Senior Report 8.11

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Case Presentation by Alex Weissman, MD

Chief Complaint: “I feel terrible.”

History of Presenting Illness:
The patient is a 32-year-old female presenting with complaint of feeling “terrible and weak.” She states that this has happened to her twice in the last 24 hours. The first episode occurred upon awakening at 3 AM this morning with a sensation of doom, shortness of breath, chest pain, and in a cold sweat with chills. Subsequently she passed out. She ate some corn, felt better, and went back to sleep. Today, prior to arrival, the patient had another episode where she went into a cold sweat with chills and had a sensation of doom with chest pain and shortness of breath; however, this time she did not pass out. She called EMS, who found her capillary blood sugar was 32 mg/dL. The patient denies being sick recently. She denies insulin or sulfonylurea use. She denies abnormal stress in her life. She states that she has been eating normally. Last menstrual period was 3 years ago, the patient has always had irregular menses. The patient denies associated headache, sudden change in vision, abdominal pain, nausea, vomiting, diarrhea, constipation, dysuria, pain or numbness in the extremities, recent illness, or recent travel.

Review of System:
Constitutional: Complains of cold sweats and chills
HEENT: Denies headache
CVS: Complains of substernal chest pain
Lungs: Complains of SOB
Abdomen: Denies abdominal pain
Musculoskeletal: Denies pain in the extremities
Genitourinary: Denies dysuria
Skin: Denies rash
Neurologic: Denies numbness
Psychiatric: Denies depression

 

Past Medical History:
Bronchitis, splenomegaly, anemia, thrombocytopenia

Past Surgical History:
Bone marrow biopsy

Social History:
The patient denies use of tobacco, alcohol, or illicit drugs past or present.

Family Medical History:
Addison’s disease in her mother

Physical Exam:
Vitals: Blood pressure: 100/75, Pulse: 60, Respiratory rate: 18, Pulse Oximetry: Not initially recorded, Temperature: 36.2 degrees Celsius
General: Alert and oriented x3, no acute respiratory distress
Head: normocephalic, atraumatic
Eyes: PERRL, EOMI, bilateral conjunctival pallor, no scleral icterus
ENT: No cervical lymphadenopathy, no pharyngeal edema, mucous membranes moist
Cardiovascular: regular rate and rhythm, no appreciable murmurs, capillary refill <2 seconds
Respiratory: no tachypnea, no retractions, clear to ausculation bilaterally, no appreciable wheezes, rhonchi, or rales
Gastrointestinal: normoactive bowel sounds, nondistended, no tympany to percussion, soft and nontender to palpation
Musculoskeletal: Extremities are atraumatic, dorsalis pedis and radial pulses 2+ and regular bilaterally, no peripheral edema
Skin: no rashes or lesions
Neurological:
MENTAL STATUS: awake, alert, oriented
CRANIAL NERVES: face symmetric, pupils 3mm -> 2mm bilaterally, PERRL, EOMI, visual fields full to confrontation
MOTOR: patient moving all four extremities spontaneously, gait normal
SENSORY: intact to light touch

ECG:
Alex

 

Labs:

Initial CBG – 32 mg/dL

Electrolytes:

132 99 13 9.3 51
5.2 22 0.46 2.1

TSH: 3.586 Micro IU/mL

CBC:

4.7 11.1 109
33.3

Serum pregnancy: negative
Insulin: <0.5 mcUnits/mL
Random cortisol: 2.2 mcg/dL

 

Questions:

1) What are the classic physical exam and laboratory findings in primary adrenal insufficiency (Addison’s Disease)?
a) High blood pressure, high serum potassium, high serum sodium, low random cortisol, low serum glucose
b) Low blood pressure, high serum potassium, low serum sodium, low random cortisol, low serum glucose
c) High blood pressure, high serum potassium, low serum sodium, high random cortisol, high serum glucose
d) Low blood pressure, low serum potassium, low serum sodium, low random cortisol, low serum glucose

2) What laboratory test is used to diagnose adrenal insufficiency, what distinguishes primary versus secondary adrenal insufficiency, and what test value would you expect in primary adrenal insufficiency?
a) ACTH stimulating test; ACTH; low or normal ACTH level
b) Random cortisol; cortisol; low cortisol
c) ACTH stimulating test; ACTH; high ACTH level
d) Random cortisol; ACTH; low or normal ACTH level

