Intern Report 8.5

internreport

Case Presentation by Xue Tian, MD

 

CC:  Left eye swelling, pain, and discharge

HPI:

A 26-year-old man presents to the ED complaining of a 6-day history of left eye pain, drainage, erythema and swelling of the eyelid. The patient says that he went to an urgent care 2 days ago and was prescribed ciprofloxacin eye drops. However, he has not seen an improvement in symptoms and states that the swelling is worse now. He also developed subjective fevers and chills at home today and he has pain with eye movement as well as decreased visual acuity.

ROS : Otherwise neg

PMHx:  None

PSHx:  None

Medications:  None

Allergies:  NKDA

FHx:  Heart disease

SHx:  Social drinker, smokes a pack a week x 10 years, denies other illicit drugs

 

Physical Exam: 

Vitals: BP 140/80        HR 80             RR 18              Temp 38.0      O2 99% RA

Gen – Lying in bed, eyes closed

Eyes – Chemosis of the L eye, scleral swelling, swelling and erythema of the eyelid, crusty. Visual acuity of L eye is 20/200, unable to count fingers. EOM restricted, significant pain with eye movement. Picture below.

 

IR8.5

 

Questons:

1. Which of the following is the most likely diagnosis?

A) Bacterial conjunctivitis

B) Pre-orbital cellulitis

C) Orbital cellulitis

D) Subconjunctival hemorrhage

 

2. What are the most pertinent questions to ask during history taking?

A) Pain with eye movement

B) Decreased visual acuity

C) Headaches

D) Fever

E) All of the above

 

3. Which of the following should be initiated for treatment?

A) IV ceftriaxone

B) IV ceftriaxone and vancomycin

C) Ciprofloxacin eye drops

D) IV antibiotics and surgical drainage

 

Answers:

1.C 2.E 3.B

  1. C. Pre-orbital (or peri-orbital) cellulitis (B) must be differentiated from orbital cellulitis (C), since orbital cellulitis can lead to blindness. Pre-orbital cellulitis is an infection of the anterior eyelid, while orbital cellulitis involves structures inside the orbit. Pre-orbital cellulitis is less severe, whereas orbital cellulitis is associated with complications including orbital abscess, infection extending into the intracranial space, and Pott’s puffy tumor. Both of these diseases are more common in children. Bacterial conjunctivitis (A), also known as “pink eye,” is treated with erythromycin eye drops (or Cipro drops to cover Pseudomonas if the patient wears contact lenses or has any corneal abrasions). Subconjunctival hemorrhage (D) is usually due to spontaneous vessel rupture or trauma, and is usually flat and not associated with sclera edema.
  1. E. The history and physical exam can help to differentiate pre-orbital from orbital cellulitis. Key findings of orbital cellulitis include fever, pain with eye movement, decreased visual acuity, headaches, proptosis, edema extending beyond the eyelid margin, and signs/symptoms of CNS involvement. In pre-orbital cellulitis you typically do not see proptosis or pain with extraocular eye movements. A Ct scan of the orbit and sinus can aid in differentiating between pre-orbital and orbital cellulitis.
  1. B. The most common organisms seen in orbital cellulitis includes Staph spp., Strep spp., Bacteroides, and rarely Haemophilus influenza. Gram-negative bacteria are associated with post-traumatic orbital cellulitis. Mixed aerobes and anaerobes are associated with extension of a dental infection. Fungi, mucor, zygomycosis, and aspergillosis are associated with cases seen in immunocompromised individuals. Treatment includes IV vancomycin PLUS ceftriaxone, cefotaxime, unasyn, or zosyn. Cipro eye drops (C) are appropriate treatment for bacterial conjunctivitis. Surgical drainage (D) is not always necessary in orbital cellulitis.

References:

Block S. Getting an Eyeful of Preseptal Cellulitis. Pediatric Annals. 2013; 42: 99-102. doi: 10.3928/00904481-20130222-05 [link]

Nageswaran, Savithri (08/2006). “Orbital cellulitis in children”. The Pediatric infectious disease journal (0891-3668), 25 (8), p. 695.

Nickson C. The goggle-eyed fisherman. Life in the fast lane. 2010. [http://lifeinthefastlane.com/ophthalmology-befuddler-023/]

Quintana, E.C. Development of a clinical severity score for preseptal cellulitis in children

Annals of Emergency Medicine , Volume 44 , Issue 4 , 433

Thorner, A. Orbital cellulitis. In: UpToDate, Post TW (Ed), UpToDate, Waltham, MA. Accessed on November 14, 2014.

Senior Report 8.4

Case Presentation by Mike Antoniolli, MD

 

A 28-year-old male presents to the emergency department with complaints of 3 days of eye pain, photophobia, redness, and decreased vision. The pain has become so severe that he has had 2 episodes of emesis. He denies any fevers, chills, recent infections, or URI symptoms. He denies any inciting event, trauma to the eye, dust or foreign body exposure.

Physical Exam:

General: Patient is holding a hand over his left eye leaning forward. Appears uncomfortable

Eyes: Left eye reveals scleral injection, epiphora, photophobia, and blepharospasm in addition to the findings shown in the image below. A contact lens is noted in the unaffected eye. Pain/photophobia was only partially relieved with proparacaine.

