed 4+sugar, 2+ ketones but no evidence of infection Serum Osmolality 305

Serum Ketones - high

ABG showed metabolic acidosis, compensated by respiratory alkalosis (pH of 7.3)

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How do you approach this case?

So, this patient most likely has either DKA or Non-ketotic hyperglycemia. The diagnosis is based on clinical features, elevated blood sugars, and increased anion gap. To confirm the diagnosis we need to order serum ketones and serum osmolality, as above. She has pseudohyponatremia i.e. secondary to elevated blood sugars. Treatment of hyperglycemia resolves her hyponatremia.

Review orders:

Admit the patient to the intensive care unit

NPO

Bed rest

Vitals as per ICU protocol

Urine output

KCl, IV, continuous

HbA1C level, routine

Phosphorous, serum, stat (optional)

Follow the patient with

1.BMP Q 2-4 hours, then Q 8-12hours, then Q day

2.ABG Q 2 hoursx2

After 4 hrs

1. Stop 0.9% NS and give ½ Normal saline, IV, continuous Monitor potassium deficiency and add IV potassium chloride as needed

Consider antibiotics if the precipitating cause is an infection, get a chest X-ray, obtain blood cultures, U/A and urine cultures.

Once nausea is decreased, start oral fluids.

Once the patient is stabilized transfer to ward/floor.

During discharge:

D/C IV insulin, IV fluids, cardiac monitor

NPH insulin, subcutaneous, continuous

Regular insulin, subcutaneous, continuous

Diabetic diet (Diet, American diabetic association)

Advance diet

Counseling:

Diabetic teaching

Patient education, diabetes

Diabetic foot care

Home glucose monitoring, instruct patient

No alcohol

No smoking

Safe sex

No illegal drug use

Regular exercise

Seat belts use

*Follow up appointment in 10 days

Discussion:

Diagnosis of DKA is based on an elevated blood glucose (usually above 250mg/dl), a low serum bicarbonate level (usually below 15 mEq/L), and elevated anion gap, and

36

demonstrable ketonemia. Both amylase and lipase are often elevated in patients with DKA by an unknown mechanism (do not to confuse with pancreatitis).

Diagnosis of Hyperosmolar hyperglycemic is based on: serum glucose levels in excess of 600 mg/dl, serum osmolality greater than 330 mOsm/kg, absent or minimal ketonemia, arterial pH above 7.3, and a serum bicarbonate above 20 mEq/L. Hyperosmolar hyperglycemic state is characterized by severe fluid and electrolyte depletion due to the osmotic diuresis produced by the extreme levels of glucose in the serum (often >1000 mg /dL).

Hydration: Patients with DKA are profoundly dehydrated and foremost in the treatment of DKA is restoration of the intravascular volume. Estimates of fluid deficits in the decompensated diabetic is 4 to 10 liters (usually 5-6 liters). Initially, one to two liters of normal saline is given as bolus, followed by 500 mL/h for the first four hours followed by 250 mL/h for the next several hours. This initial management should be guided by the patient's general condition and response, with more or less fluid as indicated. After the first 3-4 hours, as the clinical condition of the patient improves, with stable blood pressure and good urine output, fluids should be changed to 1/2 normal saline at 250-500cc an hour for 3-4 hours. Ongoing reassessment is critical.

Insulin: The standard insulin dose is an initial bolus of 10 to 15 units of regular insulin followed by a continuous infusion at a rate of 8 to 15 units per hour. When the glucose levels begin to approach 250 mg/dl, insulin infusions are continued, but the fluid composition is changed to include 5-10% dextrose in water to avoid hypoglycemia.

Potassium: Regardless of the serum potassium level at the initiation of therapy, during treatment of DKA there is usually a rapid decline in the potassium concentration in the patient with normal kidney function.

Potassium replacement is indicated in all patients with the following features: K of <6, no EKG changes, and normal renal function.

Bicarbonate Therapy: The use of bicarbonate in the treatment of DKA is highly controversial. Current recommendations for bicarbonate therapy are as follows. Use of bicarbonate is considered unnecessary when the blood pH is greater than 7.1.

Phosphate is normally an intracellular substance that is dragged out of the cell during DKA. Similarly to potassium, at presentation the serum level may be normal, high, or low while the total body supply is depleted. Despite this depletion, replacement of phosphate has not been shown to affect patient outcome and routine replacement is not recommended.

Primary diagnosis:

DKA

Case13

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Print

Location: Emergency room

Vitals: BP 100/60 mm Hg; HR is 50/min, regular; RR is 10/min; Temp. 37C(98.6).

HPI:

28-yr old white female is brought to ER in unconscious state. Family reports that she is a very healthy female, has no medical problems, not on any medications, and did not find any empty bottles. She has no allergies. She doesn't smoke or drink alcohol. She has a boyfriend. She has never been pregnant. Her father is very healthy except borderline hypertension. Mother has diabetes. No other history is available.

How do you approach this patient? Discussion:

Step I: Emergent management: This patient is hemodynamically unstable, so A, B, C, D is the most important component of the management of this patient.

A:Airway suction, pulse oximetry, stat, and continuous monitoring, O2

B:Endotracheal intubation is indicated in patients who cannot protect their airway or if O2 saturation does not improve with O2 nasal/face mask, or PaO2<55, or PCO2>50 on ABG.

C:IV access; continuous cardiac monitor; place a Foley; obtain a finger stick glucose.

D:Drugs: Administer thiamine, dextrose 50%, and naloxone - all are IV bolus one time dose

Exam:

Respiratory (assess the breathing pattern)

Order review:

Suction airway, stat

Pulse oximetry, stat and continuous Oxygen, inhalation, stat or Intubation IV access, stat

Cardiac monitor , continuous Finger stick glucose, stat Thiamine, IV stat, one time Dextrose 50%, stat, one time Naloxone, IV stat, one time

Normal saline 0.9% NaCl, stat, continuous ABG, stat

*She is slightly awake with the above treatment

Step II: Physical Examination:

General

HEENT/Neck

Heart/CVS

Skin

Chest/Lung

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Abdomen

Extremities Neurological exam

Results:

On examinations she found to have pinpoint pupils. She is very drowsy. So, she has bradycardia, hypotension, and pinpoint pupils, which are classic symptoms for narcotic overdose.

Step III: Diagnostic Investigations:

EKG 12 lead, stat

CBC with differential, stat

BMP, stat

CXR, portable, PA, stat

LFT's, stat

UA, stat

Urine toxicology screen, stat

B-HCG, serum, qualitative, stat

Blood alcohol, stat

Initial Treatment:

NG tube, gastric lavage, stat (which revealed pill fragments)

Activated charcoal, oral, one time

Naloxone, IV, stat, continuous

Step IV:

Decision about changing patient location

Move patient to ICU

NPO

Bed rest, complete Urine output

BMP, next day

*Once the patient is better

D/C oxygen, NG tube, cardiac monitor, IV fluids, and naloxone Regular diet

Step V: Educate patient and family:

Psychiatry consult, stat (Reason: 28-year-old with suicide attempt) Suicide precautions

Suicide contract Patient counseling Reassurance

No alcohol No smoking Safe sex

No illegal drug use Regular exercise Seat belts use

*Start the patient on antidepressant if needed

Final Diagnosis:

Narcotic overdose

Discussion:

Orthostatic hypotension resulting from mild peripheral vasodilation is

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common. However, persistent or severe hypotension should raise the suspicion of co-ingestants.

In all patients with moderate-to-severe toxicity, it is important to obtain baseline studies, including a CBC with diff, basic metabolic panel, LFT's, ABG, and CK (Creatine kinase level).

Positive urine drug screens are observed up to 36-48 hours postexposure.

A 12 lead EKG should be obtained on all patients with intentional overdose, as there is always a possibility of cardiotoxic co-ingestants.

Chest x-ray is important to rule out any pulmonary edema or aspiration especially in a patient with an unprotected airway.

Naloxone should be given to patients with significant CNS and/or respiratory depression.

Continuous IV infusion of naloxone is very safe in patients who were not opioid dependent. However, in patients who are opioid dependent this practice is dangerous and may precipitate withdrawal symptoms.

Activated charcoal should be administered to all patients with opiate intoxication following ingestion. Because of the delayed gastric emptying produced by opiate intoxication, it is effective even in patients who present late following ingestion. Orogastric lavage is indicated if the patient presents within one hour of ingestion.

All patients with significant respiratory depression, recurrent sedation should be observed in the hospital for at least a period of 12-24 hours. Most physicians admit the patients if they require a second dose of naloxone.

Patients should have continuous cardio respiratory monitoring.

Case14

Print

Location: Emergency room

Vitals: BP 150/90 mm Hg, HR 70/min, RR 16/min, and Temperature 37C.

HPI:

A 65 yr old white male is brought to the ER by his wife after he dropped a glass on the floor. His speech became slurred and he was unable to understand what she was saying. She asked him to write something. He wrote a couple of sentences that didn't make any sense. The episode lasted a few hours. She brought her husband to ER. He denies any residual weakness or sensory changes. He also denies any visual changes, headache, nausea, vomiting, bowel, or bladder dysfunction. His other medical problems include hypertension, hypercholesterolemia, and DM. He takes enalapril 10 mg po QD, Simvastatin 10 mg po QD, and metformin 500 mg BID. He

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has no allergies. He has been smoking one PPD for the past 30 years. He occasionally drinks alcohol. His father died with MI at the age of 68. His mother died from a stroke. He has no known allergies.

How do you approach this patient?

Consider the D.D: Thrombotic or embolic TIA Subdural hematoma Seizure

Hypoglycemia Brain tumors

Labyrinthine disorders

Step I: Emergent management:

A, B, C, D- Not needed.

Step II: Physical Examination

General appearance, HEENT/Neck, Lymph Nodes, Skin, Heart, Lungs, Abdomen, Extremities, Neuro.

Results:

A loud bruit is present over the left carotid; no murmurs, rubs, or bruits were heard over pericardium. Neuro exam is nonfocal. Rest of the exam is within normal limits.

Step III: Diagnostic Investigations:

IV access, stat

CBC with differential, stat

BMP, stat

EKG 12 lead, stat

CT scan of the brain, (without contrast), stat

Results:

CBC and BMP are normal.

CT: NEGATIVE for acute cerebrovascular event. (Most of the time CT scan will not show any deficits in the first 24 hours.)

Diagnosis:

Considering history, physical, & the test you have done: this patient most likely had a TIA. TIA by definition, deficit lasting <24hrs.

There is a bruit on left carotid. It might represent a plaque that sent a small embolus to the brain.

Step IV: Decision about changing the patient’s location

Admit to ward

Vitals Q 6 hours

Diabetic diet

Ambulate at will

Continue his home medications

Accucheck glucose, every 8 hours

Carotid Doppler, stat

Telemetry (cardiac monitoring)

Echocardiogram, stat

Aspirin, oral, continuous

Results:

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>70% stenosis in left carotid artery by carotid Doppler. No arrhythmia on tele monitoring

ECHO: No valvular disease, no evidence of thrombus, normal left ventricular function, normal atrial size

Treatment plan:

Vascular surgery consult, stat (reason: 65-year old with TIA and >70% LCAS) for CEA

If the patient is accepted for surgery: PT/INR, stat

PTT, stat

Type and cross match, stat Consent for procedure NPO

Step V: Educate patient and family:

Patient counseling No smoking

No alcohol Safe sex

No illegal drug use Regular exercise Seat belts use Diabetic diet

Medication compliance

Better BP control (exercise, diet, and pharmacological)

DM control (exercise, diet, and pharmacological)

Continue aspirin

Step VI: Final Diagnosis:

Transit Ischemic Attack.

Discussion:

Basically TIA has three pathophysiologic subtypes:

Large artery low flow TIA (true TIA)

Embolic TIA,

Lacunar TIA

The best way of differentiating these entities is by good history. Low flow TIAs are brief (lasts minutes to few hours), recurrent, and stereotyped. The underlying pathology is some kind of atherosclerotic stenosis in cerebral vascular system, most likely the internal carotid artery. On the other hand, embolic TIAs are characterized by discrete, usually single, and more prolonged (several hours) episodes of focal neurologic symptoms.

All patients with suspected TIA require urgent evaluation. Routine inpatient evaluation following TIA is controversial. American Heart Association does not recommend inpatient evaluation following TIA, unless the time to obtain the basic tests takes longer as an outpatient. Initial evaluation should include good history, physical examination, and some basic tests. CBC with differential and BMP should be obtained to exclude the hematologic (thrombocytosis) and metabolic causes (hypoglycemia, hyponatremia) of neurologic symptoms. ECG is useful to diagnose an unsuspected atrial fibrillation and a recent MI. CT of the head without contrast and carotid doppler should be performed on all patients. MR angiography is used primarily

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to diagnose abnormalities in the posterior cerebral circulation.

Patients with embolic TIA should have a cardiac evaluation, preferably with transesophageal echocardiogram. Most of the emboli are <3mm and transthoracic echocardiogram cannot visualize these. TEE is also useful for suspected atrial thrombi. However, TTE can be considered in elderly patients with H/O CHF or previous MI since the left ventricular apex is not well seen with TEE (This is a common site for left ventricular thrombi.). In general, we proceed with TTE because it is noninvasive. TEE is indicated if the TTE is negative and the decision of the management depends on TEE findings.

Treatment:

Aspirin is the mainstay of therapy regardless of the pathophysiology of the TIA. Patients who cannot tolerate aspirin should be treated with either clopidogrel or ticlopidine. There is no evidence that the combination use has superior results than aspirin alone. However, the combination therapy can be considered in patients who have a TIA while on aspirin alone.

Further therapy depends on weather the TIA is: 1. Atherothrombotic 2. Embolic.

Atherothrombotic:

If a large vessel, like internal carotid artery, is involved carotid endarterectomy should be performed. A Multidisciplinary Consensus Statement from the American Heart Association concluded that carotid endarterectomy is of proven benefit for symptomatic patients with 70% to 99% stenosis, provided the surgical risk is less than 6%. The presence of 100% carotid stenosis, previous stroke with persistent neurologic symptoms, and presence of multiple co morbid medical conditions are contraindications for CEA.

There are no indications to give either warfarin or heparin to this patient population, unless they have an associated H/O atrial fibrillation.

Risk factor management includes treatment of hypertension, diabetes mellitus, smoking, dyslipidemia, and hyperhomocysteinemia.

Embolic:

There is definitive evidence that patients with obvious cardiac source of embolism will benefit from antithrombotic therapy. The use of heparin is controversial in patients with acute TIA and has an evidence of atrial fibrillation. However, all patients should be treated with warfarin unless there are contraindications.

If the patient is on warfarin because of atrial fibrillation and develops a stroke/TIA, low dose aspirin can be added while maintaining the patient on warfarin with a target INR.

Case15

Print

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Location: Emergency room

Presenting complaint:

A 22-year-old woman presents with fever and pelvic pain

Vitals: Pulse:102/min, Temp:102.5F, R.R:19/min, B.P:125/80mm Hg, Height:162.5cm, Weight:60 kg (132lbs).

HPI:

A 22-year-old female presents to the ED with a one-day history of severe lower abdominal and pelvic pain with high-grade fever and chills. The pain is dull and aching and does not radiate. Movement and coitus make the pain worse. This type of pain is completely new for the patient. Her last menstrual period was 4 weeks ago but there is an ongoing slight vaginal bleed. The patient is also nauseated and has vomited on three occasions. She is sexually active with her boyfriend and uses hormonal contraception. She has never been pregnant. She has no known allergies. She has no other medical problems. She is not on any medications other than OC pills. Her vaccinations are up to date. FH: Father is 50 and has diabetes; mother is 47 and has asthma. She has one older sister who is healthy. SH: She does not smoke; however she drinks alcohol daily. She denies recreational drug use. She is un-married and has no children. ROS are unremarkable.

How to approach this case:

This young woman presents with pelvic and abdominal pain and high-grade fever. Based on the history, she most likely has PID. Another possible cause is appendicitis, which needs to be ruled out in all cases of acute abdomen. Pregnancy related problems are likely when the duration of the LMP is greater than 6 weeks. In patients of age greater than 35, MI, cholecystitis and pancreatitis must be considered. Therefore, do the following:

Order physical examination:

General examination HEENT/Neck

Heart and lungs examination Abdominal examination Genital/pelvic examination Rectal examination Extremities

Here are the results of examination:

General examination: Patient appears ill and in moderate pain. Abdomen: There is bilateral lower abdominal tenderness, normal bowel sounds, no hepatosplenomegaly. No rebound or rigidity. No evidence of abdominal distention. Genital examination: There is bilateral adnexal tenderness as well as cervical motion tenderness. Mild bloody discharge is present on the cervical os. Rectal examination: Sphincter tone is normal; heme negative brown colored stools; no palpable masses. Rest of the exam in normal.

Discussion:

The following minimal clinical criteria has been suggested for the diagnosis of PID: adnexal tenderness, abdominal tenderness and cervical motion tenderness plus fever of 38C or greater or Leukocytosis or evidence of pus in the peritoneal cavity or evidence of pelvic abscess or sexual contact with someone who is infected with

44

chlamydia or gonococcus.

This patient meets the clinical diagnostic criteria for PID. Obtain a CBC, gonococcal and chlamydial cultures as well as gram stains to increase the specificity of the diagnosis. Other non-specific tests, which can be ordered, are ESR and C-reactive protein. Urinalysis is appropriate to rule out a co-existent UTI. Pregnancy testing should be done in every sexually active female of childbearing age. An abdominal ultrasound is appropriate when pregnancy related problems are considered (LMP is greater than 6 weeks).

Order review:

IV access, stat

CBC with differential, stat

Basic metabolic panel (BMP), stat Pregnancy test, serum, qualitative, stat Urinalysis, stat

Urine culture and sensitivity, stat Gram stain, cervix, stat Gonococcal culture, cervix

Chlamydial culture, cervix (or DNA probe test) PAP smear, routine

ESR, stat (Optional; usually we don’t do in real time practice) VDRL, serum, routine

HIV test, ELISA, routine (or HIV 1 and 2)

Result of Labs:

Pregnancy test is negative.

CBC with differential: WBC counts: 12000/cmm with slight left shift (85% N, 3% bands, 6% L, 3% M, 2% E, 1% B), Hemoglobin of 15.9 g/dL, and platelet count of 200,000/mm3. Peripheral blood smear: Normochromic normocytic erythrocytes. Leukocytes and platelets normal in number and morphology.

Basic metabolic panel is normal. ESR: 40

Urinalysis: normal Gram-staining: no bacteria found Gonococcal cultures: pending Chlamydial culture: pending

*Meanwhile, start the management of this patient of acute PID. This patient needs inpatient treatment, as she is nulliparous, has GI complaints, and fever greater than 102.2F. Other criteria for inpatient treatment include elevated WBC, adolescence, peritoneal symptoms, uncertain diagnosis, failure to respond to 48 hours of outpatient management, inability to tolerate outpatient treatment, pregnancy and immunodeficiency.

Antibiotic treatment is empirical. The inpatient regimen is IV cefoxitin or IV cefotetan plus oral or IV doxycycline administered until at least for 48 hours after clinical recovery. Then continue oral doxycycline for 14 days.

(Or)

IV clindamycin and a loading dose of IV gentamycin. Continue IV clindamycin for 24 hours after the clinical recovery. Give oral doxycycline treatment for 14 days.

Outpatient treatment is a single oral dose of cefoxitin or a single IM injection of ceftriaxone plus a single oral dose of Probenecid and oral doxycycline for 14 days.

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Order review:

Shift the patient to ward NPO (as she is vomiting)

Bed rest with bathroom privileges Vitals: Every 4 hours

Normal saline, IV, continuous

Metaclopropamide (or Phenergan), IV, continuous (for nausea and vomiting) Morphine, IV, one time (for pain)

Cefoxitin, IV, continuous Doxycycline, IV, continuous

Acetaminophen, oral, continuous (as needed) *Evaluate next day

Results:

The patient is pain free, afebrile and her condition remains improved for 48 hours.

Order review:

Stop Metaclopropamide Stop IV fluids

Start regular diet as soon as she is able to take D/C IV Cefoxitin

D/C IV Doxycycline Doxycycline, oral, continuous

Counseling:

Patient counseling

Contraception counseling

Medication compliance

Safe sex counseling

Smoking, cessation

No alcohol

No illegal drugs

Drive with seat belts

Regular exercise

Follow-up in 7- days.

Primary Diagnosis:

Acute PID

Case16

Print

Location: office

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Presenting complaint: A 25-year-old African-American male presents with jaundice.

Vitals: Pulse:95/min, B.P:110/75 mm Hg, Temp:98.8 F, R.R:16/min, Height:72 inches (180 cm), Weight:72 Kg (158.4 lbs)

HPI: A 25-year-old African-American male presents to the outpatient clinic with the sudden onset of jaundice and dark colored urine. He complains of back pain and fatigue. The patient is afebrile and denies recent travel. He does not smoke, drink alcohol or use recreational drugs and uses condoms whenever he engages in sexual activity. On further questioning, it is revealed that he took TMP-SMZ for diarrhea a few days ago. An uncle has a history of some type of blood disorder.

Hospitalization/Procedures

None

Other Medical Problems

None

Allergies

NKDA

Current Medications

None

Vaccinations

Up to date

Family History

Mother died at the age of 60 yrs due to MI. Father is alive and healthy at the age of 65 yrs. No sibling.

Social History

He is single but has a girl friend. Denies tobacco, alcohol and drug use.

Sexual History

He is sexually active with his girl friend.

Occupational History

Restaurant owner.

Recreational

He plays basketball and enjoys traveling.

Review of Systems:

General see HPI

Skin

pallor, itch, no rashes

HEENT

Icterus

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Musculoskeletal

No muscle aches or joint stiffness

Cardio respiratory

Without complaint

Genitourinary

Dark colored urine, denies dysuria

Abdominal see HPI

How to approach this case:

This is a presentation of jaundice. Jaundice can be due to hemolytic causes and disorders involving the liver or biliary tracts.

First perform a physical examination:

General examination Skin

Lymph nodes HEENT/Neck Heart exam Lung exam

Abdominal examination Extremities

Neuro

Results of PE:

General: Icterus is noted on sclera; He also appears pallor. Abdominal examination: no masses, tenderness, or organomegaly. Normal bowel sounds. Rest of the exam is WNL

Routine Orders:

CBC with differential, routine Basic metabolic panel, routine LFTs, routine

Prothrombin time, routine

Results of Labs:

 

 

WBC count:

8200/mm3

 

RBC count:

1.8 million/mm3

Hemoglobin:

9 g/dL

 

 

Hematocrit:

33 %

 

 

Platelet count:

200,000/mm3

MCV:

 

98 cu microns

MCH:

 

28pg/RBC

MCHC:

 

35 g Hb/dL

WBC differential:

 

 

Segmented neutrophils:

72%

Juvenile neutrophils:

 

2%

Lymphocytes:

 

18%

 

Monocytes:

5%

 

 

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Eosinophils: 2%

Basophils: 1%

Peripheral blood smear:

Normochromic normocytic erythrocytes, bite cells are also present. Leukocytes and platelets are normal in number and morphology.

LFTs

 

 

Bilirubin, serum, total

5 mg/dL

Bilirubin, serum, direct

0.5 mg/dL

Aspartate transaminase, serum

25U/L

Alanine transaminase, serum

20U/L

Alkaline phosphatase, serum

182U/L

Protein, serum, total 7.2 g/dL

 

Prothrombin time

 

11 sec

Discussion:

This patient has no history of fever or abdominal pain and also no risk factors for hepatitis. Thus, acute cholangitis or hepatitis is unlikely as a cause of his jaundice. Normal abdominal examination with absence of tenderness further excludes liver or biliary tract pathology. The presence of pallor, and dark colored urine suggests an intravascular hemolytic cause of the jaundice. Other points to elicit are positive family history and exposure to sulpha drugs.

Normal LFTs rule out liver or biliary tract disease. Elevated levels of indirect bilirubin are a clue towards hemolysis. CBC shows anemia and presence of bite cells on peripheral smear. This suggests that the jaundice is due to hemolysis. Next do the following tests to confirm the presence of hemolysis and to determine if it is intravascular or extravascular.

Routine Order review:

Admit the patient in floor/ward IV access, stat

Normal saline, IV, continuous

Diet: Regular diet (avoid fava beans) Activity - ambulation at will

Reticulocyte count, stat (to confirm that jaundice is hemolytic as reticulocyte count is elevated in cases of hemolysis)

Calculate reticulocyte production index (to correct reticulocyte count for the degree of anemia)

Serum haptoglobin

LDH, serum, stat (it is elevated in intravascular hemolysis)

Urinalysis, stat (to detect hemoglobin or hemosiderinuria)

Type and cross match, stat (for 2 units of blood)

PRBC, transfuse, stat (packed RBC transfusion)

*Repeat Hb and hematocrit (H& H) in 12 hours

Results:

 

BUN

12 mg/dL

Serum creatinine

0.6 mg/dL

Rest of the BMP

WNL

Serum LDH

400 IU/L

Serum haptoglobin

20 mg/dL

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Urinalysis

normal

Elevated reticulocyte count confirms the presence of hemolytic anemia and elevated LDH with low haptoglobin indicate that the hemolysis is intravascular. A positive family history, history of exposure to sulpha drugs and presence of bite cells on peripheral smear are all suggestive of G6PD deficiency anemia. G6PD deficiency is confirmed by G6PD assay. Other hereditary causes of hemolytic anemia are sickle cell anemia, thalassemias and hereditary spherocytosis.

In sickle cell anemia, peripheral smear shows sickle shaped RBCs and in hereditary spherocytosis RBCs exhibit a loss of central pallor. Thalassemias produce a microcytic picture with target cells. For thalassemias and sickle cell anemia, hemoglobin electrophoresis provides useful diagnostic information. Autoimmune hemolytic anemia is an important non-hereditary cause and in such cases coomb’s test is an important diagnostic tool. Intravascular hemolysis can also be a part of thrombotic thrombocytopenic purpura, but in such cases fragmented RBCs are found on peripheral smear and platelet counts are also low along with renal impairment. Regarding treatment of G6PD deficiency anemia, all affected individuals should avoid exposure to drugs with oxidant potential. Heterozygous females should also avoid exposure to such drugs during pregnancy and lactation as they may trigger hemolysis in the fetus or neonate. Transfusions are needed when anemia is very severe due to impaired compensatory erythropoiesis.

Routine Order:

G6PD blood, quantitative, stat

Coomb's test, direct, stat (optional-depending on the scenario)

Result:

G6PD levels are low (levels can be normal during or immediately after the acute hemolytic episode, therefore you can repeat the test to confirm the diagnosis)

Order review:

Schedule an appointment after 2 months and at that time re-evaluate G6PD assay Reassurance

Patient counseling Limit alcohol use Regular exercise Safe sex counseling

Primary Diagnosis:

G6PD deficiency anemia

Case17

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50

Location: Office

Presenting complaint: A 2-year-old boy is brought with complaints of failure to gain weight and loose stools.

Vitals: Pulse

:100/min, B.P

:80/56 mm Hg, Temp

:101.2

F, R.R

:18/min, Height

:

27.2 inches (68cm), Weight

:7.2 Kg (16 lbs)

 

 

 

HPI:

A 2-year-old Caucasian child is brought to the doctor’s office by his parents for an evaluation of loose greasy stools and failure to gain weight despite adequate nutrition. His other problems are intermittent productive cough and rhinorrhea. The parents state that he has been wheezing and coughing up a purulent expectoration for 4 days. They deny fever or chills. He has had pneumonia 4 times since birth. Delivery of the child and neonatal course were uncomplicated. He was breast-fed until the age of 4 months. There is a history of CF in the family of both of his parents.

Review of Systems:

 

General:

 

Skin:

No rashes or lesions

HEENT:

Nasal discharge

Musculoskeletal:

No joint swelling

Cardio respiratory:

see HPI

Genitourinary:

No complaints

Abdominal:

see HPI

Development:

Delayed

Vaccinations:

Up-to-date

How to approach this case:

This child presents with failure to thrive. Failure to thrive has both organic and non- organic causes. The etiology of failure to thrive in this child is most likely cystic fibrosis. Clues to cystic fibrosis in this patient are positive family history, repeated chest infections and malabsorptive diarrhea.

Order:

Complete physical examination (except breast)

RESULTS:

The child seems to be emaciated; his height and weight are lower than expected for his age. Chest examination shows generalized hyper-resonance and scattered crepitations bilaterally. He also has wheezing especially during expiration.

ORDER REVIEW:

Admit to the ward

Pulse oximetry, stat and every 4 hours IV access, stat

Sputum gram stain, stat

Sputum culture and sensitivity, stat (Type sputum C&S)

Blood cultures, stat

CBC with differential, stat

BMP, stat

CXR-PA/Lateral, stat

Sinus x-ray, routine

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Sweat chloride, routine

72-hour fecal fat estimation, routine

Treatment:

Oxygen inhalation, continuous (If saturation are <92% on room air) Amoxycillin and Clavulonic acid, oral, continuous (Type Augmentin) Nebulized Albuterol, inhalation, continuous (4 times a day)

Multivitamin tablets, oral, continuous

Chest physiotherapy

Vitals Q 6 hours D5NS, IV, continuous Regular diet Ambulation at will

RESULTS:

CBC shows neutrophilic leukocytosis Sweat chloride is 85 meq/L

BMP showed low sodium and potassium CXR shows hyperinflation of both lung fields.

X-ray PNS shows opacification of paranasal sinuses.

Gram staining of sputum does not show any predominant organism. Sputum culture is pending.

72-hr fecal fat estimation is pending

DISCUSSION:

Cystic fibrosis is an autosomal recessive disorder commonly affecting Caucasians. Its clinical manifestations include acute or persistent respiratory symptoms, failure to thrive, meconium ileus, diarrhea, rectal prolapse, nasal polyps, electrolyte or acid- base disorders and hepatobiliary disease. Diagnosis of cystic fibrosis is made when evidence of CFTR dysfunction is present along with typical clinical features or positive family history. Elevated sweat chloride on two separate occasions is an evidence of CFTR dysfunction. Other important tests are gram stain, culture and sensitivity of the sputum, chest X-ray, X-ray of the para nasal sinuses. 24 hour fecal fat estimation should be used to diagnose the malabsorption. Genetic testing is not required to make the diagnosis as it is associated with multiple mutations.

All children who are suspected to be suffering from CF should be admitted to the hospital. Evaluation should include baseline testing, accurate diagnosis, initiation of treatment and education of the patient and parents. Follow-up should be done every 2-3 months for monitoring. History, physical examination and staining and culture of sputum or pharyngeal swab are required on each follow-up visit. Prophylactic immunization against influenza, measles, and pertussis should be given.

Treatment:

Antibiotics are given when a patient of CF develops acute or sub-acute increase in sputum production, cough, dyspnea and/or fever. Antibiotics are selected according to the results of sputum culture. Sputum cultures are performed at least on yearly basis to help identify the bacteria, which are chronically inhabiting the respiratory tract. Oral antibiotics are used when exacerbation is mild, while IV antibiotics are used when exacerbation is severe and when bacteria are resistant to oral antibiotics. For S. aureus, oral antibiotics used are cephalexin, dicloxacillin or amoxicillin-clavulanate. For P. aeruginosa, ciprofloxacin is used as an oral antibiotic. IV regimen for P. aeruginosa is a combination of tobramycin and anti-pseudomonal penicillin

52

like piperacillin.

Bronchodilators like albuterol or salmeterol are used in patients with airflow obstruction.

DNase is usually prescribed for those with daily productive cough plus airflow obstruction.

Combination of physiotherapy and exercise should be considered in patients with more retained purulent secretions.

Inhaled glucocorticoids can be used in patients of CF who have clinical evidence of airway hyperactivity.

Oxygen therapy should be considered in all patients who have evidence of hypoxemia at night or rest or pulmonary HTN.

Lung transplantation is the only definitive treatment in patients with severe infections and grossly damaged lungs with a FEV1 of 30% or less of the predicted value.

Nutrition: Recommended diet is one with high protein and high calories. Vitamin supplementation of fat-soluble vitamins and pancreatic enzyme replacement are also very important.

Results review:

72-hours fecal fat is elevated.

Sputum culture grew staphylococcus aureus, sensitive to cephalexin.

