Intern Report Case Discussion 2.9

intern-report

Presented by Katie Ohlendorf, MD

History and Physical

CC – Altered mental status

HPI – 88 year old white male presenting to the ED with a history of being found “down” in an apartment which was noted to be in disarray.  According to EMS, the pt was unable to provide any history at the time of presentation; however, was noted to exhibit slurred speech.  Also, he was unable to ambulate, but was reported to be moving all four extremities equally.  EMS found diltazem and synthroid in his medicine cabinet.    Landlord and neighbors had not seen him in several days therefore EMS was called.

PMH, surgical history, meds, allergies, social history and family history are unknown.

PE

Vital signs: BP150/100, HR 54 and irregular, RR 22, Temp 90 degrees F (rectal)

HEENT: Normal cephalic, atraumatic.  Pupils unequal but reactive bilaterally (L – 3mm, R – 2mm), eyes noted to move past midline bilaterally, no pallor, non-icteric, no papilledema.  TM clear bilaterally.  Oral mucosa very dry.  Gag reflex intact.   Neck has nuchal rigidity.

Pulmonary: Tachypneic with Kussmaul-type respirations.  Clear to auscultation bilaterally.

Cardiac: Irregularly irregular rhythm with a rate of 54.  No murmur, gallop, rub. Capillary refill< 4 seconds.

GI: Abdomen soft, nontender, nondistended.  No masses.  Positive midline supraumbilical scar.  Positive bowel sounds.

GU:  Negative.

Rectal: NST, prostate not enlarged.  Positive guiac.  Stool was dark in color.

Ext:  RLE externally rotated but not shortened, old scar on right hip.  No clubbing, cyanosis, or edema.  Pulses intact and symmetrical – radial, femoral, and dorsal pedis.

Neuro:            Patient is awake making incomprehensible sounds moving all 4 ext. equally.  Gag reflex is intact.  DTR’s- prolonged hyporeflexia.  No clonus.  Plantar reflexes down going bilaterally.  No obvious facial asymmetry or focal weakness noted.  Further neuro testing unable to be performed due to patient’s condition.

Lab Results and Diagnostic Studies

Sodium – 148

Potassium – 4.8

Chloride – 112

Bicarbonate – 18

BUN – 75

Creatnine – 2.3

WBC – 23.2

Hgb – 10.6

Platelets – 252

CPK – 3000

Lactate – 1.5

SDS/UDS – negative

Head CT – negative

CSF – WBC – 0, Glucose – 60, Protein – 76, RBC – 22, Gram stain negative

EKG

________________________________________________________

Questions

  1. What is the likely cause of this patients altered mental status?
    1. Graves disease
    2. Uremia
    3. Myxedema coma
    4. Psychosis
    5. Adrenal insufficiency
  2. What will the thyroid studies show in myxedema coma?
TSH level Free T4 T3
A Low High High
B Low Low High
C High Low low
D High High High
E Low Low L

3.  What drugs should be avoided in hypothyroidism because they are known to exacerbate it?

A Lithium Benzodiazepines Motrin
B Phenytoin Lithium Benzodiazepines
C Benzodiazepines Phenytoin Keflex
D Keflex Rifampin Lithium
E Rifampin Phenobarbital Motrin

4.  What is the initial ED treatment of myxedema coma?

A.  200-500 mcg T4

B.  200-500 mcg T4 plus 100 mg IV prednisone

C.  100 mg IV prednisone

D.  Supportive care

E.  BB, PTU, dexamethasone and iodine

Discussion

Answers

  1. Myxedema coma
  2. High TSH, low T3 and T4
  3. Phenytoin, lithium and benzodiazepines
  4. 200-500 mcg T4 plus 100 mg IV prednisone

This patient has several acute issues that he presented with including atrial fibrillation, GI bleed and myxedema coma.  Myxedema coma is a life threatening form of hypothyroidism.  It is an uncommon presentation; however mortality rates as high as 80%.  These patients usually have a medical history of a chronic thyroid disorder that leads to this state.  Myxedema coma is most common in elderly females.  Many cases are triggered by cold weather with the majority of patients presenting during the winter.  Other causes include infection, medication and trauma preventing access to medications.  Medications to avoid in hypothyroidism include phenothiazines, phenobarbital, narcotics, anesthetics, benzodiazepines, lithium, phenytoin, rifampin, amodarone and iodides as they may exacerbate symptoms.

The hypothalamic-pituitary-thyroid axis controls thyroid hormone production via a negative feedback loop.  Release of thyroid hormone is regulated by TSH and free T4 acts as a negative feedback inhibiting further TSH release.  Thyroid hormones affect many body systems including cardiac, renal, pulmonary and neuromuscular systems.

