Clinical Case 118: Thinking outside the box

OK team – a Paeds case for you today.  It’s one where I am going to give you just a few clues and you have to think up the diagnosis.

Here we go…..

Jemimanisha is an 8  yo. girl who lives in an Aboriginal community about an hour away.

She has been brought to ED by her mother after being up all night complaining of a headache.  She has never had headaches before.  Her Mum is concerned that she ate too much junk food at her friend’s home the night before.

On further questioning – the headache is really quite global – she points at both parietal areas and rubs her head on both sides to show where it hurts.  She has had no recent URTI sxs, no fevers, cough or injury.  She isn’t bothered by lights or the ED noise.  Up until bedtime she was fine.  She woke around 11 PM with the headache &  slept in with her mother after that – her mum says she was restless and crying out all night long [Mum looks tired!].  This morning she vomited after eating toast.  Her belly feels OK and she reports no diarrhoea.

PMHx:

  • Obese with a BMI of 32 [currently seeing dietician]
  • Recurrent ear disease with grommets as a child, multiple presentations with acute OM in last 5 years. None recently.
  • Had a laceration to her ankle last month that required repair under sedation in ED – that went well and she was discharged.  Wound healing OK.

On examination

  • Afebrile, HR 90 SR, well perfused,  SpO2 = 99% RA,  RR = 15/min
  • Neuro exam is NAD – PEARL, no meningism, walking well, coordinated and fundi look ok – no papilloedema.
  • ENT – old scarred TMs bilaterally, no coryza, throat NAD
  • Chest and abdo unremarkable, soft, no signs of lung disease
  • No LN or rash, mucosa looks moist.
  • Leg wound has healed but there is a 3mm dehiscence of the edge of the scar – there is clear, serous fluid oozing out.  It is non-tender, no pus or cellulitis.

OK, that is all I am going to give you at this stage…

Here are the questions:

Q1:  What further information do you want [it is a weekend in Broome – so no labs or X-rays !]

Q2:  What is the diagnosis?

Q3:  What do you need to confirm the diagnosis?

I am sure you super sleuths can work this out!  Who is fastest?

Casey

Clinical Case 117: Cancer Fishin’

OK – this case is for all the GPs and Internal Medicine types out there.  This is a relatively common scenario…  how do you play it?

Here’s the case.

Bruce is a 53 y.o. accountant.  He is a little overweight at 89 kg (BMI 31).  He is otherwise relatively well, he cycles to the cafe each morning in lycra and drinks a cappuccino in his helmet… why do they do that?

He has hypertension which is controlled by ramipril 5 mg daily.  No other meds or relevant medical history.  He is interested in his health and even has annual “Mens’ Health checks”.  He was in last month for one – which was unremarkable other than a borderline BP and his prostate screen (post full consent and shared decision-making) revealed a normal DRE and PSA level.

Today he has come to see you with a discharge letter from the local hospital.  He was admitted for work-up of “unilateral leg swelling” which occurred spontaneously last Friday.

The letter reads:

Dear Dr Leeuwenburg,

Thanks for following up Bruce who had an unprovoked DVT diagnosed on Doppler.  US showed a 5 cm proximal DVT at the Femoral-saphenous junction (L) leg.

He also had a series of tests: FBP, UECr, LFTs, Ca, Mg, PO4, CRP, TFTs, a prothrombotic screen was unhelpful and serum rhubarb – these were all normal.  WE did a CXR to be sure and this was also reported as normal.  

Bruce was commenced on enoxaparin until his warfarin was therapeutic.  He’s on 8 mg nocte with an INR of 2.3 today .  Please chase his subsequent INRs

Oh – and – please screen for occult malignancy as we have not found anything yet.

Yours truly….

So Bruce is sitting in front of you looking a bit worried.  He says that he feels fine, and the leg swelling is improving.  He was a bit spooked when the “young-looking” hospital doctor told him that DVTs “like this” are usually due to some underlying problem “like cancer”.  He really wants to know what to do next.  Does he have cancer?

OK – so here are my questions to you:

Q1:  What is the chances that Bruce has an occult malignancy?

Q2:  what screening tests, inquiries, imaging etc would you recommend / order for Bruce?

Specifically will you get a CT of the torso?

Q3:  Does it really matter if he has an asymptomatic cancer? Will it reveal itself in time anyway?

Let me know your thoughts / practice and experience.

Casey

Clinical Case 116: FEAST or Flush Fluids

Today’s case is about the Resus of severely dry children – very typical of Broome.  But before we get to the case – here is a bit of a review of some recent learning I have had on the topic.   I have started to rethink the traditional acute fluid resuscitation management of these kids.  The FEAST trial was published 4 years ago now.  IN a nutshell it showed that giving IV fluid boluses to sick kids was harmful – lead to higher mortality.  It was one of those trials that, if nothing else, should make us rethink our practice.  Kids with severe dehydration due to diarrheal illness were NOT included in the study, so we cannot really apply it directly to the following case. However, it certainly does make me wonder…

At SMACC in Chicago recently there was an awesome panel discussion by world leaders in fluids / sepsis management.  Dr Kathryn Maitland [lead author of FEAST] was on the stage and answered some tough questions about the role of fluids in extremely sick kids.  The mechanism by which the kids in the “bolus fluid” arm died was discussed.  The children in the “bolus” group seemed to suffer an acute cardiovascular collapse more often than the “no bolus” cohort.  Why is this?  There were a few ideas postulated.  The one that made the most sense to me is that we just might be pushing the pH over the brink of life when using bolus fluids.  But there were a few other mechanisms invoked by the brains trust also.

