Intern Report 8.28

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Discussion by Mirjana Dimovska, MD

Case 1

45 year old female presents to the emergency department with intense bilateral hand pain after a glass etching arts and crafts project this morning. The patient states that she thinks she got some of the solution on the palms of her hands. On visual inspection, skin has corrugated appearance.

images

1. Which of the following electrolyte abnormality is most likely to lead to adverse effects in this patient?

A. hyponatermia

B. hypocalcemia

C. hypernatremia

D. hypokalemia

Case 2

A 56 year old dissolved male is brought into the emergency department via EMS. The patient smells strongly of alcohol and was noted to be sleeping on a metallic park bench during a thunderstorm. Upon exam, the patient has a feathering patterned burn to the right upper extremity and chest. GCS is 12 however patient is confused and unable to provide a history.

2. Which of the following physical exam findings is most likely?

A. Muscle necrosis distant to the site of injury

B. Compartment syndrome in RUE

C. Kissing burns

D. Tympanic membrane rupture

Case 3

A 3 year old child is brought in by his mother for mental status changes. The patient’s past medical history is significant for a recent emergency room visit for treatment of an extensive scald burn that the patient sustained while trying to lift a bowl of ramen noodles. On exam, the child is cyanotic, short of breath and lethargic. He has superficial scald burns on the left shoulder and upper back covered in ointment.

3. What is the most appropriate treatment plan?

A. Administration of methylene blue and supplemental O2

B. Contact child protective services immediately

C. Admit to burn service for debridement and pain control

D. Massive fluid resuscitation and supplemental O2

Bonus Question:

Which of the following does not fulfill criteria for transfer to a burn center?

A. 37 year old male pulled from a house fire with singed nose hairs and DIB

B. 15 year old female with partial thickness burns to the bilateral left upper and lower extremities

C. 6 year old male with full thickness burn to the right arm totaling <5% BSA

D. 52 year old female who sustained a superficial partial thickness grease burn to the right breast while cooking this morning.


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Intern Report 8.27

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Case Discussion by Matt Ciejka, MD

HPI:

23 year-old female presents with complaint of intermittent left lower abdominal pain for the past 3 days. She also complains of occasional vaginal spotting that began 1 day prior. Her last menstrual period was 26 days ago. She denies any vaginal discharge otherwise. Her abdominal discomfort is characterized as a sharp sensation over the left lower abdomen, lasting for several minutes at a time. She endorses some associated nausea but no vomiting, diarrhea, nor blood in stools. She has not taken anything at home for her symptoms. She denies any lightheadedness or syncope. She has no other complaints at this time.

PMH: HTN, migraines, Graves’ disease

PSH: foot surgery

Meds: propranolol, PTU

Allergies: amoxicillin, Keflex, doxycycline, clindamycin, (all cause hives)

Social history: denies tobacco, alcohol, and illicit drugs

Family history: CHF, diabetes, HTN

EXAM:

Vitals: BP 142/79, HR 106, RR 18, T 36.6, SpO2 99% on RA

Gen: A/Ox3, NAD

HEENT: PERRL, TMs WNL, no rhinorrhea, no oropharyngeal erythema

CV: regular rhythm, tachycardic, no m/r/g

Resp: lungs CTAB, no respiratory distress

Abd: obese, soft, mild tenderness over left lower abdomen, no distension, no peritoneal signs

Musc: 5/5 strength in all extremities throughout

Skin: no rashes appreciated

Neuro: follows all commands, answers all questions appropriately, sensation intact throughout extremities

Pelvic: no vaginal discharge, scant blood in vaginal vault but no active bleeding, no cervical motion tenderness, no palpable adnexal masses, mild tenderness over left adnexal area, slightly enlarged soft uterus

 

Questions:

1) Which of the following is the most appropriate next test?

A. Abdominal x-ray

B. Abdominal/pelvic CT scan

C. Abdominal ultrasound

D. Urine human chorionic gonadotropin

E. Progesterone concentration

 

2) Which of the following is the most common etiology of ectopic pregnancy?

A. Previous medically-induced abortion

B. Previous tubal surgery

C. Intrauterine device (IUD) contraception use

D. History of pelvic inflammatory disease

E. In utero exposure to diethylstilbestrol (DES)

 

3) Which of the following combinations of ultrasound findings and blood work is most suggestive of an ectopic pregnancy?