Approximately 90% of hypothyroidism is primary, where the thyroid itself is affected.  It is typically due to an autoimmune process.  In the US, the most common autoimmune process is Hashimoto thyroiditis, where anti-TSH antibodies are produced, therefore inhibiting thyroid hormone production.  These patients typically have a large goiter.  The thyroid destruction is a chronic process, taking months to years.  Patients present with nonspecific symptoms of hypothyroidism including weight gain, hair loss, fatigue, etc.  These patients should have thyroid studies as well as well as thyroid antibody testing.  Treatment includes thyroid hormone replacement.

In undeveloped countries the most common cause of hypothyroidism is iodine deficiency.  Other causes include congenital abnormalities, malignancies, infiltrative disorders, as well as iatrogenic causes (thyroid ablation).

Differential diagnosis for myxedema coma is broad and many conditions can mimic the symptoms.  Things to consider are sepsis, hypothermia secondary to environmental exposure, CVA, hypoxia, hyperglycemia, acute MI, ICH, panhypopiuitarism, adrenal insufficiency, hyponatremia, GI bleed and psychiatric disorders.

Emergency center care is focused on stabilizing the patient and initial resuscitation focuses on ABC’s – cardiac monitoring, pulse oximetry, airway management, and IV access.

The history is important to obtain especially regarding previous thyroid disease, medication changes, and symptoms of hypothyroidism (weight gain, hair loss, fatigue, dry skin, voice changes, depression, constipation and menstrual changes).  Also ask about history of cold exposure, trauma (may prevent access to medications), infections or other life stressors.

On physical exam, vital signs are essential.  The temperature is often less then 35.5 degrees C.  Patients are hypotesive and bradycardic.  A thyroidectomy scar can provide a clue to diagnosis.  Look for myxedema, a nonpitting edema present in the hands, face and pretibial areas.  The GI exam may have abdominal distension secondary to constipation and decreased gut motility.  The neuro exam may include parasthesia (especially median nerve) and pseudomytonic reflexes (prolonged relaxation phase).

Diagnostic studies will help confirm your clinical diagnosis.  Check CBC, electrolytes, BNP, troponin, lactate, UA, pregnancy test (treatment is different in pregnancy), ABG as well as thyroid studies including TSH, T3 and T4 (total and free).  The thyroid studies will reflect the chronic thyroid state.  In the chronic hypothyroid patient the TSH will be high and the patient will have low T3 and free T4.  An EKG will show sinus bradycardia as the most common dysrhythmia in those with hypothyroidism.  Chest x-ray is useful to look for pneumonia, cardiomegaly and effusions (pleural and pericardial).  A CT head may be done to look for intracranial pathology.  A lumbar puncture may be done to look for an infectious cause.  Also check a random cortisol level to evaluate for adrenal insufficiency, which may mimic myxedema coma.  If suspecting adrenal causes a ACTH stimulation test may be done, but do not delay treatment.

Treatment includes airway and cardiovascular support as well as treating the cause for myxedema coma (infection, hypothermia, etc.).  IV fluids must be used with caution.  Although patients are typically dehydrated, bradycardia and underlying cardiac disease may tip the patients into a hypervolemic state.  Therefore invasive cardiac monitoring as well as frequent physical exams are required with fluid resuscitation.  If a patient requires vasopressors, dopamine is first line.  Treatment for myxedema coma is IV thyroxine.  T4 is classically used and dosed at 200-500 mcg IV.  Glucocorticoids are also recommended as adrenal insufficiency may mimic this condition.  Stress does hydrocortisone is recommended (100 mg IV).

Patients will be admitted to the ICU for further evaluation and management.  Clinical improvement is seen within 24-36 hours of thyroid hormone replacement.  Even with medical treatment, mortality rates exceed 20%.

On the opposite end of the spectrum are the hyperthyroid states.   Graves disease is the most common form of hyperthyroidism, accounting for 50-60% of the cases.  It is an autoimmune state where antibodies stimulate the TSH receptor and causes thyroid hormone production and release.   Symptoms include heat intolerance, tremor, palpitations, weight loss, anxiety, nervousness, or hyperactivity.  On physical exam the thyroid is often enlarged, ocular abnormalities such as proptosis and periorbital edema may be seen, and signs of thyrotoxicosis may be present including sinus tachycardia, atrial fibrillation, systolic hypertension, excessive perspiration, tremor and large muscle weakness.  Lab studies include TSH (low), T3 (usually normal), and free T4 (high).  Thyroid antibodies can also be measured.  Imaging studies include nuclear medicine imaging using radioactive iodine; in graves disease the thyroid will have increased uptake as compared to normal.  Treatment includes symptomatic relief with beta blockers as well as antithyroid drugs (PTU), radioactive iodine ablation or surgical removal.