So anyone who has ever done the APLS or other Paeds Resus course will tell you that the treatment for severe shock is a 10 – 20 ml/kg bolus of IV (or IO) 0.9% saline.  We expect our Med Students to have this number in the front of their mind – it is the “hammer” for all Paeds Resus “Nails”.  However, if you follow the blog or are a fan of the excellent Emcrit series on acid-base therapy then you will know that “normal” SALINE is in fact a nett acidotic fluid which will raise the chloride level [narrow ones’ SID] and force your body to retain H+ ions.  Now this doesn’t matter so much in kids whom are fasting for a theatre case or otherwise well.  However if you are in a scenario where your little patient is sailing very close to the edge of biochemical disaster then a big slug of unbalanced NaCl may just be the thing that pushes them over the egde.  Do we have any direct evidence for this?  No, none that I know of.

Severe dehydration with hypovolemia and malperfusion certainly needs aggressive treatment – we have to try and restore volume / flow and pull them back from multiorgan dysfunction.  So giving fluids seems like a good idea.  But how much, how fast and which fluid to use is certainly a question that I think remains unanswered. Dr John Myburgh gave a great lecture on the ICN series on the history and current state of resuscitation fluids HERE.   My favourite line from his talk was from Dr Malcolm Wilson: “I don’t care if you use dog’s piss, as long as you use it carefully.”  Very Aussie!  But the principle is important – when dealing with really sick kids and fluid Resus – you have to think it through and reassess frequently, proceed with caution.  Fluids are ‘drugs’ just like antibiotics etc.   We need to prescribe the right stuff for the patient in front of us.

So here is the case:

JJ is a 4 month old boy whom has had a diarrheal illness for 5 days.  He has been lethargic and had a few vomits today.  His parents noticed he has been “breathing fast” all afternoon and now at midnght presents with a low-grade fever, diarrhea and lethargy / somnolence.  He is refusing to feed.

Back ground history: born at 36 weeks with IUGR  LBW = 2100g.

Breastfed and has received 1 round of infant immunisations.  Was doing well and putting on weight.  He was weighed in the clinic last week at 4000 g…   but tonight he is weighing in at 3500 g [not good!]

At triage his Obs :  Temp  = 37.3  HR 200, sluggish central cap refill, RR 55/min. He has no recession / tug.  His feet are cooler than his legs

His belly feels soft with hyperactive bowel sounds.  The chest is clear [to Ultrasound!]  The bladder is empty.

This is all consistent with Gastro.  A 500 gram weight loss in this kid equates to about 12% i.e. severe end of the spectrum.

This kid is very sick – we need to know what is going on with his electrolytes / acid:base and renal function.

Luckily an IVC is able to be placed and bloods drawn.  Here is the VBG:

pH = 7.10,   pCO2 = 17    HCO3-= 6.1   BE =  -23.1   Lactate = 3.3

Na = 156  Cl = 128  K+ = 5.1    Creat = 99      The CRP is as always…. 42!

OK…  lets hit the pause button there.  A few questions.

Q1:  Does JJ require a fluid bolus?

Q2: Which fluid and what volume would you give IV in the first instance?

Q3: Assuming he need ongoing fluid replacement – what are you going to prescribe over the coming hours?

Clinical Case 115: Pneumothorax puzzle

This case was interesting for a number of reasons.  It starts with a 50 year old lady whom has been assaulted.  She says she was kicked in the head and chest.  In ED she is looking sore but stable – and it was felt that she had enough mechanism to warrant a CT of her head and neck.  On the neck CT it was noted that she had some surgical emphysema on the lower slices – so she stayed in the tube for a chest scan too!  Here it is:

Pneumothorax = Tense CT!

 

Now – I know what you are all thinking…  that is a CT image that should never had been captured!  We have all heard the addage that you should always pick a tension clinically and never need to image it… but…  the honest truth is that we just are not that good at picking pneumothorax clinically.  As you know I am an ultraosund tragic – and I believe we can certainly pick em with a quick chest probe.  However, relying on clinical exam is just not, well, reliable.

In recent years one error that I have seen creeping into my practice is the tendency to “fast-track” trauma patients to imaging where appropriate without completing a fully thorough secondary survey.  There are a lot of reasons (? excuses) for this:

– trying to get the imaging done in office hours,

– trying to get patients out of collars ASAP,

– relying on second-hand info via handover which may be innaccurate….

– search satificing. Stopping at one major injury!