A. Fluid in pouch of Douglas on ultrasound; serum progesterone 30 ng/mL

B. Absence of intrauterine gestational sac on transvaginal ultrasound; serum hCG 1,600 miU/mL

C. Absence of intrauterine gestational sac on transvaginal ultrasound; serum hCG 800 miU/mL

D. Absence of intrauterine gestational sac on transabdominal ultrasound; serum hCG 4,000 miU/mL

E. Absence of intrauterine gestational sac on transabdominal ultrasound; serum hCG 2,000 miU/mL

Answers:

1. (D) Female patients who are of reproductive age and present with complaints of abdominal pain and vaginal bleeding should initially receive a urine or serum pregnancy test. A qualitative urine hCG test is sensitive for detecting early pregnancy with thresholds as low as 10 mIU/mL to 100 mIU/mL, depending on the test brand. The test is 99% sensitive and 99% specific for pregnancy. If the urine hCG test is positive, one can initially perform transabdominal ultrasound examination to determine the location of the pregnancy and help rule out an ectopic. If an intrauterine pregnancy is not visualized, a transvaginal ultrasound examination can be performed. It should be noted that a serum progesterone level may help to ascertain whether or not a pregnancy is viable (>25 ng/mL suggests viability). If the urine hCG test is negative, one should consider other diagnoses such as PID, urinary tract infection or stone, gynecological issues such as fibroids or ovarian cysts, or GI issues such as diverticulitis or appendicitis. For evaluation of these issues, the other listed tests may be beneficial.
2. (D) The risk for ectopic increases secondary to mechanisms that affect the movement of a fertilized egg through the fallopian tube. Such mechanisms can be anatomical, such as tissue scarring, or functional, such as a decrease in fallopian tube motility. Pelvic inflammatory disease is the leading cause of ectopic pregnancy, and at least 50% of first ectopic pregnancies are associated with a history of PID. It is most often caused byN. gonorrheaor C. trachomatis, whose long-term untreated course can damage the structural integrity within fallopian tubes. Other risk factors for ectopic pregnancy include a prior ectopic pregnancy, endometriosis, and tubal and pelvic surgery by way of formed adhesions obstructing the fallopian tubes. Normal fallopian tube motility can also be impeded by hormonal imbalances involving progesterone. A pharmacological elevation of progesterone, such as from progesterone-only OCPs or IUDs is associated with ectopic pregnancy. In utero exposure to diethylstilbestrol (DES) has been shown to increase risk of ectopic pregnancy as well. A history of medically-induced abortion has not been shown to increase risk.
3. (B) The “discriminatory zone” is the range of serum hCG concentrations above which a gestational sac can be visualized consistently. Transabdominal ultrasound examination can consistently detect a gestational sac when the hCG level is greater than 6,500 mIU/mL. Absence of an intrauterine gestational sac on transabdominal ultrasound with hCG level greater than 6,500 is highly suggestive of an ectopic pregnancy. Transvaginal ultrasound is more sensitive for detection of intrauterine pregnancy and has a lower “discriminatory zone” than transabdominal ultrasound, as it can consistently detect intrauterine pregnancy in conjunction with a hCG level greater than 1,500 mIU/mL. Transvaginal ultrasonography with serum hCG level greater than 1,500 mIU/mL is 67-100% sensitive and 100% specific for detecting ectopic pregnancy. However, it must be noted that there is no hCG level at which the possibility of visible ectopic pregnancy can be ruled out with absolute certainty. Serum progesterone levels can identify patients at risk for ectopic pregnancy, although they are not diagnostic of ectopic pregnancy. Serum progesterone concentrations are higher in viable IUPs than in ectopic pregnancies or IUPs that are destined to abort. A progesterone level of 5 ng/mL or less indicates a nonviable pregnancy, such as ectopic or miscarriage, and excludes normal pregnancy with 100% sensitivity. Due to the poor reliability of progesterone levels in detecting ectopic pregnancy, however, serum hCG levels are used more often in conjunction with ultrasound.
SOURCES

http://www.aafp.org/afp/2005/1101/p1707.html

http://www.aafp.org/afp/2000/0215/p1080.html

http://www.uptodate.com/contents/ectopic-pregnancy-clinical-manifestations-and-diagnosis

Herbst AL, et al. Ectopic pregnancy. Comprehensive gynecology. 2nd ed. St. Louis: Mosby-Year Book; 1992:457–88

Malhotra N, et al. Operative Obstetrics and Gynecology. JP Medical Ltd 2014: 439-440

 


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Intern Report 8.26

 

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Case Presented by Barry Kang, MD

Questions:
1)
Patient is brought into resuscitation as a trauma code 1. He has been shot multiple times in the chest. He is intubated and is swept off to the operating room. As your are leaving the resuscitation bay a DPD officer approaches you and asks you about the patient and what is going on. What do you respond?

a) I’m sorry sir the only thing I can tell you is that the patient is in critical condition and that he is one his way to the operating room.
b) His name is John Brooks and he got shot multiple times in the chest and abdomen. He had to be intubated and is in critical condition. He was just taken to the operating room.
c) He is middle age African American male who has sustained multiple gunshot wounds and was just taken to the operating room.
d) Here is FIN number with his name, age and birthday. He has sustained multiple gunshot wounds to the chest and abdomen. He was just taken to the operating room.