ORDER REVIEW:

D/C Amoxycillin and Clavulonic acid; D/C Iv fluids Stat cephalexin, oral, continuous

Influenza vaccine Pneumococcal vaccine Consult dietitian

Pancreatic enzymes, oral, continuous Genetic counseling

*Follow up at 2-3 months

PRIMARY DIAGNOSIS:

Cystic fibrosis

Case18

Print

Location: Office

Presenting complaint: A 26-year old female presents with amenorrhea and abdominal pain.

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Vitals: PR: 84/min; Temp: 98.90F; R.R: 17/min; B.P: 125/80mm Hg; Height: 162.5cm; Weight: 60 kg (132lbs).

HPI:

A 26-year-old white female presents to your office with a one-day history of lower abdominal pain. The pain is dull and aching, 4/10 in severity, and does not radiate. She feels nauseated but has not vomited. Her last menstrual period was 7 weeks ago. Previously, her menstrual cycles have always been regular, 29-30 days in duration. Now, she complains of slight vaginal bleeding. The patient is sexually active with her husband and uses safe period for contraception. Her history includes two episodes of PID. She has never been pregnant and does not smoke or drink alcohol. She has no known allergies. She is not on any medications. FH: Father is 50 and has COPD; mother is 46 and healthy. She has two older sisters who are healthy. ROS are unremarkable.

How do you approach this case?

This young woman presents with amenorrhea, abdominal pain, and vaginal bleeding. Differential diagnosis includes: ectopic pregnancy, abortion, molar pregnancy, degenerating leiomyoma, adnexal torsion, ruptured corpus luteum, PID, acute diverticulitis, pyelonephritis, or IBD.

The triad of amenorrhea, abdominal pain, and vaginal pain suggests ectopic pregnancy The condition of this patient is stable; therefore we can safely proceed towards a compl examination. Stable patients require continuous monitoring for signs of rupture like increasing abdominal pain, or tenderness, shock, and bleeding. In addition to doing a focused examination, also perform a pregnancy test, which will help us include or exclu conditions related to pregnancy. If the patient is unstable, as indicated by hypotension and tachycardia, obtain immediate IV access, administer normal saline, type and cross match blood and start the blood transfusion along with continuous BP monitoring follow by consultation with Surgery/Obstetrics & Gynecology for possible laparotomy.

Start with the following orders: General examination HEENT/Neck

Heart examination Lungs examination Abdominal examination Genital examination Rectal examination Extremities

Result of examination:

General examination: Well nourished, well developed woman in pain and appears sick. Abdominal examination: abdominal tenderness in left lower quadrant; normal bowel sounds; no bruits; spleen and liver are not palpable; no hernias.

Genital examination: Uterus is slightly enlarged and feels boggy. A small amount of dark brownish-red blood is coming from cervical os. There is mild left adnexal tenderness.

Rectal examination: Sphincter tone is normal; stool is brown colored without occult blood; no palpable masses.

Rest of her exam is unremarkable.

Order:

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beta HCG, urine quantitative, stat or Pregnancy test, serum, qualitative, stat

Result of Labs:

Positive urinary beta-HCG

Discussion:

Positive urinary beta-HCG testing coupled with the classic triad of abdominal pain, amenorrhea, and vaginal bleeding is highly suggestive of ectopic pregnancy. But other pregnancy related problems like spontaneous abortion, molar pregnancy, and ruptured corpus luteum are included in the differential. They can all be excluded by ultrasonography. With molar pregnancy, there may be a history or evidence of passage of vesicles, hyperemesis gravidarum, large for date pregnancy, very high serum beta-HCG levels, or a snowstorm pattern on pelvic ultrasonography. With incomplete or compete abortion there is a history of vaginal passage of products of conception. To confirm the presence of ectopic pregnancy, perform a quantitative serum HCG plus transvaginal ultrasonography.

Progesterone measurement add nothing to the information already obtained by quantitative serum HCG and transvaginal U/S. Therefore, they need not be performed routinely.

Perform coagulation studies, blood typing, and cross matching, as well as cervical culture for Gonococcus and Chlamydia.

LFTs and renal function tests are important studies to perform, as impaired functioning of these organs is an important contraindication to the use of methotrexate. Methotrexate can be used as a medical treatment for ectopic pregnancy. Culdocentesis will show any blood in the cul-de-sac but this information can be obtained by transvaginal ultrasonography.

Laparoscopy is used mostly for treatment purposes as diagnosis is often established by ultrasound and hCG measurements.

Admit the patient to the ward

NPO

IV access, stat

Normal saline, IV, continuous

Bed rest, complete

Vitals every 1-hour

Transvaginal ultrasonography, stat

Beta-HCG, serum, quantitative, stat

Type and cross matching, stat

Blood group and Rh, stat

CBC with differential, routine

PT/INR, routine

PTT, routine

BMP, routine

Gonococcal culture, cervix

Chlamydia culture, cervix

PAP smear (if not documented before)

Discussion:

If beta-hCG level is greater than 1500 IU/L and TVS shows an intrauterine pregnancy,

55

ectopic pregnancy is ruled out. If beta-hCG level is greater than 1500 IU/L and TVS does not show any intrauterine pregnancy, EP is very likely. When beta-hCG level is less than 1500 IU/L and there is no intrauterine or extrauterine pregnancy on TVS, repeat these tests within two to three days. If there is an adnexal mass along with beta-hCG level greater than 1500 IU/L, EP is almost certain.

Results of labs:

Transvaginal ultrasonography: A non-specific left adnexal mass is observed, 2.2 cm in size.

Quantitative serum beta-HCG levels: 2000 IU/L Blood typing and cross matching: A-positive

CBC with differential, stat:

WBC count:

8200/mm3

RBC count:

5.1 million/mm3

Hemoglobin:

15.9 g/dl

Platelet count:

200,000/mm3

PT, stat:

9.5 sec

PTT, stat:

24 sec

LFTs:

Within normal limits

BMP:

Within normal limits

Cervical culture:

Pending

Discussion:

Presence of an adnexal mass along with elevated serum beta-HCG levels confirms the presence of ectopic pregnancy. Treatment can now be started. The available treatment options are medical therapy with methotrexate, laparoscopic surgery, laparotomy, and expectant management.

Laparotomy is indicated when the patient is in shock and when the size of ectopic pregnancy is greater than 3.5 cm. When the patient is hemodynamically stable and the size of gestation is less than 3-3.5 cm, she can be treated with either methotrexate or laparoscopy.

MTX treatment can be employed successfully in those who are asymptomatic, whose serum beta hCG level is less than 5000 IU/L, US shows that tubal size is less than 3 cm, and there is no fetal cardiac activity. Post treatment compliance is also an important consideration in these patients. There are some contraindications to the use of MTX like renal failure, liver failure, hypersensitivity to MTX, and breast-feeding.

Some patients who are asymptomatic, stable, and have un ruptured EP can be managed expectantly.

Patients of ectopic pregnancy who are Rh negative should receive Rh immunoglobulin.

The patient here is stable hemodynamically, the size of her gestation is smaller than 3 cm, and there is no contraindication to the use of methotrexate therapy; therefore treat with either MTX or laparoscopic surgery.

Order Review:

OBGYN consult, stat (Reason: Management of ectopic pregnancy) Methotrexate IV, stat, one time

Morphine, IV, one time (for pain)

*Send her home with follow up visit at 4 days for quantitative serum beta-HCG. Safe sex counseling

Contraceptive counseling

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Patient counseling

Medication compliance

Primary Diagnosis:

Ectopic pregnancy

Case19

Print

Location: office

Presenting complaint: A 5-year-old boy presents with continuous oozing of blood after dental extraction two days ago.

Vitals: Pulse:80/min B.P:110/70 mm Hg Temp:98.70F R.R:16/min Height:103cm Weight:18.0 kg

HPI: A 5-year-old boy is brought to the physician’s office by his mother complaining that there is continuous oozing of blood from the site of his extracted tooth. He underwent tooth extraction two days ago. The bleeding stopped initially but restarted spontaneously a few hours later and continues to bleed. Mom denies, cough, SOB, vomiting, fever, epistaxis, bleeding per rectum, easy bruising, petechiae or other illnesses. The child takes no medicines. The mom has one brother who is a hemophiliac.

Hospitalization/Procedures None

Other Medical Problems

None

Allergies

NKDA

Current Medications

None

Vaccinations

Up to date

Family History

Father is healthy at 28; mother is 24 and has asthma.

Developmental history

He attends kindergarten. He achieved all developmental milestones at the appropriate

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ages. One sister who is healthy

Review of Systems:

General:

Skin

No rashes

HEENT

No complaints

Musculoskeletal

Stiff right elbow

Cardio respiratory

No complaints

Genitourinary

Wets the bed

Abdominal

Denies complaints

How to approach this case:

This child presents with a probable bleeding disorder. His bleeding is minor and his condition is stable. Assess his general condition, skin and oral cavity for evidence of blood loss. Bleeding problems may be due to the disorders of blood vessels, platelets or clotting factors.

ORDER

Complete physical examination

Labs:

CBC with differential, stat (to determine platelet count as low platelet counts result in disorders of primary hemostasis)

Basic metabolic panel, stat

Bleeding time, stat (bleeding time is prolonged in disorders of primary hemostasis) Prothrombin time, stat (PT is prolonged in disorders of extrinsic pathway of coagulation cascade)

Partial thromboplastin time, stat (PTT is prolonged in disorders of intrinsic pathway of coagulation cascade)

Liver function tests, stat

Results of PE:

General examination: well developed and well nourished.

Skin examination: no petechiae, warm, pink, normal turgor, no lesions, hair and nails normal

HEENT: normocephalic, normal vision and fundus, hearing and ears are normal. Blood is oozing from the site of the extracted tooth. No abnormality detected in nose or oropharynx.

The remainder of the examination is WNL.

Results of Labs:

 

WBC counts:

8200/mm3

RBC counts:

5.6 million/mm3

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Hemoglobin:

15.5 g/dl

Hematocrit:

45%

Platelet counts:

200,000/mm3

MCV:

90 cu microns

MCH:

28pg/RBC

MCHC:

35 g Hb/dL

WBC differential:

Segmented neutrophils: 72%

Juvenile neutrophils:

2%

Lymphocytes:

18%

Monocytes:

5%

Eosinophils:

2%

Basophils:

1%

Peripheral blood smear:

Normochromic normocytic erythrocytes, Leukocytes and platelets are normal in number and morphology

Bleeding time: 5 minutes Prothrombin time: 12.2 seconds

Partial thromboplastin time: 50 seconds

DISCUSSION:

Bleeding disorders may be divided into two broad categories of primary and secondary hemostasis. Primary hemostasis involves interaction of platelets with the vessel wall and secondary hemostasis requires clotting factors. Thus vessel wall abnormality or reduced or dysfunctional platelets result in disorders of primary hemostasis. These disorders present with skin or mucosal bleed and labs show prolonged bleeding time. Mucosal bleeding may manifest as epistaxis, hematuria, hematochezia or metrorrhagia. Cutaneous bleeding manifests as petechiae or superficial ecchymoses. Bleeding after trauma is immediate as apposed to delayed bleeding in disorders of secondary hemostasis. Bleeding in disorders of secondary hemostasis is deep-seated resulting in large hematomas and cutaneous bleeds are large palpable ecchymoses. Labs show pronged clotting time.

Here we are dealing with a child who has delayed post-traumatic bleed, which is usually a manifestation of a disorder of secondary hemostasis, which is further confirmed by prolonged clotting time. This patient has a prolonged PTT with normal PT. Prolonged PTT with normal PT may be due to a number of hereditary or acquired causes involving the intrinsic coagulation pathway. Inherited disorders include deficiency of factor VIII (hemophilia), factor IX (Christmas disease) or factor XI. This patient is most likely has hemophilia, as one of his maternal uncles is also a hemophiliac. Von Willebrand’s disease may also cause prolonged PTT with normal PT. Antiphospholipid syndrome is an important acquired disorder, which prolongs PTT, however, it is associated with thrombosis. Heparin therapy prolongs PTT. Prolonged PTT and prolonged PT are due to inherited deficiencies of the clotting factors of the common pathway of the clotting cascade. Acquired causes include DIC, vitamin K deficiency and liver disease. Normal PTT with prolonged PT is due to factor VII deficiency.

Review order:

Factor VIII, plasma

Factor IX, plasma

Results of Labs:

Factor VIII: 3%

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Factor IX: normal

Review order:

Factor VIII, therapy

Counsel patient

Counsel parents

Consult, genetics (for carrier detection and future pregnancies)

No aspirin

Patients with hemophilia should be given monoclonal purified or recombinant factor VIII to prevent viral infection and exposure to other proteins. Counsel about the avoidance of aspirin as it may cause bleeding by inhibiting platelet aggregation. Before surgery every hemophiliac should be screened for factor VIII inhibitor and if it is not present, he needs to be given factor VIII before surgery. Before tooth extraction, hemophiliacs should also receive factor VIII and they need to be started on EACA, which is an antifibrinolytic agent that stabilizes clot formation. Genetic counseling and carrier detection should also be done. The patient can engage in exercise and sports but should avoid contact sports.

Primary Diagnosis:

Hemophilia

Case20

Print

Location: E.R

C.C: Severe shortness of breath

Vitals:

Pulse: 130/min,Temp: 99° F, B.P: 120/70 with pulsus paradoxus, R.R: 34/min

HPI:

A 36-year-old asthmatic man is brought to the ED by his co-workers with complaints of severe shortness of breath, cough, wheezing, chest tightness, and diaphoresis. He is unable to speak in phrases and his speech is restricted to single syllables between breaths. He was doing his routine work when he developed breathless and wheezing. He used his prescribed as needed inhalers twice, but his condition deteriorated. The patient has never been intubated or mechanically ventilated for asthma. He denies any chest pain, fever, chills, and hemoptysis. His other ROS are unremarkable. PMH: Bronchial asthma. FH: Mother has H/O bronchial asthma and father is healthy. SH: Married for 12 years. No children. Smokes 10 cigarettes for the last 10 years and drinks alcohol occasionally. Allergies: Pollen and

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dust. Medications: Albuterol 2 puffs Q 4 hrs prn. Vaccinations: Up-to-date.

How would you approach this patient?

Dyspnea alone doesn’t signify pulmonary disease; it may be present in cardiovascular and pulmonary diseases. This patient has severe dyspnea. The management in such patients depends upon identifying the cause of dyspnea. The patient is a known asthmatic. Start with a broad differential diagnosis. Dyspnea in a patient with known asthma may be due to:

Asthma exacerbation Status asthmaticus

Pneumonia Pneumothorax

And few causes in the context of any case of acute dyspnea; Pulmonary Embolism

Cardiogenic pulmonary Edema Cardiac tamponade

Upper airway obstruction (foreign body aspiration, anaphylaxis)

On the basis of history and vitals, we cannot rule out the possibilities of pneumothorax, or pulmonary embolism; however most likely cause of acute dyspnea in this patient is Asthma exacerbation.

Order:

Pulse oximetry, stat, and continuous IV access, stat

Oxygen inhalation, stat Head elevation

Results:

Pulse oximetry showed 89% O2 saturations on room air

Order examination:

General, HEENT, Chest/Lungs, Heart, Abdomen, Extremities

Results of Physical Examination:

HEENT: WNL, no JVD; LUNG/CHEST: Patient is agitated and unable to recline. He is gasping for breath and using his accessory muscles. Respiratory rate is 34/min. Percussion note is resonant in all lung fields. On auscultation of lungs, air entry is bilaterally equal. Loud inspiratory and expiratory wheezing is audible in all lung fields. CVS: Decrease in systolic B.P. on inspiration is 20 mmHg (pulsus paradoxus). There is no pedal edema. The rest of the exam is normal.

How do you approach now?

Pneumothorax is unlikely in the presence of breath sounds in all lung fields. Cor pulmonale refers to acute right heart failure due to pulmonary disease. Pulmonary embolism is mostly responsible for the acute decompensation of right heart. Pulmonary embolism is unlikely in the absence of chest pain, any predisposing factor such as orthopedic surgery. Wheezing may be present in such patients due to reflex bronchospasm. Pulsus paradoxus again is non-specific for pericardial tamponade. It may be present in asthma and severe COPD. Pneumonia is unlikely in the absence of fever and productive cough. Respiratory examination didn’t reveal any crackles or bronchial breath sounds.

Order review:

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Arterial Blood Gas (ABG), stat

Peak expiratory flow rate, stat (Type - PEFR) EKG, 12 lead, stat

CXR, PA, portable, stat (to determine infectious exacerbation of asthma and rule out other causes)

Albuterol nebulization, stat and repeat for every 20 minutes

Methyl prednisolone, IV, continuous

CBC with diff, stat (to determine infectious exacerbation of asthma) BMP, stat

Results:

ABG shows

pH

7.35

pO2

60 mmHg

pCO2

40 mm Hg

PEFR 40% of the documented personal best

CXR shows hyperinflation, no infiltrate, no pneumothorax or effusions EKG is unremarkable for new changes except sinus tachycardia

*Examine the patient in 20 minutes

Results:

He is breathing better but still in distress (If he doesn't respond give ipratropium inhalations as well).

Review orders:

Admit to ward Vitals every 2 hours PEFR every 2 hours Regular diet Ambulation at will

Fluid replacement may be necessary due to volume depletion secondary to diaphoresis

Monitor the patient’s condition frequently

Next day:

D/C albuterol nebulization

Start metered dose albuterol - type albuterol, inhalation, continuous D/C IV steroids

Start oral steroids - type prednisone, oral, continuous (Usually we will taper but the option is not available in software)

Start inhaled steroids - type beclomethasone, inhalation, continuous

Counseling:

Patient counseling

Smoking cessation

Limit alcohol

Regular exercise

Use of seat belt

Safe sex

No illegal drug use

Medication compliance

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Change Location: Send home

Follow-up in 1-week

Primary diagnosis:

Acute exacerbation of bronchial asthma

Summary:

Carefully assess the patient for degree of severity

Use Beta agonists early

Monitor the patient frequently and assess the response

Recognize features of impending respiratory failure and act accordingly Do not forget to taper steroids

Emphasis on post exacerbation care plan (medication compliance, use, follow-up, recognition and self-management of attack)

Who should be hospitalized?

Patients who do not respond to initial treatment should be hospitalized. Generally patients who do not respond to 3 doses of bronchodilators are considered as non- responders. Other factors such as severity of attack, severity of airflow obstruction, duration of symptoms, and past history of such episodes

Response to initial treatment is a better predictor for the need of hospitalization in a patient than is a severity of an attack

What are the features of impending respiratory failure?

Impending respiratory failure is very important to identify. Patient will become mute and respiratory muscle fatigue will lead to paradoxical respiratory efforts. Chest will be silent and there will be no wheezes due to reduced air entry. Patient will be confused. PEFR will be less than 50% of personal best

What is the role of antibiotics?

In most cases, which are usually due to viral infection, antibiotics have no role. Antibiotics are prescribed to patients with fever, leukocytosis and pulmonary infiltrate on CXR.

Is there a role of anxiolytics?

Anxiolytics are contraindicated in patients with status asthmaticus due to concomitant respiratory depressant action.

Is there a role of mucolytics?

Mucolytics are not useful in asthmatic patients as it may worsen airway obstruction.

Case21

Print

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Location: Office

Vitals signs: B.P: 110/70 mmHg; HR: 88/min, regular; Temp: 37.8 C; R.R: 16/minute.

C.C: Constipation

HPI:

A 62-year-old Caucasian male, who has a 15-year history of Type 2 diabetes, taking insulin, presents for evaluation of recent onset of constipation. The patient reports that he has been having only one or two bowel movements per week for the last four to six weeks. He has been experiencing intermittent constipation for the last four or five years but usually has three to four bowel movements per week. He also reports abdominal bloating and distention, especially after eating meals, but denies abdominal pain. He denies any nausea, vomiting, history of abdominal surgery, trauma, weakness in the limbs, or prolonged immobility. He describes the stools as very hard, and he must strain to defecate. His diet consists primarily of red meat. He has no known allergies.

PMH:

Is significant for diabetes. He takes a total of 20 units of NPH and 10 units of regular insulin every day. He was diagnosed with congestive heart failure following an acute MI two years ago. At that time, lisinopril 10 mg QD, furosemide 80 mg BID, and isosorbide dinitrate were prescribed. He says that his blood sugar has been under control for the last 15 years. He admits to regular exercise. His other medications include aspirin 81 mg po QD, simvastatin 20 mg po QD, and KCL 40 mg PO QD. He never had colon checked.

FH is significant for heart disease in his mother.

SH: Quit smoking when he had an MI. Occasionally takes alcohol. Denies IV drug abuse.

How would you approach this patient?

He is a 62-year old man with a past medical history of Type 2 diabetes and congestive cardiac failure, presents with progressively worsening constipation.

Consider the common causes of constipation. The causes of chronic constipation include: irritable bowel syndrome; poor bowel habits; inadequate fiber or fluid intake; systemic diseases such as diabetes mellitus, neurologic gut dysfunction as seen in spinal cord injury, Parkinsonism, or Multiple Sclerosis. Hypothyroidism or medications like narcotics, calcium channel blockers, antidepressants, and anticholinergics can be responsible for constipation. (This patient does not use any of these medications.) Approximately 10 to 20 percent of the general adult population report symptoms compatible with irritable bowel. Other causes to consider are: chronic pseudo-obstruction due to slow colonic transit; megacolon, obstruction of rectal evacuation caused by Hirschsprung’s disease; pelvic floor dysfunction; rectal mucosal prolapse; or rectocele. Also, evaluate the patient for eating disorders and depression. The common causes of recent onset constipation are: colonic obstruction, which could be due to a neoplasm stricture; diverticular disease; anal sphincter spasm resulting from anal fissure, painful hemorrhoids or medications.

Order:

Complete physical examination

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Here are the results of your physical examination:

On general examination, the patient appears alert, awake, oriented times three, and not in any distress. No thyroid abnormalities. Heart examination is within normal limits. Abdomen is soft, but mildly distended. Bowel sounds are active in all quadrants. There is no guarding, rebound, or tenderness. Examination of the extremities does not reveal any edema or ulcerations. The neurological examination does not show any weakness or changes in sensation. Rectal examination shows normal prostate, normal sphincter tone, no fissure, but the rectal vault is empty.

How would you proceed from here?

Order the initial investigations on an outpatient. This patient could have constipation because of electrolyte disturbances, especially hypokalemia, due to prolonged use of furosemide.

CBC with differential, routine

BMP including calcium, routine

TSH, routine

Magnesium, routine

Phosphate, routine (Hypermagnesemia, hypercalcemia, and hypokalemia can all cause constipation)

Hemoglobin A1C, routine

Hem-occult

LFTs (He is on simvastatin, which can cause elevation of LFTs)

Advise the patient to: begin a high fiber diet; increase water intake; exercise regularly; do frequent Accu-Checks; keep tight control of blood sugar. Ask him to return

with the results of the lab tests.

Order:

High fiber diet

Plenty of fluids

Regular exercise

Accu-Checks QID (4 times a day)

Patient education

Metamucil 2 tsp 3 times a day

Return to clinic in one week

On return to your office, the rectal examination does not reveal any anal fissures, hemorrhoids, or an enlarged prostate. The rectal vault is empty. Thyroid function tests, magnesium level, CBC with differential, and BMP are all within normal limits. Hemoglobin A1C is 6. The patient has tried increased bulk and water intake. He is exercising and his blood sugar is under control. However, he is still constipated.

How would you proceed?

This patient likely has an underlying GI problem that requires further evaluation. The next step for this patient should be colonoscopy. You could choose to do a barium enema with sigmoidoscopy but a colonoscopy is more appropriate, especially if you want biopsies of possible mucosal lesions.

Order:

NPO past midnight

Colon preparation

GI consult: Reason Colonoscopy'

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Treatment:

First make sure that the patient does not have nausea, vomiting, abdominal pain or fecal impaction. Docusate is used prophylactically to prevent constipation, especially when the patient is bedridden or on narcotic medications. Magnesium containing compounds (milk of magnesium or magnesium sulfate) can be used in patients without renal insufficiency. Osmotic laxatives, alone or in combination with fiber supplements, should be tried before more expensive nonabsorbable carbohydrates like lactulose or sorbitol are used. For nonresponsive patients consider giving enemas, either Fleets or tap water. Oral Lactulose 30 cc PO Q4-6H, until bowel movements begin, is another option. In the initial investigations get abdominal and chest x-rays to rule out obstruction. Colonic transit studies, anorectal manometry, and pelvic floor studies are usually reserved for patients who have resistant constipation without any organic explanation.

Diagnosis:

Constipation secondary to ?

Case22

Print

Location: Emergency room

Vitals:

BP: 120/70, HR: 70/min, regular, RR: 28 min, Temperature: afebrile

C.C:

Shortness of breath

HPI:

A 64 yr old Caucasian male with a history of orthopnea and PND presented to the ER at 7 PM with a complaint of 2 months of progressively increasing shortness of breath. His condition has acutely become worse over the past 2 days such that he now has shortness of breath at rest. The SOB is slightly relieved when he sits upright. He denies any chest or abdominal pain. He complains of mild cough with deep inspirations that are associated with occasional pink frothy sputum. He has a 20- pound weight gain since the symptoms began. He is also complaining of easy fatigability, swollen legs, and decreased appetite. He denies any fever, chills, nausea, vomiting or headache. Bowel movements are regular and he denies urinary problems. PMH: He is a known hypertensive and diabetic of 19 yrs. He had a Q wave MI 6 yrs ago that was treated with thrombolytic therapy. He also has a history of hypercholesterolemia. Medications: He is on metoprolol, lisinopril, glyburide, simvastatin, aspirin, and isosorbide dinitrate. Allergic history: NKDA. SH: The patient

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has smoked 1 PPD for the past 40 years. Occasionally drinks alcohol on the weekends.

He is retired and lives at home with his wife. FH: Father died of a heart attack at the age of 70. Mother died at the age of 68 from breast cancer metastasis.

How would you approach this patient?

Elevate head of bed

Pulse oximetry, stat and continuous Oxygen, inhalation

IV access, stat Cardiac monitor 12 lead EKG, stat

Results:

Pulse oximetry shows oxygen saturation of 89% on 3 liters oxygen.

EKG shows an old Q wave in inferior leads with no significant changes from the old EKG.

Now do the physical examination:

General

Heart

Lungs Abdomen Extremities

Here are the results of the Examination:

Moderate JVD+, Mucosa is moist. Lungs: Bilateral decreased breath sounds with bibasilar crackles. Heart: Rate and rhythm is regular. S1 and S2 heard. S3 gallop present. Abdomen: Soft, Right upper quadrant tenderness is present. Liver is 1 cm below the right costal margin. Bowel sounds are present. No free fluid clinically. Extremities: 3 + bilateral pitting edema, no calf tenderness, no cyanosis

So how would you approach this case?

So basically the issue here is the differential diagnosis of progressive shortness of breath. Again in the CCS all cases are really straightforward.

As we said this is a straightforward case of congestive heart failure, but you should consider 2 other things in this pt. One is renal failure due to diabetes and hypertension and liver failure due to some other reason (for example; alcoholism, hepatitis etc) even though they are unlikely. So, always start with a relevant broad differential diagnosis and then work from there because the ECFMG (CCS) expect this from you. You should be considering why he is having CHF recently even though he had an MI 6 yrs ago. One possibility is another MI, which may be silent because he is a diabetic patient (autonomic neuropathy). The other possibilities are worsening hypertension leading to diastolic dysfunction or noncompliance with medication and diet resulting in decompensation of systolic dysfunction.

Order the following.

Furosemide (Lasix), IV, stat and continuous Chest- X ray PA and lateral views, stat CBC with differential, stat

BMP, stat

CK-MB, stat, and every 8 hours x 2 Troponin I, stat and every 8 hours x 2

Results:

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Chest – X ray is consistent with bilateral pulmonary edema. CK-MB and Troponin-I are normal. CBC and differential is normal. BMP shows Na 134 (Dilutional hyponatremia), K – 4.0, Chloride, CO2 and Ca are WNL. Blood glucose is 380.

Order:

Admit to ward Telemetry Ambulate at will Low salt diet

Low cholesterol diet Diabetic diet

Fluid restriction Urine output

Daily weights (type - weight, every day)

DVT prophylaxis (type - Pneumatic compression stockings) Continue all his home medications

EKG, repeat in the morning

BMP, next day (to check K and other electrolyte abnormalities with Lasix) HbA1C, routine

Lipid profile, routine Accucheck, every 6 hours

KCL, oral, continuous (as long as you give Lasix) Digoxin, oral, continuous

Echocardiogram, routine (to assess the left ventricular function)

Make sure the patient is on following medications for heart failure: Aspirin

Digoxin

Beta blocker (metoprolol)

ACE inhibitor (Enalapril or lisinopril)

Diuretic

Ok now we know that this most likely due to CHF. So what do you do for this pt?

Determine the LV function by obtaining a 2D echocardiogram.

Continue IV furosemide along with oral potassium because furosemide will cause hypokalemia. Order daily BMP.

Continue lisinopril (ACE inhibitors should be added if the pt is not on ACEIs) Beta blockers have clearly shown benefit in heart failure; so, they should be continued unless the patient is in acute pulmonary edema or has hypotension.

Digoxin is optional. It is particularly indicated if the patient is having atrial fibrillation or severely symptomatic.

Start insulin– order NPH and regular insulin

Continue aspirin

Continue simvastatin

You have admitted the patient. The next day is the day two. What is the plan?

Examine the patient

Consider converting IV to oral diuretics Determine if the patient stable for discharge?

Assess the need for oxygen therapy. The goal saturation is 92 to 96%. Wean the oxygen if his pulse oxygen shows saturations of >92.

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At the time of discharge consider the following:

Patient education

Cardiac rehabilitation program

Smoking cessation program

Alcohol cessation program

Regular exercise

Medication compliance

Seat belt use

*Follow up in 2 weeks

Primary diagnosis:

Exacerbation of CHF

Case23

Print

Location: Emergency Room

Vitals: BP: 102/68 in both arms , HR: 110/min regular rhythm , RR:16/minute , Afebrile

C.C:

A 75 yr old nursing home patient with decreased urine out put and altered mental status.

HPI:

A 75-year-old Nursing home patient is brought to ER for one day of altered mental status and decreased urine output. The patient is unable to give any history. The nursing home staff says that he has been having watery stools for the last 4 days.

He has 7-10 loose bowel movements per day. Stools have no foul smell, no mucous or blood. He has been drinking fruit juices and oral formula for the last 3 days, but has not urinated in the last 12 hours. They denied any history of fever, chills, chest pain, shortness of breath and abdominal pain.

PMH:

His past medical history is significant for type II DM, hypertension and osteoarthritis.

SH:

The patient does not smoke or drink alcohol.

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FH:

Father died at the age of 90 with Alzheimer’s disease and mother died in motor vehicle accident. One brother has diabetes.

Medications:

Current medications are lisinopril 5mg once daily, NPH insulin 10 U in the morning and 15 U in the evening, metoprolol, simvastatin, aspirin, ibuprofen and multi vitamins. His vaccinations are up-to-date.

All: Iodine and shellfish.

How would you approach this case?

Based on the history you may consider decreased urine output secondary to acute renal failure. Also consider dehydration leading to acute prerenal failure, diabetes causing possible intrinsic renal cause (DM), and post-renal obstruction (BPH). The other possible causes of altered mental status in this patient include DKA, hypoglycemia, hypertensive crisis, stroke etc.

Order:

Complete physical examination

Results of the physical examination:

HEENT: PEARL, EOM intact, mucosa is dry, no JVD and moderately dehydrated. Heart and lungs are normal to auscultate.

Abdomen: Scaphoid, soft, non tender, BS are hyperactive, no organomegaly Rectal: Prostate is normal in size, sphincter tone normal, no gross blood, and no masses.

CNS: Patient is not alert and not oriented to time, place or person. Otherwise there are no focal sensory or motor deficits.

Extremities: There is no edema, cyanosis or clubbing. Skin is dry with poor turgor, no rash, petechiae or bruises.

Now how would you approach this patient?

This patient is dehydrated, so the primary things to order are:

Pulse oxy, stat

STAT IV line placement

STAT NS fluid bolus followed by continuous drip

STAT Foley catheter, you are not sure of bladder residual volume in this elderly patient

12 lead EKG, stat

ABG, stat

CBC with differential, stat

Mg and Phosphate, stat

BMP (Na, K, Chloride, HCO3, BUN, Cr, Blood sugar, and Ca) stat and Q 8 hrs

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Urine analysis, stat

Urine culture and sensitivity, stat

Urine sodium and creatinine, stat

The Foley is placed; 30 ml of residual volume is noted. NSS IV fluid is running. What do you do now?