Thyroid storm is the extreme state of hypothyroidism.  Like myxedema coma the mortality rate is high with 90% mortality if not diagnosed and treated quickly.  The patient may have a known history of hyperthyroidism.  Thyroid storm is usually precipitated by infection.  Patients have fever, tachycardia, and hypertension.  They may have GI complaints such as nausea, vomiting, diarrhea or abdominal pain.  Patients may present with seizures, coma, or anxiety.  Thyroid storm is a clinical diagnosis but thyroid studies will show elevated T3 and T4 with low TSH levels.  If thyroid storm is suspected, treatment is a three step process involving first beta blockers (to block effects of thyroid hormone), followed by PTU (to stop thyroid hormone production) and iodidine (to inhibit thyroid hormone release).  Patients should be admitted to the ICU and clinical improvement seen within 24 hours of treatment.

Intern Report Case 2.9

intern-report

Presented by Katie Ohlendorf, MD

History and Physical

CC – Altered mental status

HPI – 88 year old white male presenting to the ED with a history of being found “down” in an apartment which was noted to be in disarray.  According to EMS, the pt was unable to provide any history at the time of presentation; however, was noted to exhibit slurred speech.  Also, he was unable to ambulate, but was reported to be moving all four extremities equally.  EMS found diltazem and synthroid in his medicine cabinet.    Landlord and neighbors had not seen him in several days therefore EMS was called.

PMH, surgical history, meds, allergies, social history and family history are unknown.

PE

Vital signs: BP150/100, HR 54 and irregular, RR 22, Temp 90 degrees F (rectal)

HEENT: Normal cephalic, atraumatic.  Pupils unequal but reactive bilaterally (L – 3mm, R – 2mm), eyes noted to move past midline bilaterally, no pallor, non-icteric, no papilledema.  TM clear bilaterally.  Oral mucosa very dry.  Gag reflex intact.   Neck has nuchal rigidity.

Pulmonary: Tachypneic with Kussmaul-type respirations.  Clear to auscultation bilaterally.

Cardiac: Irregularly irregular rhythm with a rate of 54.  No murmur, gallop, rub. Capillary refill< 4 seconds.

GI: Abdomen soft, nontender, nondistended.  No masses.  Positive midline supraumbilical scar.  Positive bowel sounds.

GU:  Negative.

Rectal: NST, prostate not enlarged.  Positive guiac.  Stool was dark in color.

Ext:  RLE externally rotated but not shortened, old scar on right hip.  No clubbing, cyanosis, or edema.  Pulses intact and symmetrical – radial, femoral, and dorsal pedis.

Neuro:            Patient is awake making incomprehensible sounds moving all 4 ext. equally.  Gag reflex is intact.  DTR’s- prolonged hyporeflexia.  No clonus.  Plantar reflexes down going bilaterally.  No obvious facial asymmetry or focal weakness noted.  Further neuro testing unable to be performed due to patient’s condition.

Lab Results and Diagnostic Studies

Sodium – 148

Potassium – 4.8

Chloride – 112

Bicarbonate – 18

BUN – 75

Creatnine – 2.3

WBC – 23.2

Hgb – 10.6

Platelets – 252

CPK – 3000

Lactate – 1.5

SDS/UDS – negative

Head CT – negative

CSF – WBC – 0, Glucose – 60, Protein – 76, RBC – 22, Gram stain negative

EKG

________________________________________________________

Questions

  1. What is the likely cause of this patients altered mental status?
    1. Graves disease
    2. Uremia
    3. Myxedema coma
    4. Psychosis
    5. Adrenal insufficiency
  2. What will the thyroid studies show in myxedema coma?
TSH level Free T4 T3
A Low High High
B Low Low High
C High Low low
D High High High
E Low Low L

3.  What drugs should be avoided in hypothyroidism because they are known to exacerbate it?

A Lithium Benzodiazepines Motrin
B Phenytoin Lithium Benzodiazepines
C Benzodiazepines Phenytoin Keflex
D Keflex Rifampin Lithium
E Rifampin Phenobarbital Motrin

4.  What is the initial ED treatment of myxedema coma?

A.  200-500 mcg T4

B.  200-500 mcg T4 plus 100 mg IV prednisone

C.  100 mg IV prednisone

D.  Supportive care

E.  BB, PTU, dexamethasone and iodine

Please submit your answers to the questions in the “leave a reply” box or click on the “comments” link.  Your submission will not immediately post.  Answers with a case discussion will post on Friday.  If you have any difficulty, please contact the site administrator at arosh@med.wayne.edu. Thank you for participating in Receiving’s: Intern Report.