 

2) You have just seen an interesting case in MOD 2 and the patient was just sent up to the MICU. The intern in MOD 2 has just started their shift at 9am. You think it’s a great case to learn from and want to tell the intern about the case. What should you do?

a) Give them a sticker and tell them to look up the labs, ECG, HPI and physical you just finished dictating. After that ask them what they think.
b) Give them the ECG and ask for their interpretation.
c) Present them the HPI and physical and show them the ECG without the top strip with the reading and patient information.
d) Don’t talk to them about the case because it would a HIPAA violation.

 

3) You come in for a shift and check your mail box in 3R, you have received a subpoena from a law firm requesting the medical records and your testimony about a patient you had seen about 6 months previously. It turns out the patient is suing his employer since he was hurt at a job site and received care from you after the accident. What should you do next?

a) Ignore it. Someone else will deal with the legal aspect, you didn’t get into medicine to deal with legal system.
b) Send all the medical records to the law firm. It’s ok since they are representing the patient.
c) Contact the patient and ask them to fill out a medical release form.
d) File the form away and take care of it when you have more time.

 

Bonus Question: You walk into MOD 6 to evaluate a patient for altered mental status. You see an 85 year old male who looks thin. He has stool caked onto his backside and after you clean this off you see multiple decubitus ulcers along his backside. Over the course of his ED evaluation his mental status has improved and you begin to talk him about what happened. He states that he lives at home with his son. He says sometimes his son doesn’t come and check on him all day. He is unable to ambulate on his own and has to sit in a dirty adult diaper. What is your role in this situation?

a) Tell the patient he can file a report of abuse if he wants.
b) Tell him that you are sorry for his living conditions and tell him a geriatric consult has been put in for further evaluation.
c) Report elder abuse and admit the patient for placement in a nursing home since he is not getting the care he needs at home.
d) Ignore the situation and move on to the next patient.


Filed under: Intern Report

Intern Report 8.25

internreport

Case Presentation by Jonathan Najman, MD

History of Present Illness:

12-yo boy presents to the ED with sudden onset of abdominal pain and vomiting for 1 day. The patient states that he woke up suddenly early in the morning with severe abdominal pain and subsequently had multiple episodes of non-bloody and non-bilious emesis. The pain is intermittent in nature, sharp, radiates to his groin, is the worst pain he has ever felt and seems to be worsening with time. The patient’s mother states that he has been afebrile at home.  The patient denied feeling any symptoms the day prior as well as any recent trauma, urinary symptoms, sexual activity or masturbation, or any sick contacts.  Denied sexual activity.  There is no change in urination, no burning with urination, and reported skin changes.  He was well yesterday.

PMH: no known medical problems or hospitalizations

PSH: none
FH: no sick contacts
SH: lives at home with mother and father, denied sexual activity

Physical Exam:

Vital Signs: BP 108/68, HR 101, RR 20, T 37.9, 98% on RA

General: uncomfortable, with intermittent moments of extreme pain and discomfort

HEENT: NCAT, no pharyngeal erythema, no cervical lymphadenopathy palpated

Cardiovascular: RRR, normal S1 and S2, no murmurs noted

Respiratory: Clear to auscultation bilaterally

GI: Abdomen is mildly tender to palpation over the suprapubic region, otherwise it is soft, nondistended and nontender, with +BS

GU: Mild scrotal tenderness to palpation. There is slight swelling of the left testicle noted with significantly tenderness to palpation. Lifting the testicle does not seem to reduce the pain. The left testicle appears to be higher than the right. Cremasteric reflex is intact bilaterally. Negative blue dot sign bilaterally. There are no rashes or bruises noted over the genitalia.  There is no discharge from the penis.

MSK: moving all extremities

Neurological: Alert and conversational, moving all four extremities spontaneously.