Your initial assessment of the patient

1) What is the hemodynamic status?

Dehydrated patient should be hydrated. A volume overloaded patient should be given diuretics. CVP (central venous pressure should be recorded by placing an order for central venous line in unstable patients)

2) What is the type of renal failure?

Prerenal, renal or post renal - will decide the main mode of treatment.

3) Is there a need for urgent hemodialysis?

The indications for urgent hemodialysis are refractory acidosis, refractory electrolyte disturbances, intoxicants, volume overload (pulmonary edema), pericardial rub, uremic encephalopathy, bleeding tendencies, and arrhythmias.

4) What is the most likely etiology?

Labs reveal a BUN of 90, creatinine of 2.3, potassium of 5.6 and mild protenuria. So how would you proceed?

If the BUN (Normal is 7-20) and creatinine (0.6 to 1.2) is elevated, then the diagnosis of renal failure is confirmed. Check the electrolytes that are part of the BMP. If the potassium level is elevated (normal is 3.5 to 5) then give D5/Insulin and re-check the potassium level. If the potassium is high always get the EKG. If the potassium is low, then replace the potassium cautiously and recheck the level.

If the patient is taking nephrotoxic drugs like NSAIDs, stop the drugs immediately. Ibuprofen is an NSAID and it aggravates the renal failure. ACEIs are indicated in DM type 2 for their renal protective effect, but in established renal failure with a creatinine of more than 2.0 to 2.5 their use should be restricted.

Now it’s the time to determine the cause of the renal failure. 1st determine whether the cause is low renal perfusion (prerenal) (or) disorders of parenchyma (renal) (or) obstructed urine flow (post renal).

There are 3 ways to differentiate prerenal from renal causes. The best way of assessing is by calculating FENa (Fractional Excretion of Sodium).

Prerenal:

FENa <1

Spot urine sodium <20 meq/L

Disproportionate increase of BUN/Cr ratio >20:1

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Renal:

FENa >1

Spot urine sodium >20 meq/L

Proportionate increase of BUN/Cr ration < 20:1 A short explanation to understand the causes:

Prerenal azotemia can lead to ATN, which is the most common cause of the acute renal failure. Two basic mechanisms:

a) Decreased effective intravascular volume (includes third space loss)

b) Decreased cardiac output.

Renal causes have specific etiologies ranging from infectious to toxin mediated and can be treated with specific etiology directed therapy.

Post renal or obstructive must be promptly treated to avoid any damage to the kidney. Two most common are BPH and nephrolithiasis.

Here the case scenario is of a pre renal failure most probably due to dehydration resulting from diarrhea.

Order routine:

Discontinue lisinopril

Discontinue ibuprofen

Continue rest of his current medications

Transfer to the floor/ward

Vitals q2h

24hr urine protein

Diabetic and renal diet with 100% hand assistance (Only if the patient is awake)

Complete bed rest until his mental status returns to baseline

Heparin 5000 U SQ Q12 hrs to prevent DVT

Renal ultrasound, routine. Stat order is placed only if you suspect an infective/renal/obstructive cause.

Daily weights

Strict input and output

Acu checks (blood sugar), QID (4 times a day)

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HBA1C levels, routine

Sliding scale insulin Finally treatment:

In prerenal the goal of the treatment is to increase the renal blood flow. If the patient is dehydrated continue I.V hydration. If the patient does not respond to fluids, start Lasix (furosemide) to increase the urine output. If the cause of the renal hypoperfusion is heart failure you can start dobutamine and dopamine.

The use of sodium bicarbonate (type NaHCO) is rarely needed unless the patient is in severe acidosis i.e. pH of <7.2.

Review orders:

Once the patient’s mental status is improved

Discontinue (D/C) bed rest

Out of bed to chair

D/C Foley catheter

Continue renal diet

Plenty of oral fluids

Other considerations:

Pericardial rub or rales – Chest X- ray (Both PA and lateral view)

Fever – Blood cultures, Immediate renal ultrasound, urine culture and start antibiotics (Ciprofloxacin)

Treat hypertension

Obstruction - order urology consult. Before getting a consult please order urgent renal ultrasound and don’t forget to catheterize.

Patient may take days to weeks to recover

Recovery diuresis should be treated with half (0.45%) NS and frequent electrolyte monitoring.

Primary diagnosis:

Acute renal failure or prerenal azotemia

Case24

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Print

Location: office

CC: A 16-year-old girl presents with heavy menstrual bleeding.

Vitals:Pulse 86/min, Temp 98.7 F, R.R 16/min, Height: 162.5cm, Weight: 55 kg (12lbs)

HPI:

A 16-year-old girl presents with the complaints of irregular and heavy menstrual bleeding for the last two months. She started menstruating at 13 and her cycles have been regular until 2 months ago. She has been sexually active with her boyfriend for the last month and they have always used condoms. She denies any burning on urination or vaginal discharge. She uses no medications. Her appetite and weight are normal. She is doing well at school and has no emotional stressors.

The rest of the ROS is negative. Allergies:

Penicillin. Immunization

history:

Up to date. FH:

Father is healthy at 43; mother is 38 and has

asthma. Maternal grandfather died of colon cancer at 60. She has one younger brother who is healthy. SH :She does not smoke, drink alcohol or use recreational drugs. Recreational history :Attending parties and watching movies

How to approach this case:

This young woman presents with abnormal uterine bleeding. In adolescent females and in perimenopausal women, dysfunctional uterine bleeding is in most cases due to anovulation thus it exposes the endometrial lining to unopposed estrogen stimulation. DUB is a diagnosis of exclusion, therefore other causes of abnormal uterine bleeding need to be ruled out. Any woman of reproductive age with DUB, pregnancy must be suspected. Reproductive tract problems like Leiomyoma, adenomyosis, endometriosis, PID and sexually transmitted diseases may be responsible. Polycystic ovary disease is another important cause. There may be endocrine causes like hypothyroidism, hyperthyroidism and hyperprolactinemia. Liver disease and other coagulation disorders may also be responsible. Therefore, careful history and examination as well as certain lab tests need to be performed before a diagnosis of DUB can be made.

ORDER Examination:

General

HEENT (especially for thyroid enlargement and visual field defects) Skin examination (especially for pallor, petechiae)

Heart exam Abdominal exam

Genital examination (for vaginal discharge, enlarged uterus, adnexal masses etc.) Extremity

Result of examination:

Skin: no petechiae, no pallor, and no hirsutism

HEENT: normal eyes, normal visual fields, normal vision, ears are normal set and normal hearing. Thyroid gland is normal.

Genital: normal female genitalia, no vaginal discharge, no vaginal or cervical lesions,

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uterus is of normal size, no adnexal masses or adnexal tenderness. Rest of her exam is WNL.

Labs:

Pregnancy test, serum, qualitative, routine (for ectopic pregnancy, abortion)

Pap smear, routine (pap smear should be performed when sexual activity is initiated even in a female younger than 18)

Serum TSH, routine (hypo or hyperthyroidism) Serum prolactin, routine

CBC with differential, routine (to determine platelet count as low platelet counts result in disorders of primary hemostasis, to look for anemia due to chronic blood loss)

PT, routine (for disorders of secondary hemostasis) PTT, routine (for disorders of secondary hemostasis)

There are other tests, which can be performed, in selected patients. If alcoholic or viral hepatitis is suspected and other features of liver disease are found, LFTs need to be performed. In perimenopausal women, endometrial biopsy must be performed to rule out endometrial cancer. Pelvic ultrasound may be needed in cases of PCOS, in cases where pelvic examination is suboptimal due to obesity and in suspected cases of ovarian tumor. Generally patients with DUB can be managed without imaging studies.

Result of Labs:

Pregnancy test is negative Pap smear: normal Serum TSH: 1microU/mL Serum prolactin: 5ng/mL

CBC with differential: WBC counts: 8,200/mm3 (normal differential); Hemoglobin: 10.9 g/dL; Platelet counts: 200,000/mm3; MCV: 78fl. Peripheral blood smear: Hypochromic and slightly microcytic erythrocytes; Leukocytes and platelets normal in number and morphology.

PT: 10 sec PTT: 25 sec

*Normal PE and normal lab tests exclude other causes of abnormal uterine bleeding and DUB is the most likely cause in this patient. When contraception is desired, oral contraceptives are usually used to treat DUB. They make the cycle more predictable and decrease the amount of menstrual flow. When bleeding is prolonged or severe, estrogen alone is used in high doses. If bleeding is not controlled by high dose estrogen therapy, D & C is indicated. Endometrial ablation is an option for those patients who have completed their family and are unresponsive to hormonal treatment.

Review order:

OCP, low estrogen, low progestin, continuous Iron sulfate, oral, continuous

Iron enriched diet Reassure the patient Safe sex counseling Medication compliance No smoking

No alcohol

No illegal drugs

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Regular exercise

Seat belt use

Primary Diagnosis:

Dysfunctional uterine bleeding

Case25

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Location: Emergency Room.

Vitals:

Temperature 38.0, respirations 30 per minute, blood pressure 101/68, heart rate is 90/min.

HPI:

The patient is a 16-month-old male who is accompanied by his mother who provides the history. This patient began to get ill two days prior to coming to the Emergency Room with a runny nose and mild cough. The mother reports that she thought he had a low-grade fever because he felt subjectively hot; however, she did not take his temperature. The patient has continued with his regular activities and is eating, drinking and urinating as usual. However, on the evening of presentation, the patient began to have a more severe, harsh, barking-like cough that has increased in severity over the past ten hours. The patient has become increasingly hoarse and has, according to mother, “noisy breathing.” REVIEW OF SYSTEMS is negative except for some complaints of sore throat, although it is difficult to determine because of the patient’s age. Mother denies the patient getting into any small objects which he may have ingested.

PMH:

The patient was born by normal spontaneous vaginal delivery. He had a circumcision. He went home with his mother after 24 hours. He is up to date on all of his immunizations including DTaP, Haemophilus influenza B, and pneumococcal conjugate vaccines. He has had one episode of otitis media in the past year.

Social history: He attends daycare three times a week. His lives with his mother, father, and seven-year-old sister. They have no pets in the house.

How do you approach this patient:

Pulse oxy, stat

Result:

O2 saturation is 98% on room air,

Perform physical examination:

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General

HEENT Lymph nodes Lungs

Heart Abdomen Extremities Skin Neurologic

Here are the results:

In general, the patient is in no acute distress. He is sitting on his mother’s lap and is somewhat playful, although he does have a harsh barking cough. HEENT: Mucous membranes are moist. There is no perioral cyanosis. Oropharynx shows erythema without any exudate. The neck is supple. There are a few scattered shotty nodes on the anterior cervical chain. Conjunctivae are slightly injected. Coryza is present. Tympanic membranes are pale with normal light reflex bilaterally without any bulging of the tympanic membranes. Cardiovascular: The patient has a regular rate and rhythm without murmurs, rubs or gallops. Lungs are clear to auscultation bilaterally, although there is a harsh barking cough, and there are chest wall retractions. There is slightly diminished air entry bilaterally. No crackles, rhonchi or wheezes. Abdomen is soft, nontender, nondistended with positive bowel sounds in all four quadrants. Extremities show capillary refill of less than two seconds. The extremities are pink and well perfused with 2+ pulses in all four extremities. Neurologic: The patient is awake and alert. He gets upset during the exam but is easily consoled by his mother.

Discussion:

The differential diagnosis for this patient’s problem includes:

1.Viral croup.

2.Bacterial croup.

3.Spasmodic croup.

4.Epiglottitis.

5.Foreign body ingestion.

6.Bacterial tracheitis.

7.Angioneurotic edema.

The case presentation and history are more consistent with a viral etiology for the patient’s croup. The most common viruses are parainfluenza 1, 2, and 3, but croup can also be caused by adenovirus, respiratory syncytial virus, and influenza A and B viruses. Influenza A in particular can cause a fairly severe croup syndrome. Children with croup can also become secondarily infected and develop a bacterial tracheitis. It is important to recognize which children have a benign viral picture compared to those who have a bacterial etiology necessitating antibiotics to cover for the most common pathogens, which are Strep. pneumoniae, Staphylococcus aureus, Haemophilus influenza, Moraxella catarrhalis as well as Streptococcus pyogenes.

In general, the child with viral croup is going to look less toxic than the child who has bacterial croup or bacterial tracheitis. In the latter two disorders, fever is usually higher, the severity of respiratory symptoms is worse and the child may have a more toxic appearance. Since the introduction of the Hib vaccine, very few cases of epiglottitis have been seen in the United States; however, in an unimmunized child this diagnosis should still be considered. In general, epiglottitis is a more rapidly progressive disorder evolving over the course of 4-12 hours and presenting with high

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fevers and a more toxic appearance. The child is usually in more respiratory distress, shows drooling, leans forward and is much more apprehensive, probably secondary to hypoxemia and airway obstruction.

In cases of viral croup, the diagnosis is made clinically. Neck X rays can be obtained and they may show a classic steeple sign with subglottic narrowing. However, in children in whom the tracheal cartilage is still soft, there can be a false steeple sign secondary to the respiratory phase as the trachea slightly collapses on expiration. Therefore, a good inspiratory film is necessary to evaluate steeple sign in children.

Acute angioneurotic edema is a rare cause of upper airway obstruction in children and they usually have other evidence of swelling in their face and neck area. Aspiration of a foreign body should also always be considered in the differential diagnosis. Usually these children have no preceding upper respiratory symptoms prior to having their upper airway obstructive symptoms, so history is the most important part in the evaluation.

Laboratory workup:

Croup is a clinical diagnosis and laboratory studies are usually not very helpful; however, a CBC may show an elevated white count around 10 with a predominance of polymorphonuclear leukocytes on the differential. Pulse oximetry usually reveals normal oximetry as this is not a lower airways disease and air exchange is good.

Treatment:

The first line of treatment is to start the child on cool humidified mist. This simple treatment can relieve airway edema and decrease the viscosity of tracheal mucus so that patients can clear their secretions better. Many children’s croup will be relieved just with cool mist treatment. However, patients should be monitored during cool mist treatment because it may induce or exacerbate bronchospasm in susceptible children. In most cases, however, at least a trial of cool mist treatment is warranted and further treatment is warranted if there is no improvement.

The next line of treatment is oral or IV steroids. Decadron (Dexamethasone) is the most extensively evaluated corticosteroid used in the treatment of croup. The usual dose is 0.6 mg/kg of dexamethasone up to a maximum of 10 mg. This can be given orally or intramuscularly and clinical trials of dexamethasone have shown that it has improved symptoms of croup compared to placebo. The use of nebulized racemic or L-isomer epinephrine is also used to treat severe croup symptoms. Epinephrine is thought to increase fluid resorption in the airway vessels within the bronchial tree and reduce capillary leakage from interstitial space and therefore decrease mucosal edema. A predictable side effect, however, of epinephrine is tachycardia and therefore it should not be used in patients who have a history of congenital heart defects in whom tachycardia can be deleterious, including those children with tetralogy of Fallot or those with ventricular outlet obstruction. Children with moderate to severe croup should be treated with the cool mist as well as nebulized epinephrine. There is some concern for rebound mucosal edema after nebulized epinephrine treatment and therefore children should receive a dose of Decadron prior to or shortly after receiving the epinephrine in order to decrease rebound edema. The patient should also be monitored for approximately four hours in the Emergency Room prior to discharge home. If they have no stridor at rest, normal air entry bilaterally, normal color and normal level of consciousness, and they have received their dose of Decadron, they can then be safely discharged from the Emergency Room.

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Other management options for children with croup that is severe include heliox which is a mixture of helium and oxygen. This can be used in croup because the children usually do not have significant hypoxemia. Heliox can be used when the amount of oxygen being provided to the patient is 40% or less. The heliox mixture allows for laminar flow through the airways and provides better delivery of oxygen. It may be used in children who have laryngotracheitis which has extended into the bronchii and small airways causing a pneumonitis. These children are usually sicker and require inpatient management.

In those children in whom possible secondary bacterial infection is suspected, treatment should be directed at the most common pathogens which were noted above and initial treatment can be with a second generation cephalosporin such as cefuroxime or a combination of a semi-synthetic penicillin like Nafcillin or oxacillin and a third generation cephalosporin.

Most cases of croup, however, are viral in nature and supportive therapy is all that is required.

Primary diagnosis:

Viral croup

Case26

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Location: Ambulatory Clinic.

Vitals:

Temperature 38 rectally, heart rate 155/min, blood pressure 95/55mm Hg. The patient’s weight is 7.2 kg.

C.C: Vomitings and diarrhea

HPI:

The patient is a six-month old white female who is brought in by her mother for evaluation of a three-day history of vomiting and profuse diarrhea and low-grade temperatures. Mother brings her to the clinic today because the infant has become increasingly irritable and fussy when she is awake and today has become much more somnolent and does not want to feed. She has not had any wet diapers since the evening before. However, she still is having bowel movements. Mother reports that the patient has had approximately eight to ten bowel movements a day for the past two days. She has been giving the infant an increased number of breast feeds at approximately three-hour intervals; however, the child frequently vomits the milk and also has runny diarrhea. The baby has refused to take any of the rice cereal

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which she has been introduced to for the past month. Mother reports that the vomiting is nonbilious. It mainly consists of partially digested milk. It is not projectile and it is nonbloody. The diarrhea is watery and yellow and there does not appear to be any blood or mucus in the stool. The mother reports that the baby’s temperature has been as high as 101. The mother reports that at her visit to the doctor’s about three weeks ago for her immunizations she was almost 8 kg.

PMH:

The patient was delivered at 40 weeks gestation by normal spontaneous vaginal delivery. She had no birth complications and was discharged home with her mother. This patient has been meeting her developmental milestones appropriately. She is able to roll over front to back and back to front. She babbles and coos and can sit upright for brief periods with minimum support.

IMMUNIZATIONS are up to date. She just had her six-month vaccinations about two and a half weeks ago.

Social history:

She lives with her mother and father and a three-year-old sibling (brother) who attends daycare one day a week. The parents are nonsmokers. There are sick contacts in the house as the older brother had a diarrheal illness earlier last week. The family has city water. They have not traveled.

REVIEW OF SYSTEMS: is positive for irritability, decreased urine output, decreased PO intake, increased somnolence, and decreased physical activity. Review of systems is otherwise negative.

How do you approach this baby:

General

HEENT

Neck

Lungs

Heart Abdomen Genitourinary Skin Extremities CNS

Here are the results:

In general, the patient is a well-developed, well-nourished white female lying somewhat listlessly in her mother’s arms. She does not fight against the examiner during the physical examination. HEENT: Anterior fontanel is open and depressed. Posterior fontanel is closed. Mucous membranes are dry. Eyes are slightly sunken with dark circles underneath them. Tympanic membranes are pale with good light reflex bilaterally. Neck is supple. There is no evidence of meningeal irritation to neck flexion or extension. There is no cervical lymphadenopathy. Pupils are equal, round and reactive to light. Oropharynx is clear. Cardiovascular: Heart rate is regular rhythm but somewhat tachycardic. There is a II/VI systolic ejection murmur along the left sternal border. Lungs are clear to auscultation bilaterally. Abdomen is soft, nondistended and nontender. There are hyperactive bowel sounds in all four quadrants. Extremities: Pulses are +2 in all four extremities. Capillary refill is about 3-4 seconds. GU: Normal female genitalia, mild diaper dermatitis present. Neurologic: The patient is somewhat listless and irritable but after a time is able to be consoled. Skin shows decreased turgor. There are no rashes.

DIFFERENTIAL DIAGNOSIS for this child with acute diarrhea as well as vomiting: At

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the top of the list is an infectious gastroenteritis with the two main groups being viral gastroenteritis--with etiologies including rotavirus, enterovirus, adenovirus and Norwalk agent--and the bacterial enterocolitis agents including Shigella, Salmonella, Yersinia, Campylobacter, enteroinvasive E. coli, enteropathogenic E. coli, and C. difficile colitis. Other possible etiologies of acute diarrhea include extraintestinal infections such as otitis media and urinary tract infections, and GI causes including intussusception, appendicitis, and hyperconcentrated infant formula. Other causes include antibiotic-induced diarrhea, vasculitides such has Henoch-Schonlein purpura, renal diseases including hemolytic uremic syndrome and toxic ingestions including iron, mercury, lead and fluoride ingestion.

This patient’s clinical presentation includes (1) a sick contact with a three-year-old sibling who had self-limited gastroenteritis symptoms the prior week, (2) low-grade temperature, (3) the lack of any preceding use of antibiotics, and (4) nonbloody stools. The most common cause for this picture is acute viral gastroenteritis.

How do you proceed:

LABORATORY STUDIES: Depending on how dehydrated the patient appears clinically, one might forego any laboratory studies and just treat her symptomatically with either oral electrolyte replacement solutions or IV rehydration in the clinic setting. However, based on her change in weight, it appears that she has lost about 7-10% of her body weight and is showing clinical signs that she is significantly dehydrated. Therefore, appropriate labs to obtain would be a basic metabolic panel and a CBC with differential. Stool should be heme checked and if it is positive, then stool samples could be sent for culture. If there had been a past history of antibiotic use, then a C. difficile antigen could be sent to rule out C difficile colitis. If the patient is being seen during the winter months, then stool can be sent for rotazyme assay since rotavirus can cause up to 65% of infant diarrhea during winter months. Stool can also be sent for fecal leukocytes, which also help to indicate that it is an infectious or inflammatory process. Because this child is moderately dehydrated, a urinalysis should also be sent to look for urinary tract infection.

ORDERS: Labs as above. The patient should be given a fluid bolus with normal saline 20cc/kg IV until the labs come back. A repeat fluid bolus can be given as well. The patient should be allowed to feed as tolerated. In this case, the patient is breast-fed so orders for breast-feeding ad lib would be appropriate. It can be helpful if the mother can feed the infant in smaller more frequent feedings whether breast- fed or bottle-fed. In addition, bottle fed infants can also be given an oral electrolyte solution; again small frequent feedings are preferable to decrease stomach irritation and reflex vomiting.

Review orders:

IV access

CBC with diff, stat BMP, stat

Urine analysis IV NS, bolus

IV NS, continuous Stool heme check Stool for leukocytes Stool culture Breast-feeding ad lib

Here are the results:

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Laboratory studies return. CBC shows a white blood count of 11, hemoglobin 14, hematocrit 42.1, platelets 370, differential shows segmented cells 52%, lymphocytes 20%, monocytes 5%, eosinophils 10%. Basic metabolic panel shows a sodium of 131, chloride 106, potassium 3.2, CO2 18, BUN 22, creatinine 0.6, calcium 9.8, glucose 87. A catheterized urine specimen yielded a scant amount of dark amber clear fluid. Specific gravity 1.032, negative for esterase, negative nitrates, no blood, 1-5 white blood cells, 0 red blood cells, no casts. Culture eventually is negative.

DISPOSITION: This patient should be admitted to the hospital for IV fluid rehydration because she is greater than 5% dehydrated, not taking enough oral fluids to meet her maintenance needs, and showing a declining mental status with irritability and listlessness.

Review orders:

Admit in ward/floor IV Potassium Vitals Q 4 hours

Recheck the BMP next day

Repeat physical exam for every 4-6 hours

Once the patient is adequately hydrated and the BMP is normal, discharge the patient to home.

DISCUSSION: Acute gastroenteritis is a very common pediatric problem and because many of the etiologies are self-limited, the clinician should direct attention to the patient’s overall fluid and electrolyte status as top priorities in management. Attention should be paid to the patient’s vital signs looking for tachycardia and evidence of weight loss. The physical exam should focus on hydration status by looking at mucous membranes, sunken eyes, skin turgor and capillary refill, which in normal children is less than two seconds. Abdominal exam should focus on whether there is any distention, tenderness or masses; frequently bowel sounds are hyperactive in viral or bacterial gastroenteritis. Direct inspection of the stool can be helpful as bloody or mucous stool is more often associated with bacterial pathogens and would direct investigations towards those etiologies. One would send a stool culture for Shigella, Campylobacter, Salmonella and Yersinia as well as the enteroinvasive E. coli. Pathogens that will require more than just supportive treatment with fluids and electrolytes include Campylobacter jejuni infection, which is treated with erythromycin; C difficile colitis, which is treated with metronidazole; and systemic salmonellosis, which is treated with fluoroquinolones or azithromycin or third generation cephalosporins such as ceftriaxone or cefotaxime. Bactrim may also be started empirically, but there is increasing resistance of Salmonella to Bactrim. In those children whose diarrhea is due to Giardia, a variety of drugs are used: metronidazole, furazolidone, or quinacrine, for example.

History taking should include questions about travel, well water (since Giardia can contaminate well water), immunization status, sick contacts, and daycare attendance (since Campylobacter outbreaks have been found in daycare centers). One should also ask about the duration of symptoms, fever, and the number, character, and color of the stools, particularly whether there is any blood or mucus in the stools.

Primary diagnosis

Acute gastroenteritis

Case27

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Print

Location:

Emergency department

Vitals:

Temperature 38.4, blood pressure 101/62 mm Hg, heart rate 95/min, and respirations 14/min.

HPI:

The patient is a nine-year-old African-American male who presents to the ER with his mother with a 16-hour history of fever, poor eating, and abdominal pain. The mother reports that the patient only picked at his dinner the night before and then went to bed early. During the middle of the night, she noted that he was hot to the touch but she did not take his temperature. In the morning, the patient had emesis one time, did not eat any breakfast and complained to his mother of abdominal pain. She then made an appointment to bring him to the clinic for further evaluation. You see the patient walking down the hallway of the clinic to go to his room and note that he is slightly bent forward and walking very carefully without lifting his feet very far off the ground. He looks ill. The history from the patient reveals that he has abdominal pain which he poorly localizes and points to the center of his stomach as to the site of the pain. He had one loose bowel movement this morning but otherwise denies any diarrhea, constipation, melena, bright red blood per rectum, dysuria, and frequency. He also denies sore throat, cough, rashes and joint complaints. Mother reports that the patient had been in his usual state of health until about suppertime the prior evening.

REVIEW OF SYSTEMS is as above and otherwise negative.

PMH:

The patient is a healthy nine-year-old boy with no past medical history. He attends the fourth grade. His immunizations are up to date. He has never been hospitalized. Past surgeries only include circumcision which was uncomplicated. Development: He is in fourth grade, a B student. He does well socially and plays Little League baseball.

SH:

The patient lives with his mother and five-year-old sister. There are no sick contacts in the house. There are no smokers in the house. They have city water.

How do you approach this patient?

General

HEENT

Neck

Heart

Lungs Abdomen Rectal Extremities

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Skin Genitourinary

Here are the results:

PHYSICAL EXAM: In general, the patient is alert and oriented, in moderate distress, lying very still on the exam table with both knees bent up. He’s cooperative with the exam, but appears apprehensive. HEENT: No abnormalities detected. Cardiovascular exam shows regular rate and rhythm without murmurs, rubs or gallops. Lungs are clear to auscultation bilaterally. Abdomen: Decreased bowel sounds. No hepatosplenomegaly. The patient has voluntary guarding during the exam. He points to the periumbilical area when asked to define where the location of the pain is. On palpation of the left lower quadrant, he complains of pain on his right lower quadrant. He has moderate voluntary guarding over the right lower quadrant. There is no distention and no tympany. Upon palpation of the right lower quadrant, there is rebound tenderness. Extension of the right leg from its flexed position where the patient has kept it elicits increased pain and the patient resists the extension manuever. GU: Tanner I circumcised male. Testes are descended bilaterally. There are no hernias appreciated. Femoral pulses are +2. Rectal is heme negative. No masses are palpated nor does exam elicit any further tenderness. Extremities reveal +2 pulses in all four extremities with good capillary refill. Skin is without rashes or signs or trauma.

Order:

Pulse oxy, stat CBC with diff, stat BMP, stat

LFTs, stat PT/INR, stat PTT, stat FOBT

Abdominal x-ray, stat NPO

IV fluids, NS

Abdominal ultrasound, stat

Next order:

Surgery consult, stat

Analgesia, stat (once the diagnosis is confirmed) IV cefazolin, stat

IV metronidazole, stat

Discussion:

This patient’s presentation is strongly suspicious for acute appendicitis. However, in some children a Strep throat infection can also cause abdominal symptoms. In the absence of any history of sore throat and with this patient’s presentation, one probably does not need to order a rapid Strep test. Any child who does have any complaint of sore throat, however, probably should have a rapid Strep done before going to surgery for an appendicitis. Other labs to order include basic metabolic panel, CBC with differential, heme check the stool, plain film of the abdomen. A urinalysis is frequently obtained to rule out a urinary tract infection. Results can be confusing since the inflamed appendix is often in close proximity to the bladder and ureter; as a result, microscopic hematuria and pyuria are found in up to one-third of patients with acute appendicitis. Pelvic cultures may be useful in sexually active, menstruating women. A beta-HCG is mandatory to rule out an ectopic pregnancy.

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Further imaging studies depend on what the initial laboratory results show and include an abdominal ultrasound to see if there is any fluid collection. However, ultrasound on pediatric patients is sometimes difficult to interpret because of the lack of qualified technicians to perform the study. Spiral CT scan is another diagnostic modality that can be used in equivocal cases. Frequently appendicitis is a clinical diagnosis.

DISCUSSION: The most common age range for appendicitis in children is between the ages of 10 and 15 years of age. This child is nine years old and a little bit outside of the range. Less than 10% of children with appendicitis are under five years of age and those children who are under two years of age are frequently missed and often have a perforated appendix before they are diagnosed. Other causes of abdominal pain that can mimic an appendicitis include enterocolitis caused by Campylobacter and Yersinia. They both can have right lower quadrant abdominal pain and tenderness.

Here are the results:

A basic metabolic panel may just show an elevated BUN, suggesting some dehydration. A CBC may show an elevated white blood count with a left shift, although the white count usually is not above 20,000. The plain film of the abdomen may show a fecalith, although this is not very frequent. An abdominal ultrasound may sometimes show the inflamed appendix. CT of the abdomen with oral contrast may show the enlarged dilated appendix.

DISCUSSION: For any child in whom one suspects appendicitis, an early surgical consult should be obtained as these patients need to be taken to surgery expeditiously. The risk for perforation increases markedly after 24 hours and those who are not diagnosed prior to 36 hours have a very high risk of perforation. Perforation carries with it the increased risk of abscess formation and diffuse peritonitis with higher morbidity and mortality. The role of antibiotics for an unperforated appendix just includes perioperative antibiotics (We prefer a combination of cefazolin and metronidazole; Postoperative antibiotics are unnecessary); for those who have perforated, triple antibiotics with ampicillin, gentamicin and metronidazole would be appropriate.

Primary diagnosis:

Acute appendicitis

Case28

Print

Location: Outpatient clinic

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Vitals: His temperature 37.8, pulse 145, respiratory rate 33, blood pressure 88/52.

HPI:

The patient is a three-month-old infant who is brought to the clinic by his mother because of a two to three day history of runny nose with congestion, low-grade fever, and poor eating. He also vomited several times and the emesis is usually mucus mixed with some of his feeds. He is more irritable and has difficulty feeding but appears to be still taking in his usual amount of formula. Mother reports, however, instead of feeding the formula over 15 minutes, it is taking the baby 35-40 minutes to finish his usual bottle of formula. The patient’s temperature has been a maximum of 100.6. He has two older school age siblings who had upper respiratory infections during the past week. Mother is concerned because the baby’s breathing is much more noisy.

ROS:

Somewhat increased irritability but consolable. Urine output is normal. No diarrhea. No constipation. Vomiting as noted above. No episodes of cyanosis or apnea episodes or rashes.

PMH:

The patient was born via normal spontaneous vaginal delivery. He was circumcised and had no bleeding diathesis. He went home with his mother after 48-hour hospital stay. He has had his two-month immunizations including DTAP, HIB, second hepatitis B, pneumococcal conjugate vaccine, and IPV.

Development: He has been meeting his milestones. His eyes track to 180 degrees bilaterally. He moves all of his arms and legs well. He does not yet roll over. He has a fair degree of head control. He has a social smile and interacts well with his family.

SH:

He lives with his parents and two older siblings. They have two cats in the house. They have well water. The patient does not attend any daycare. There is no smoking in the home.