Intern Report Case Discussion 2.8

intern-report

Presented by Brian Junnila, MD

CHIEF COMPLAINT:
Abdominal pain, nausea and vomiting

HISTORY OF PRESENT ILLNESS
14 year old male presents with acute onset of abdominal pain 3 hours duration which woke him up from sleep at 0300 this morning.  Pt is accompanied by his mother and father who relate a history of being awakened by their son complaining of abdominal pain and crying inconsolably.  Pain is located to the right lower quadrant radiating to the right inguinal region and scrotum.   Pain is ranked 10/10, constant and stabbing in nature.   Associated symptoms include nausea and vomiting, 2 episodes last 3 hours described as the contents of his dinner, no blood or greenish discoloration reported.  Last oral intake was at 2000 last night and consisted of macaroni and cheese.  Pt acknowledges multiple previous episodes of abdominal and scrotal pain over the last year which always spontaneously resolved in 1-2 hours and had never been this severe.   Pt denies any recent dysuria, hesitancy, urgency or penile discharge.  Pt denies any change in recent change in bowel pattern; last bowel movement was yesterday and normal in consistency.  He denies any recent fever, sore throat, chest pain or shortness of breath.

REVIEW OF SYSTEMS
The following systems were reviewed:  Constitutional, eyes, ears, nose, throat, cardiovascular, respiratory, gastrointestinal, genitourinary, musculoskeletal, skin, neurologic, psychiatric, endocrine, lymphatic and immunologic.  All review and negative except as document in history of present illness.

PAST MEDICAL HISTORY:  Buckle fracture left radius
PAST SURGICAL HISTORY:  Tonsillectomy at age 5
MEDICATIONS:  None
ALLERGIES:  NKDA, peanuts cause swelling
FAMILY HISTORY:  Father with HTN, DM type 2
SOCIAL HISTORY:  Denies tobacco, alcohol, illicit drug use.  In 9th grade, does well in school.

EXAMINATION OF ORGAN SYTEMS AND BODY AREAS

VITALS:  BP 126/56, HR 112, RR 22, T 37.7˚C, Pulse ox 98% RA
CONSITUTIONAL:  A&O x 3, in moderate distress, crying and uncomfortable
HEAD:  NC/AT
EYES:  Injected conjunctiva, PERRLA, EOMI, sclera anicteric
EARS:  TM good light reflex no bulging or erythema bilaterally
NOSE:  Mucous membrane moist, clear rhino rhea
MOUTH:  Mucous membranes moist, no intraoral lesions, no pharyngeal erythema
NECK:  Supple, full ROM, no C-spine tenderness.  No lymphadenopathy, no thyromegaly.
CARDIOVASCULAR:  Tachycardia, regular rhythm.  Normal S1 and S2.  No M, R, G
RESPIRATORY:  Good air movement bilaterally, CTAB, No wheezes, rhonchi, rales
ABDOMIN:  Soft, discomfort to palpation of the right lower quadrant, no rebound, no guarding, ND, no masses.  BS positive throughout.
BACK:  No tenderness to palp of C,T L vertebrae.  No CVA tenderness.
GENTIOURINARY:  Uncircumcised.  No external genital lesions, no urethral discharge, no inguinal lymphadenopathy.  Loss of the cremasteric reflex on right.  Left cremasteric reflex intact.  Scrotal edema.  Right testicle firm and tender to palpation.
MUSCULOSKELETAL:   Full range of motion in all 4 extremities with strength 5/5 both proximally and distally.  No joint effusions.
SKIN:  Warm dry and normal color, no rash, no ecchymosis, no petechiae.