Skin: intact, no rashes or bruises noted

The following ultrasound was obtained:

8.25

Questions:

1) What does the patient most likely have?

  a) Varicocele

  b) Epididymitis

  c) Testicular torsion

  d) Hydrocele

2) How would you treat this patient?

  a) Manually detorse testicle in a clockwise fashion, if successful, DC home

  b) Consult urology for emergent surgical repair

  c) Ceftriaxone and Doxycycline

  d) Levofloxacin

3) What is the most common cause of epididymitis in prepubertal patients?

  a) Idiopathic

  b) E. coli

  c) C. trachomatis

  d) Ureaplasma


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Senior Report 8.24

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Case Presentation by Eugene Rozen, MD

Case 1

25 year old female with headache, fever, malaise, rash, left sided eye pain. Symptoms have been worsening over the 2 days. She has a history of congenital HIV, she has not seen her doctor in over 1 year and takes no medication.

Right Eye Left Eye
Conjunctiva Normal Red
Photophobia None Positive
Pupils 4mm, brisk 4mm, brisk
Acuity 20/30 20/70
Pressure 15 15
Fluorescein Normal Normal
Fundus Normal Normal

8.242

1. What treatment should be started?

A. Acyclovir IV

B. Clindamycin IV

C. Dexamethasone (High Dose) IV

D. Gatifloxacin Eye Drops

E. HAART

Case 2

53 year old male with history of AIDS presents complaining of blurry vision. He has been on multiple HAART regimens. His last CD4 count, 4 months ago, was 48 with a high viral load.

Right Eye Left Eye
Conjunctiva Normal Normal
Photophobia None None
Pupils 5mm, relative afferent pupillary defect 5mm, brisk
Acuity 20/200 20/50
Pressure 14 14
Fluorescein Normal Normal
Fundus See below See below

8.24

2. Pathology of what structure does the relative afferent pupillary defect signify?

A. Ciliary Body

B. Choroid plexus

C. Cornea

D. Optic Nerve

E. Retina

Case 3

52 year old male complaining of “seeing double”. Symptoms reported as worsening over the last 3 months. No other symptoms except occasional headache over the same period. Patient has a history of AIDS. No diplopia is reported when each eye is tested individually.

Right Eye Left Eye
Conjunctiva Normal Normal
Photophobia None None
Pupils 3mm, reactive 3mm, reactive
Acuity 20/40 20/20
Pressure 21 14
Fluorescein Normal Normal
Fundus Slight papilledema Normal

8.241

3. What study should be ordered next?

A. CT head, non-contrast

B. CT head/orbits with contrast

C. ESR and CRP

D. Lumbar puncture

E. TSH/T4


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Senior Report 8.23

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Case Presentation by Aditee Jodhani, MD

 

History of Present Illness:

A 45 year old female presents to the ED with shortness of breath worsening for the past 2 weeks. She states for the last several days she has also been experiencing fatigue, subjective fever, and chills. The patient denies any productive cough, hemoptysis or chest pain. She does have a history of HIV and intermittently follows up with a physician for treatment. She denies any current or past tobacco use. The patient has been living at a homeless shelter for the past 2-3 months and doesn’t know if she’s had contact with sick individuals.

 

Physical Exam:

Vital Signs:

BP 112/76, HR 102, RR 22, T 37.7, pulse ox 91% on RA

General: mildly uncomfortable, sitting upright

HEENT: no pharyngeal erythema, no palpable cervical lymphadenopathy

Cardiovascular: RRR, normal S1 and S2, no murmurs

Respiratory: Clear breath sounds bilaterally, mildly tachypneic speaking in short sentences, no wheezing or rales

GI: abdomen soft, nontender, +BS

Neurological: Alert and oriented x3, moving all four extremities spontaneously.

 

A chest xray and ABG was obtained. ABG: pH 7.46, C02 28, p02 68

8.23

Questions:

1. Based on the information given above what is the most likely cause for the patient’s presentation?

A. bacterial pneumonia

B. COPD exacerbation

C. Pneumocystis jiroveci pneumonia

D. Pneumothorax

 

2. What is the most appropriate treatment for this patient?

A. Nebulized beta agonists with oral steroids

B. Ceftriaxone and doxycycline

C. Trimethoprim-sulfa

D. Trimethoprim-sulfa and corticosteroids

 

3. The patient states she has an allergy Bactrim, what other medications can be used to treat the patient’s condition?

A. Dapsone and trimethoprim

B. Clindamycin and primaquine

C. Lower dose Bactrim 10mg/kg daily

D. Caspofungin aerosolized pentamidine

 


Filed under: Senior Report, Uncategorized