FH:

Family history is positive for allergic rhinitis and is otherwise negative. Mother was Group-B Streptococcal infection positive and received prophylactic antibiotics intrapartum.

How do you approach the baby?

Pulse oximetry, stat

Result:

O2 saturation is at 95% on room air,

Order physical exam:

General

HEENT

Neck

Lungs

Heart

Abdomen

Extremities

Skin

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Here are the results of physical exam:

The patient weighs 6.3 kg and is in the 75th percentile for length and 50th percentile for head circumference. In general, the patient is awake, alert, and in no acute distress. HEENT: Pupils are equal, round and reactive to light. Extraocular eye movements are intact. The patient follows past the midline. His mucous membranes are moist. Neck is supple without lymphadenopathy. There is occasional nasal flaring. Nares are patent bilaterally but the mucosa is edematous. There is a profuse clear rhinorrhea. Tympanic membranes are pale with good light reflex bilaterally. Anterior fontanel is open, flat and soft. Heart is within normal limits (WNL). Lungs show bilateral diffuse wheezes and rhonchi in all lung fields. There are mild subcostal retractions but no paradoxical abdominal movement with breathing. Abdomen is within normal limits. Extremities show +2 pulse in all four extremities. The capillary refill is about two seconds. GU: Normal circumcised male. Testes are descended bilaterally. Anus is appropriately positioned.

Orders:

Admit the patient in ward/floor Continuous cardiorespiratory monitoring Pulse oxy, Q 1hour

ABG, stat (for baseline)

Chest X-ray ( Mainly to rule out any coexisting pneumonia, which requires antibiotics)

Humidified oxygen (40%), continuous IV NS, continuous

Suction, Q 1 hour (Nasal and posterior pharyngeal) Chest PT, Q 2 hours

Epinephrine, nebulization, prn (as needed) Albuterol, nebulization, Q 2-4hours

Discussion:

This is a classic presentation of bronchiolitis and it should be suspected in any child who presents with coryza, cough, dyspnea, prominent wheezing, and hyperinflation of lungs. Evaluation should include assessment of hydration and respiratory distress. Management of bronchiolitis respiratory infections in children is somewhat controversial. Agreed upon therapy includes oxygen therapy for those children who are hypoxic and severely distressed as well as inpatient monitoring for worsening respiratory distress. Children who cannot maintain good fluid intake or who do not have reliable caretakers to monitor their status should also be admitted to the hospital for observation. The role of bronchodilators and corticosteroids is not fully clear in these patients. Most clinicians will give a trial of bronchodilators to see if it improves the patient’s wheezing. These nebulizers such as albuterol can then be continued to improve wheezing and hypoxemia associated with bronchoconstriction. Judicious use of epinephrine nebulizers can also help temporize the patient’s symptoms probably by decreasing edema and allowing better airflow. The use of corticosteroids is not clear. Aggressive pulmonary toilet is necessary for these children with frequent nasal and posterior pharyngeal suctioning, frequent chest percussion therapy to help relieve the congestion secondary to excessive secretions. Nasal washings for respiratory syncytial virus and viral culture for parainfluenza and adenoviruses should be part of one’s work up.

Etiologies for this patient’s bronchiolitis are mainly viral in origin and include

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respiratory syncytial virus, parainfluenza viruses 1, 2, and 3, influenza viruses A and B and adenovirus.

For infants who need to be hospitalized, orders should include continuous cardiorespiratory monitoring, supplemental oxygen, frequent nasal suctioning and chest percussion therapy and, if they show benefit, albuterol nebulizer treatments. Continuous cardiorespiratory monitoring is warranted especially for very young infants with respiratory syncytial virus bronchiolitis because frequently their presentation involves apnea and, in fact, they may have very few wheezes on physical exam and have apnea as their sole presentation of RSV. Ribavarin is indicated for those with respiratory failure, immunosppression or severe coexisting medical condition.

Primary diagnosis:

Bronchiolitis

Case29

Print

Location: Office

Vitals: Temperature 39.1C, Blood pressure 118/80 mm Hg, Heart rate 98/min, regular, and Respiratory rate is 20/minute.

C.C: Knee pain with swelling, and fever

HPI: A 40-year-old white male with no significant past medical problems presents to your office with two-day history of fever, chills, and pain in his left knee associated with swelling. The patient reports that the fever and chills started two days ago. Last night he noticed moderate to severe pain and swelling in his left knee. The patient is unable to ambulate well due to the severity of the pain. There is no history of trauma to the joint. He denies any previous episodes of these symptoms. He also denies IV drugs use or insect bites. The patient’s mom has a history of rheumatoid arthritis. ROS are unremarkable. He has no allergies. He is not taking any medications. PMH: No past medical history, no history of hospital admissions. SH: He is sexually active with his wife and denies having multiple sex partners. He does not smoke or drink alcohol.

How would you evaluate this patient?

First list the patient problems:

40-year-old healthy male presented with two-day history of fever, chills, and sudden onset of pain and swelling in the knee, without a history of trauma or any prior joint disease.

The differential diagnosis of bacterial arthritis includes gout, pseudogout, Reiter's syndrome, RA, and Lyme disease, each of which can present with acute involvement

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of one or a few joints.

Always obtain a detailed history and physical examination. In this patient, examine the skin, joints and extremities, abdomen, heart, and lungs. This patient may have infective endocarditis, anemia, or murmurs as part of a diffuse septic process.

Order:

General

HEENT /Neck

Heart

Lungs

Abdomen

Extremities

Skin

Here are the results of the physical examination:

GENERAL EXAMINATION: The patient appears ill and is in obvious pain. He is awake, alert, oriented to time, place and person. The skin is without rash or any pustular lesions. The lungs are without crackles, wheeze, or rhonchi. The heart is within normal limits. There are no audible murmurs, rubs, or gallops. His abdomen is soft and non tender. Bowel sounds are present in all quadrants. His left knee is erythematous, tender, swollen, and has limited range of motion (ROM). The rest of his exam is unremarkable.

Order:

Admit in floor/ward Vitals Q 4 hours NPO

Blood cultures, stat CBC with diff, stat

Basic metabolic panel, stat ESR (Optional, non specific) PT/INR, stat

PTT, stat

Morphine, IV, one time, stat Consent for procedure Aspirate joint fluid, stat

Joint fluid for Gram stain, culture & sensitivity, GC culture, cell count and differential, crystals (all are stat)

X-ray knee, stat Acetaminophen, oral, continuous

Once you draw the blood and aspirate the joint

Ceftriaxone, IV continuous

How would you continue?

This patient is clearly ill and in severe pain. He needs to be hospitalized to confirm the diagnosis, rule out endocarditis, start treatment including joint aspiration and to monitor the clinical response. Admit the patient to the general medicine floor. The next step should be joint aspiration. The fluid should be sent for gram stain, culture and sensitivity, cell count with the differential and examined for crystal microscopy. Synovial fluid total protein, lactic dehydrogenase, and glucose level are not required because they are nonspecific in making the diagnosis. Obtain blood cultures from at

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least two sites. Also, order a CBC with a differential, ESR, and basic metabolic panel. Serological testing for Lyme disease may be indicated if suspicion is high. Radiographs should be taken but are usually normal early in the disease process. Culture the skin if there are any skin lesions.

Infectious arthritis can be separated into either nongonococcal or gonococcal. Usually, nongonococcal infectious arthritis occurs in adult patients with previous joint damage or in compromised host. Gram-negative bacilli should be considered in a compromised host. For example, those with malignancies, immunosuppression, HIV, or IV drug abusers. Staph aureus is the single most common cause of nongonococcal bacterial arthritis in the adult population. It is also, the most common organism associated with underlying rheumatoid arthritis. Gonococcal arthritis occurs in patients between the age of 15-40 who are otherwise healthy and sexually active. Staphylococcus epidermidis should be considered if the patient has a prosthetic joint infection. Lyme disease should be considered if the patient has a history of rash or insect bites. Gonococcal arthritis commonly presents as a migrating polyarthritis accompanied by tenosynovitis and erythematous pustular skin lesions. Cutaneous lesions and articular findings are believed to be the consequence of immunoreaction to circulating gonococci and immunocomplex deposition in tissues. However, culture is positive in less than half of the cases and gram stain in 25 percent of cases. Leukocyte counts average 10,000 per microliter. In gonococcal septic arthritis, blood cultures are almost always negative and gonococcus is only occasionally evident on gram stain smears. X-ray of the involved joint is indicated primarily to rule out osteomyelitis.

Empirically administer broad-spectrum antibiotics while awaiting lab results. The drug of choice is ceftriaxone, given intravenously. It is a broad-spectrum third generation cephalosporin and covers gram-negative diplococci (Neisseria, gonorrhea), gram- negative bacilli, as well as Lyme disease. If the initial gram stain of the synovial fluid shows gram-positive cocci, IV nafcillin or cefazolin are the drugs of choice. Vancomycin is considered for penicillin allergic patients or if it is a hospital or nursing home-acquired infection. If the initial Gram stain shows gram-negative bacilli, treatment should be started with a third generation cephalosporin such as ceftriaxone. If the suspecting organism is a Pseudomonas, such as in patients with H/O IV drug abuse, the treatment should be started with Ceftazidime along with an aminoglycoside, such as gentamicin.

Treatment should be changed according to the culture results. If the patient is on vancomycin and the culture showed methicillin sensitive S. aureus, vancomycin should be discontinued and nafcillin should be started. Patients should be treated with at least 10-14 days of IV antibiotics, followed by an additional 14 days of oral therapy.

Analysis of synovial fluid usually reveals most of the important diagnoses. Normal synovial fluid contains less than 180 cells per microliter with mostly mononuclear cells. Synovial fluid cell count of 25,000 to 50,000 per microliter with more than 90% neutrophils, is most likely due to bacterial infection. Crystal-induced, rheumatoid, and other noninfectious inflammatory arthritis are usually associated with a count of less than 30,000 to 50,000 cells per microliter. The presence of positively birefringent calcium pyrophosphate crystals indicates pseudogout. The presence of negative birefringent monosodium urophosphate crystals indicate gouty arthritis.

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RESULTS:

WBC count reveals 15,000/dl with 12% bands. Blood cultures are pending.

Because it is very difficult to isolate gonococcal from synovial fluid and blood cultures, specimens for culture should be obtained from mucosal surfaces, especially urethral discharge, oropharyngeal mucosal surface, and rectal cultures.

X rays of the joint revealed no osteomyelitis, but there is a joint effusion and soft tissue swelling.

Synovial fluid analysis revealed WBC count of 120,000 with 85% polymorphs and gram stain smear showed gram-positive cocci in clusters. Synovial fluid culture is pending. There are no visible crystals on microscopy.

How do you approach now?

This patient clearly has an infectious process of the knee joint. The most likely organism is Staphylococcus aureus. IV antibiotics should be started. If the patient is allergic to penicillin or the organism is methicillin resistant then the drug of choice is vancomycin. Repeated joint aspiration may be necessary. When response to antimicrobial therapy has been demonstrated, NSAID’s or Cox 2 inhibitors can be used to reduce pain. Splinting can be used but septic joints usually do not require immobilization.

For recurrent gonococcal arthritis, complement deficiencies must be ruled out.

Order:

D/C ceftriaxone Nafcillin, IV, continuous

Consult orthopedic surgery, stat (Reason: Patient with septic arthritis and needs incision and drainage)

*Patient is accepted for surgery

Primary Diagnosis:

Septic Arthritis

Case30

Print

Location: Emergency room

Vitals: Blood pressure: 130/80 mm Hg; Heart rate: 82/minute; Temperature: 38.7 C; Respiratory rate: 16/minute.

C.C: Chest pain

HPI:

A 47-year-old white male who has a past medical history significant for two years of hypertension presented to your office with the chief complaint of chest pain of one day duration. The patient states that he had a flu-like illness with nasal congestion and mild cough one week ago, which resolved with symptomatic treatment without

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antibiotics. The patient states that the chest pain has been occurring for the past 24 hours, is primarily retrosternal, increases in intensity with inspiration, and is relieved by sitting up and leaning forward. He says that the pain is 4-5/10 in severity and radiates to back and both arms. For the last two days, the patient has been feeling febrile but he denies any nausea, vomiting, or abdominal pain. He denies any history of shortness of breath, orthopnea, or PND. He has been on a low salt diet and hydrochlorothiazide 25 mg PO BID for his hypertension. His past medical history is significant for the flu-like illness three weeks ago and hypertension for the past two years. FH: Father had an MI at 60. SH: He smokes one to two packs of cigarettes per day. He occasionally drinks alcohol, especially on the weekends. All: He has no known allergies.

Based on this history, how would you approach this patient?

This is a presentation of acute pericarditis. Severe constant pain that localizes over the anterior chest, radiates to the arm, shoulder, back, epigastrium or neck, is intensified with inspiration, and relieved by sitting up and leaning forward is a classic picture of acute pericarditis. The pain is often difficult to differentiate from myocardial infarction because often the pain is very severe, short, and sometimes a very constricting pain that radiates either to one or both arms. However, pain which is relieved by sitting up and leaning forward and is intensified by inspiration or lying supine is characteristic of acute pericarditis. Acute pericarditis has a very broad differential diagnosis. The causes are primarily infectious, noninfectious or secondary to hypersensitivity or autoimmunity. The most common infectious causes are Coxsackie virus A and B, mumps, adeno, hepatitis, and HIV. The other common infectious causes are usually pyogenic for example: Pneumococcus, Streptococcus, Staphylococcus, Listeria, and Legionella. Tuberculosis can also cause pericarditis but it is usually of chronic origin rather than acute. In those patients the pain is less severe or absent. Fungal infections such as histoplasmosis, coccideal mycosis, candida, and blastomycosis, have been known to cause pericarditis.

The most common noninfectious causes of acute pericarditis are: acute myocardial infarction; renal failure resulting in uremia; neoplastic disorders which infiltrate the pericardium such as breast cancer, lymphomas, and leukemia; endocrine abnormalities (hypothyroidism or myxedema); and radiation. Pericarditis could also be due to autoimmunity or hypersensitivity reactions. This is especially true with rheumatic fever, collagen vascular diseases such as SLE, rheumatoid arthritis, ankylosing spondylitis, or scleroderma. Acute pericarditis may be due to drug toxicity, especially hydralazine, procainamide, and minoxidil. Other common causes of pericarditis are postmyocardial infarction (also called Dressler’s syndrome), post pericardiotomy, posttraumatic or cardiovascular surgery.

Start with a focused physical examination.

General examination

HEENT/Neck

Heart

Lungs

Abdomen

Extremities

Skin

Here are the results:

The general examination shows that the patient is alert, awake, and oriented times three. The patient is in pain but not in any acute distress. His heart examination

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revealed normal S-1, S-2. There is a pericardial friction rub present, but there are no murmurs.

Lung examination is within normal limits. Abdominal is benign. Extremities are within normal limits.

How would you approach this patient now?

Begin by ruling out myocardial infarction.

Pulse oximetry, stat

Oxygen inhalation, stat

IV access, stat

Cardiac monitor, stat

Results:

98% on room air

Order:

Aspirin, oral, stat, one time 12 lead EKG, stat

CBC with a differential, stat

BMP, stat (elevated BUN or creatinine may reveals the underlying uremia as the cause of acute pericarditis.)

Chest X-ray, PA and lateral, stat CK-MB, stat and repeat in 8 hours x 2

Troponin I, stat and repeat in 8 hours x 2 ESR, stat

Blood cultures, stat

Ok here are the results:

CBC with differential shows mild leukocytosis with a WBC count of 12,000 with 2% bands and 50% polymorphs. There is a mild lymphocytosis. ESR is elevated to 40. The BMP reveals normal electrolytes, BUN, and creatinine. The CK is mildly elevated at 300 but MB is normal. Troponin I is normal. The CXR shows cardiac enlargement, an indication that fluid has collected.

The classic findings of pericarditis on EKG are:

Diffuse ST segment elevation with upward concavity at J point.

No new Q waves

PR segment elevation in aVR with PR depressions in other leads.

Now, how would you approach this patient?

The presence of above clinical, EKG, and other lab findings strongly suggest that this patient has acute pericarditis.

The following approach is recommended to all patients presenting with signs and symptoms of acute pericarditis in whom there is no apparent cause such as clear URI, uremia, post myocardial infarction, or prior cardiac surgery.

Order antinuclear antibody titer, tuberculin skin test, and HIV serology. Obtain blood cultures in febrile patients. Routine viral cultures are not indicated as the yield is low and it doesn't affect the management.

Echocardiography is indicated in the following circumstances:

1.If tamponade or purulent pericarditis are suspected

2.CXR shows cardiomegaly

3.If there is concern about myocarditis

After the diagnosis is made, treatment is usually symptomatic. The treatment of choice is aspirin or other NSAID. The primary goal of therapy is

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to provide prompt pain relief. These agents do not alter the course of the disease. Corticosteroids should not be used unless the patient is clearly refractory to NSAID's and all the possible causes for the pericarditis has been excluded. Tapping is indicated in: 1. Febrile patient with pericardial effusion. 2. Persistent symptomatic pleural effusion. Fluid should be sent for gram stain, culture, sensitivity and cell count. Antibiotics are indicated for suspected bacterial infection.

Review orders:

Admit to floor Regular diet Ambulate at will Vitals Q 4 hours Echocardiogram, stat Telemetry

D/C Oxygen

Indomethacin, oral, continuous

Once the echo is clear (small fluid) i.e. no evidence of tamponade

Reassurance Patient counseling No smoking

No alcohol Seat belt use Safe sex

Regular exercise D/C to home

Follow up appointment in two weeks

Primary diagnosis

Acute pericarditis

Case31

Print

Location: Emergency room

Vitals: Temperature is 39.50C, H.R 110/minute and regular, B.P - 110/64 mmHg, Respiratory rate 22/minute.

C.C: Pain and swelling in the right lower extremity

HPI:

A 62-year-old white male with a past medical history significant for poorly controlled diabetes mellitus type II presents to your office with a three-day history of painful swollen, right lower leg. The patient reports that he has had an ulcer on the anterior aspect of the right lower extremity for two months but did not seek medical attention because it was not painful and had no discharge. There has been no increase in the

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size of the ulcer, but for the last two to three days the patient has been having a moderate to severe throbbing pain. This morning he noticed fever, chills, rigors, increased redness, and swelling. The patient denies any trauma, nausea or vomiting, bowel or bladder dysfunction. He has no history of peripheral vascular disease. The patient has not been exposed to salt water and has not eaten crustaceans or shellfish. He has no allergies. Family History: Mom had a heart attack. Dad had a stroke. He denies any smoking, alcohol or IV drug abuse. ROS are unremarkable. PMH: Type 2 diabetes mellitus treated with diet modification and oral hypoglycemics. He has no history of hospitalizations. He takes metformin 500 mg twice daily.

How do you approach this patient?

First do physical examination

General

HEENT /Neck

Lungs

Heart

Abdomen

Extremities

Skin

Lower extremity motor and sensory exam

Here are the results of the examination:

General exam showed patient is alert, awake, and oriented x 3. He looks very ill and is in moderate to severe leg pain.

HEENT, heart, lungs and abdomen are all within normal limits.

Extremities: There is diffuse erythema and swelling of the right lower leg from below the knee down to the metatarsal joints. A small 2-3 cm ulcer with a pustular base is noted on the shin. Bullae are present but there is no demonstrable crepitus or discharge. The area is very tender. Peripheral pulses are intact.

Review Orders:

Pulse oxy, stat IV access

IV NS, continuous

Admit in medicine floor/ward Vitals Q 4 hours

Bed rest with leg elevation

NPO except medications (as he may require surgery if there is any evidence of gangrene)

CBC with differential, stat Basic metabolic profile, stat Plain X-ray of the leg, stat Blood cultures x 2, stat HBA1C, routine

Accu checks, 2 – 3 times daily D/C metformin

Sliding scale insulin (Type 'regular insulin')

Gram stain and culture of the aspirated material and the wound swabs Analgesia, stat and prn

Acetaminophen, stat and Q 6hours prn 1gram

Once the blood cultures are obtained, start:

Clindamycin, IV Q 8 hours

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Ciprofloxacin, IV Q 12 hours Daily CBC with diff and BMP

Check the patient’s leg, (Interval history and physical) every 4 hours until you see improvement

D/C NPO if there is no need of surgical intervention Start diabetic diet

Here are the results:

CBC revealed a WBC of 15,000 with 85% polymorphonuclear cells and 10% bands. Basic metabolic profile is normal except for blood sugar of 346.

Plain X-ray of the leg shows soft tissue swelling. No evidence of gas, abscess, or bone infection is noted.

Blood and wound cultures are pending.

Order review:

We usually give at least two days of IV antibiotics.

Switch to Ciprofloxacin PO BID and Clindamycin po TID

D/C IV fluids

D/C to home

Patient education

D/C sliding scale insulin

D/C Accu checks TID

Accu checks BID

Diabetic diet

Regular exercise

Weight reduction (if obese)

Restart metformin

Medication compliance

Diabetic foot care

Follow up appointment in 2 weeks

Discussion:

Cellulitis is primarily a clinical diagnosis. In most of the patients blood cultures, wound cultures, and skin biopsy specimens do not provide microbial etiology. So, in general we do not recommend any of the above-mentioned cultures. However, blood cultures are indicated in the following circumstances

1.Patients who appears toxic.

2.Failure to respond to initial antibiotic regimen

3.Patients with recurrent infections

We usually do not recommend/ perform streptococcal serologies.

The patient should be admitted to the general medicine service for treatment of cellulitis and uncontrolled diabetes mellitus. This patient has bullae without crepitance. Empirically, give a broad-spectrum antibiotic to cover gram-positive and gram-negative as well as anaerobic organisms. The best combination of drugs is ciprofloxacin and clindamycin (based on our clinical experience), or third generation cephalosporins like ceftriaxone. Clindamycin is affective in treating beta-hemolytic streptococci and S. aureus infections. In contrast to beta-lactam antibiotics, clindamycin has a unique property of preventing toxin production. IV nafcillin or cefazolin are the drugs of choice for staphylococcal or beta hemolytic streptococcus infections. Vancomycin can be given in patients with penicillin allergy and isolates of methicillin resistant S. aureus. If the gram stain shows gram-negative rods then the most likely organism is E. coli. The treatment of choice is IV ceftriaxone.

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A diabetic patient who has chronic non-healing plantar foot ulcers usually requires broad-spectrum antibiotics to cover gram positives, gram negatives, and anaerobes. Cultures should be obtained in all patients. Ampicillin and sulbactam and imipenem are the drugs of choice.

Usually, within the first ten days of osteomyelitis, a plain X-ray of the bone is negative. However, this does not rule out osteomyelitis. A technetium bone scan is a more sensitive test and it will detect osteomyelitis in the earlier stages. IV antibiotics should be continued for six-eight weeks for cases of osteomyelitis. If the infection is extensive and there are areas of necrotic skin or tissue, surgical debridement may be necessary. In diabetic patients, osteomyelitis can be due to atypical organisms such as gram- negative bacilli like Pseudomonas or E. coli. Therefore, administer antibiotics that cover Pseudomonas (ciprofloxacin, IV ceftazidime, or piperacillin). The patient's extremities should be immobilized for severe pain or for joint instability. Hyperbaric oxygen can be used if an anaerobic infection is suspected or if the blood cultures grow anaerobic organisms.

Primary Diagnosis

Cellulitis

Case32

Print

Location: Emergency room

Vitals: B.P 110/70 mm Hg, HR 100/min, regular, R.R is 24/min, and the temperature is 36.7C

HPI: A 34-year-old, previously healthy, white female was brought into the ER after she was involved in a high-speed car accident. She never lost consciousness. She complained of pain in her left upper quadrant. She felt nauseated but never vomited. She ate her last meal three hours earlier. She denied any other past medical problems except being in a drug rehabilitation program one time. She had no known allergies. She said she usually drinks alcohol every evening and smokes one PPD. She denied any drug abuse. Her last menstrual period was four weeks ago. She was reluctant to give any history secondary to severe pain.

How do you approach this patient?

When you get a case of trauma 3 things are very important

1.Primary survey with Initial resuscitation (Airway, Breathing, Circulation)

2.Secondary survey

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Order review:

Cervical spine immobilization (Most likely that paramedics might have done this before)

IV access, stat

Normal saline, IV, continuous Pulse oximetry, stat

Oxygen inhalation Continuous BP monitoring Continuous cardiac monitoring

Now perform the secondary survey

Physical examination should consists of a complete head-to-toe secondary survey General

Skin HEENT/Neck Lungs Heart Abdomen Genitalia Rectal

Extremities/Spine

Neuro/Psych

Here are the results:

Patient is alert, awake, oriented x3, but is in severe abdominal pain No pain over the spine; no abrasions are noted

HEENT is normal except small nonbleeding abrasions Lungs and heart are within normal limits

Abdomen: Steering wheel-shaped contusion is noted on the LUQ. There is no flank swelling or bruising. Patient has severe abdominal tenderness over the left upper quadrant. There is no rigidity or guarding. No bruit heard. Crepitation or instability is noted at the left lower rib cage. There is no pelvic instability noted.

Rectal and pelvic exams did not reveal any evidence of bleeding. No other evidence of fractures noted.

Now order the following labs:

Morphine, IV, bolus

Blood type and cross match, stat CBC with diff, stat

BMP, stat

12 lead EKG, stat Serum amylase, stat LFTs, stat

Urine analysis, stat PT/INR, stat

PTT, stat

Blood ethanol, stat

Urine toxicology screen, stat Pregnancy test, stat

X-ray spine, stat

X-ray chest, PA and lateral, stat X-ray abdomen, stat

X-ray pelvis, stat (if any suspicion of pelvic fracture)

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The most important question here is, what is the imaging modality of choice to find out the intraabdominal injury?.

If the patient is unstable, a rapid bedside ultrasonogram is the 1st step. If the patient is stable, an abdominal CT is the investigation of choice.

Order review:

CT abdomen, stat (with contrast)

Hb and hematocrit, every 6 hours (Type H&H) Surgery consult, stat

Results review:

Hb is 12; LFTS are WNL.

CT abdomen showed splenic hematoma and the surgeon decided to treat conservatively.

All the other investigations are normal.

Order review:

D/C cervical immobilization

Transfer to ICU (if the patient is unstable), or to floor/ward (if stable) NPO

Oximetry every 6 hours Foley catheter, stat Urine output

Morphine, IV, continuous (for pain)

Take brief history and examine abdomen for every 4-6 hours Repeat the ultrasound or CT next day if needed

Discharge:

Nausea or vomiting, increased abdominal pain/distention, or new bleeding in urine or feces mandates immediate return and further evaluation.

Continue acetaminophen and codeine combination (Percocet for pain) *Follow up visit in one week

Patient counseling

No smoking

No alcohol

Seat belts use

Safe sex

Discussion:

Follow serial hemoglobin and hematocrit as initial values may be normal with acute blood loss. An initial hematocrit of < 30 % indicates severe blood loss.

Platelet transfusions are indicated in patients with thrombocytopenia of <50,000/mL and ongoing hemorrhage.

LFTs are useful in any patient with blunt abdominal trauma.

ABG should be obtained in all major trauma patients, as they are more prone to develop metabolic acidosis (lactic acidosis) from shock.

Elevated serum amylase is not specific in diagnosing pancreatic injury.

Obtain serum or urine pregnancy test on all females of childbearing age.

Obtain drug and alcohol screens on all trauma patients who have a H/O drug abuse or evidence of altered mental status.

Urinalysis is an important screening test for genitourinary trauma. We obtain urinalysis in all patients with blunt abdominal trauma. Gross hematuria

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indicates a workup with CT contrast.

Abdominal CT with oral contrast (who are able to protect their airway) is the investigation of choice to detect intraabdominal injury in hemodynamically stable patients who have sustained blunt abdominal trauma.

Rapid bedside ultrasound is the imaging of choice in hemodynamically unstable patients. This essentially replaced the need for DPL (Diagnostic

peritoneal lavage).

Primary Diagnosis

Splenic Rupture

Case33

Print

Location: Office

Presenting complaint:

A 29-year-old female presents with 7 day H/O dry cough and breathlessness.

Vitals: B.P 130/75 mm Hg, Pulse 92/min, regular, Temp 99.9F, R.R 24/min, Height: 70 inches (175 cm), Weight: 65 Kg (143 lbs)

HPI:

A 29-year-old white female presents with the complaints of a dry cough and breathlessness for the last one week. Her other complaints are weight loss of 15 lbs over the last few months and low-grade fever for the last few weeks. There is no personal or family history of asthma or other atopic disorder. She is not taking any prescribed or recreational drugs. She has been sexually active with multiple male and female partners for the last several years and does not use any barrier or other method of contraceptive. She has never been tested for HIV. She was once treated for gonorrhea. She has no known allergies. Her vaccinations are up-to-date. FH: Father died at the age of 70 yrs due to MI. Mother is diabetic. SH: She is a widow as of the last five years and has many boyfriends. She is a waitress in a restaurant. She likes parties and traveling. She is a non-smoker but drinks alcohol heavily. ROS: she has no previous history of STD or UTI. Denies chest pain, expectoration, hemoptysis, orthopnea or PND. Rest of the ROS are unremarkable.

How do you approach this case?

Her symptoms of dry cough, dyspnea, and low-grade fever indicate lung infection. Her high-risk sexual behavior puts her at an increased risk for HIV. A lung infection might be some opportunistic infection of AIDS. There fore, we will do a complete physical examination of this patient with special attention to the respiratory system. We will also do staining and culture of expectorated or induced sputum and chest radiography for her lung infection. Her high-risk sexual behavior is an indication of

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HIV testing which is done after getting informed consent from the patient.

ORDER:

Any suspected HIV/AIDS patient should have a complete physical exam. Complete physical examination

RESULT OF PE:

Lung examination is significant for scattered rhonchi and crackles. Otherwise, the rest of the physical exam is within normal limits.

LABS:

Pulse oxy, stat

ABG is indicated if the patient is having hypoxemia or significant respiratory distress CBC with differential, routine

Basic metabolic panel, routine

Gram staining and culture of sputum, routine

Methenamine silver staining of induced sputum (Wright-Giemsa stain or direct fluorescent antibody (DFA) for Pneumocystis if PCP is strongly suspected) Acid-fast staining of sputum

CXR-PA and lateral view, routine HIV testing by ELISA

RESULTS OF LABS:

CBC shows Leukocytosis BMP is within normal limits

Gram staining and culture of sputum is negative. Acid-fast staining of sputum is negative

CXR shows diffuse bilateral interstitial infiltrates Silver staining is positive for PCP

HIV testing is positive

DISCUSSION:

Pulmonary infections in HIV patients has broad differential diagnosis.

Suspect bacterial infection if an HIV patient presents with acute onset, high- grade fever, and pleural effusion. Pneumococcus is the MC organism. Mycobacterium tuberculosis: Patients presents with chronic cough, fever and weight loss.

Disseminated fungal infection: Miliary pattern or nodular infiltrates on chest X-ray. Kaposi sarcoma: Present with mild a cough and chest X-ray shows pulmonary nodules.

Pneumocystis carinii pneumonia presents with dry cough and dyspnea; pleural effusion is not a feature. PCP is confirmed by silver staining or direct fluorescent antibody of induced sputum. If sputum induction is nondiagnostic or cannot be performed, then fiberoptic bronchoscopy with bronchoalveolar lavage (BAL) is recommended, with or without a transbronchial biopsy.

Repeatedly positive ELISA should be confirmed with western blot to make the diagnosis of HIV. PCP is often associated with CD4 count of less than 200 cells/mm3 and an elevated lactate dehydrogenase level (LDH). The TMP-SMX remains the initial drug of choice. Mild PCP is treated oral trimethoprim-sulfamethoxazole. Patients with severe pneumonia or those who cannot tolerate the drug orally should receive intravenous therapy. High-dose therapy is associated with hyperkalemia (Trimethoprim acts as a potassium sparing diuretic).

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When to use steroids?

Corticosteroids along with TMP-SMX have significantly decreased the mortality associated with PCP, when used in moderate to severe cases of PCP. It is used when a Pa O2 is 70 mmHg or less, and/or an A-a O2 gradient of 35 mmHg or more on room air

When to admit the patient?

Mild-to-moderate disease - Patients are usually have milder symptoms and nontoxic in appearance. They are not hypoxic; CXR may even be a normal. Outpatient TMP- SMX is the treatment of choice.