LABORATORY DATA
Electrolytes:  141/3.8/102/26/15/0.5<79
CBC w/diff:  6.7>13.9/4.2<281
Urinalysis:  Clear, yellow, glucose negative, bilirubin negative, ketones negative, specific gravity 1.029, blood negative, pH 5.5, protein negative, urobilinogen negative, nitrite negative, leukocytes esterase negative, RBC < 2, WBC < 5, epithelial cells < 5, casts none, mucous negative, bacteria none, sperm none, trichomonas none

RADIOLOGY
Bilateral transverse color Doppler ultrasound
Right testicle             Left testicle

________________________________________________

QUESTIONS

1. What is the first step in management of patients with this condition?
a.  Color-flow duplex Doppler ultrasound
b.  Manual detorsion
c.  Radionuclide scintigraphy
d.  Systemic intravenous analgesia
e.  Urologic consultation

2. After what time from symptom onset will the salvage rate for the affected testes drop below 90%?
a.  3 hours
b.  6 hours
c.  9 hours
d.  12 hours
e.  24 hours

3.  What is the correct procedure for manual detorsion of the right testis?
a.  180˚ clockwise rotation
b.  180˚ counterclockwise rotation
c.  360˚ clockwise rotation
d.  360˚ counterclockwise rotation
e.  540˚ clockwise rotation
f.  540˚ counterclockwise rotation

4.  Which physical exam finding is present in nearly 100% of all adolescent patients with our patient’s condition?
a.  Tender firm testicle
b.  High position of affected testicle
c.  Loss of the ipsilateral cremasteric reflex
d.  Prehn sign
e.  Transverse orientation of affected testicle

Answers

E.  Immediate urologic consultation
B.  6 hours
F.  540˚ counterclockwise rotation
C.  Loss of the ipsilateral cremasteric reflex

DISCUSSION

Testicular torsion is a urologic emergency which requires prompt recognition and treatment for preservation of testicular viability.  Twisting of the spermatic cord produces venous outflow obstruction and arterial occlusion.  Undiagnosed torsion leads to testicular infarction and impaired fertility.

Torsion is the most common cause of acute scrotal pain in prepubertal boys.  It has a peak incidence in the first year of life and a second peak incidence at puberty.  There are two types, extra and intravaginal.

Extravaginal torsion is a diagnosis of newborns.  An anatomic abnormality of the attachment of the tunica vaginalis to the dartos layer of the scrotum leaves testicle and tunica vaginalis unanchored.  Testicle and the tunica vaginalis are unanchored in the scrotum and are free to rotate as a unit. This can happen in-utero and by the time the condition is noted at birth the testicle is not salvageable.

Intravaginal torsion is spermatic cord rotation within the tunica vaginalis.  Predisposing factors include increased cord length and an abnormally high insertion of the tunica vaginalis onto the testicle, the so called “bell clapper deformity.”  The testicle lacks normal fixation to the fascial and muscular coverings that surround the spermatic cord within the scrotum.  It freely moves within the tunica vaginalis.  Contraction of the cremasteric muscle causes a rotational force and can lead to torsion.  Testicular trauma has also been associated with torsion.  Consider torsion in the setting of persistent scrotal pain after trauma.

The classical presentation of testicular torsion is the acute onset of unilateral scrotal pain.  The pain may radiated to the inguinal canal and the lower abdomen.  Associated symptoms of nausea and vomiting are common.  Patients by relate a history of prior episodes of scrotal pain which resolved spontaneously representing the spontaneous torsion and detorsion of the spermatic cord.

Physical exam findings include

  • Ipsilateral loss of the cremasteric reflex (most common finding, nearly 100%)
  • Erythema and swelling of the scrotum
  • Testicular enlargement
  • High-riding testicle in the scrotum due to twisting and shortening of the spermatic cord
  • Transverse/horizontal lie of the testicle
  • Firm and painful testicle
  • Displacement of the epididymis from the usual posterior aspect of the scrotum.

The initial management in cases of strong clinical evidence of torsion high suspicion is immediate urologic consultation.  Surgical exploration should not be delayed for imaging studies.  The definitive treatment for testicular torsion is surgical exploration, detorsion and bilateral orchiopexy.

After consultation, IV access and analgesia manual detorsion may be attempted.  Normally torsion occurs from lateral to medial.  Detorsion should be attempted by rotating the affected testicle away from the midline, 540˚ from medial to lateral.  This is a counterclockwise rotation for the right testicle and clockwise rotation for the left.  The rotation can be thought of as opening a book.
For cases in which the history and physical findings are equivocal or after manual detorsion, obtain laboratory and radiographic studies.

Color Doppler ultrasound imaging is inexpensive, rapid and be performed in the emergency department.  It has a sensitivity of 88-100% and specificity of 90%.  Testicular torsion is demonstrated suggested by an absence of blood flow to one testicle.  False positive tests can occur early in the course of the injury and in very young boys.   Radionucleotide scintography has improved sensitivity 100% compared with ultrasonography however it takes more time and is more expensive.