3) What are some basic differences in symptomatology between primary and secondary adrenal deficiency?
a) Primary: Hypokalemia, hypernatremia, hypoglycemia, dehydration, hypotension, Cushingoid habitus
Secondary: Hyperkalemia, hyponatremia, normotension, hyperpigmentation, hyperglycemia

b) Primary: Hyperkalemia, hyponatremia, hypoglycemia, dehydration, hypotension, hyperpigmentation,
Secondary: Hypokalemia, hyper/hyponatremia, +/- Cushingoid habitus, hypoglycemia

c) Primary: Hypokalemia, hyponatremia, dehydration, hypotension, +/- Cushingoid habitus, hyperglycemia
Secondary: Hypernatremia, hyperkalemia, hyperpigmentation, normotension
d) Primary: Hyperkalemia, hyponatremia, hyperglycemia, normotension
Secondary: Hypokalemia, hypernatremia, hypoglycemia, hypotension, dehydration, hyperpigmentation, +/- Cushingoid     habitus

 

Bonus Question 1. What is the preferred steroid treatment for adrenal crisis and what vital sign abnormality should raise the ED physician’s clinical suspicion for an adrenal crisis?
a) Hydrocortisone – unexplained hypotension
b) Prednisone – unexplained hypertension
c) Dexamethasone – unexplained hypotension
d) Hydrocortisone – unexplained hypertension

 

Bonus question 2: What is the most common infectious cause of primary adrenal insufficiency in the US?
a) Tuberculosis
b) Meningitis
c) Influenza
d) HIV


Filed under: Senior Report, Uncategorized

Intern Report 8.10

internreport

Case Presentation by Amy Buth, MD

A 12 y/o G0P0 presents to the ED with her mother and grandfather with complaints of vaginal bleeding for the past 20 days. Four days prior, she developed a severe frontal headache with fatigue. This morning she felt nauseated and had one episode of nonbloody/nonbilious emesis. She also developed diffuse abdominal cramps with extreme fatigue, leading to her collapsing at home. Her mother therefore brought her daughter in to the ED right away. Per the mother, the patient has irregular heavy periods which last 7 -10 days. Menarche was December 2013. Last cycle was October 14-November 4, 2014. She missed her cycle in August and September of 2014. During the past 20 days, she has been using 10 pads/day and noticing clots. She is not sexually active and denies any trauma or abuse. She currently feels weak and dizzy. She denies any fevers, chills, chest pain, shortness of breath, dysuria, hematuria, increased urgency or frequency with urination, or diarrhea.

PAST HISTORY:
PMH: Asthma (resolved)
SurgH: Right inguinal hernia repair 2011
Gyn: G0P0. Began menstruating December 2013; typically as a 7 day cycle
Meds: Tylenol for pain PRN
Allergies: none
FH: Denies family history of bleeding, bruising, thrombotic disease, breast/uterine/ovarian/colon cancer, hypertension, or diabetes
SH: denies alcohol, tobacco, illicit drug use. The patient is a Jehovah Witness

PHYSICAL EXAMINATION:

Vitals: Temp 37.0 oral, BP 120/66, HR 118, RR 20, 98% on RA. Positive orthostatics

Constitutional: Lethargic, poor eye contact, laying on the bed in mild distress.

Eye: PERRL, EOMI, no discharge, conjunctival pallor

Respiratory: Lungs CTA bilaterally, no cough, no wheezing, no cyanosis.

Cardiovascular: Tachycardia, regular rhythm, no chest pain, no palpitations, no peripheral edema, good pulses equal in all extremities

Gastrointestinal: Bilateral lower quadrant tenderness, no distension, no rebound tenderness, no palpable masses

Genitourinary: Pelvic exam: normal external genitalia, blood at the introitus, blood noted in the vaginal vault, there is slow active bleeding from the cervix. Bimanual exam: uterus is anteverted and normal in size, no adnexal masses or tenderness, no cervical motion tenderness

Integumentary: Warm, dry, pallor

Hematology/Lymphatics: No petechia or bruising

Neurologic: Symmetric face, decreased strength in all extremities bilaterally secondary to fatigue and poor effort

LABORATORY STUDIES:

Pregnancy test: negative

CBC: 6.8>4.6/14.7<393 with 77% PMNs and 19% lymphs. MCV 75 and RDW 13.6

BMP: 137/3.8/103/24/11/0.52, glucose 98

Lactate 2.8

PT/PTT/INR: 11.4/21.5/1.07

TSH 6.149 (NL 0.210 – 4.940), T3 total 139 (NL 60 – 180), T3 free 3.9 (NL 1.4 – 4.4), total Thyroxine 8.7 (NL 6.2 – 14.6), free Thyroxine 1.1 (NL 0.8 – 1.8)

Prolactin 15.3 (NL 2.8 – 29.2)

von Willebrand activity 348 (NL 43-138), von Willebrand antigen 244 (60-153), Factor VIII 395.7 (63-150)

Questions:

1) What is the patient’s most likely diagnosis?
a) Leiomyoma
b) Hypothyroidism
c) Anovulatory bleeding
d) von Willebrand Disease

2) After placing the patient on a cardiac monitor and starting a fluid bolus, what would be the best next step?
a) Uterine packing
b) Order O negative blood
c) Order a stat transvaginal ultrasound
d) Consult pediatric gynecology

3) What is the typical treatment for this diagnosis?
a) Gonadotropin-releasing hormone agonists
b) Synthetic thyroid hormone therapy
c) High dose estrogen therapy
d) Desmopressin / DDAVP

4) BONUS: The patient and her family are Jehova’s Witnesses. You develop great rapport with the family and have a heart to heart discussion about the patient’s treatment and safety. The patient and her family are grateful for your recommendations but are refusing a blood transfusion. They are agreeable to discuss alternative treatment plans. The patient is tachycardic, lethargic, orthostatic, and actively bleeding with Hg 4.7. You again strongly encourage the importance of the blood transfusion. The family then asks to be discharged so they can go to another Children’s Hospital that has a Jehovah’s witness liaison for more direction. What do you do?
a) Follow the patient/family’s wishes and do not give a blood transfusion. Consider other options.
b) Discharge the patient so they can go to another facility of their choice
c) Contact the court to make a ruling
d) Call security to keep the patient and proceed to give the blood transfusion


Filed under: Intern Report

Intern Report 8.9

internreport

Case Presentation by Devina Mohan, MD

Chief Complaint: “I’ve been feeling bad for one week”

HPI: 56-year-old female with PMH of diabetes and hypertension comes to the ED complaining of feeling bad for the past week. She states that it all started after she was cleaning her basement after the flood last week. Initially she just feeling sick and in the past 2-3 days she has had cough with productive white sputum and subjective fevers. She states that she has not taken anything for her symptoms. She states her children were concerned about her today and sent her in. Patient denies sore throat, congestion, numbness or weakness in extremities, dysuria, hematuria, blood in stool, diarrhea, constipation.

PMH: hypertension, diabetes
PSH: cholecystectomy, small bowel resection, umbilical hernia repair
MEDS: Humulin 70/30, Quinapril 40 mg, Chlorthalidone 25 mg
ALLERGIES: Penicillin
SH: Denies tobacco, alcohol, or drug use
FH: Hypertension

EXAMINATION OF ORGAN SYSTEMS/BODY AREAS:
Vitals: BP 82/54, HR 137, RR 18, temp 39.8, O2 sat 100% on RA
Cardiovascular: Tachycardic rate with normal rhythm, no murmurs
Respiratory: Diminished breath sounds on left lower lobe, no wheezing, no crackles
Gastrointestinal: Soft, +BS, non-distended, mildly tender to palpation diffusely, no rebound, no guarding
Musculoskeletal: No obvious deformities, 2+ bilateral radial and DP pulses, good capillary refill
Skin: Skin is cool to the touch but good capillary refill, no rashes
Neurological: AOx3, moving all 4 extremities, gait not observed as patient is feeling too weak to stand

 

CXR:
8.9

CBC
WBC – 14.6
Hgb – 13.7
Platelets – 116

BMP
Na – 127
K – 3.9
Cl – 90
CO2 – 18
BUN – 31
Cr – 3.41
Glucose – 454

Troponin – 0.272

 Questions:

1. Given the above data, which would be the best diagnosis and disposition for this patient?

a) Community acquired pneumonia – oral levofloxacin, discharge home
b) Community acquired pneumonia – ceftriaxone and azithromycin, admit to medicine
c) Community acquired pneumonia – cefepime and azithromycin, admit to ICU
d) Healthcare associated pneumonia – vancomycin and levofloxacin, admit to ICU

2. What is the patient’s CURB65 score?
a) 1
b) 2
c) 3
d) 4

3. What additional test is indicated to best treat this patient?
a) CT Chest
b) ABG
c) RSV swab
d) Urine legionella antigen


Filed under: Intern Report

Senior Report 8.8

seniorreport

Case Presentation by Sarah Michael, DO

 

Chief Complaint: “My chest has been bothering me.”

History of Present Illness:

A 67-year-old female patient presents to the ED complaining of chest discomfort slowly worsening over the past 10-12 hours. It has been relatively mild but constant since the time of onset. The patient reports a left substernal nonradiating pressure sensation. She has never experienced anything similar in the past and has not taken anything for pain. She is not short of breath, diaphoretic, dizzy, or lightheaded. When questioned further, the patient reports she thinks her symptoms are “due to stress” as she has been hosting several extended family members at her home over the past few days. She drove herself to the ED.

 

Past Medical History: hypothyroidism, hyperlipidemia

Past Surgical History: none

Medications: simvastatin, levothyroxine

Allergies: NKDA

Social: Lives alone. Drinks alcohol infrequently (none recently). No tobacco or drug use.

Family History: Denies significant family history. No family history of early myocardial infarction.

Physical Exam:

BP 138/86

HR 82

RR18

T 37.5

Oxygen saturation 100% RA

General: Alert, oriented, well-appearing Caucasian female, sitting in a chair without distress. She speaks in complete sentences.
Cardiovascular: Regular rate & rhythm. No murmurs. No chest wall tenderness or exacerbation of pain with palpation.
Respiratory: Clear to auscultation bilaterally
GI: Abdomen soft, non-tender, non-distended
Neuro: Alert, oriented, appropriate. Strength 5/5 in all extremities.
Psychiatric: No acute psychiatric decompensation is noted. She is appropriate, lucid and able to formulate and articulate complex thought processes without delusions. No evident anxiety.

A cardiac workup was initiated and the following EKG was obtained.

 

Web Case EKG

1. Where does the pathology demonstrated in the EKG localize?

A. right coronary artery
B. left circumflex artery
C. left anterior descending artery
D. pericardium

The following bedside echocardiogram was obtained in the ED.

 

echo

2. On the basis of the echocardiogram, where does the patient’s pathology localize?

A. right ventricle
B. left ventricle
C. mitral valve
D. pericardium

3. What is the underlying pathologic mechanism resulting in this clinical picture?

A. catecholamine surge
B. plaque rupture
C. inflammation with PMN infiltration
D. infection of a pletelet-fibrin nidus with circulating bacteria


Filed under: Senior Report, Uncategorized

Senior Report 8.7

seniorreport

 Case Presentation by Heather Bowman, MD

 

Chief Complaint: “I took all of my pills”

 

History of Present Illness:

A 40 year old male with PMH DM, HTN, depression and recent cocaine use comes in reporting he wanted to kill himself. He admits to taking 10 tablets of remeron (mirtazapine) (15 mg tablets), and “whatever was left in the bottle”, possibly up to 30 tablets of simvastatin (20mg) as well as 8 tablets of a “cold medication”. He reports some chest pain and ringing in his ears. Otherwise denies nausea, vomiting, difficulty breathing, abdominal pain, or headaches. He denies taking any other substances including other pills, alcohol or drugs.

 

Past Medical History: DM, HTN, depression, closed head injury

Past Surgical History: “head surgery” following closed head injury

Medications: aspirin, lantus, lisinopril, simvastatin, remeron

Allergies: Tylenol

Social: no smoking or drinking, last use cocaine 4-5 days ago, no IVDA

Family History: HTN

 

Physical:

Vitals: BP 193/106, HR 77, resp 18, temp 36.3, oxygen saturation 100% RA

Cardiovascular: regular rate & rhythm, no murmurs. Radial and DP pulses strong and symmetric, chest pain is not reproducible