Moderate-to-severe disease - Patients presents with severe respiratory distress, and hypoxemia. CXR may be markedly abnormal. Inpatient management with IV TMP- SMX should be considered. Admit patient to ward for moderate to severe disease (ICU if patient unstable).

ORDER REVIEW:

ABG, stat LDH, routine

TMP-SMX, PO (use IV if hypoxemia is present) Western blot testing for HIV

RESULTS:

PaO2 is 77mmHg

Positive western blot for HIV

DISCUSSION:

Once the diagnosis of HIV infection has been established, CD 4 count and viral load should be measured to assess the severity of the disease and rate of progression.

All HIV patients should get the following investigations:

CBC with diff, at the time of diagnosis and for every 3-6 month intervals (30-40 % of HIV patients will have anemia, leukopenia, lymphopenia, and thrombocytopenia)

SMA 12 should be obtained initially as it will be useful as baseline.

Yearly VDRL or RPR - Because of high association of coinfection

All patients should be checked for hepatitis serology, which include HBsAg, anti-HBc, and anti-HCV.

Toxoplasma serology is useful to begin prophylaxis and to differentiate it from other neurological complications.

The CDC recommends routine testing with PPD initially and annually in high risk patients if the initial test is negative.

CDC recommends a PAP smear at the time of diagnosis and every 6 months to one year thereafter.

Influenza and Pneumococcal vaccine should be given to all HIV patients.

Antiretroviral therapy is started in HIV-infected patients if the CD4 count is less than 500 ( some say less than 350) or viral load by PCR greater than 20,000 copies/ml.

ORDER REVIEW:

CD4 count

PCR for HIV RNA

PPD testing

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LFTs

VDRL Anti-HCV HBsAg Anti-HBc

Toxoplasma serology, serum Pap smear

Influenza vaccine Pneumococcal vaccine Zidovudine, oral Didanosine, oral Indinavir, oral

Counsel about limit alcohol intake and safe sex practices HIV support group

Report positive result to Department of Health and Human services Medication compliance

Regular follow up visits

PRIMARY DIAGNOSIS:

PCP

Case34

Print

Location: Office

Vitals: B.P 138/80 mm Hg, Pulse 80/min, regular, R.R 22/min, Temp 98.6 F, Weight: 50 Kg, Height: 160 cm

Presenting Complaint:

A 50-year-old man presents with 10-day H/O constipation, extreme weakness.

HPI:

A 50-year-old white male presents with 10 day H/o constipation. He has been having abdominal discomfort and feeling nauseated. He says he has been experiencing fatigue for the past few months but from the past few days he is having severe weakness. He feels that he doesn’t have the energy to carry out the routine activities. He complaints of weight loss for the last 4 months. His other complaints are increased urinary frequency, persistent right flank discomfort and on & off night sweats for the last 2 months. Recently, he started using over-the-counter vitamin supplements. He hasn’t had feelings of anhedonia, guilt, suicidal thoughts, or lack of concentration. Nor has he complained of cold intolerance, diarrhea or polyphagia. He never had jaundice. He was never admitted in the hospital. He has no known

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allergies. He takes acetaminophen for headaches. FH: Mother died at the age of 56 due to CVA. Father alive and healthy at the age of 65 yrs, he has diabetes and hypertension. SH: The patient has been married for 20 years and has no kids. He has been smoking 20 cigarettes for the last 20 years and drinks alcohol on weekends. He is sexually active in a monogamous relationship with his wife. ROS: There is no blood in the urine, hesitancy, dysuria, or urethral discharge. He has complaints of persistent flank discomfort the last two months. The rest of the ROS are unremarkable.

How do you approach this patient?

This 50 yr old, known smoker presents with several months H/O constitutional symptoms, extreme fatigue, constipation, frequency of urination, and persistent right flank discomfort. So, the most important thing to rule out in this patient is malignancy.

Order physical exam:

Complete physical examination

Here are the results:

The patient is looking ill and pallor. He is in no obvious discomfort. No lymph nodes are palpable. Lungs and heart are clear to auscultation.

Abdomen: Bowel sounds are diminished. No abdominal tenderness. Right flank discomfort is noted with deep palpation. No organomegaly. No masses palpable. No shifting dullness or fluid thrill.

Genitals: No masses, rash or ulcer.

Rectal exam: Sphincter tone normal, No tenderness, and no ulcer. Prostate not enlarged. Stool color brown. No occult blood.

Order:

CBC with differential, stat Basic metabolic panel, stat LFTs, stat

U/A, stat

Here are the results:

CBC showed HB of 9, MCV of 88.

BMP showed calcium of 20 mg/dL, BUN of 60 and creatinine of 2.3. LFTs are WNL

U/A showed moderate amount of blood.

Discussion:

Constipation is the MC GI complaint n patients with hypercalcemia. Differential diagnosis of hypercalcemia is very broad. However, upto 90% of the cases belong to primary hyperparathyroidism and cancer. Primary hyperparathyroidism is the most frequent cause in ambulatory patients. The degree of hypercalcemia provides useful diagnostic clues. Hypercalcemia in primary hyperparathyroidism is mild (often <11 mg/dL) while it is more marked in cases of malignancy (>13 mg/dL).

Careful history taking and examination and a few lab tests are usually sufficient to establish the cause of hypercalcemia. These tests include chest x-ray (for malignancy or sarcoidosis), serum protein electrophoresis (M. Myeloma) and intact serum PTH assay. Because of the higher incidence of associated hyperparathyroidism in patients with malignancy it is reasonable to obtain an intact PTH even in a patient with known malignancy.

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Review orders:

Admit the patient in ward/floor (2 reasons 1. For the treatment of hypercalcemia with IV NS, 2. Workup for the underlying cause of his hypercalcemia)

IV access

IV NS, bolus (2 liters) (Please do not give diuretics without prior hydration; We have treated a Ca of 24 without giving any diuretics)

IV NS, 150 cc/hr, continuous Chest - X ray, routine (PA view) Serum ferritin, routine

TIBC, routine

Serum iron levels, routine PTH intact, routine Repeat BMP next morning USG of the abdomen SPEP

Serum alkaline phosphatase

Review orders:

CT of the abdomen and chest (If the USG showed renal mass suspicious for malignancy). Do not give IV contrast if the renal function is not improved with IV fluids. To give the contrast creatinine should be <1.5.

Bone scan (If the alkaline phosphatase is elevated)

Monitor serum calcium level every day and adjust the IV NS Consult oncology

Discussion:

Hyperparathyroidism should be suspected in any patient with the following features:

Family history of hyperparathyroidism

Family or personal H/O MEN (multiple endocrine neoplasia) syndromes

H/O pancreatitis

Prolonged asymptomatic hypercalcemia

This patient is most likely having renal cell carcinoma. Bladder cancer is usually associated with irritative voiding symptoms and hematuria.

Renal cell carcinoma is often associated with paraneoplastic symptoms. Constitutional symptoms include fever, anorexia, weight loss are common and should make the physician think about malignancy. Moderate to severe anemia is common. Iron studies usually reveal anemia of chronic disease.

Hepatic dysfunction is commonly seen in patients with renal cell carcinoma even without hepatic metastasis (termed Stauffer's syndrome). Nephrectomy usually relieves the hepatic dysfunction, but persistent or recurrent dysfunction indicates local recurrence or metastatic disease.

Long-acting bisphosphonates, such as pamidronate or zolendronate, are the drugs of choice for the treatment of hypercalcemia. They have also shown a reduction in bony metastases and an improvement in survival.

One the diagnosis of renal cell carcinoma id made the next step is to evaluate the presence/extent extra renal disease. Ct of the chest and abdomen is part of the routine staging procedure. Bone scan is indicated if the patient has elevated alkaline phosphatase or complains of bone pain.

Criteria using the size of the tumors to differentiate between benign and malignant tumors are no longer used. Histological criteria should be used to confirm the diagnosis. Biopsy of the metastatic lesion if the preferred way of obtaining histologic diagnosis. However, if there is an isolated, solid

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resectable renal mass is present complete or partial nephrectomy is the preferred way of making the diagnosis and treatment. Preoperative needle biopsies are not recommended in a patient with resectable tumors because of the risk of peritoneal seeding.

Primary Diagnosis

RCC

Case35

Print

Location: Office

Vitals: BP 130/70 mm Hg, HR 76/min, RR 18/min, and Temperature is 36.8C. C.C: Vaginal discharge

HPI: A 39-yr old Caucasian female presents to your office with a 1-week history of foul smelling vaginal discharge. She also complains of pruritus of vulva. She denies any abdominal pain, nausea, vomiting, or fever. She also denies any vaginal bleeding. Her only medications are inhaled betamethasone and albuterol for bronchial asthma. She had a similar problem 6 months ago and it went away after applying over-the-counter antifungal cream. She doesn’t use any other medications. Her appetite, bowel movements, and bladder functions are not affected. She is not allergic to anything. FH: Mother has diabetes and father has hypertension. SH: She doesn’t smoke or drink. She has never used recreational drugs. GYN: She is G2 P2 and her LMP was 25 days ago. She is sexually active with her husband only. He's had a vasectomy. She had her PAP smear one and half years ago.

How do you approach this case?

Order physical exam: Abdomen

Pelvic exam Extremities

Here are the results?

Pelvic examination reveals curdy white discharge with white patches along the vaginal walls. There is a significant erythema noted over the vulva. There is no uterine or adnexal tenderness. No cervical discharge is noted.

The rest of the examination is within normal limits.

What would be your approach?

Based on the inflammatory findings this patient has vaginitis. This could be due to Candida (most likely), or Trichomonas (very less likely). Vaginosis (no inflammation) is very unlikely with the signs of inflammation. You have to keep in mind that there may be a coexistent vaginosis, especially in a patient with a recurrent infection. One more thing that we can say at this stage is that the chance of PID is also very unlikely without adnexal or uterine tenderness and cervical discharge.

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Order:

Vaginal PH

Wet mount preparation (Saline + KOH) Gram staining of discharge

Pap smear, routine GC, culture Chlamydia, culture CBC with differ U/A

Workup:

All patients presents with vaginal discharge should have vaginal pH measurement. This is the single most important test that differentiates candida form the other 2 common infections. A pH above 4.5 suggests bacterial vaginosis or trichomoniasis, and excludes candida vulvovaginitis. Wet mount preparation with saline and KOH (destroys cellular elements) should be ordered on all patients. Saline microscopy is helpful in identifying candidal hyphae, motile trichomonads, clue cells (epithelial cells studded with adherent coccobacilli), and PMNs. Culture for candida and trichomonas is usually not indicated unless the microscopy is negative.

Cervical culture for Neisseria gonorrhoeae or Chlamydia trachomatis, must always be performed in any women with purulent vaginal discharge.

Patients with high-risk sexual behavior should have screening for syphilis, HIV, hepatitis B, and other STDs.

Candidiasis:

Diagnosis:

White curdy patches with inflammatory signs on exam.

Mycelia on KOH preparation.

Presence of inflammatory cells on Gram stain.

Treatment:

Miconazole / Clotrimazole suppositories or vaginal cream for 2 weeks.

If no response give a single oral dose of oral fluconazole.

Trichomonas vaginalis:

Patents usually present with purulent, malodorous, thin greenish frothy vaginal discharge with associated burning, pruritus, dysuria, and dyspareunia. Physical examination reveals inflammatory signs (erythema of the vulva and vaginal mucosa). In 2% of patients punctate hemorrhages may be visible on the vagina and cervix.

Treatment:

Non pregnant - Metronidazole 500 mg BD for 7 days (or) 2 gm single dose.

Pregnant - 1st TM - Clindamycin cream; 2nd - 3rd TM - again metronidazole.

Many physicians are now using metronidazole in 1st TM also, as CDC no longer discourages its use in 1st TM.

Advice:

Patients should be advised not to drink alcohol (at least 48 hours) because of a disulfiram-like (Antabuse effect) reaction with metronidazole.

Treatment is required for partner.

Safe sex.

Bacterial vaginosis:

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Diagnosis is made by:

"Fishy smelling" discharge especially after unprotected intercourse.

Clue cells (epithelial cells studded with bacteria) on saline wet mount.

Positive whiff-amine test - The presence of a fishy odor when 10 % KOH is added to vaginal discharge samples.

No inflammatory signs on examination.

No inflammatory cells on the Gram stain smear.

Treatment:

The treatment of choice is 500 mg twice daily for 7 days. Topical vaginal therapy with metronidazole gel for 5 days is as effective as oral metronidazole. The use of single-dose therapy with 2 g of metronidazole is controversial, as it has shown a higher rate of relapse is some studies.

There is no need to treat partner.

Advise to all the above patients:

Patient education Safe sex

No alcohol No smoking

No recreational drugs Pap smear annually

Annual mammogram from the age of 50 yrs

Annual FOBT and colonoscopy for every 10 years from the age of 50 yrs Lipid profile for every 5 yrs from the age of 20 yrs

Primary Diagnosis

Candida Vagnitis

Case36

Print

Location: Office

C.C: High blood pressure is noted in a 55 year-old male patient during his routine medical check-up.

Vitals: Pulse: 72/min; B.P.160/95 mm Hg; Temp. 98.50F; R.R: 17/min.

HPI:

A 55-year-old white male comes to the doctor’s office for his routine medical check- up which shows high blood pressure. He denies any headache, chest pain, shortness of breath, palpitations, leg swelling, dizziness, or syncope. His bowel movements are regular and his bladder function is good. He has no other complaints. He has no known allergies. He is not taking any medication. For the last 25 years he has

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smoked 10 cigarettes per day. He drinks alcohol occasionally and does not use illegal drugs. He is sexually active with his wife. FH: Father died at the age of 50 due to MI. Mother is 85, alive, and healthy. The rest of his ROS are unremarkable.

How would you approach this case?

Diagnosis of HTN is made when high blood pressure is confirmed on three separate occasions. Once the diagnosis has been made, one should determine cardiovascular risk factors, cause of HTN (secondary and curable causes), and target organ damage.

Physical examination:

It is done to find out the cause of HTN and to assess the target organ damage. Ophthalmoscopy, palpation of pulses, and abdominal examination for bruits provide useful information.

Order:

Complete physical examination (Because the patient is stable and needs an assessment for end-organ damage).

Results of your examination:

Complete physical examination is within normal limits. Therefore, order the following tests and ask the patient to return in one week for reevaluation of his BP. When evidence of end-organ damage is found on examination, start antihypertensive therapy immediately.

Laboratory testing:

All patients who are found to have hypertension should have routine hematocrit, urinalysis, lipid profile, 12-lead EKG, serum electrolytes, serum creatinine, and blood glucose. Other tests are indicated only in certain settings. Ambulatory blood pressure monitoring is required when blood pressure readings in the office setting are high and they are normal in ambulatory settings. Limited echocardiography (more cost effective than complete echocardiogram) may be performed to detect left ventricular hypertrophy when blood pressure values are borderline. Plasma renin activity is determined when primary hyperaldosteronism is suspected (unexplained hypokalemia). Workup up for renovascular hypertension is performed when history is suggestive and when corrective measures are being considered. Intra-arterial digital subtraction angiogram or spiral CT can be used for this purpose.

Thus we will perform the following examination and lab testing in this patient.

LABS:

CBC, routine (no need of differential) BMP, routine

Urinalysis, routine Lipid profile, routine EKG, 12 lead, routine

Follow up visit in one week

The patient returns one week later with lab results, which are all normal. Repeated blood pressure measurements, both at home and office over a period of two months, shows stage-1 HTN. A diagnosis of essential HTN is made. Essential HTN is not associated with end-organ damage in this case.

DISCUSSION:

Non-pharmacologic measures should be advised to all patients for the treatment of

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HTN. These measures include regular exercise, weight reduction, reduced salt intake, and avoidance of excessive alcohol.

Definitions:

Blood pressure and hypertension are classified as follows: Optimal blood pressure: systolic <120 mmHg and diastolic <80 Normal blood pressure: systolic 120-129 and diastolic 80-84 High-normal blood pressure: systolic 130-139 or diastolic 85-89

Hypertension:

 

 

 

 

 

 

Stage

1:

systolic

140-159

or

diastolic

90-99

Stage

2:

systolic

160-179

or

diastolic

100-109

Stage

3:

systolic

>180 or

diastolic

>110

 

Recommendations:

Borderline or high-normal blood pressure:

They are treated with non-pharmacological measures and their blood pressure tested every year unless they have DM, target organ damage, or CVS disease.

Stage 1:

Nonpharmacological measures should be tried initially for up to 12 months (if no other risk factors are present) or 6 months (presence of other cardiovascular risk factors except DM). Treatment with antihypertensive drugs

is indicated when there is associated end-organ damage, diabetes, or other vascular risk factors.

Stage 2 and 3:

Patients should be started on pharmacological therapy immediately. General approach:

Recommended approach for the pharmacological therapy of HTN is to start with either thiazides or beta-blockers. If low-dose thaizide is not effective, beta-blocker, calcium channel blocker, or ACE inhibitor can be added or substituted.

ACE inhibitors are the first line antihypertensives for all diabetic hypertensive patients with or without evidence of end organ damage, symptomatic or asymptomatic left ventricular failure with an EF of <40, post myocardial infarction, and nondiabetic proteinuric chronic renal failure.

ARBs are indicated when a patient can't tolerate ACE inhibitor due to dry cough. It is also indicated in hypertensive patient with LVH, and in type 2 Diabetic patient with nephropathy.

This patient has stage 1 HTN without any target organ damage and clinical cardiovascular disease but has multiple risk factors including cigarette smoking, obesity, and family history of early CAD. Therefore, advise both pharmacological and non-pharmacological therapy.

Order review:

Oral atenolol, continuous

Patient education, smoking cessation Patient education, regular exercise Patient education, medication compliance Limit alcohol intake

Diet, low sodium Diet, weight loss Safe sex counseling

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Seat belt use

Regular follow-ups

Primary diagnosis:

Essential HTN

Case37

Print

Location: Office

Vitals: B.P: 110/76 mm Hg; H.R: 76/min; R.R: 16/min; Temperature: 36.9C. C.C: Short stature, and primary amenorrhea.

HPI: Her mother for evaluation of short stature brings a 13 yr old teen to your office. She is concerned about her daughter being shorter than her classmates. Her height is 4 foot 6 inches. She says that she and her husband were of normal height. She also concerned about her menarche. She says that her other (older) daughter had developed secondary sexual characters and menstruation by the age of 14. She denies any other complaints. The patient has shown age appropriate developmental skills and teeth eruption. At school she shows moderate to high performance in studies. Her past medical history is nothing significant except for ear and throat infections during childhood. She has no known allergies. Her family history is nothing significant. The mother denies any use of alcohol, smoking, or drugs while she was pregnant. Remaining ROS are unremarkable.

So how would you approach this case?

Basically, this patient is having short statute as a chief complaint. Even though she did not develop menarche or secondary sexual characters it is very premature to say that this patient is having problems. You have to wait at least until 14 to 16 years to assess the amenorrhea, and secondary sexual characters.

Basically the differential diagnosis in this patient is Turner’s syndrome, familial short stature, hypopituitarism, hypothyroidism, constitutional growth delay, derivational dwarfism, and some other syndromes like Noonan’s syndrome etc.

First, do a complete physical examination except rectal. Also, order vitals that include blood pressure in both upper limbs and lower limbs.

Here are the results:

She has low occipital hairline, wide neck, high arched palate, and widened spaced nipples. No abnormalities in the rest of the examination.

Based on these findings the is most likely having Turner's syndrome.

Discussion:

First confirm the diagnosis with serum FSH, LH (elevated), and karyotyping. Also

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order some other important investigations.

Every girl with Turners syndrome must be screened for associated medical problems. At least 2D echo to detect heart defects, ultrasonography of the kidney (to detect renal problems), skeletal survey (to detect skeletal problems), and thyroid function tests. Hearing should be tested clinically regularly to detect hearing loss. Despite the short stature these patients do not have the growth hormone deficiency. So, the routine testing is not indicated. The metabolic syndrome comprises of hypertension, hyperlipidemia, type 2 DM, and obesity is more common among adults with Turner syndrome. So, all patients should have tested for blood glucose, BUN, serum creatinine, and urinalysis initially and once yearly thereafter because of the risks of diabetes mellitus and chronic renal failure.

Order the following:

UA, routine BUN, routine

Creatinine, routine

Fasting blood sugar, routine Serum FSH, serum

Serum LH, routine Karyotype, routine

*Schedule an appointment in one week

Results:

UA, BUN, Cr, and blood sugar are normal. FSH and LH are elevated. Karyotyping is reported as 45XO.

Order:

Skeletal survey, routine (short 4th metacarpal) Pelvic ultrasound, routine (streaked ovaries) TSH, routine

Echocardiogram, routine - For Coarctation of aorta Audiometry, routine (or) hearing testing, routine

Treatment:

Once the diagnosis of Turner's syndrome is confirmed, consider the following: Growth hormone therapy, subcutaneous, continuous - It should be started as soon as the height falls below the 5th percentile (till epiphysis is closed). Once the girl reaches 9 yrs, combination therapy with growth hormone and an anabolic steroid like oxandrolone is recommended until the age of 12 yrs.

Estrogen, conjugated, oral, continuous - If the patient is of pre-pubertal age group (< 13 years), continue till puberty is achieved. If the patient is >13 years, then start combination of "estrogen and progestin"

Vitamin D, therapy, oral, continuous; to prevent osteoporosis. Estrogen replacement counseling

Psychiatry consult - (Reason - IQ estimation)

Ob/Gyn consult - (Reason - Gonadal resection (Children with ‘Y’ chromosome may have to be operated to remove their gonads to prevent cancer from occurring in the gonads), and for in vitro fertilization (if patient wants to have children.)

If there is any evidence of thyroid problem, treat accordingly.

Advice:

Patient counseling Counsel parent

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Medication compliance

No smoking

No alcohol

Safe sex

No illicit drugs

Regular exercise

Regular diet

Seat belt use

Make follow-up appointments:

Echocardiogram for every 2 years

Thyroid function tests for every one year

Annual complete physical examination

Primary diagnosis:

Turner's syndrome

Case38

Print

Location: Emergency Room

Vitals: BP: 110/70 mmHg; HR: 95/min; Temp: 37.7C(99.8C); RR: 16/min.

C.C: A 65-year-old white male presents with fever and severe pain in the left lower abdomen.

HPI: A 65-year-old male presents to the ER with fever, and abdominal pain. Pain started four days ago in the left lower abdomen and has progressively increased in severity. It does not radiate anywhere and is associated with nausea, vomiting, and low-grade fever. Pain is of 7-8/10 in severity now and it is a constant type of pain. There is no history of change in bowel habits or bleeding per rectum. He had similar episodes of pain in left lower abdomen in the past, which subsided spontaneously. However, he states that he has been suffering from constipation for the last 10 years. PMH: He had a cholecystectomy at the age of 50. He has no known allergies. FH: Mother died at the age of 60 due to MI. Father died from Alzheimer's disease at the age of 85. SH: He quit smoking 20 years ago. He does not drink or use any recreational drugs. The remaining ROS is unremarkable.

How to approach this case?

This patient has presented with lower abdominal pain and fever. Here we are dealing with the DD of acute abdomen. We will perform abdominal examination and rectal examination, which will narrow the list of our differential diagnosis.

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Order the physical examination:

General

HEENT/Neck

Heart

Lungs

Abdomen

Rectal examination

Genitalia

Extremities

Results of PE:

Patient is in moderate to severe pain. There is marked tenderness and a mass is felt in the left lower abdominal quadrant. No rigidity or guarding noted. Bowel sounds are present. Sphincter tone is normal with normal prostate, brown colored stools without any gross blood, no palpable masses. Rest of the exam is unremarkable.

Discussion:

This is probably a straightforward case of acute diverticulitis, which is suggested by history of chronic constipation, episodic left lower quadratic pain, and by the presence of mass and tenderness in the left lower quadrant. But still diagnosis of acute diverticulitis needs to be confirmed and other causes of acute abdomen need to be excluded. Treatment of acute diverticulitis depends upon its severity and the presence of complications. Patient with mild symptoms may be treated as outpatient with oral fluids and antibiotic coverage against gram-negative rods and anaerobes. Patients with more severe disease are hospitalized and given conservative therapy. They are maintained on NPO status, given IV fluids, and IV antibiotics covering both gram-negative bacteria and anaerobes. If patients fail to respond to conservative therapy, some sort of surgery needs to be done. Complications of diverticulitis include peritonitis, obstruction, fistula formation, and abscess, all of which need to be treated surgically. Abscess formation is an important complication of diverticulitis. It should always be suspected when a patient fails to respond to conservative therapy and CT scan confirms its presence. It is drained under CT guidance through abdominal wall, transgluteally, transvaginally, or transrectally, depending upon its location.

Orders:

IV access, stat

Pulse oximetry, stat (result- 96% on room air) Normal saline, IV, continuous

EKG, 12 lead, stat

CBC with differential, stat (to establish infectious or inflammatory process) BMP, stat (to see the impact of disease on renal function, as dehydration due to

vomiting and loss of fluid in inflammatory exudate may result in pre-renal azotemia) Serum amylase, stat (to exclude pancreatitis)

Serum lipase, stat

LFTs (to exclude hepatitis), stat Urinalysis, stat (to exclude UTI) Metronidazole IV, continuous Ciprofloxacin, IV continuous Morphine, IV, one dose, stat

Phenergan (promethazine), IV, one time (for nausea)

X-ray abdomen, acute series, stat (to exclude intestinal obstruction or peritonitis)

CT scan of abdomen, stat (to establish the diagnosis of acute diverticulitis and document

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its severity) FOBT, stat

*Repeat vitals and abdominal examination every hour

Results:

EKG is normal.

CBC shows elevated white blood cell count with left shift. BMP, LFT’s, U/A, serum amylase, and lipase are within normal limits.

X-ray abdomen, acute series: No evidence of obstruction or free fluid.

CT scan of abdomen consistent with the diagnosis of acute uncomplicated diverticulitis. FOBT is negative.

When a female presents with acute abdomen, we also perform pregnancy test to rule out ectopic pregnancy or abortion. This patient is most likely suffering from moderated to severe diverticulitis; therefore we do the following.

Review order:

Shift the patient to ward

Bed rest with bathroom privileges

Vitals every 4 hours

Pulse oximetry every 4 hours

NPO

Urine output

Pneumatic compression stockings

Repeat CBC with diff and BMP following day

Morphine, IV, continuous (if patient has persistent pain)

Result of repeat vitals, history, examination, and CBC at 24 hours:

Pulse 80/min B.P 110/70 Temp 99 F R.R 16/min

CBC with differential is WNL

He is having no pain and his abdominal examination elicits no tenderness.

Review order:

D/C IV antibiotics

Start oral ciprofloxacin and metronidazole D/C IV fluids, IV analgesia

Start oral analgesics (Percocet) Advance diet as tolerated

Send him home and schedule next visit after 4 weeks

Sigmoidoscopy and Barium enema or colonoscopy after 4 weeks (this is done in every patient with acute diverticulitis after the acute episode is over. This is to determine the extent of the disease, to detect the presence of any co-existent pathology, or to detect stricture, which may be a sequel of acute diverticulitis) High fiber diet

Docusate, oral daily Medication compliance

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Regular exercise

Patient counseling

Primary Diagnosis:

Acute diverticulitis

Case39

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Location: Emergency room

Vitals: Pulse: 100/min; BP: 90/60 mmHg; Temp: 36.7C(98F); RR: 28/min; Height: 30 inches (75 cm); Weight: 9.5 Kg (21 lbs).

C.C: A 16-month-old boy is brought with burns on his buttocks

HPI:

A 16-month-old male infant is brought to the ER by his stepmother. She states that the child fell on the iron, which was on the floor at that time. Hot iron caused blisters on his buttocks. On further questioning, she states that the child has the history of frequent falls and has multiple bruises on his shoulders and back. She further states that he feeds poorly and is usually very irritable. He is the only child in the family. His real mother died a year ago. He has been living with his stepmother since then. His father is a drug addict and is hospitalized these days for heroin abuse. ROS are unremarkable.

How to approach this case:

This is most likely a case of child abuse. In every case of child abuse we are required to perform complete physical examination regardless of the presentation.

Order:

Complete physical examination

Results:

The child seems to be malnourished and shows poor grooming. There is a large blister on his buttocks. Bruises of various stages are also noted on his shoulders and back. Rest of the examination is unremarkable.

Order:

Silver sulphadiazine cream, continuous

Wound dressing

Admit the patient in ward

Regular diet

Skeletal survey, stat

Bone scan, stat

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PT, stat

PTT, stat

Bleeding time, stat

CBC with differential, stat

BMP, stat

UA, stat

Results:

PT/PTT/BT, UA, CBC and BMP are WNL. Skeletal survey showed old fractures.

Order review:

Consult, child protection services

Consult, psychiatrist

Ophthalmology consult for retinal hemorrhages

Counsel parent

Primary Diagnosis:

Child abuse

Discussion:

Child abuse must be suspected whenever there is inconsistent or discrepant history that fails to explain the pattern of injury. It is also suspected when there is a delay in seeking medical care, history of previous suspicious events, substance abuse in parents, and failure to thrive in the child. Certain injury patterns are also suggestive of child abuse. They include bruises in multiple stages of healing, retinal hemorrhages, bruise or burns in protected areas like chest, abdomen, back or buttocks. Vaginal bleeding, injury to external genitalia and injury involving the anal region are other important clues to the child abuse. Shaken baby syndrome presents with fractures, CNS manifestations like seizure and retinal hemorrhages. Important differential diagnoses of child abuse are osteogenesis imperfecta, scurvy and syphilis. Bony changes in cases of syphilis and scurvy are symmetric which are highly unlikely in cases of child abuse. Children with osteogenesis imperfecta have blue sclera in many cases and they don’t have bruises.

Complete physical examination must be done in every case of child abuse. Coagulation profile including PT, PTT, bleeding time and platelet count is done in all children with bruises. In cases of suspected physical abuse in children younger than 2 years, skeletal survey is essential. Bone scans are useful in detecting new fractures. In children older than 2, skeletal survey is indicated in selected cases. For children aged 2-4, skeletal survey is not needed when the child can communicate effectively and when his injuries are mild. For children older than 4, skeletal survey is indicated only when there is bony tenderness or limited range of motion. CT scan is indicated in cases where infant is severely injured. LFTs and pancreatic enzymes are ordered when there is suspicion of injury to these organs. CT abdomen may also be needed in such cases. In cases of suspected abdominal trauma, urine and stools are screened for blood. CT scan of head is indicated all severely injured patients, and patients with CNS symptoms. Hospitalization is needed in many cases especially when diagnosis is in doubt, when the child’s condition requires inpatient management, and when no safe place is immediately available for the child. The child is treated promptly with appropriate therapy and child protection services are reported immediately in every case of suspected child abuse or neglect. Complete evaluation of family dynamics is needed in all cases and consultation with a psychiatrist may be required.

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Case40

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Location: Emergency room

Vitals: B.P: 92/60 mm Hg; HR: 130/min; Temp: 38.3C(10150 F); R.R: 24/min; C.C: Sudden onset of abdominal pain.

HPI:

A 45-year-old White male is brought to the ER with sudden onset of severe epigastric pain. The pain started 2 hours ago after he took his supper at a local fast food center. He states that the pain was initially mild and vague which later on became more intense. Now his pain is 9-10/10 in severity, burning in nature, and non- radiating. Pain gets aggravated by deep breaths and movement. The patient feels somewhat better when he is lying still. He has never had such episodes before. He is feeling nauseated and vomited non-bloody contents twice. He takes ibuprofen occasionally for the tension headaches. There is no history of steroid intake, fever, diarrhea, and constipation. Patient has a several year history of on and off epigastric discomfort partially responsive to antacids. He has no other medical problems except tension headaches of 1-year duration. There is no history of penetrating or blunt trauma. There is no history of alcohol abuse. He is a smoker with 20 pack years smoking history. He has no known drug allergies. Family history is not significant. Rest of the ROS is unremarkable.

How would you approach this patient?

1.This patient has acute upper abdominal pain. Important causes of upper abdominal pain include perforated duodenal ulcer, severe gastritis, acute pancreatitis, biliary disease, lower lobe pneumonia, splenic abscess and infarct, myocardial infarction, and ruptured aortic aneurysm.