The duration of vascular obstruction is directly related to the ability to salvage the testicle.  Prompt recognition and treatment is essential.  Salvage rate is 90% if treatment is rendered within 6 hours of symptom onset.  After 24 hours of symptoms testicular necrosis is certain.

Intern Report Case 2.8

intern-report

Presented by Brian Junnila, MD

CHIEF COMPLAINT:
Abdominal pain, nausea and vomiting

HISTORY OF PRESENT ILLNESS
14 year old male presents with acute onset of abdominal pain 3 hours duration which woke him up from sleep at 0300 this morning.  Pt is accompanied by his mother and father who relate a history of being awakened by their son complaining of abdominal pain and crying inconsolably.  Pain is located to the right lower quadrant radiating to the right inguinal region and scrotum.   Pain is ranked 10/10, constant and stabbing in nature.   Associated symptoms include nausea and vomiting, 2 episodes last 3 hours described as the contents of his dinner, no blood or greenish discoloration reported.  Last oral intake was at 2000 last night and consisted of macaroni and cheese.  Pt acknowledges multiple previous episodes of abdominal and scrotal pain over the last year which always spontaneously resolved in 1-2 hours and had never been this severe.   Pt denies any recent dysuria, hesitancy, urgency or penile discharge.  Pt denies any change in recent change in bowel pattern; last bowel movement was yesterday and normal in consistency.  He denies any recent fever, sore throat, chest pain or shortness of breath.

REVIEW OF SYSTEMS
The following systems were reviewed:  Constitutional, eyes, ears, nose, throat, cardiovascular, respiratory, gastrointestinal, genitourinary, musculoskeletal, skin, neurologic, psychiatric, endocrine, lymphatic and immunologic.  All review and negative except as document in history of present illness.

PAST MEDICAL HISTORY:  Buckle fracture left radius
PAST SURGICAL HISTORY:  Tonsillectomy at age 5
MEDICATIONS:  None
ALLERGIES:  NKDA, peanuts cause swelling
FAMILY HISTORY:  Father with HTN, DM type 2
SOCIAL HISTORY:  Denies tobacco, alcohol, illicit drug use.  In 9th grade, does well in school.

EXAMINATION OF ORGAN SYTEMS AND BODY AREAS

VITALS:  BP 126/56, HR 112, RR 22, T 37.7˚C, Pulse ox 98% RA
CONSITUTIONAL:  A&O x 3, in moderate distress, crying and uncomfortable
HEAD:  NC/AT
EYES:  Injected conjunctiva, PERRLA, EOMI, sclera anicteric
EARS:  TM good light reflex no bulging or erythema bilaterally
NOSE:  Mucous membrane moist, clear rhino rhea
MOUTH:  Mucous membranes moist, no intraoral lesions, no pharyngeal erythema
NECK:  Supple, full ROM, no C-spine tenderness.  No lymphadenopathy, no thyromegaly.
CARDIOVASCULAR:  Tachycardia, regular rhythm.  Normal S1 and S2.  No M, R, G
RESPIRATORY:  Good air movement bilaterally, CTAB, No wheezes, rhonchi, rales
ABDOMIN:  Soft, discomfort to palpation of the right lower quadrant, no rebound, no guarding, ND, no masses.  BS positive throughout.
BACK:  No tenderness to palp of C,T L vertebrae.  No CVA tenderness.
GENTIOURINARY:  Uncircumcised.  No external genital lesions, no urethral discharge, no inguinal lymphadenopathy.  Loss of the cremasteric reflex on right.  Left cremasteric reflex intact.  Scrotal edema.  Right testicle firm and tender to palpation.
MUSCULOSKELETAL:   Full range of motion in all 4 extremities with strength 5/5 both proximally and distally.  No joint effusions.
SKIN:  Warm dry and normal color, no rash, no ecchymosis, no petechiae.

LABORATORY DATA
Electrolytes:  141/3.8/102/26/15/0.5<79
CBC w/diff:  6.7>13.9/4.2<281
Urinalysis:  Clear, yellow, glucose negative, bilirubin negative, ketones negative, specific gravity 1.029, blood negative, pH 5.5, protein negative, urobilinogen negative, nitrite negative, leukocytes esterase negative, RBC < 2, WBC < 5, epithelial cells < 5, casts none, mucous negative, bacteria none, sperm none, trichomonas none

RADIOLOGY
Bilateral transverse color Doppler ultrasound
Right testicle             Left testicle

________________________________________________

QUESTIONS

1. What is the first step in management of patients with this condition?
a.  Color-flow duplex Doppler ultrasound
b.  Manual detorsion
c.  Radionuclide scintigraphy
d.  Systemic intravenous analgesia
e.  Urologic consultation