Respiratory: clear to auscultation bilaterally

GI: Abdomen soft, non-tender, non-distended

Neuro: pupils 3mm, round reactive to light, facial smile symmetric, alert & oriented x 3, interacting appropriately

Psychiatric: admits to suicidal ideation, no homicidal ideation, no visual or auditory hallucinations

 

Questions:

1. What is the most important study to get on the patient?

A. CBC and chem-7
B. EKG
C. Aspirin level
D. Urine drug screen

 

2. Chem 7 shows Na=140, K+=3.9, Cl=107, HCO3=25, BUN=13, creatinine=0.9, glu=346, Ca=0.9, Mg=1.8. EKG is as pictured. Aspirin level is negative. UDS shows cocaine otherwise negative. ECG as below; HR 81, PR interval 138, QRS 106, QTc 529

Bowman%20prolong%20qtc%20ekg
What is your next step?

A. Make sure magnesium >2mg/dL, potassium >4 mMol/L, and calcium and phosphorous are normal and call MICU
B. Tell pharmacy to mix 3 amps of bicarb in 250cc of normal saline and begin bicarb infusion on the patient and admit the patient.
C. Give the patient a few liters of normal saline, maybe some insulin, and clear the patient for psych when glucose is <300
D. Order a troponin and get ready to call CCU

 

3. Which substance that the patient took is likely causing the above EKG findings?

A. Remeron (mirtazapine)
B. Simvastatin
C. Cocaine
D. Antihistamine cold medication

 

4. (Bonus Question) Which dysrhythmia do you worry about above EKG progressing to?

A. Ventricular tachycardia
B. Bradycardia
C. Torsades
D. Atrial fibrillation


Filed under: Senior Report

Senior Report 8.6

seniorreport

Case Presentation by Katherine Shulman, MD

Chief Complaint: Difficulty swallowing

History of Present Illness: This is a 66-year-old male with no significant medical history who comes in to emergency department complaining of difficulty in swallowing beginning 3 months ago. He further describes it as a foreign body sensation in his throat and has started eating a soft diet, which he tolerates well. He reports only mild discomfort with swallowing. Also, three months ago he noticed a change in his voice. He reports a “very mild” baseline shortness of breath over the same timeframe. He denies any neck pain, chest pain, fevers, night sweats, or headaches. No recent dental procedures. Denies any URI symptoms in the past several months.

Past Medical History: none

Medications: None

Social History: Denies tobacco, alcohol, or illicit drug use.

Family History: His brother just died of laryngeal cancer two months ago.

 

Physical Exam:

Vital Signs: BP 145/82; HR 98; RR 16; Temp 36.8; 98% RA

General: Patient sitting semi-fowler in stretcher in no acute apparent distress, with no acute respiratory distress. Handling oral secretions well. Speaking in full sentences with a muffled voice. Resting comfortably.

Head: normocepahlic; atraumatic

Eyes: EOMI; PERRL; pink conjunctiva

Mouth: moist mucous membranes, no tongue or submandiblar swelling, good overall dental hygiene, uvula midline; significant area of swelling in the right oropharynx just posterior to the tonsil with normal appearing overlying mucosa; no erythema, exudates, ulcerations in the anterior or posterior pharynx.

Neck: Supple; trachea midline; no palpable lymphadenopathy

Cardiovascular: s1, s2; regular rate and rhythm; no murmur

Respiratory: no stridor, lungs clear to auscultation bilaterally; symmetrical chest rise and fall; no accessory muscle use

 

Workup: We obtained laboratory tests and a CT – Neck w/ contrast.

 

8.62

8.63

8.61

 

Questions:

  1. What is the most likely diagnosis?
  2. Peritonsillar Abscess
  3. Nasopharyngeal Carcinoma
  4. Diphtheria
  5. Ludwig’s Angina

 

  1. What is the most likely causative organism?
  2. Streptococcus Species
  3. Staphylococcus Aureus
  4. Haemophilus Influenzae
  5. Fusobacterium

 

  1. What are the next steps in management?
  2. Initial dose IV Clindamycin, discharge home w/ PO Clindamycin, and ENT f/u
  3. IV Unasyn, consult ENT, medicine admit
  4. IV Zosyn, consult ENT, ICU admit for compromised airway
  5. Consult ENT, obtain blood cultures, medicine admit

Filed under: Senior Report