2.Acute cholecystitis presents with RUQ pain radiating to the right shoulder or back. It is steady and severe. Associated symptoms are nausea and vomiting. Another important feature is fatty food indigestion. Acute cholangitis is characterized by jaundice, fever, and right upper quadrant pain. Pain in cases of acute pancreatitis is in the epigastrium, RUQ or diffuse. Its onset is rapid and it lasts for days. One important feature is band like radiation to the back. Pain is often associated with nausea and vomiting. Other important features are restlessness and feeling of relief on bending forward. Sometimes, lower lobe pneumonia presents with acute abdominal pain. MI may present with upper abdominal pain, therefore EKG must be done in such cases if cardiac risk factors are present. Splenic abscess presents with left upper quadrant pain and fever. In cases of splenic infarct, an evidence of some source of embolus is usually found. After reviewing all the causes. This patient is most likely has perforated peptic ulcer. We should proceed to the

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physical examination.

Order:

IV access, stat

Oxygen inhalation, continuous Pulse oximetry, stat

Cuff, BP, continuous EKG, 12 lead, stat

Cardiac monitor, continuous

Here are the results:

Oxygen saturation is 97% on 2-lit O2

EKG is within normal limits without any evidence of ischemia or infarction

Now, order the physical examination:

General appearance; HEENT/Neck; Heart; Lungs; Abdomen; Rectal exam; Extremities.

Here are the results of your examination:

General Appearance: Patient is a well-nourished male. He is pale, ill looking, and sweaty; lying quietly on the bed with acute pain.

Abdomen: Abdomen is rigid, very tender, and bowel sounds are absent. There is a rebound tenderness elicited all over the abdomen. No skin ecchymoses.

Rectum: Sphincter tone is normal. Prostate is normal. No tenderness is elicited. Stools are brown.

Rest of the examination is within normal limits.

Discussion:

This is most likely a case of localized peritonitis due to perforated duodenal ulcer. If a patient with prior history of peptic ulcer symptoms develops sudden and severe abdominal pain, ulcer perforation should be suspected. Perforated duodenal ulcer is largely a clinical diagnosis; therefore history and physical examination are of utmost importance. Unnecessary delay in establishing the diagnosis worsens the prognosis significantly. X-ray studies will show free air under the diaphragm. CT scan and gastrograffin studies will confirm the diagnosis but are usually not required.

Review order:

NPO

NG tube, suction, stat Normal Saline, IV, Continuous Serum amylase, stat

Serum lipase, stat LFTs, stat

X-ray abdomen, acute series, stat CBC with differential, stat

BMP, stat

Results:

Erect X-ray abdomen reveals free air under the diaphragm.

CBC with differential reveals slight leukocytosis with left shift, Hb of 13, and platelets of 200,000/mm3. BMP is WNL. Lipase, amylase, and LFTs are WNL.

Review order:

Morphine, IV, one dose Phenergan, IV, one time

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Ranitidine, IV, continuous (ideally IV proton pump inhibitor (Protonix-pantoprazole) – but not available in CCS software)

Ampicillin IV, stat, continuous Gentamicin, IV, continuous Metronidazole, IV, continuous

Surgical consultation, stat (Reason: Patient with peritonitis secondary to perforated viscus)

Pre-operative preparation:

Consent for procedure

PT/INR, stat, one time

PTT, stat, one time

Blood group and typing, stat

If the surgeon is not ready to take the patient to OR, order he following: Transfer the patient to ICU

Bed rest, complete

Pulse oximetry, every 4 hours Urine output

Pneumatic compression stocking to prevent DVT

Continue NPO status, IV fluids, antibiotics, analgesics, and antiemetics.

*Frequent exams every 2 hours

Treatment of perforated duodenal ulcer:

1.1. Non-surgical management may prove to be successful in some patients. It includes IV fluids, NPO status, nasogastric suction, IV antibiotics, and drugs that decrease or inhibit gastric secretion. All except patients older than 70 are first given a trial of nonoperative treatment.

2.2. For patients with perforated duodenal ulcers, simple patch closure or truncal vagotomy with pyloroplasty are the recommended surgical procedures. Perforated gastric ulcers have much worse prognosis and the surgical procedure of choice is distal gastrectomy.

3.3. H. Pylori and NSAIDS may be the cause of peptic ulcer disease and their presence should be ruled out. If H. Pylori is present, antibiotics must be given to eradicate its infection.

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Case41

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Location: office

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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 (198lbs).

HPI:

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. ROS 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

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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

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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

Case42

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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.

HPI:

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

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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

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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 Cholesterol

190 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.

Primary Diagnosis

Menopause

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Case43

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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.

HPI:

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. ROS 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

IV 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) 126 BMP, stat

LFTs, stat (for alcoholic liver disease)

PT/INR, stat (associated live disease and its coagulopathy)

Case44

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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 .

HPI: 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. His ROS is positive for constipation. He denies 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 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. ROS 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 constipation. Rectal examination: In the presence of abdominal complaints, rectal examination should be performed.

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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, LFTs, 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

LFTs, 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 LFTs 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.

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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

Case45

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Location: A nursery in a community hospital.

CC: Infant with jaundice.

HPI:

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.

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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

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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

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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.

Primary Diagnosis

Jaundice

Case46

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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

HPI:

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

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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

LFTs

Lipid panel

PT/INR, PTT

Complement 3 and 4 levels

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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 (LFTs + 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

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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

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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

Case47

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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.

HPI:

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

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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.

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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

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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

Case48

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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

HPI:

The patient is a seven-year-old boy brought in by his parents after he came home

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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. ROS: 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

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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.

Primary Diagnosis

Child Intoxication

Case49

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Location: Emergency room

Vitals: BP: 90/60 mmHg; PR: 112/min, regular; Temperature is 36.7C(98F); RR: 34/min. C.C: Shortness of breath and chest pain.

HPI:

A 65-year-old white female, with a past medical history of ovarian carcinoma treated with

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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, or exertional chest pain. 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. ROS: Her ROS 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:

IV access, stat Pulse oximetry, stat

Oxygen inhalation, continuous Elevate the patient head Cardiac monitoring, continuous Aspirin, sublingual, one dose

Sublingual nitroglycerine is not indicated in this patient, as his BP is borderline low.

Results:

Pulse oximetry showed oxygen saturations of 83% on room air and 94% on six liters of oxygen.

Order focused physical exam:

General

Lungs

Heart Abdomen Extremities

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. Rest of the exam is WNL.

Patient is still having shortness of breath.

Review orders:

12 lead EKG, stat

Portable chest X-ray, PA view, stat CK-MB, stat

Troponin I, stat ABG, stat

PTT, stat, one time PT/INR, stat, one time CBC with diff, stat

Basic metabolic panel, stat

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Normal saline, IV, continuous

Results:

EKG showed sinus tachycardia and new onset right bundle branch black. Chest x-ray is within normal limits.

ABG, showed PO2 of 60, PCO2 of 34, and PH of 7.50. CK - MB, and Troponin I or T are within normal limits. PTT is 30

PT is 12.5 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:

FOBT (Fecal Occult Blood Testing), stat (Result-Negative) Heparin, IV, continuous

V/Q scan, stat D-dimer, stat

Results:

V/Q scan: Intermediate to high probability for PE. D-dimer is elevated.

Results:

Patient is slightly better on oxygen

Review orders:

Admit the patient to ICU

Continue cardiac monitoring (telemetry) Pulse oximetry, every 2 hours

Maintain oxygen saturations >90-92% with high flow oxygen (100% Non-rebreather mask) NPO

Vitals: ICU routine Complete bed rest Urine output

CBC with diff in 24-hours

PTT 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 clinical 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 cardiac 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 PTT/PT/INR

Check the platelet count and Hb (CBC with diff), as heparin is associated with thrombocytopenia and bleeding.

Discharge the patient:

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Once the INR is above 2, plan for discharge (goal is 2-3) D/C heparin on 4th or 5th day

Anticoagulation teaching Patient counseling

Follow-up in 2 days for PT/INR checked.

Continue warfarin for 12-months and 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 who presents with sudden onset of SOB, and chest pain.

Findings suggestive of PE:

1.Positive D-dimer assay. 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.

2.ABG: Increased A - a gradient, low PO2, low PCO2, and respiratory alkalosis. A-a gradient is more sensitive than PO2 alone.

3.EKG: Right ventricular hypertrophy & new onset RBBB.

4.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 case of pulmonary embolism. V/Q scan is the most helpful initial evaluation to rule out pulmonary embolus after chest x-ray, ABG and EKG are obtained. But V/Q Scan is not necessarily done prior to the use of heparin, and so are other diagnostic tests. If you suspect a pulmonary embolism clinically, and chest X ray, ABG and EKG results rule out other differential diagnoses then you should begin treatment with heparin without waiting for a V/Q scan to confirm your diagnosis. If the classic pattern of mismatched perfusion defect is observed, you should proceed with treatment. If the scan is normal, you can actually rule out significant pulmonary thromboembolism. But, in a substantial number of patients, the ventilation/perfusion scanning results are inconclusive. The next best step in this case is venous ultrasonography to reveal DVT or CT angiogram of the chest. Diagnosing DVT makes the probability of pulmonary thromboembolism very high, and you should proceed with treatment. Although considered the ‘gold standard,’ pulmonary angiography, an invasive procedure is employed if venous ultrasonography or CT angiogram is negative. A negative result by pulmonary angiogram essentially excludes pulmonary thromboembolism as the diagnosis. Chest CT angiogram is also frequently used in indeterminate cases of pulmonary embolism, but the problem with CT angiogram is that it can diagnose only large emboli. Small emboli can be easily missed.

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. 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

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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 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?

1.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.

2.Patients 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.

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

Case50

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Location: Office

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

HPI:

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

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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; Lymph nodes; Heart; Lungs; Abdomen; Extremities; Skin

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

Uric acid, serum, routine 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:

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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, culture and sensitivity, crystals, 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.

Counseling:

Low protein diet Patient counseling No smoking

No alcohol

Medication compliance No illegal drugs

Seat belt use

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

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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.

Primary Diagnosis

Gout

Case51

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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

HPI:

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

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HEENT/Neck Lungs Heart Abdomen CNS Extremities

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. Rest is normal.

Order:

IV access, stat

IV Toradol (ketorolac), stat ESR, stat

CT head (without contrast), stat

Discussion:

Indications for CT head in patients with headache are:

1.Occurrence of severe new onset headache even in a patient with H/O chronic headache and previously normal CT

2.Sudden onset of severe headache in any patient of >50 yr. age

3.Presence of focal neurological findings

Results:

ESR is WNL

CT head demonstrate evidence of subarachnoid hemorrhage. No midline shift. Patient is still in mild to moderate pain

*In this case if the CT scan does not show bleeding, you should order lumbar puncture and the fluid should be sent for xanthochromia. But, the option of

xanthochromia is not available in software.

Order:

Admit in ICU

Continuous cardiac monitoring Pulse oximetry, every 2 hours NPO

Complete bed rest Urine output

Neurochecks, every 1 hour CBC with diff, stat

BMP, stat and daily

EKG, 12 lead, one time (for baseline) PT/INR, stat

PTT, stat

Transcranial Doppler (For baseline) - Not available in software Neurosurgery, consult, stat

Normal saline, IV, continuous

Acetaminophen with codeine (Percocet), oral, continuous for pain Stool softener (Docusate), oral, continuous

Nimodipine, oral, continuous for 21 days Omeprazole, oral, continuous Pneumatic compression devices

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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 CSF 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 is 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.

Primary Diagnosis:

Headache

Case52

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Location: Office

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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.

HPI:

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. ROS: 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

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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, cadiomyopathy, 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:

1.Graves' disease and toxic multinodular goiter.

2.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.

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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 LFTs 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.

Primary Diagnosis:

Hyperthyroidism

Case53

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Location: Outpatient Clinic, Pediatrics.

Vital signs: Normal.

C.C: 2-1/2-year-old girl with abdominal pain and constipation.

HPI:

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

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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.

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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.

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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

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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 followup blood lead level measurements on these children.

Order review:

Followup 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.

Case54

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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.

HPI:

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. ROS: 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

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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)

IV access

IV fluids at 100 cc an hour with normal saline

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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.

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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.

Case55

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Location: Emergency room

Vitals: B.P: 110/70 mmHg; P.R:100/minute; Temperature: 1020F; R.R: 15/minute. C.C: Fever and chills.

HPI:

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. ROS: 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 IV 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

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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

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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

Case56

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Location: Office

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

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

HPI:

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. ROS: 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:

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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

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Primary Diagnosis

DVT

Case57

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Location: Office

Vital signs: PR: 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

HPI:

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. ROS 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

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CBC with diff, stat

Comprehensive metabolic panel (CMP), stat Abdominal ultrasonogram, stat

Chest - X ray, PA and lateral, stat UA, stat

FOBT, stat PT/PTT, routine

Results:

Pulse oxymetry 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, routine

CT chest, routine Mammogram, routine PAP smear, routine CA 125, routine

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

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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 - nongestational 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.

Primary Diagnosis

Ovarian Cancer

Case58

Print

Location: Emergency room

Vitals: B.P: 130/70 mm Hg; P.R: 90/min; R.R: 20/min; Temperature: 37.8C.

HPI:

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

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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:

IV 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.

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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.

Case59

Print

Location: Emergency room

Vital signs: B.P: 130/70 mm Hg; H.R: 80/min; R.R: 18/min; Temperature: 38.7ºC.

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HPI:

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. ROS 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 IV 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)

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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, LFTs, 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.

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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.

Case60

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Location: Emergency Room.

Vitals signs: Temperature 38.9; heart rate 72; blood pressure 125/78 m Hg; respirations 14 per minute;

HPI:

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,

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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:

IV access, stat

Normal saline, IV, continuous Pulse oximetry, stat

NPO

NG tube to suction (If the patient has vomiting) CBC with diff, stat

Comprehensive metabolic panel, stat (Type CMP) Serum amylase, stat

Serum lipase, stat UA, stat

Beta HCG, serum qualitative, stat Abdominal X-ray, acute series, stat PT/PTT, stat

IV Morphine or Fentanyl for pain management. (Type morphine, IV, stat, one dose) Phenergan, IV, one dose

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:

Oxygen saturation is 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.

Review orders:

Abdominal ultrasound, stat (type USG, abdomen, stat)

Begin IV antibiotics with cefuroxime or a combination of ampicillin and gentamicin (Type ampicillin, IV, continuous then gentamicin, IV, continuous)

Results:

Ultrasound of the right upper quadrant reveals numerous echogenic foci within the

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gallbladder with thickening of the gallbladder wall and dilatation of the cystic duct. Findings are suggestive of acute cholecystitis.

Order:

General surgery consult, stat (reason: 35-year-old female with acute cholecystitis)

Results:

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

Order:

Change setting to inpatient management (Floor/ward)

Vitals Q 4 hours

Activity - Bed rest with bathroom privileges

Urine output

Pneumatic compression stocking (for DVT prophylaxis)

CBC with diff, next day

Comprehensive metabolic panel, next day

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%.

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 an additional attack of biliary colic within two years of their first attack. Recurrent episodes of biliary colic even without acute cholecystitis is an indication for cholecystectomy. The fourth stage of gallstone disease is the development of complications 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

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sensitive, specific, and noninvasive and a relatively inexpensive test for evaluating for gallstone disease. Other tests include HIDA scans, which stands for hepatobiliary iminodiacetic acid radionuclide 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 reveal 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 are 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.

Case61

Printing Not Allowed

Location: Emergency Room.

Vital signs: Temperature 39.3C(103F); heart rate 112/min, regular; blood pressure 112/70 mmHg; respirations 12 per minute;

HPI:

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

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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

Neuro/psych

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 mid tibia. 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

IV access, stat

CBC with differential, stat

BMP, stat

PT/PTT, stat

Blood cultures, stat every 10 minutes x 3

UA, stat

Chest -X-ray, PA and lateral, stat

ECG, 12 lead, stat

Urine toxicology screen, routine

Results:

O2 saturation is 97% on room air. CBC with differential shows a white count

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18,000/cmm with 89% polymorphonuclear leukocytes, 10 band neutrophils, 12 lymphocytes, hemoglobin 12, hematocrit 35.5, and platelets 309,000/cmm. X ray of the chest shows 2 very small wedge shaped infiltrates with cavitation. Electrolytes are normal; BUN is 25 and creatinine is 0.9. PT/PTT are WNL. EKG shows sinus tachycardia. UA is WNL. Tox screen is positive for opiates.

Order:

Vancomycin, IV, continuous

Gentamicin, IV, continuous

Acetaminophen, oral, one time (for fever)

Normal saline, IV, continuous

*Admit to floor/ward Vitals every 4 hours

Pulse oximetry every 4 hours Urine output, routine

Bed rest with bathroom privileges Pneumatic compression stockings NPO

*Advance the clock for 8 hours

TEE (Transesophageal echocardiogram), stat CBC with diff, next morning

Consider ordering following if he was not tested before:

HbsAg, routine (For hepatitis B screening)

Hepatitis C antibody, serum, routine

HIV-1/HIV-2 serology, routine

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 reveal vegetations on the tricuspid valve approximately 5 mm in length. There is no evidence of perivalvular disease.

Review orders:

D/C Vancomycin (double click on this order; the software will ask you, do you want to cancel this order?)

Order Nafcillin, IV, continuous

Centra line placement, routine (for continued IV antibiotic therapy for a total of four to six weeks).

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:

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The patient’s temperature down trends with a T-max of 37.8 on first day of admission. He is hemodynamically stable.

Order review:

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).

Smoking cessation Limit alcohol Safe sex

Seat belt use

No illegal drug use Exercise program

Advise patient SBE prophylaxis

* Follow up in 1 week.

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.

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3. Blood culture-negative prosthetic valve endocarditis is treated with ceftriaxone and 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 patients 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 patients 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.

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Case62

Printing Not Allowed

Location: Office

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

HPI: 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 ROS 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. All: 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 IV 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.

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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

LFTs, 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. LFTs 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.

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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 followup 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

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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.

Primary Diagnosis

Atrial Fibrillation

Case63

Printing Not Allowed

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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).

HPI:

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:

IV 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.

CXR 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

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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.

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Primary Diagnosis:

Pericardial Tamponade

Case64

Printing Not Allowed

Location: Emergency Room

Vitals: BP: 90/60 mm Hg; HR: 124/min; RR: 24/min; Temp: 37.2C (99F)

C.C: Sudden onset abdominal pain

HPI:

A 55-year-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:

IV access, stat

Start IV fluids: Normal Saline, IV, continuous

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:

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General appearance

HEENT/Neck

Examination of CVS

Examination of lungs

Examination of Abdomen

Examination of Rectum

Extremities

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:

NPO

Fentanyl or Meperidine, IV, continuous

Phenergan, IV, stat, one time (for nausea)

Serum amylase, stat

Serum lipase, stat

LFTs, stat

Erect abdominal X-ray, portable, stat

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

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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 with 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:

Transfer to ward or ICU (if unstable or has severe pancreatitis)

Bed rest

Pneumatic compression devises

Omeprazole, oral, continuous (for stress ulcer prophylaxis)

Urine output

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:

PT/aPTT, stat (preoperative preparation)

Gastroenterology consult for ERCP: Reason: Gallstone pancreatitis; requires possible intervention with ERCP. Please evaluate and treat.

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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:

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Acute Pancreatitis, secondary to gallstones

Case65

Printing Not Allowed

Location: Office visit

Vitals: BP: 120/80 mmHg; HR: 84/min; RR: 14/min; Temp: 37.2C(99F)

C.C: “I am not feeling well, can’t eat anything and my urine has become dark yellow”

HPI:

A 34-year-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; appetite 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, melena, 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

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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:

LFTs, stat

CBC with differential, stat

Reticulocyte count, stat

BMP, stat

PT/INR, 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:

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 bilirubin) 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

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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.

Rest at home

Antiemetics PRN (Phenergan, oral, continuous because there is no PRN (as needed) option in software)

Reassure patient Regular diet

No alcohol No smoking

Hepatitis precautions counseling

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 LFTs in 3 days

PT in 3 days

Notify public health department

* 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/INR- 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

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PT/INR in 3 days

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/INR in 3 days

Final Diagnosis:

Acute Hepatitis A

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.

Case66

Printing Not Allowed

Location: Emergency Room

Vitals: BP: 100/60 mm Hg (supine), 80/50 mm Hg (sitting); HR: 124/min; RR: 24/min; Temp: 98.4F

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C.C: Black colored stools

HPI:

A 55-year-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:

IV access, stat- 2 large (18 G) IV bore needles

Start IV fluids: Normal saline, continuous

Make NPO

Cardiac monitor, continuous

Continuous BP 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

Extremities

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

196

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.

Order No.2

CBC with differential, stat BMP, stat

LFTs, stat PT/INR, stat aPTT, stat

EKG, 12 lead, stat

IV Ranitidine or Pantoprazole (Protonix), continuous (Protonix IV is not available in CCS software)

NG tube, gastric lavage Type and crossmatch, stat 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

*Admit in ICU

Order No. 3:

Continue NPO Bed rest Urine output

Pneumatic compression stockings Stop IV NS

Start packed RBC transfusion (type PRBC), stat - 3 Units 4 Units fresh frozen plasma (FFP), stat

Hb and Hematocrit every 6 hours (Type H&H) PT after FFP transfusion

Continue Protonix/Ranitidine infusion

*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

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Order No. 3:

Gastroenterology consult, routine for EGD (Also order H. Pylor biopsy) Continue NPO

Restart IV NS, continuous H and H every 6 hours

Continue Protonix/Ranitidine infusion Continuous BP monitoring

Call me when the lab results available

Results for Order No. 3:

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. 4

Discontinue NPO

Stop IV NS

Starts clears and advance to regular diet as tolerated

H and H every 12 hours

Stop IV Protonix/Ranitidine

Start Protonix, oral

Results of order No. 4:

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.5

Discharge the patient home after overnight watch

Send home on Protonix for 4-8 weeks, make follow-up appointment in 2 weeks Patient counseling

Medication compliance

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 melena 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. Melena 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. melena 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

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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 is not needed for diagnostic purposes in this patient, as there was a definite history of hematemesis. However, gastric lavage can be performed for cleaning the stomach.

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.

Final Diagnosis:

Upper gastrointestinal hemorrhage, secondary to duodenal ulcer

Management:

1.Hemodynamic stabilization is more important before an EGD. 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

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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).

Case67

Printing Not Allowed

Location: Emergency Room

Vitals: BP: 104/70 mm Hg (supine), 80/50 mm Hg (sitting); HR: 120/min; RR: 24/min; Temp: 98.4 (36.9C)

C.C: Bright red blood per rectum

HPI:

A 65-year-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.

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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:

IV access, stat - 2 large (18 G) IV bore needles

Start IV fluids: Normal Saline, continuous

Continuous cardiac monitoring

Continuous BP monitoring

Pulse oximetry, stat

NPO

*If the CCS doesn’t provide orthostatic vitals you can order: Postural vitals, 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

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

LFTs, stat PT/aPTT, stat EKG, 12 lead, stat

Type and Crossmatch, stat - in preparation for blood transfusion Nasogastric tube, aspiration

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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:

Admit in ICU

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

Urine output

Apply pneumatic compressions for DVT prophylaxis

Accucheck every 6 hours (use regular insulin as needed, based on blood sugar levels)

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, stat 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

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Start bowel preparation for colonoscopy - 4 liters of polyethylene glycol (Golytely, Colyte) given over two hours

Vitals every 2 hours

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 12 hours

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).

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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. 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.

3.Calcium levels should be monitored as multiple transfusions may lead to hypocalcemia requiring specific therapy.

4.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:

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Lower gastrointestinal hemorrhage, secondary to diverticulosis.

Case68

Printing Not Allowed

Location: Emergency Room

Vitals: BP: 80/50 mm Hg; HR: 40/min; RR: 24/min; Temp: 98.4F

C.C: Lightheadedness

HPI:

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:

IV 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

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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:

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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

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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)

Case69

Printing Not Allowed

Location: Emergency Room

Vitals: BP: 100/60 mm Hg; HR: 104/min; RR: 30/min; Temp: 100.4F

C.C: Generalized bodyache and weakness

HPI:

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

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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:

IV 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

209

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 muscl ischemic muscle damage. The hot climate and dehydration contributed to the myoglo acute tubular necrosis. This resulted in acute renal failure with anion gap metabolic a 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,

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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.

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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

Case70

Printing Not Allowed

Location: Emergency Room

Vitals: BP: 120/80 mm Hg; HR: 112/min; RR: 28/min; Temp: 37.8C(100F)

C.C: Fatigue and right upper quadrant abdominal pain

HPI:

A 74-year-old white male presents to the ER with a 3 days history of fatigue and

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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-year-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

IV access, stat

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

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.

Order No. 3:

X-ray Chest (CXR), PA and lateral, stat

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EKG, 12 lead, stat

CBC with differential, stat

BMP, stat

LFT, stat

Lipase, 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 %

LFTs and Lipase – Completely normal EKG – Sinus tachycardia

Order No. 4:

Admit the patient on regular floor Blood cultures, stat

Sputum Gram stain, stat (Optional) Sputum cultures, stat (Optional)

Start antibiotics after drawing blood cultures - Levofloxacin/gatifloxacin or Ceftriaxone + azithromycin, IV continuous

Acetaminophen, continuous (for fever and pain) Vitals every 4 hours

Pulse Oximetry, Q 2 hours

Bed rest with bathroom privileges Pneumatic compression for DVT prophylaxis Diabetic diet

Diet, 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

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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.

Counseling:

Patient counseling

Medication compliance

Discussion:

This is a case of community-acquired pneumonia (CAP) with an atypical presentation. With an abnormal chest x-ray, normal LFTs 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:

1. a. Fluoroquinolone alone - levofloxacin or gatifloxacin; Do not use ciprofloxacin

2. 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.

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Levofloxacin alone also covers atypical organisms.

For uncomplicated pneumonia in the out patient setting:

1. 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.

1.1. Age greater than 65 years

2.2. Coexisting disease: Diabetes, renal failure, heart failure, chronic lung disease, chronic alcoholism, immunosuppression, and neoplastic disease.

3.3. Clinical findings: Hypoxia requiring oxygen; RR >30 breaths/min, Systolic BP<90mm Hg or Diastolic BP< 60 mm Hg, Temperature>38.3 C, altered mental status, extrapulmonary site of infection (meningitis, septic arthritis).

4.4. Laboratory tests: WBC <4,000/mm3 or >30,000/mm3; Pao2<60 mmHg; renal failure; multilobar involvement on chest radiograph; pleural effusion; Hct<30%.

Primary Diagnosis:

Pneumonia

Case71

Printing Not Allowed

Location: Office.

Vital signs:

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

HPI:

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

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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 up-to-date.

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, moist 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 small 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.

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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:

LFTs are within normal limits.

Serum uric acid is normal

Ophthalmology consultation: Normal ocular study

Order review:

INH, oral, continuous*6months

Pyridoxine oral, continuous*6months

Rifampin oral, continuous*6 months,

Pyrazinamide oral, continuous*2 months

Ethambutol, oral, continuous*2months

Counseling:

Patient counseling

Reassurance

Smoking cessation counseling

No illegal drug use

Regular diet

Medication compliance

Notify public health department

Change location to home and fix appointment after 15 days.

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

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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, LFTs, chest-x ray and serum uric acid.

Case72

Printing Not Allowed

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Location: Office

Vital signs: Pulse: 110/min; BP: 110/60 mmHg, Temperature: 39.6C(103.4F), RR: 20/min, Height: 70”, Weight: 165Lb.

HPI: 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:

General

Lungs

Heart

Abdomen

Rectal

Genitalia

Extremities

Here are the findings:

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

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.

IV access, stat

CBC with diff, stat

BMP, stat

Urinalysis, stat

Urine Gram stain, stat

Urine culture and sensitivity, routine

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Blood cultures, stat

Vital signs Q 6 Hrs

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

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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

Normal saline, IV, continuous

Acetaminophen, oral, continuous

Promethazine, IV, one time

*If the pain is severe consider IV NSAIDs such as ketorolac

Click call me if needed; advance the clock for 6 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 the patient is afebrile, D/C IV medications (Double click on the medication and choose delete)

Order CBC with diff and urinalysis after 24-hours of treatment Ciprofloxacin, oral, 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 counseling

Regular diet

Medication compliance

Safe sex practice

Contraception counseling

Seat belt while driving

Discharge the patient (change location to home) once afebrile and make 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.

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Order:

Urinalysis, stat

Change antibiotic depending on C/S results for a period of 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.

Case73

Printing Not Allowed

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Location: Office

Vital signs: BP: 120/70mmHg, HR: 90/min, regular: Temp: 37.8C(100F), RR: 18/min, Weight: 120 lbs: Height: 5’5”

CC: Fever, cough and right-sided chest pain for three months.

HPI: A 30-year-old, previously healthy white female presents to the office because of fever, dry cough and pain in the right lower chest. The pain is gradual in onset, 4- 5/10 in intensity, sharp in nature, non-radiating, and increases with deep breathing. Her other symptoms include mild exertional dyspnea, irritability, decreased appetite and fatigue. She has unintentional weight loss of about 10 lbs over a period of two months. She denies any allergies, recent travel or sick contacts. She is not on any medication. She says that her mother has some joint disease. She denies smoking but occasionally drinks alcohol. Her menstrual cycles are always regular and last menstrual period was two weeks ago. She is sexually active with her boyfriend and uses OCPs for contraception. Her immunizations are up to date.

How do you approach this case?

Since the patient is stable based on the vital signs, order the following physical examination:

General

HEENT and Neck Lungs

Heart Abdomen Extremities CNS

Skin

The following are the examination findings:

The patient is anxious and sitting comfortably on the table. An erythematous rash is present over the face, more in the malar region. Decreased breath sounds and tactile fremitus, along with dullness to percussion are noted over the right lower lobe. No rhonchi or wheezing is noted. The rest of the exam is normal.

What is your clinical impression?

A 30-year-old, previously healthy, white female with symptoms of pleurisy found to have findings suggestive of pleural effusion and a malar rash. She also has a family history of some joint decease. All these findings should make you think about SLE as the number one diagnosis in this patient.

*Since the patient needs to be evaluated with pleural fluid analysis, shift her to ward by clicking on change location to ward.

Orders:

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Pulse oximetry, stat

CBC with diff, routine

BMP, routine

Chest X-ray PA, lateral views, routine

EKG 12 lead, routine

Serum ANA, routine

Urinalysis, routine

ESR, routine

Activity: Ambulation at will

Diet: Regular diet

Vitals: Vital signs every 4 hours.

*Call me when results are available

Results of your tests:

Oxygen saturation is 94% on room air.

Labs:

Hb

10 g/dL

MCV 86 fl

WBC

10,000/cmm (Neutrophils: 62% Lymphocytes: 29%, Eosinophils: 3%, Monocytes: 6%, Basophiles: 0%)

Platelets 140,000/cmm

Blood glucose 118 mg/dL

Serum Na 135 mEq/L

Serum K 3.8 mEq/L

Chloride 110 mEq/L

Bicarbonate 18 mEq/L

BUN

16 mg/dL

Serum creatinine 1.0 mg/dL

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Urine analysis

WNL (no hematuria, casts, protein, or infection)

Serum ANA

Positive at 1:320

Chest X-ray

Right-sided pleural effusion is seen.

EKG 12-lead

Normal sinus rhythm; normal EKG.

Review of orders:

Chest-x ray, decubitus films

PT/INR, routine

PTT, routine

Anti-Ds DNA, routine

Complement C3, serum, routine

Complement C4, serum, routine

*Call me when results are available

Results:

Decubitus films show free flowing effusion without any loculation; there is a 1.5 cm layering.

PT/INR/PTT - Normal Anti-Ds DNA is pending

Review of orders:

Thoracocentesis, diagnostic Informed consent

Pleural fluid analysis (Gram stain, AFB, C&S, Protein, glucose, LDH, cell count, cytology, pH)

Serum LDH, routine Serum protein, routine

Perform physical exam after the thoracocentesis.