So my “lesson learned” here is to be systematic and make sure that you are imaging everything that needs imaging and that you have excluded the big “killers” before settling for a CT.

OK – back to the case.

A chest tube was placed and the pneumothorax decompressed.  Post ICC films showed a well expanded lung.  Our patient was admitted to the ward.  Lets jump to the next day…..

Our patient starts to deteriorate.  She is becoming more hypoxic with tachypnoea.  What is going on?

Well there is a few possibilities.  The chief concern was that the tube was occluded / dislodged resulting in reaccumulation of the Ptx.  So another CXR was performed…

Take a few minutes to look at this CXR.  It was reported by the Radiologist as “recurrence of pneumothorax on the right, with overlying subcutaneous emphysema mimicking lung markings.”

Q1.  What is your interpretation of this image?

Q2.  What other imaging might be useful in this case?

Q3.  What will you do next?

OK –  let’s hear your comments.  I you were at #SMACCUS last week then you will have a distinct advantage over the other readers as this case was put up in a session there and discussed.

There are so many potential errors that we can make in even the simplest of cases.  Trauma is a complex scenario with information overload, serious sequelae and time critical decisions to be made. So over the next few months I am hoping got run with a theme of “common errors and their mitigation”.  Hoping to have a few special guests on to help show how we can avoid the pitfalls and do better on the floor.

Casey

SMACCUS : Feeling the FOAM love

Writing this post from O’Hare Airport on my way back to Broome after SMACCUS.  40 hours in an aluminium tube….  [Kevin Fong has re-analysed the safety of air travel, so I’m feeling relatively safe… a bus would be safer!]

Looking back on the conference of the year.  There were some great moments, some spectacular ideas shared and plenty of education.  However, the best aspect of SMACC is the amazing connectedness and camaraderie that I feel at the tea breaks and social functions.  Sure, we all introduce ourselves by our Twitter handles! For the newcomers it seems a bit strange at first, but that moment of recognition when you can connect a smiling face to the years of digital dialogue you have shared is priceless.

On Day 1 I was due to give a talk after lunch.  As always I was a bit nervous.  I had planned a bit of an impromptu experiment in public speaking, and was a little concerned that it may flop!  Sometime in the morning I dropped my credit card in the hallway.  Man, another stress I did not need on the day!  But the awesome thing about SMACC is that a complete stranger, somebody whom I had never met online sent me a Tweet and handed it back within 20 minutes!  That is cool.  At what other conference or mass gathering would that happen?  I was feeling the FOAM Love!  And I knew that my little social experiment in evangelical Karaoke was going to work!  Everyone at this conference wants to be here, to connect, to share and get involved in the FOAM movement.

Sometimes I hear criticism of the SMACC / FOAM movement – people liken it to a cult of celebrity.  Is this true?  I don’t think so.  If anyone at the conference spent a moment chatting to the luminaries like Scott Weingart, Simon Carley, John Hinds, Chris Nickson, Vic Brazil or the other leaders – they would quickly realise that these people have tiny egos and do what they do because they want to improve healthcare.  They want the rest of us to walk out inspired, educated and challenged – to go back home and deliver the best care that is possible.

SMACC was particularly special for me this year.  I was able to meet a heap of the North American FOAMites that I have spent years working “alongside” and admiring.  On day 2 I watched the awesome spectacle that my Ultrasound buddies put together – SONOWARS.  At the end of the session James Rippey asked me to come up on stage.  James is my Ultrasound mentor – a true master under whom I have apprenticed in this crazy electronic age.  Although it did feel a bit indulgent to share this special moment in front of the crowd – I am glad we did.  For this is what FOAM is all about – finding your master, teacher or mentor.  And becoming a teacher to the next generation of brilliant young minds.

And then there was the song…

I wrote these lyrics for my lecture: “No Xray, No Problem!”  It was a talk about how we can use Ultrasound to be better doctors.  But it seems to have served as a sort of anthem for the FOAM LOVE which we all feel.  So here it is [Thanks to  @GruntDoc for the video].  Please share it with your colleagues.  See you in Dublin.   Casey

Imagine there’s no X-ray from GruntDoc on Vimeo.

Countdown to SMACCUS

G’day All

I am sitting in Jackson Lodge writing this post after what has been an amazing week of learning, meeting new friends and seeing some spectacular parts of the U.S.A.   I have been inspired by my fellow Yellowstone US teachers and our awesome students.  And this is just a small taste of what SMACC has to offer!

IMG_3636

My favourite part of the last few SMACC events has been having to opportunity to meet in person all of you – the FOAMites.  Yellowstone has been great, so many new friends… but now I am off to Chicago for the main game, SMACCUS.

So if you are a Broome Docs reader / listener and are coming to SMACC, then please come and say “hello”.  Share a few ideas and if you have a “Lessons Hard Learned” tale that you want to share, just let me know – I will have my mic in hand and want to hear your story.

OK… last chance for a SMACC RUN warmup at altitude – gotta get those lungs working!

See you all in Chicago… or on Twitter if you cannot make it

Casey