2. After what time from symptom onset will the salvage rate for the affected testes drop below 90%?
a.  3 hours
b.  6 hours
c.  9 hours
d.  12 hours
e.  24 hours

3.  What is the correct procedure for manual detorsion of the right testis?
a.  180˚ clockwise rotation
b.  180˚ counterclockwise rotation
c.  360˚ clockwise rotation
d.  360˚ counterclockwise rotation
e.  540˚ clockwise rotation
f.  540˚ counterclockwise rotation

4.  Which physical exam finding is present in nearly 100% of all adolescent patients with our patient’s condition?
a.  Tender firm testicle
b.  High position of affected testicle
c.  Loss of the ipsilateral cremasteric reflex
d.  Prehn sign
e.  Transverse orientation of affected testicle

Please submit your answers to the questions in the “leave a reply” box or click on the “comments” link.  Your submission will not immediately post.  Answers with a case discussion will post on Friday.  If you have any difficulty, please contact the site administrator at arosh@med.wayne.edu. Thank you for participating in Receiving’s: Intern Report.

Intern Report Case Discussion 2.7

intern-report

Presented by Daniel Seitz, MD

CC: “I’m coughing up blood”.

HPI: A 44-year-old man presents to the Emergency Department complaining of coughing up blood for two days.  The patient states that two months ago he began experiencing progressively worsening cough and fatigue.  The cough was initially non-productive, but for the past month he’s been coughing up thick yellow sputum.  One week ago he noticed that his sputum was intermittently blood streaked, and yesterday he coughed up gross blood.  Over the last 24hrs the patient reports coughing up a cup and a half of gross blood.  He describes the blood as bright red, frothy and devoid of food particles.  He also reports a history of weight loss, approximately 20lbs in the last 6 months. The patient occasionally has fevers in the afternoon, and reports night sweats over the past three weeks. The patient states that he experiences a diffuse achy pain on deep inhalation and with cough.  He denies any shortness of breath or difficulty breathing.

ROS: Negative except for as mentioned in the HPI.
PMH: Hypertension which he’s treating with diet and exercise.
PSH: Denies.
Medications: None.
Allergies: No known drug allergies.
FH: Hypertension, heart disease, and diabetes.
SH: The patient smokes 1 pack per day, has smoked for ten years, occasionally drinks alcohol, and denies any illicit drug use.  The patient lives alone and works as an actuary.  He was born in China and immigrated to the United States as a teenager.

PE:
VITAL SIGNS: BP 92/55, P 109, R 21, T 38.4, SpO2 95% on room air.
GENERAL: Patient is sitting comfortably in his stretcher and is in no apparent acute distress.
HEAD: Head is atraumatic, normocephalic, and no tenderness to palpation.
EYES:  Mild conjunctival pallor.  Pupils are 4 mm bilaterally, are equally round and reactive to light and accomodation.  No nystagmus.  No conjunctival injection, but mild conjuctival pallor.  No scleral icterus
EARS: Tympanic membranes are normal.
NOSE: No nasal drainage, no blood in nares, no swollen turbinates.
MOUTH:  Dried  blood around the patient’s mouth.  Moist mucous membranes, no tonsillar enlargment or exudates, no intraoral lesions.
NECK: Supple without lymphadenolpathy.  There is no nuchal rigidity, no tenderness to palpation, no carotid bruits, trachea is midline.
CARDIOVASCULAR: S1, S2, tachychardic rate with normal rhythm.  No murmurs, rubs or gallops.  Peripheral pulses are present , 2+, and symmetric in all four extremities.
RESPIRATORY: Good air entry bilateral.   Diffuse post-tussive rales, distant breath sounds heard over the lung apices .
GASTROINTESTINAL: Abdomen soft, non-tender, non-distended, no tenderness to palpation, no appreciable organomegaly.  Bowel sounds present in all quadrants.
MUSCULOSKELETAL: Patient is mildly cachexic.  Strength 5/5 proximally and distally in all extremities.
SKIN:  No rashes, lesions or ulcerations.  Increased pallor.
NEUROLOGIC: Patient is awake, alert and oriented to person, place and time.  Face is symmetrical.  Sensation is equal and intact throughout.  The patient walks with a normal gait and performs finger to nose examination without difficulty.

Course in the ED: While waiting to be seen in the module, the patient expectorates 700 mLs of gross blood.  The patient is rushed to resuscitation; where he’s placed on a monitor and two large bore peripheral IVs are placed.  A stat portable chest x-ray is obtained which shows a cavitary lesion at the apex of the patient’s left lung.  The patient’s vital signs in resuscitation are as follows:  T: 38.6 HR: 112 RR: 25 BP: 81/50 O2Sat: 87% on non-rebreather.