Results:

Serum C3 and C4 are low Anti-Ds DNA is positive. Serum LDH: 90U/L Serum protein:

Total protein 7 g/dL

Albumin

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4.5 g/dL

Globulin 2.5 g/dL

Pleural fluid analysis:

Appearance

Slightly turbid

PH

7.6

LDH

240 U/L

Protein

10.5 g/dL

Glucose

46 mg/dL

Gram stain

Negative for organisms

(Calculate the ratios: PF LDH/Serum LDH-2.7, PF protein/Serum protein-1.5, which are characteristic of an exudate)

Orders review:

Rheumatology consult, stat (Reason: 30-year-old female with confirmed SLE. Please evaluate and treat)

Orders review:

Patient counseling

Prednisone, oral, continuous

Safe sex

Contraception counseling (avoid OCPs)

Regular exercise

No smoking

No alcohol

No illicit drugs

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Medication compliance

Low fat, high fiber diet

Discharge to home

*Review after two weeks

Discussion:

The best clue for the presence of pleural effusion on chest-x ray is the blunting of the posterior costophrenic angle on lateral chest-x ray. So, if you see that finding on the chest-x ray, bilateral decubitus chest radiographs should be obtained to ascertain whether free pleural fluid is present. If the free fluid is present, layering will be seen. If the distance between the inside of the thoracic cavity and the outside of the lung is less than 1 cm, the pleural effusion is not clinically significant and it would be difficult to tap (risk outweighs benefits). If the distance is greater than 1 cm, a sample can be obtained for the diagnosis.

A diagnostic thoracentesis should be performed on nearly every patient with free pleural fluid that measures more than 1 cm on the decubitus films. However, in a patient with obvious congestive heart failure, the procedure can be withheld until the heart failure is treated.

Before you tap, make sure the patient does not have coagulation abnormalities. The absolute contraindications for thoracocentesis include:

1.PT or PTT > twice normal

2.Platelet count < 25,000/cmm

3.Serum creatinine > 6 mg/dL

The pleural fluid can be an exudate or transudate. Exudative effusions result from increased capillary protein leak secondary to pleural and lung inflammation. Transudative effusions result from the imbalance between hydrostatic and oncotic pressures in the pleural space.

The important diagnostic criteria for separating pleural fluid into exudate or transudate are measurement of serum and pleural fluid protein and LDH. At least one of the following three values should be present for an exudate. If none is present then it is almost always a transudate.

1.1. Pleural fluid protein/serum protein ratio > 0.5

2.2. Pleural fluid LDH/serum LDH ratio > 0.6

3.3. Pleural fluid LDH >2/3rds of the upper limit of normal serum LDH.

The determination of pH is important in parapneumonic effusions in which a value of less than 7.2 requires a chest tube aspiration to prevent empyema.

Pleural fluid ANA and rheumatoid factor can be obtained in undiagnosed/suspicious cases; but they are not routinely required in obvious cases. The elevated ANA titers in pleural fluid are neither specific nor sensitive for diagnosing lupus pleuritis. The diagnosis of lupus pleuritis is based primarily on the clinical picture and the serologic findings for lupus.

The most common clinically significant complication of thoracocentesis is a pneumothorax. However, a routine chest-x ray after thoracentesis is not indicated.

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Careful physical examination is all that is required.

Common causes of transudative pleural effusions:

Congestive heart failure

Cirrhosis

Nephrotic syndrome

Peritoneal dialysis

Myxedema

Pulmonary emboli

Common causes of exudative pleural effusions:

Neoplastic diseases

Infectious diseases (pyogenic bacterial infections, tuberculosis, fungal infections, viral infections, parasitic infections)

Pulmonary embolism

Gastrointestinal disease such as esophageal perforation, pancreatic disease etc. Collagen vascular diseases such as RA, SLE etc.

Recent surgery (postpericardiectomy or CABG)

*The effusions secondary to pulmonary embolism can be a transudate or an exudate.

Treatment:

The treatment of plural effusion requires the treatment of underlying cause. Large effusions may require therapeutic thoracocentesis. Unlike rheumatoid pleuritis, the patients with lupus pleuritis very well respond to corticosteroids. The standard treatment includes oral prednisone 80 mg every other day, with rapid tapering once the symptoms are controlled. Many medications (hydralazine, procainamide, isoniazid, etc.) have been incriminated in producing drug-induced lupus erythematosus. If that is the case, the offending drug should be stopped.

Primary diagnosis:

Pleural effusion secondary to SLE

Case74

Printing Not Allowed

Location: Office

Vital signs:

T.38.9’C (102F), HR 96/min, RR 21/min and BP 118/65 mm Hg.

C.C: Chest pain

HPI:

A 7-year-old African American child who has a history of sickle cell disease is brought to

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the office by his mother with a one-day history of right arm pain, chest pain, fever, non- productive cough, and mild shortness of breath. He describe the left sided chest pain, 8-9 /10, constant, aggravated by deep breath, but not relieved by anything. Child denies having had any kind of injury. Patient is on prophylactic penicillin, and had received polyvalent pneumococcal vaccine. His past medical history is significant for sickle cell anemia. Developmental history: Age Appropriate per Denver Developmental growth scale. Family History: Sickle cell disease in maternal cousin. No other major medical problems in the family. Social history: Lives with mom, dad and older sister. No smokers at home. All: None. Meds: Penicillin VK and folic acid. How do you approach this patient?

Order physical exam:

General

HEENT/Neck

Lungs

Heart

Abdomen

Extremities

Skin

Results:

The 7-year-old child is in moderate to severe pain, and mild respiratory distress. Pallor is present. Severe local tenderness is noted over the right arm, ribs and sternum. Heart sounds are normal. No murmurs/rubs/gallops. There are decreased breath sounds, and increased tactile vocal fremitus (TVF) present over the right middle lobe.

Order review:

Pulse oximetry, stat

Results:

88% on room air

Order review:

Admit the patient to floor/ward

Oxygen, inhalation (to keep pulse ox greater than 93%)

IV access

CBC with diff, stat

BMP, stat

Blood cultures

Urinanalysis and urine cultures

Sputum gram stain and culture

Chest X-ray, PA, and lateral, stat

EKG, 12 lead

Type and screen for blood

Vitals Q 4 hours

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Pulse oximetry, continuous (0r) Q1-2 hours depending on the severity of hypoxia Regular diet

IV hypotonic fluids D5 1/4 NSS or D5W NS, bolus and then continuous IV Morphine, continuous

IV Cefuroxime and IV Azithromycin Incentive spirometry

Albuterol nebulization, Q4 hours

Consider blood transfusion if hypoxia does not improve on nasal canula

Next:

Advance the clock to see the next available result

Reexamine the patient in 1 hour and take interim history and focused lung exam

Order:

Repeat hemoglobin and hematocrit in 4 hours and again in 8 hours if stable Patient will say that he is feeling much better

Stop IV fluids next day

Repeat CBC with diff, and BMP next day

*Usually the case will end if you do this much.

Discharge:

Observe the patient for 48-hours, stop IV antibiotics once the cultures are negative and discharge him to home on oral antibiotics

Patient education High calorie diet

Discussion:

Acute and chronic pulmonary complications are the most common cause of death in patients with sickle cell anemia. Recurrent microvascular obstruction leading to pulmonary hypertension and pulmonary fibrosis is the underlying pathology. The primary acute pulmonary diseases seen in patients with SCD include:

1.Acute chest syndrome

2.Infection or pneumonia

3.Infarction due to in-situ thrombosis

4.Fat embolism from bone marrow infarction

Differentiation of pneumonia from acute chest syndrome is difficult, as the sputum and blood cultures are often nondiagnostic.

Microvascular occlusion resulting in bone marrow infarction can cause pulmonary fat embolism (PFE). Sickle cell disease (SCD) patients who have PFE manifest altered mental status, thrombocytopenia, petechial rash, falling hematocrit, and severe hypoxemia. The therapeutic options for PFE include exchange transfusion, plasma infusions, and glucocorticoids.

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Acute chest syndrome is the most common form of acute pulmonary complication in patients with SCD. Intravascular sickling resulting in macrovascular or microvascular infarction within the pulmonary vasculature is assumed to be the most frequent cause of ACS in patients with SCD. Previous studies have shown that upto 50% of ACS is the result of bacterial infection. ACS should be suspected if the patient presents with chest pain/extremity pain, fever of >38.5ºC, tachypnea, wheezing, or cough. On examination, local tenderness over the ribs or sternum and signs of consolidation are present. Leukocytosis, thrombocytopenia or thrombocytosis, falling hemoglobin concentration, elevations in lactate dehydrogenase and bilirubin levels, presence of a new pulmonary infiltrate, involving at least one complete lung segment (not atelectasis) are the other common findings.

The acute management of ACS is primarily a supportive care:

1.Patient should be given supplemental oxygen to prevent further sickling

2.Pain should be controlled with judicious use of narcotics

3.Dehydration should be corrected with volume replacement

4.Incentive spirometry can be used to prevent atelectasis. Some SCD patients may manifest airway hyperreactivity, and these should be given bronchodilators.

5.Antibiotics to cover S. pneumoniae, H. influenzae type b, Mycoplasma pneumoniae, and Chlamydia pneumoniae.

6.Exchange transfusion is indicated for patients with hypoxia with new infiltrates.

Chronic therapy:

1.Penicillin prophylaxis with penicillin V potassium 125 mg BID is recommended in children aged 4 months to at least 3 years.

2.Polyvalent pneumococcal vaccine for both adults and children.

3.Hydroxyurea for recurrent vasoocclusive crisis.

Primary Diagnosis:

Sickellcell Anemia

This copy of the material is licensed to chakradhar venkata. Copyright @2002-2005 All Rights Reserved www.usmleworld.com

Case75

Printing Not Allowed

Location: ER

CC: A 28-year-old Caucasian female with sudden onset of shortness of breath and swelling of the face

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Vital signs:

Her temperature is 36.7C(98F), blood pressure is 100/62 mm Hg, pulse is 126/min, and respirations are 38/min.

HPI: A 28-year-old Caucasian female is brought to the emergency room by her friend because of the sudden onset of shortness of breath and swelling of her lips, face and extremities. The symptoms have started suddenly after a bee sting. She denies any other medical problems. Other history is unobtainable.

How do you approach this patient?

You have a 28-year old, healthy, female with no other medical problems with sudden onset shortness of breath and what appears to be an asymmetric edema of the body after a bee sting. This is all quit consistent with anaphylactic reaction with angioedema. Other common acute conditions such as asthma exacerbation, pneumothorax, acute pulmonary embolism, and panic attacks are unlikely given the asymmetric edema of the body.

The first step in the management of this patient is to secure airway, breathing and circulation. In all patients with airway compromise or vasomotor instability, epinephrine should be promptly administered.

Order:

Pulse oximetry, stat Oxygen inhalation, stat Cardiac monitor, stat

Continuous BP monitoring, stat IV access, stat

Epinephrine, subcutaneous, stat (repeat every 15 to 20 minutes if there is no improvement)

Normal saline, IV, bolus Normal saline, IV, continuous

*Advance clock by 5 minutes and repeat epinephrine if needed.

Here are the results:

She is saturating 82% on room air and 93% on 4-liters oxygen

She is feeling better with one dose of epinephrine

*If the patient is having severe respiratory compromise (cyanosis, stridor, low oxygen saturations despite of 100% oxygen), she should be intubated and mechanical ventilation is required. You can order like:

Intubation, endotracheal, stat Ventilation, mechanical, stat

Now, perform the physical exam:

General

Skin

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HEENT/Neck

Lungs

Cardiovascular

Abdomen

Extremities

Physical exam findings:

The patient is very anxious, frightened and in mild to moderate respiratory distress. There is no skin rash. Face, lips, neck and tongue are swollen. Pupils are equal and reacting to light. Mucus membranes are dry. Diffuse expiratory wheezing is present. Extremities are acyanotic and swollen. Non-pitting edema is present in an asymmetric fashion over all extremities.

Review orders:

ABG, stat

CXR, portable, PA, stat 12-Lead EKG, stat CBC with diff, stat BMP, stat

Albuterol, nebulization, continuous (for bronchospasm) Hydrocortisone, IV, continuous

Diphenhydramine, IV, continuous Ranitidine, IV, continuous

Here are the results:

ABG- Po2-70% on 4-lit oxygen, PCo2 –30, pH- 7.5 (consistent with respiratory alkalosis)

BMP is insignificant

CBC-WBC count is elevated at 12,000/cmm with mild left shift; Hb and platelets are normal.

EKG shows sinus tachycardia CXR is with in normal limits

Review orders:

Transfer to ICU

Dopamine, IV, continuous – This can be started if the patient is still hypotensive despite of receiving intravenous fluids.

Management in ICU:

Bed rest

Vitals routine (per ICU protocol)

Pulse oximetry, routine, every 4 hours

Urine output, routine

Diet, NPO

*Examine the patient for every 30 minutes in the beginning

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Results:

Patient is improving with the treatment

*Usually the case will end if you manage this much; in case if it continue

Discussion:

Once the patient is improved change the location to ward/floor

Now discontinue IV fluids, IV steroids, IV diphenhydramine and other IV medications Start prednisone, oral, continuous

Start diphenhydramine, oral, continuous

Discharge planning:

Discharge the patient after 24-hours of observation. Schedule an outpatient radioallergosorbent test (RAST) testing after 6-weeks. Also, request an immunologist consult as an outpatient. If they ask reason, type: Patient with recent episode of anaphylaxis. Please evaluate with skin testing. Order medical alert bracelet and counsel about medication compliance. Ideally, we should provide preloaded syringes with epinephrine (EpiPen) to the patient and advice avoid allergens.

*USMLE software doesn’t have options for EpiPen and avoid allergens.

Final diagnosis:

Acute anaphylaxis with angioedema from Bee sting

Discussion:

Management of anaphylaxis starts with rapid assessment of airway and breathing. Airway should be secured and patients may require intubation if there is significant upper airway edema, stridor, cyanosis, or if the patient is not improving with oxygen inhalation (from bronchospasm). The drug of choice for acute anaphylaxis is epinephrine, typically given though subcutaneously in mild to moderate cases; intravenous epinephrine should be given in patients with severe hemodynamic instability, severe upper airway edema, or severe bronchospasm. If the patient is on beta-blockers for some reason, the effect of epinephrine may not be prompt and enough; in these patients glucagon is given. Once the airway and breathing is secure, hemodynamic status should be assessed. Patients may require several liters of crystalloids to maintain the perfusion. If the patient is not responding to crystalloids, vasopressors such as dopamine or phenylephrine should be started.

A combination of both H1 and H2 blockers should be given to all patients. Corticosteroids are also routinely given to prevent the late phase reaction.

Once the acute episode is over, the patient should have formal evaluation with allergist. The patient should also have skin tests and RAST to identify the allergen. Patient’s should be educated and provide EpiPen.

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Case76

Printing Not Allowed

Location: Emergency room

Vital signs: B.P: 130/80 mmHg, H.R: 100/min, Temp: 36.7C(98F), R.R: 22/min

C.C: Palpitations

H.P.I:

A 25-year-old man presents to the E.R with complaints of sudden onset palpitations, chest pain, sweating and breathlessness associated with anxiety of 30 minutes duration. He was working at his office desk when he developed a pounding sensation in his heart associated with tightness in his chest and profuse sweating. He denies similar episodes in the past. He has no history of any major medical illness. He denies any major allergies. He is not on any prescription or over the counter medications. He is not a smoker and drinks beer only occasionally. He denies any recreational drug use. His family history is significant for ischemic heart disease in his father and paternal uncle.

Review of systems:

He admits to mild nausea. He denies any fever, chills, weight changes, and hair, skin or nail changes, changes in bowel movements, urinary problems, heat or cold intolerance, vertigo or visual disturbances.

How do you approach this case?

Whenever a patient presents to the ER with symptoms of a possibly critical condition, irrespective of the age and the risk factors, the first step is a complete medical history and a physical examination.

Make a mental checklist of differential diagnosis:

1.Cardiovascular disorders: Coronary artery disease and Cardiac arrhythmias

2.Pulmonary disorders: Bronchial asthma

3.Endocrine disorders: Hyperthyroidism, hypoglycemia

4.Drug intoxication: Cocaine, amphetamine

5.Drug withdrawal: Alcohol

6.Panic attack

First step:

Pulse oxy, stat

IV access, stat

EKG, 12 lead, stat

Finger stick glucose test, stat

Connect to cardiac monitor

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Results:

Pulse oxymetry showed 96 % on room air

Finger stick glucose 110 mg/dL

IV access is obtained

EKG shows sinus tachycardia

*Now, you know that the patient is hemodynamically stable and nothing life threatening is going on at this point.

Order:

Do a quick focused physical examination

General

HEENT/Neck

Heart

Lungs

Abdomen

Extremities

Results of the exam are:

General: Patient appears very anxious, diaphoresis present HEENT / Neck: EOM intact, no bruits heard, no JVD

Heart: Normal heart sounds, no murmurs; tachycardia present Lungs: Clear to auscultation B/L

Abdomen: Soft, non-tender, normal bowel sounds, no organomegaly Rest of the exam is normal.

Next step:

Order the following:

CBC with differential, stat

Chest x-ray, portable, stat

BMP, stat

TSH, stat

U/A, stat

Urine toxicology screen, stat

Results of labs are as follows:

WBC 5,000 with normal differential; Hb 14 gm/dL; platelets 240,000/cmm Chest x-ray normal

Basic metabolic panel shows:

Serum Na

135 mEq/L

Serum K

3.8 mEq/L

Chloride

106 mEq/L

Bicarbonates

20 mEq/L

BUN

16 mg/dL

Serum Creatinine

1.0 mg/dL

Calcium

9.0 mg/dL

Blood Glucose

118 mg/dL

TSH within normal limits

 

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U/A within normal limits

Urine toxicology screen – negative for substance abuse

How do you approach this case?

Based on this patient’s young age with the given symptoms, normal physical examination (except tachycardia), and normal lab results, a diagnosis of Panic attack is most likely.

DSM – IV describes Panic attack as:

A period of intense discomfort and anxiety associated with 4 or more of the below symptoms, lasting not more than an hour:

Palpitations or pounding heart, Chest pain, Dizziness, Nausea, Shortness of breath, Sweating, Choking sensation, Fear of dying and Tingling and numbness.

Presence of atypical symptoms like loss of bladder control, vertigo and loss of consciousness requires further evaluation.

This diagnosis is made primarily by history. The symptoms of panic attack can mimic many medical disorders. Hence it is essential to rule out other conditions before making a diagnosis of Panic attack. Recurrent panic attacks can be labeled as Panic disorder. The age at incidence of the first attack is between the age group of 20-30 (first attack occurring at the age of 45 or > requires further investigation). This disorder is more common in women, though it can occur in males as well.

Acute attacks respond well to Benzodiazepines (like Xanax). Recurrent attacks would require a psychiatric consultation as well as medication therapy in the form of SSRI drugs, which are considered as first-line drugs in the therapy of Panic disorder. Other drugs used are Tricyclic antidepressants and MAOI drugs. Long-term therapy with Benzodiazepines should be avoided, as chances of physical dependence are high, although symptomatic relief is faster with this group. Drug therapy should be given for a minimum of 8-12 months, depending on the response. Cognitive behavioral therapy used in combination with drug therapy gives superior results than drug treatment alone.

Order review:

Alprazolam (Xanax) 0.5mg, sub lingual, stat Change patient location

Send home if stable Schedule office appointment

Educate patient and family: Avoid potential triggers like Caffeine, nicotine, alcohol and certain medications like Flumazenil, Cholecystokinin, Pondimin, and Isuprel Avoid alcohol intake

Seat belt precautions Safe sex

Final diagnosis:

Panic attack (acute episode)

Case77

238

Printing Not Allowed

Location: Office

Vital signs:

Temperature is 36.7 C (98 F), blood pressure is 162/94 mmHg, pulse is 78/min, and respirations are 14/min.

CC: A 35-year-old African-American male came for routine exam.

HPI:

A 35-year-old African-American man comes to the physician’s office for a routine health maintenance examination. He complains of weakness and anorexia for the past few weeks. His review of systems is positive only for flank discomfort. He has no other medical problems. The patient is a postal worker. He does not drink alcohol and has smoked one pack of cigarettes daily for 15 years. His father died at the age of 45 from kidney disease. He takes no medication and has no other complaints.

How do you approach this patient?

We have a 35-year-old male with weakness, anorexia, and flank discomfort. His family history is positive for kidney disease.

Perform physical exam:

General

HEENT/Neck

Lungs

Heart

Abdomen

Extremities

Here are the results of the exam:

Examination is significant for bilateral palpable cystic kidneys. Clear lung fields and normal first and second heart sounds are noted. No ankle or periorbital edema is noted. Rest is unremarkable.

Discussion:

Based on his presentation and the presence of bilaterally enlarged cystic kidneys, it is most likely an autosomal-dominant, polycystic kidney disease (ADPKD). Other causes such as congenital simple cysts, medullary cystic kidney disease, and acquired cystic kidney disease should be considered in the DD.

Order:

CBC with differential, stat

BMP, stat

UA, stat

Ultrasound kidneys, stat

Results of your tests:

The UA showed many RBC (50+), negative nitrite, negative esterase, no bacteria,

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and few white cells. No casts are seen.

CBC showed Hb of 9.0 g/dL, MCV 88 fl, WBC of 6,000/cmm and platelets of 230,000/cmm.

BMP

Serum Na

135 mEq/L

Serum K

6.8 mEq/L

Bicarbonate

17 mEq/L

BUN

76 mg/dL

Serum Creatinine

6.4 mg/dL

Calcium

8.0 mg/dL

Blood Glucose

118 mg/dL

Ultrasound of the kidneys shows bilateral polycystic kidneys.

Discussion:

This patient has evidence of renal failure (most likely chronic) with resulting metabolic acidosis, hyperkalemia, hypocalcemia, and anemia of chronic disease. This patient needs to be admitted in the hospital to manage his acidosis, hyperkalemia, and for long-term dialysis by a nephrologist. Once you see hyperkalemia of this degree, an EKG should be obtained; and, if there are any EKG changes (peaked T waves), calcium gluconate should be given to stabilize the membrane. Insulin and dextrose is useful in the acute setting for rapid correction. Sodium bicarbonate is useful to correct both acidosis and hyperkalemia. Kayexalate is the only medication, which removes the potassium from the body. Once these treatments are given, the potassium level should be rechecked in 2-4 hours; and, if it is still high, medical treatment should be repeated. If it is still high after the second round of treatment, dialysis is indicated.

Once the patient is out of danger, other evaluation should be continued. Serum phosphorus level should be checked and PhosLo (calcium acetate – binds phosphorus and prevents absorption) is recommended if it is elevated. Iron deficiency is also commonly associated with chronic renal failure; so, this should be ruled out with iron studies. Anemia of chronic disease with an Hb of <10 is an indication to start erythropoietin. Blood pressure should be controlled with either ACE inhibitors (if the Cr is less than 2-2.5) or calcium channel blockers (if the Cr is very high). A renal diet, which has low potassium, low protein, and low phosphorus, should be ordered.

If there is no family history of brain aneurysms, routine screening for brain aneurysms is not indicated.

Order:

EKG, 12 lead, stat

Results:

EKG shows peaked T waves.

Order:

Calcium gluconate IV, bolus

D50 and insulin, stat, IV, bolus

Sodium bicarbonate, oral, continuous

Kayexalate, oral, continuous

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Now, change the location of the patient to ward:

Vitals: Q 6 hours Diet: renal

Cardiac monitor: routine Urine output: routine Activity - Out of bed to chair

Nephrology consult, stat (Reason: 35-year-old male with renal failure secondary to ADPKD with resulting acidosis and hyperkalemia)

Check serum potassium 2-4 hours later BMP: every 12 hours

Phosphorus, serum, stat

Serum iron, ferritin, and TIBC: routine Amlodipine, oral: continuous

Results:

Phosphorus is high.

Fe studies indicate anemia of chronic disease.

Order:

Calcium acetate, oral, continuous

Erythropoietin, subcutaneous, routine

Finally counseling:

Counsel patient, smoking cessation, routine

Counsel patient, no illegal drug use, routine

Counsel patient, exercise program, routine

Counsel patient, medication compliance, routine

Final diagnosis:

Adult autosomal-dominant, polycystic kidney disease (ADPKD) resulting in renal failure.

Case78

Printing Not Allowed

Location: Emergency room

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Vitals: Temperature is 36.7C(98F), blood pressure is 120/76 mmHg, pulse is 80/min, and respirations are 16/min. Height is 5'6"(167.5cm) and weight is 60kg (132.3lb)

HPI:

A 68-year-old white female who lives alone at home is presented to the ER because of the sudden onset of severe low back pain while removing a turkey from the freezer. The pain is 10/10 in severity, constant, and there is no radiation. She has never had this pain before. She denies weakness, sensory changes in the legs, or bowel or bladder incontinence. She also denies any fever, chills, loss of appetite, and loss of weight. Since the age of 53, she has been postmenopausal and has not taken any hormone replacement therapy. Her only other medical problem is high blood pressure, for which she takes hydrochlorothiazide. She has had no surgeries. She smokes one pack of cigarettes per day, for the past 40 years. Occasionally, she drinks alcohol and has no known drug allergies. Family history is not significant. Her last Pap smear was six years ago, and it was normal. She had her last mammogram one year ago, and it was normal. A colonoscopy performed five years ago was also normal. The rest of ROS is negative.

How would you approach?

Back pain has broad differential diagnosis. Since her vital signs are stable, perform a physical exam.

Order:

Select General, HEENT, Skin, Lymph nodes, Lungs, Heart, Abdomen, Rectal, Extremities, and Neurological.

Results:

Patient is moaning in severe pain. Severe tenderness is present over the L3 and L4 area. Straight-leg raising test (SLR) at 90 degrees is negative. Anal sphincter tone is normal. Neurological examination is unremarkable. The rest of the exam is normal.

Order:

IV access, stat

IV Toradol, stat, one dose

CBC with diff, stat

BMP, stat

Serum calcium, stat

ESR, routine

Spine x-ray, lumbosacral, stat

*Call me when the results are available.

Results:

CBC, BMP, calcium, and ESR are normal.

Spine x-ray shows diffuse osteopenia and a vertebral compression fracture at L3 and L4.

*Order brief history.

Results:

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Patient is feeling much better

Order:

SPEP, routine (to rule out myeloma)

TSH, serum, routine

Naproxen, oral, continuous

Calcium carbonate, oral, continuous

Vitamin D therapy, oral, continuous

Fosamax (alendronate), oral, continuous

Calcium enriched diet

Counseling:

Patient education

Smoking cessation

Limit alcohol intake

Regular exercise

Medication compliance

Seat belt use

*Change the location of the patient to home. Schedule an outpatient appointment in 3-7 days.

Order:

Once she comes, order extremities and neuro exam

DEXA scan, routine

Final diagnosis:

Osteoporotic vertebral compression fracture

DD of acute back pain (Extremely important for Step-3 MCQS):

Vascular causes:

Acute aortic dissection: Tearing abdominal pain radiating to the back, and associated nausea and vomiting are present. Clues on the exam are hypertension, unequal upper-extremity blood pressure, and new onset of an aortic insufficiency murmur. Abdominal aortic aneurysm: Pain radiating to the back, unstable vital signs, abdominal bruit, and pulsatile abdominal mass are the clues.

Mechanical:

Vertebral fracture with or without cord compression (osteoporosis or malignancy): Risk factors for osteoporosis (smoker, thin body habitus, steroid use, etc.) are present. Systemic features suggestive of malignancy (weight loss, loss of appetite) may be present. History of lifting heavy objects may be present. Spinal tenderness will be present. SLR is usually negative. Malignancy should be ruled out in elderly patients, especially multiple myeloma; Age-appropriate screening procedures should be done.

Disk prolapse with or without cord compression: Back pain, buttock pain, and paresthesias radiating down the leg in a dermatomal distribution is a classic presentation. History of lifting heavy objects is often present. SLR test at or above 600will be positive.

Lumbar strain: Paravertebral muscle spasm without focal spinal tenderness is present. SLR will be negative. Muscle relaxants and NSAIDs are sufficient.

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Cauda equina syndrome: Sudden onset of back pain, lower extremity weakness, bowel or bladder incontinence, and saddle anesthesia are the clues.

Epidural hematoma: Sudden onset of back pain, with underlying coagulation disorder (hereditary or anticoagulant use) is present.

Spinal epidural abscess: Predisposing factors, such as DM, renal failure, and IV drug use, etc., are present. Fever, radicular pain, elevated white count, and with or without cord compression is seen.

Management:

Basic labs to rule out infection, such as CBC, are indicated. ESR is useful to find out any occult malignancy such as myeloma or any evidence of infection. Spinal x-rays are indicated in most of the patients, except if the patient has lumbar strain. MRI is indicated only when there are neurological manifestations. Referral to an orthopedic surgeon or neurosurgeon may be needed if the MRI is abnormal. Myeloma should be ruled by SPEP and/or urine Bence-Jones protein. NSAIDs (better than narcotics), and early mobilization is the main treatment for vertebral fractures. Secondary causes of osteoporosis (hyperthyroidism) should be looked for if there is a suspicion. Obtaining TSH is routine in these patients. Calcium, vitamin D, and bisphosphonates should be given to prevent the osteoporosis and second fracture. Counseling regarding the risk factors (as advised above) is also very important. Surgery is indicated, if there is no improvement with conservative management.

Case79

Printing Not Allowed

Location: Emergency room

Vital signs: Pulse: 130/min; BP: 80/40 mmHg, Temperature: 39.4 C (103 F), RR: 22/min.

HPI: A healthy 22-year-old Caucasian woman is brought to the emergency department. She says that she has been having fever, chills, myalgias, and headache for the past 36 hours. For the past 12 hours, she has been nauseous, had two episodes of vomiting and complaining of abdominal pain and diarrhea. She has also developed a diffuse skin rash. She has no other medical problems. She does not use tobacco, alcohol, or drugs. Family history is not significant. She takes no medication. She has never been pregnant. Her menstrual cycles are always regular. This is her fifth day of menstruation. She is sexually active with her boyfriend and uses condoms. She has no known drug allergies.

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How would you approach this patient?

You have a 22-year-old healthy female presenting with a febrile illness complicated by hypotension. The definitive diagnosis is extensive at this stage. She is hemodynamically unstable at this time. Resuscitation (ABC) is the first priority.

Order:

Pulse oximetry, stat

IV access, stat

Cardiac monitor, stat

Continuous blood pressure monitoring, stat

Normal saline, 0.9% NaCl, continuous

Results:

Pulse oximetry is 97% on room air

Exam:

Order complete physical exam, except breast, lymph nodes, and neuro/psych (i.e., General, Skin, HEENT/Neck, Lungs, Heart, Abdomen, Genitalia, Rectal, and Extremities).

Physical exam results:

Patient appears very sick and anxious. Lungs, heart, abdomen, and rectal is normal. Diffuse, blanching, macular, erythematous rash is present all over the body. Hyperemia of the vulva and vagina as well as tenderness of the external genitalia and adnexa is present. A vaginal tampon is noted.

Order review:

Tampon removal, stat

Tampon C and S, stat (optional) CBC with diff, stat

CMP, stat (CMP consists of both basic metabolic panel and liver function tests) PT/INR, stat

Portable CXR, AP, stat EKG, stat (12 lead) UA, stat

Urine C & S, stat Blood cultures, stat

IV clindamycin, continuous

Here are the results:

CBC shows a WBC of 24,000/cmm with 30% bands, Hb of 11g/dL and platelet count of 120,000/cmm.

CMP shows BUN of 32, Cr of 1.8, elevated AST, ALT, and total bilirubin. EKG shows sinus tachycardia; CXR and PT/INR are within normal limits. UA and Urine C and S are pending.

*Evaluate patient by ordering a brief history and check vital signs.

Results:

Patient’s BP is still 80/60 after fluid bolus and continuous IV NS Patient is still feeling nauseated

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Order review:

IV Dopamine, continuous

IV Phenergan (Promethazine), stat, one dose (for nausea/vomiting)

*Transfer the patient to ICU

Order review (ICU orders):

NPO

Bed rest, complete

Foley catheter

Urine output

Acetaminophen (Tylenol) therapy, oral, continuous (for fever)

CBC with diff, next day

CMP, next day

*Evaluate the patient by ordering a brief history and check vital signs.

Results:

Patient’s BP is 100/70 after fluids and dopamine

Patient is feeling better

*Call me with the next set of vitals.

If you can do this much, the case will end automatically; however, if it continues, follow this:

Once the patient is feeling better, discontinue (D/C) all the IV substances. Double click with the mouse on the orders, and it will ask you, “Do you want to cancel this order?”

Discontinue dopamine, IV fluids, IV antibiotics, IV Phenergan, cardiac monitor, and Foley catheter.

Shift the patient to ward

Start oral clindamycin, continuous Contraception counseling

Safe sex counseling

Smoking cessation (if present) Limit alcohol intake

No illegal drug use Seat belt use Reassure the patient

Discharge the patient to home with 1-week follow-up appointment

Final diagnosis:

Toxic shock syndrome secondary to vaginal tampon use

Discussion:

Upto 98% of menstrual TSS cases are due to S. aureus. Most patients present with a prodrome of fever, chills, and myalgias that progress to the systemic syndrome; however, some patients may become abruptly ill within hours, resulting in hypotension and shock. TSS should be suspected in any young female who presents with a fever of ≥38.9° C (102° F), tachycardia, hypotension (SBP < 90 mmHg), and rash. The rash is typically a nonpruritic, diffuse, blanching, macular erythroderma.

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Desquamation starts after 1-2 weeks. Since TSS can involve any organ, patients may present with GI symptoms (nausea, vomiting, abdominal pain), hepatomegaly, intense headache, and altered mental status, etc.

Potential complications include ARDS, shock, DIC, and renal failure; less commonly rhabdomyolysis, seizures, and pancreatitis may be seen.

Labs:

1.CBC shows either leukocytosis or leukopenia, but a marked bandemia (up to 50%) is often present. Anemia and thrombocytopenia are also common.

2.Elevated BUN and creatinine suggests renal failure.

3.Hypoalbuminemia and life-threatening hypocalcemia can be seen.

4.Hyperbilirubinemia and elevated transaminase levels (ALT, AST) suggest liver injury.

DD:(These are important for Step-3 MCQS as well)

Kawasaki disease: Seen predominantly in children, rarely cause shock, and does not have systemic involvement.

Staphylococcal scalded-skin syndrome: Desquamation starts early, whereas, in TSS, desquamation occurs in the convalescent phase. Also, it rarely causes shock and does not have systemic involvement.

Stevens-Johnson syndrome: Usually history of drug administration and characteristic mucus membrane involvement is present, but lacks desquamation.

Rocky Mountain spotted fever: History of a tick bite is present, rash starts peripherally, and is associated with a severe headache, without an altered mental status.

Management:

Therapy is mainly supportive. Removal of the focus of infection and use of antibiotics should be done as soon as possible. The patient should be admitted in ICU, and hemodynamic monitoring and vasopressors may be necessary. They may need up to 10-20 liters of IV fluids (0.9% NS). Clindamycin has become the drug of choice because of its potent suppressor effect on bacterial toxin synthesis. The use of corticosteroids is controversial.

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Case80

Printing Not Allowed

Location: Emergency room

Vitals: Her temperature is 37.8C(100F), blood pressure is 120/76 mm Hg, pulse is 120/min, and respirations are 22/min.

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HPI:

A 20-year-old white female presents to the emergency department because of a 6-hour history of a progressive worsening of abdominal pain. She says that the pain started in the right lower quadrant, constant, 8-10/10 in severity, and nothing really relieves it; there is no radiation. She has had one episode of vomiting on the way to the emergency room. She denies constipation, diarrhea, vaginal discharge, bleeding, dysuria, or frequency. She has no other medical problems. She does not smoke and occasionally drinks alcohol. She has no known drug allergies. Family history is not significant. She takes no medication. Her last menstrual period was 16 days ago, and her cycles have always been regular. She never had this type of severe pain. She is sexually active with her boyfriend and uses condoms as contraception. The rest of the ROS is negative.

How would you approach this patient?

The DD for nausea, vomiting, fever, and right lower quadrant (RLQ) abdominal pain is broad. Physical examination and initial tests will narrow the DD.

Order:

Pulse oximetry, stat

IV access, stat

Results:

98% on room air

Order physical exam:

General, Skin, Lungs, Heart, Abdomen, Rectal, Genital, and Extremities.

Results of the exam:

Patient is in pain. Skin, lungs, heart, and extremities exam is normal. Tenderness to deep palpation is noted in the RLQ of the abdomen. There is no rebound or rigidity and bowel sounds are present. Rectal exam shows no masses. The pelvic exam showed a very tender right adnexal mass. External genitalia are healthy, and there is no vaginal discharge.

Order review:

Morphine, IV, one dose, stat

Phenergan, IV, one dose, stat

IV Normal saline, 0.9% NaCl, continuous

Pregnancy test, serum, qualitative, stat

CBC with diff, stat

BMP, stat

USG, transvaginal, stat

UA, stat

Results:

Pregnancy test is negative. CBC shows a WBC of 13,000/cmm with mild, left shift but no bands. BMP is normal. USG showed a 5 x 6 cm cystic mass in the right ovary and diminished blood flow to the ovary (by color Doppler). UA is normal.

Order review:

Consult gynecology, stat (Reason: 20-year-old female with acute torsion of the right ovarian cyst)

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*Transfer to ICU

Write pre operative orders:

PT/INR, stat

PTT, stat

NPO (nothing per mouth)

Bed rest, complete

Urine output

Type and crossmatch for blood, stat

Consent for procedure, stat

*The patient is accepted for surgery

Diagnosis:

Acute torsion of the right ovarian cyst

Discussion:

The common causes of acute pelvic pain in female patients include gynecological and non-gynecological. The gynecologic causes are dysmenorrhea, pelvic inflammatory disease, ectopic pregnancy, hemorrhagic ovarian cyst, rupture of an ovarian cyst, and adnexal torsion. The non-gynecologic causes are appendicitis, ureteric colic, intestinal obstruction, urinary tract infections, etc.

Ovarian torsion should be suspected in any female patient who presents with moderate to severe RLQ pain, tenderness, and an exam finding of a tender adnexal mass. A benign cystic ovary is the most common cause of torsion. These patients are best evaluated with ultrasound. USG is the imaging modality of choice for pelvic pathology. It is better than a CT scan. WBC can be elevated. A pregnancy test should be done to rule out pregnancy and its related complications in the above situation.

Ovarian torsion is a surgical emergency and gynecology consultation should be obtained as soon as possible.

Case81

Printing Not Allowed

Location: Office

Vita signs: His temperature is 36.7C(98F), blood pressure is 120/76 mm Hg, pulse is 80/min, and respirations are 16/min.

HPI: A 43-year-old African-American male presented to the office because of easy fatigability. He has no fever, chills, weight loss, or loss of appetite. He denies cough, breathing problem, constipation, diarrhea, melena, bleeding per rectum, or hematuria. His past medical history is nothing significant. In the past, he was

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incarcerated for driving under the influence. He has been drinking 7-8 beers a day for the past 20 years. He smokes 1 pack of cigarettes daily for the past 22 years. He denies intravenous drug use or multiple sexual partners. He is a construction worker, and his diet is mainly of tea and toast. He takes no medication and has no known drug allergies. His last office visit was two years ago. The rest of the ROS is negative.

How would you approach this patient?

We have a 43-year-old alcoholic with easy fatigability. The DD is extensive. Physical exam and the basic labs will narrow the diagnosis. His vitals are stable.

*Mark “complete physical exam,” including rectal and genitalia.

Here are the results:

The only abnormal findings on the exam are: Mucus membranes and skin have pallor, and no lymph nodes are palpable.

*This patient most likely has anemia. The most likely causes in this patient are iron deficiency from GI blood loss (GERD, gastritis, ulcer, cancer, etc.), megaloblastic anemia (folic acid or vitamin B12 deficiency), and anemia of chronic disease. CBC, fecal blood testing, and basic metabolic panel are the basic labs at this time.

Order:

CBC with diff, stat

BMP, stat

FOBT, stat

Results:

CBC shows Hb of 9.0g/dL, MCV of 118 fl, WBC count of 7,000/cmm with normal differential, and platelet count of 210,000/cmm. Peripheral smear shows hyper- segmented neutrophils. BMP is WNL. FOBT is negative.

*We have an alcoholic whose diet is mainly of tea and toast (heated food type) presenting with pallor, HB of 9, and MCV of 118. The most likely diagnosis at this time would be folic acid deficiency. B12 deficiency is a less likely possibility but must be ruled out before you treat with folic acid alone. Reticulocyte count is very useful to follow these patients once treatment is started. Liver functions tests should be obtained, since he has a significant alcoholic history. While waiting for the blood tests, this patient should be treated with folic acid, vitamin B12, iron replacement, thiamine, and multivitamins. Folic acid alone should not be given without ruling out vitamin B12. Once the folic acid supplement is started, bone marrow iron stores are quickly utilized, and they may become iron deficient; so, they should be started on iron as well. Thiamine and other multivitamins should also be given in alcoholics.

Order:

Serum Folate, routine

Serum vitamin B12, routine

LFT, routine

Reticulocyte count, routine

Folic acid therapy, oral, continuous

Vitamin B12 therapy, oral, continuous

Iron sulfate therapy, oral, continuous

Thiamine, oral, continuous

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Multivitamin, regular, oral, continuous

Iron enriched diet

Give counseling at the same time:

Patient education

No alcohol

No smoking

Safe sex

Drive with seat belts

No illegal drugs

After ordering the above tests and appropriate counseling, send the patient home and make a follow-up appointment in one week.

*Patient is back in one week feeling a little better

Results:

Folic acid level is 1.5 ng/mL (N=6.0-15.0 ng/mL).

LFTs and vitamin B12 are normal.

Reticulocyte count is low.

*If you do this much, the case will end automatically. Order a reticulocyte count as a follow-up. Discontinue vitamin B 12 therapy at this visit.

Primary diagnosis:

Folic acid deficiency

Discussion:

The number one cause of folate deficiency is nutritional (poor diet and/or alcoholism). Megaloblastosis develops within 4 to 5 months in individuals on a folate deficient diet. However, alcoholics may have a sharp fall in serum folate and may develop megaloblastosis within 5 to 10 weeks if the diet is poor and low in folate. The other causes of folate deficiency are drugs (methotrexate, trimethoprim, and anticonvulsants), malabsorption (Sprue, IBD, etc.), and increased folate requirements (pregnancy, lactation, chronic hemolysis, exfoliative skin disease). The above patient has all the risk factors to become folate deficient, so there is no need to get iron studies. This patient’s MCV may not return to normal because of the alcoholic liver disease. However, if his anemia is not corrected, then the other causes (such as associated iron deficiency, etc.) should be looked for.

Case82

Printing Not Allowed

Location: Office

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Vital signs: His temperature is 36.7 C (98 F), blood pressure is 120/76 mmHg, pulse is 80/min, and respirations are 16/min.

HPI:

A 65-year-old Caucasian male presented to the office because of bilateral stiffness in the shoulders, neck, and pelvic girdles for the past three months. He has also been having a mild fever and has lost about 15 lbs. during the last three months. He tried over-the-counter acetaminophen (Tylenol), without much relief. Now, he started having frequent headaches on the right side. He denies cough, shortness of breath, chest pain, dysphagia, seizures, constipation, diarrhea, melena, and bleeding per the rectum. His other medical problems include hypertension and diet-controlled hypercholesterolemia. He takes hydrochlorothiazide. He has no known drug allergies. He denies smoking, drinking alcohol, or using IV drugs. Family history is not significant. His last physician visit was one year ago, and he had a negative rectal exam and normal PSA level. A colonoscopy three years ago was normal. The rest of the ROS is negative.

How would you approach this patient?

Any elderly patient (> 50 years) with bilateral stiffness (more than 30 minutes) in the shoulders, neck, and pelvic girdles should be suspected for polymyalgia rheumatica. If it is associated with headaches, visual symptoms, or jaw claudication, then the associated giant cell arteritis (GCA) is strongly considered until proven otherwise. Other causes such as infection (infective endocarditis), thyroid dysfunction, malignancy, and other rheumatologic diseases (rheumatoid arthritis, SLE) should always be ruled out as well.

Order:

Complete physical exam

Results:

Examination showed tender shoulders, neck, and pelvic girdles. There is a significant tenderness present over the right temporal region. Fundoscopy is normal. Muscle power is 5/5. The rest of the exam is completely normal.

Order:

CBC with differential, stat

BMP, stat

ESR, stat

Chest x-ray, PA, stat

ANA, routine

RF, routine

TSH, routine

Results:

CBC shows HB of 11g/dL, WBC of 8,000/cmm with normal differential, and a platelet count of 430,000/cmm. BMP is normal. Chest x-ray is normal. ESR is elevated at 80/hour. ANA, RF, and TSH are normal.

Order:

Prednisone, oral, continuous

Temporal artery biopsy, routine

Results:

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Biopsy results showed temporal arteritis.

Order:

Vitamin D therapy, oral, continuous Calcium carbonate, oral, continuous Calcium enriched diet

Famotidine (or Ranitidine), oral, continuous (prophylaxis to prevent gastritis)

Counseling:

Patient education No smoking

No alcohol

Medication compliance Seat belt use

Exercise program (ideally, weight-bearing type, to prevent osteoporosis)

Primary diagnosis:

Temporal arteritis

Discussion (Very high yield for step-3 MCQS as well):

Both PMR and GCA belong to a single spectrum of disease. Diagnosis of PMR is suggested if a patient has the following findings:

1.Age > 50 years

2.Morning stiffness for 30 minutes or more and present for more than a month, and it involves the shoulder, neck, hips, and torso.

3.ESR is greater than 40 mm/hour.

4.Rapid response to corticosteroids.

A temporal artery biopsy is required only if the patient has associated headaches, visual symptoms, or jaw claudication, which represents a GCA. PMR is best treated with low-dose corticosteroids (10-20 mg/day).

GCA should also be considered in a patient with a fever of unknown origin and weight loss; however, this is a diagnosis of exclusion. Elevated ESR is often the diagnostic clue. Lab studies may also show anemia and thrombocytosis. Therapy with high-dose glucocorticoids (20-40 mg/day) is the treatment of choice and should be started immediately, when a diagnosis of giant cell arteritis is strongly suspected. Blood samples can be drawn for ESR before the start of glucocorticoid therapy, and a temporal artery biopsy (that is required to confirm the diagnosis) needs to be done after starting steroid treatment. One should not wait for a temporal artery biopsy before starting glucocorticoid therapy, as any delay in the treatment may result in visual loss. Treatment with steroids does not affect the results of a temporal artery biopsy. High-dose steroid therapy is continued until the symptoms resolve, and labs become normal.

Patients who are on high-dose steroids are at high risk to develop gastritis and stomach ulcers, and osteoporosis. Prophylactic therapy with H2 blockers for stomach protection, and vitamin D + calcium for osteoporosis is indicated. Ideally, they should also have a baseline DEXA scan, and many physicians start bisphosphonates from the beginning.

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Case83

Printing Not Allowed

Location: Office

Vitals:

Her temperature is 36.1 C (97 F), blood pressure is 150/90 mm Hg, pulse is 50/min and respirations are 16/min. She weighs 105 kg (231.5 lbs) and is 162.5 cm (5'4") tall.

HPI:

A 53-year-old African-American woman comes to the physician because of fatigue, constipation, cold intolerance, and impaired sleep. She has had these symptoms for the past three months. The symptoms are progressively getting worse. She also says that she gained almost 20 lbs of weight during the past three to four months. She denies fever, cough, nausea, vomiting, abdominal pain, and black stools. Her other medical problems include hypertension, carpal tunnel syndrome, and allergic rhinitis. She does not use tobacco, alcohol, or drugs. Family history is not significant. Her medications include hydrochlorothiazide and loratadine. She has no known drug allergies. She is in a monogamous relationship with her husband. She has not seen a physician in two years. Her LMP was two years ago. Her last Pap smear and mammogram were performed two years ago and were normal. A colonoscopy performed at age 50 was also reported to be normal. Her vaccinations are up-to- date.

How would you approach this patient?

She has bradycardia, hypertension, constipation, weight gain, cold intolerance, and impaired sleep. This is a classic presentation of hypothyroidism. Perform a physical examination.

Order:

Complete physical exam.

Results:

On examination, patient appears to be obese. Skin is cool and dry. Lungs are clear to auscultation. Heart sounds are normal. Examination of the abdomen is unremarkable. Neurologic examination shows delayed relaxation of ankle reflexes. The rest of the exam is normal.

Order:

CBC, routine BMP, routine FOBT, stat

Serum TSH, routine 12-lead EKG, stat

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Results:

FOBT is negative. EKG shows sinus bradycardia.

*Schedule appointment in three days with results

Results:

CBC shows Hb of 11.8 g/dL, WBC of 7,000/cmm (normal differential), and platelet count of 200,000/cmm. MCV is 86 fl. The peripheral smear shows normochromic normocytic anemia with normal-appearing WBCs and platelets. BMP shows a Na of 133 mEq/DL; TSH is 24 µU/mL (Normal is 0.5-5.0 µU/mL). Stool is heme negative.

*If the patient is floridly hypothyroid – TSH should be higher than 70-90.

Order:

Free T4, routine

Lipid panel, routine

Levothyroxine, oral, continuousLow-fat diet

Vitamin D, oral continuous

Calcium carbonate, oral, continuous

Counseling:

Patient counseling

Medication compliance

No smoking

No alcohol

Regular exercise

Seat belt use

Safe sex

*Follow-up in one week

Results:

Free T4 is 0.03 ng/dL (Normal is 0.9-2.4 ng/dL). The lipid panel showed increased total cholesterol.

*Follow-up in six weeks

Order:

Serum TSH, routine

Primary diagnosis:

Primary hypothyroidism

Discussion:

The clinical diagnosis of hypothyroidism is straight forward, as depicted in the above case. The best screening test is TSH measurement. Once it is elevated (> 10), confirmation of hypothyroidism is made by measuring free T4. Both TSH and free T4 identifies whether the problem is primary (free T4 is decreased and TSH is elevated) or secondary (both TSH and free T4 are decreased).

Hypothyroidism is associated with normocytic and normochromic anemia from bone marrow hypoproliferation and usually responds to thyroxine replacement. In female patients, menorrhagia resulting from thyroid dysfunction can cause iron deficiency

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anemia (microcytosis). 10% of patients may have pernicious anemia (macrocytosis). Routine iron studies and B12 levels are not generally indicated if the patient have mild normocytic normochromic anemia, as seen in the above patient. There appears to be an increased risk of celiac disease with autoimmune thyroid disorders, which leads to microcytic anemia due to iron malabsorption. Screening for celiac disease is warranted if patients with autoimmune hypothyroidism develop unexplained microcytic anemia. Screening for hypothyroidism is indicated in patients presenting with unexplained hyponatremia, hypercholesterolemia, or elevated CK. The other commonly tested associated conditions for board exams are:

1.1. Sleep apnea

2.2. Carpal tunnel syndrome

3.3. Depression

Hashimoto’s thyroiditis is the most common cause of primary hypothyroidism in the United States. Antibody measurement is not required in the work-up of overt hypothyroidism. Measurement of anti-thyroid antibodies (anti-thyroid peroxidase and anti-thyroglobulin) is performed in subclinical hypothyroidism (TSH is between 5 to 10, but normal free T4) to predict the probability of developing permanent hypothyroidism. Patients with subclinical hypothyroidism with high titers of anti- thyroid antibodies are more likely to develop permanent hypothyroidism.

Thyroxine replacement should be started, and TSH is rechecked in six weeks to monitor the response. This patient is postmenopausal; therefore, calcium and vitamin D supplementation should be started.

Case84

Printing Not Allowed

Location: In hospital

Vitals:

His temperature is 39.4 C (103 F), blood pressure is 90/62 mmHg, pulse is 110/min, and respirations are 18/min.

HPI:

A 70-year-old white male is admitted to the hospital for resection of a superficial bladder carcinoma through cystoscopy. Postoperatively, he had mild bleeding and he has a Foley catheter for continuous bladder irrigation. The next day, the nurse called you because the patient is having a high-grade fever, chills, and became hypotensive. He is also feeling nauseous. He denies cough, chest pain, shortness of breath, and headache. He has no other complaints. His other medical problems include degenerative joint disease, BPH, and hearing loss. He has no known drug allergies. Social history is not significant. He is currently not on medications, except

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Tylenol for pain. His preoperative labs include Hb, WBC count, platelet count, BUN, Cr, and Pt/PTT are within normal limits.

How would you approach this patient?

This patient has a high-grade fever, chills, nausea, and hypotension on the first postoperative day. He has had manipulation of the urogenital tract. In general, atelectasis is the most common cause of fever on the first postoperative day.

However, this should not cause very high fevers, chills, and hypotension. This patient is having sepsis most likely from Gram-negative bacteremia of the urogenital tract.

Order:

IV access, stat

Pulse oximetry, stat (Result: 98% on room air)

Examine:

General

Lungs

Heart

Abdomen

Genital

Extremities

Results:

Patient is having shaking chills. Lungs are clear. Abdomen is not tender. Bowel sounds are present. There is no rigidity or rebound. Peripheral extremities are warm. The rest of the exam is normal.

Order:

Normal saline, IV, bolus Normal saline, IV, continuous D/C Foley catheter Continuous cardiac monitor UA, stat

Urine C & S, stat Blood cultures, stat CBC with diff, stat BMP, stat

Ceftriaxone, IV, stat, continuous (order only after ordering blood and urine cultures) Transfer to ICU

Results:

UA showed many bacteria, many WBC, positive nitrite, positive esterase, and few RBC. CBC shows a WBC count of 13,000 with 10% bands. BMP is normal. The rest of the labs are normal.

Order:

ICU vitals

Pulse oximetry, every 4 hours

CXR, Portable, PA, stat (result: normal)

Acetaminophen (Tylenol), oral, continuous

Pneumatic compression stockings

NPO

Bed rest

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Urine output

*Advance the clock for one hour and check BP

*If his BP is still low despite the giving of IV fluids, he should be started on IV dopamine infusion.

*Once the BP is stable and he is afebrile:

Shift to ward

D/C IV normal saline D/C cardiac monitor D/C ceftriaxone

Check the urine and blood cultures (usually after 24-hours)

Change to appropriate oral antibiotic (Mostly oral Bactrim (TMP-SMX) or ciprofloxacin)

Primary diagnosis:

Urosepsis

Discussion:

Atelectasis is the most common cause of fever in the first postoperative day. Patients do not have significant difficulty breathing, look comfortable, and have few secretions. Chest x-ray shows areas of partial collapse; WBC count would not be elevated.

Nosocomial infections are defined as infections acquired as a result of hospitalization, and they manifest at least 48 hours after hospitalization. A urinary tract infection is the most common type of nosocomial infection. The surgical site infections (account for 19% off nosocomial infections) are the second most common cause of a nosocomial infection. Nosocomial pneumonia is the third most common cause of nosocomial infections. It is frequently seen in patients who are intubated and have other associated comorbidities, such as chronic lung disease. The major organisms of concern in nosocomial pneumonia are gram-negative aerobic bacteria-like pseudomonas.

Case85

Printing Not Allowed

Location: Office

Vitals: Her temperature is 36.7C(98F), blood pressure is 120/76 mm Hg, pulse is 80/min, and respirations are 14/min.

HPI:

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A 45-year-old white female presented to the office because of fatigue and exertional shortness of breath for the past two months. The symptoms are getting worse. She denies any chest pain, orthopnea, PND, leg swelling, palpitation, syncope, cough, and weight loss. She has no constipation or diarrhea. She has not looked at her stools for melena, but she denies any blood in the stools. The only other problem is some epigastric discomfort for which she usually takes over-the-counter antacids. She takes no other medication. Her menstrual cycles are always regular and last 3-4 days each time. She has no other medical problems. She smokes one pack of cigarettes for the past 20 years. Occasionally, she drinks alcohol and does not use recreational drugs. Her sister has asthma; otherwise, her family history is not significant. She has no known drug allergies. The last Pap smear, pelvic exam, and breast exam done one year ago was normal. The rest of the ROS is negative.

How would you approach this patient?

We have a very healthy 45-year-old female presenting with fatigue and exertional dyspnea. The only other problem that she has is epigastric discomfort. At this point, the DD is broad. Physical exam and basic labs will narrow the DD.

Order physical exam:

Complete physical exam

Results:

The patient appears comfortable. There is no lymphadenopathy. Pallor is present on exam. Lungs and heart are clear to auscultation. Abdomen is soft, but very mild discomfort to deep palpation is noted in the epigastric region. Extremities are normal. The rest of the exam is normal.

Order:

FOBT (fecal occult blood testing), stat

CBC with diff, stat

BMP, stat

UA, stat

CXR, PA/lateral, stat

Results:

FOBT is positive. CBC shows Hb of 8.0 g/dL, MCV 72 fl, WBC of 6,000/cmm with normal differential, platelet count of 220,000/cmm. Peripheral smear showed hypochromic and microcytic anemia. BMP showed a BUN of 25 and Cr of 1.1. UA is normal. CXR is normal. The rest of the labs are normal.

*Now, we can say that the patient’s most likely reason for fatigue and shortness of breath is from anemia. The cause is most likely due to bleeding from the GI tract. Since the patient has some epigastric discomfort, we can start with an upper GI endoscopy.

Order:

Admit to ward/Floor

NPO

Ambulation at will

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Serum Iron, routine

Serum ferritin, routine

TIBC, routine

Type and cross match for blood, stat

Transfuse PRBC, stat

Omeprazole, oral, continuous

PT/PTT, stat

*Advance clock for 12 hours (to give adequate time for NPO)

Upper GI flexible endoscopy, routine

Helicobacter pylori biopsy, stomach, routine (or) H. pylori serology, routine Consent for procedure

Recheck Hb next day

Results:

Serum iron and ferritin are low. TIBC is elevated. Endoscopy showed clean-based, non-bleeding duodenal ulcer. Biopsy for H. Pylori is positive.

Order:

Clarithromycin, oral, continuous

Amoxicillin, therapy, oral, continuous

Iron, therapy, continuous

Vitamin C, therapy, continuous (increases Iron absorption)

Iron-enriched diet

No aspirin

Counseling:

Patient counseling

No smoking

No alcohol

Drive with seat belts

Regular exercise

Safe sex

*Change the location to home. Follow-up in two weeks

Primary diagnosis:

Duodenal ulcer

Discussion:

In general, whole blood or serum serology is a most cost-effective test to identify H. pylori in symptomatic patients. However, if the patient is undergoing endoscopy, then endoscopic biopsy can be performed. The regimen of choice for H. Pylori eradication is triple therapy with a proton pump inhibitor, Clarithromycin, and Amoxicillin for about two weeks. Once the treatment is completed, confirmation of eradication is recommended. Urea breath testing is the test of choice for this purpose.

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Case86

Printing Not Allowed

Location: ER

Vitals: His temperature is 36.7C(98F), blood pressure is 98/60 mm Hg, pulse is 80/min, and respirations are 16/min.

HPI:

A 67-year-old white male with a past medical history of hypertension, diabetes, peripheral vascular disease, hypercholesterolemia, and coronary artery disease presented to the ER because of the sudden onset of abdominal pain radiating to the back. The pain started while having breakfast, it is 9/10 in severity, and associated with nausea. He is also a little diaphoretic. He denied any palpitations, syncope, shortness of breath, or chest pain. He has smoked for 40 years, two packs per day, but quit two years ago when he had a MI. His medications include aspirin, metoprolol, simvastatin, and nitroglycerine as needed. He is allergic to sulfa medications. Family history is not significant.

How would you approach this patient?

This is a 67-year-old male with multiple risk factors for atherosclerotic vascular disease. He has now presented with a sudden onset of severe abdominal pain radiating to back. He is also diaphoretic and borderline hypotensive. The number one diagnosis that should not be missed in this patient is a rupture of an abdominal aortic aneurysm (AAA). The other acute life-threatening things are myocardial infarction, even though quite unlikely. The other acute conditions, even though not immediately life threatening, such as, perforated peptic ulcer, acute pancreatitis etc., should be kept in mind.

The most important thing at this point is to gain IV access with 2 large bore needles and rapid diagnosis.

Order:

IV access, stat

Normal saline, IV, continuous

Continuous BP monitoring, stat

*Brief, focused physical examination will narrow differential diagnosis.

Order:

General

Heart

Abdominal

Extremities/spine

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Examination:

Abdominal exam shows pulsatile, expansile abdominal mass and mild epigastric tenderness. Extremities are cold and clammy.

*At this point, it is most likely that the diagnosis is a leaking abdominal aortic aneurysm. If the patient is hemodynamically unstable, he should be taken to the operating room immediately. If the patient is hemodynamically stable, rapid bedside USG should be performed. A vascular surgeon should be notified at the outset. Blood should be sent for type and cross match, as it may require up to ten units of blood some times. If the time permits, CBC, BMP, and PT/PTT can be obtained.

Order:

Consult vascular surgery, stat (Reason: Suspected rupture of the abdominal aortic aneurysm)

*Patient is accepted for surgery. Please continue the medical management.

Order:

Type and cross match for blood, stat

USG abdomen (or abdominal aorta), stat (Usually at bedside)

Results:

USG showed an abdominal aortic aneurysm of 7 cm x 7 cm with some leakage.

Order:

Consent for procedure

NPO

CBC with diff, stat

BMP, stat

PT/PTT, stat

Foley catheter, stat

Primary diagnosis:

Leaking abdominal aortic aneurysm

Case87

Printing Not Allowed

Location: emergency room

Presenting complaints: An 8-month-old Caucasian child with periodic crying and vomiting

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Vitals: Pulse – 140/min, BP – 80/53 mmHg, RR – 30/min, T – 36’7C (98F).

HPI: An 8-month-old Caucasian child is brought to ER with three-hour history of periodic crying spells; during these episodes that last several minutes the child is inconsolable and draws up of his legs toward the abdomen. The episodes occurred every 15-20 minutes initially, but seem to be occurring more frequently now.

Between the episodes the child behaves normally, but is sleepy. He had two episodes of bilious vomiting during the last hour. He has never had such episodes before. He had mild upper respiratory infection one week ago. His past medical history is significant for acute otitis media experienced 3 months ago that was treated with antibiotics. He is not taking any medications now. Delivery and neonatal course were uncomplicated. His vaccinations are up-to-date. He was exclusively breast-fed till 5 months of age and received iron and vitamin D supplementations. His parents and an older sister are in good health. One of his cousins was diagnosed with ‘a kind of muscle disease’.

How to approach this case?

The clinical scenario described suggests periodic abdominal pain (the child cries and draws up of his legs toward the abdomen) accompanied with vomiting and lethargy. The potential causes of these symptoms are intussusception, acute gastroenteritis, testicular torsion, Meckel diverticulum, volvulus, mesenteric adenitis as well as other causes of abdominal pain.

Order physical examination:

General

Skin

HEENT/Neck

Chest/Lungs

Cardiovascular

Abdominal

Rectal

Genital

Physical findings:

During crying spells the child is agitated, draws up of his legs toward the abdomen and strains; between episodes the child appears apathetic and sleepy. No skin rash is present. Lungs are clear on auscultation. Heart sounds are normal and no murmurs are present. Abdomen is distended; sausage-like mass is palpated on the right side of the abdomen that is vertically oriented. Rectal examination provokes defecation; stool is semi-solid and positive for blood. External genitals are normal and both testes are palpated in the scrotum.

Pre-lab discussion:

Intussusception is a difficult diagnosis because the classical constellation of symptoms and signs described in this case is not always present. Important clinical clues include the age of patients (60% of cases occur before age of 1 year); periodic abdominal pain with no signs of discomfort between the episodes of pain; and lethargy/apathy that is usually prominent, especially later in the course of the disease (the cause of this lethargy is unclear). ‘Current jelly’ stool is characteristic, but it is observed in only 50% of cases; blood-positive stool is more common (75% of patients). Sausage-like abdominal mass can be palpated on the right side of the abdomen that makes the diagnosis very likely. Meckel’s diverticulum may present as

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lower GI hemorrhage or symptoms of intestinal obstruction due to volvulus or intussusception; differential diagnosis in the latter case requires imaging studies (see post-lab discussion of secondary intussusception). Appendicitis can occur in children younger than 1 year of age, but it is rare in this age group; a palpable mass is not characteristic for uncomplicated appendicitis. Schönlein-Henoch purpura can manifest as abdominal pain, but associated symptoms like fever, rash and arthralgias are typical.

Orders:

Pulse oximetry, stat (result: 97% on room air)

IV access, stat

Normal saline, IV, continuous

NPO

Nasogastric tube suction

CBC with differential, stat

BMP, stat

Abdominal X-ray, acute series, stat

Abdominal ultrasonography, stat

Morphine, IV, one dose

Phenergan, IV, one dose

Results:

CBC demonstrates elevated white blood cell count