Questions

1.  What is the patient’s most likely diagnosis?
a) Lung cancer
b) Tuberculosis
c) Aspergillosis
d) Pneumonia
e) Bronchitis

2.  Which of the following characteristics indicates hematemesis over hemoptysis?
a) Alkaline pH
b) Dark color
c) Frothy appearance
d) Presence of macrophages

3.  What is the best course of management in this patient?
a) Emergent angiography
b) Flexible Bronchoscopy
c) Intubation of the right main stem bronchus, and place patient in left lateral decubitus position
d) Rigid Bronchoscopy
e) Rush the patient to the operating room for emergent thoracotomy

4.  What vessel is most likely responsible for this patient’s massive hemoptysis?
a) Aorta
b) Bronchial artery
c) Inominate artery
c) Pulmonary artery
d) Tracheobronchial capillaries

Discussion

-Answers-

1. B (Tuberculosis)
2. B (Dark Color)
3. C (Intubate and lie on left side)
4. B (Bronchial Artery)

Hemoptysis is the expectoration of blood of any quantity, from below the larynx.  Massive hemoptysis is defined as >600 mL of blood expectorated in 24 hours.  While massive hemoptysis only comprises 5% of all reported hemoptysis, the mortality is upwards of 80%.

The most common causes of massive hemoptysis are bronchiectasis, tuberculosis, lung cancer, lung abscess, arteriotracheobronchial fistula, and pulmonary angiodysplasia.  Based upon this patient’s history (Chinese immigrant, cough that progresses from non-productive to productive to blood streaked to massive, fevers and night sweats) the etiology of this patient’s hemoptysis is tuberculosis.  Tuberculosis is the most common cause of massive hemoptysis worldwide and until the 1960s was the most common cause of massive hemoptysis in the United States.

90% of massive hemoptysis involves the bronchial arteries.  These are high-pressure branches off of the thoracic aorta.  Alternately, the majority of trace hemoptysis originates from the tracheobronchial capillaries.

When evaluating a patient with hemoptysis it is important to exclude gastrointestinal and upper airway etiologies of bleeding.  The workup for each of these conditions is very different, but the presentations can be surprisingly similar.  History is the most helpful tool in differentiating hematemesis and hemoptysis, but the following characteristics can be helpful as well:
Hemoptysis blood – alkali, bright red, frothy appearance, macrophages
Hematemesis blood – acidic, dark color, clots and food particles, coffee grounds

Approach to non-massive hemoptysis
1. Evaluate oxygenation (pulse oximetry / ABG)
2. History and physical – does anything indicate GI or upper respiratory etiology?
3. Chest radiograph
4. Are lab studies indicated? (CBC, coags, PPD, ANA, ESR?)
5. Create differential (Bronchitis?, malignancy?)
6  Bronchoscopy / HRCT

Approach to massive hemoptysis should be managed more aggressively.  Mortality with massive hemoptysis is extremely high, and these patients will inevitably need ICU admission.  The most common cause of death in these patients is asphyxiation and not exsanguination.  Intubation of the mainstem bronchus contralateral to the hemorrhage has the potential to protect the unaffected lung.  This is most easily done on the right side. In addition, it has been suggested that laying the patient on the side of the hemorrhage can keep the non-affected alveoli from flooding with blood.

Definitive management of massive hemoptysis will involve bronchoscopy, thoracotomy or angiography, depending on your institution.   Getting either Cardiothoracic Surgery, Pulmonology or Interventional Radiology involved early will expedite potentially life saving management.

FURTHER READING:

Bidwell JL, Pachner RW. Hemoptysis: diagnosis and management. Am Fam Physician. 2005 Oct 1;72(7):1253-60.

Jean-Baptiste E. Clinical assessment and management of massive hemoptysis. Crit Care Med. 2001 May;29(5):1098.

Rudzinski JP, delCastillo J. Massive hemoptysis. Ann Emerg Med. 1987 May;16(5):561-4.

Collard HR, Gruber MP, Weinberger SE, Saint S. Clinical problem-solving. Anatomy of a diagnosis. N Engl J Med. 2003 Sep 4;349(10):987-92.

Marx JA, Hockberger RS, Walls RM, Adams J, Rosen P. Rosen’s emergency medicine : concepts and clinical practice. 7th ed. Philadelphia: Mosby/Elsevier; 2010; 223-225.

This case discussion presented by Dr Daniel Seitz