 

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Questions:

1. What is the most likely outcome of this condition if he is not treated?

A. Corneal perforation

B. Intraocular hypertension

C. Dense cataract formation

D. Orbital compartment syndrome

E. Full blown AIDS

 

2. Given the patient’s corrective lens history, what is the most likely pathway that explains the above findings?

A. Bacterial keratitis->corneal ulceration->hypopyon

B. Caustic exposure->corneal abrasion->corneal liquefaction

C. Poor contact lens hygiene->bacterial keratitis->corneal abrasion

D. Rheumatologic illness->anterior uveitis->hypopyon

E. Childhood vaccinations->autism->ocular jenny mccarthitis

 

3. What additional finding would most likely be seen on slit-lamp examination of this patient?

A. Dendritic ulcerative lesions

B. Pingueculae and pterygia

C. Cell and flare in the anterior chamber

D. Very shallow anterior chamber and iridocorneal touch

E. Enucleation

 

Answers: 1. A, 2. A, 3. C

Discussion:

1. A. The patient has evidence of layering of white blood cells in the anterior chamber otherwise known as a hypopyon. In addition, there is evidence of conjunctival injection and significant corneal opacification. Given the historical information regarding contact lens use, it is likely the patient has developed a corneal ulceration secondary to infection. If the infection is left untreated, it can progress quickly resulting in erosion of the cornea and perforation. Once this occurs, the only way to restore the visual axis is corneal transplantation. Progression of the infection may lead to uveitis, iris prolapse, hypopyon, panophthalmitis and subsequent globe loss. A corneal ulcer is a medical emergency that necessitates aggressive treatment with topical antibiotics, with special consideration of pseudomonas in contact lens wearers. Evidence of endophthalmitis necessitates parental antibiotics. B) Although endophthalmitis may result in elevated intraocular pressure, it is unlikely to occur secondary to corneal ulceration. (C) Cataract formation is unlikely to result from this infectious process. (D) Orbital compartment syndrome typically occurs secondary to trauma or surgical procedures.
2. A. As described above, contact lens use predisposes patients to bacterial keratitis. Progression of the infection through the corneal layers results in ulceration, subsequent perforation, and the above sequelae. (B) Describes an alkali chemical injury to the eye. (C) Although extended wear is an associated risk factor for development of keratitis, the above patient’s symptoms and findings cannot be explained by a simple corneal abrasion. This is also hinted by his lack of analgesia following proparacaine drops, suggesting a process occurring deep to the cornea. (D) Rheumatologic illness can cause findings similar to the image above, but the history is not consistent with this.
3. C This patient has evidence of a hypopyon in the image above, which represents white blood cells layering within the anterior chamber. Cell and flare is simply evidence of inflammation with accumulation of white blood cells and protein within the anterior chamber. The patient also has clinical evidence of uveitis, and this is a classic finding. (B) Both of these are benign conjunctival overgrowths, not typically associated with infection. (D) This answer describes the findings expected on a patient with acute angle closure glaucoma.

Intern Report 8.3

 

Case Presentation by John Yerkes, MD

 

Chief complaint: Confusion post fall

History:

A 55 year-old man comes to the Emergency Department after a recent fall at home. He was told to go to the ER by his housemate who thought he had not been not acting “right” recently. Patient does, in fact, appear to be slightly altered on examination. He states that he was walking and suddenly lost his balance and fell down while on a flat surface. Patient denies hitting his head or any LOC. Additionally, he says that he has suddenly lost his balance and fallen a couple of times over the last couple of days. Patient likewise denies head strike or loss of consciousness. He has a history of mitral valve replacement and CABG for which he is on warfarin. Patient also says that he was started on a new medication a couple of days ago but is unable to remember what it was. Other than some confusion patient has no other complaints.

ROS: negative except noted per HPI

PMH: Schizophrenia, hypertension, Diabetes

Surgical history: CABG and mitral valve replacement date unknown

Medication: Unknown, however, per the last entry in the electronic medical record, he was most recently documented as being on haloperidol, benzotropine, olanzapine, lorazepam, warfarin, lisinopril, and metformin

Allergies: morphine, hydrocodone

FH: unknown

Social: denies tobacco/alcohol/drugs

 

Physical Exam:

Vitals: T 99.2, HR 87, BP 145/100, RR 14, pulse ox 98% weight 150, 5’10”

General: 55 year old with who has some difficultly relaying history. He has tangential thinking and appears slightly altered, unsure if baseline mental status.

Skin: midline sternotomy scar consistent with previous CABG history, no bruising

Head: normocephalic, atraumatic

Eyes: equal and reactive to light, oculomotor muscles intact, no focal deficit in cranial nerves II, III, IV, VI

HR: RRR, S1 & S2 with opening snap heard best on lower left border

Respiratory: breath sounds equal bilaterally,

CNS: Alert and oriented to person and place but not time, cranial nerves II-XII intact no deficits or sensory loss. DTRs 2+ in all four extremities. Muscles strength 5/5 in all 4 extremities. Romberg test, heel to shin, and rapid alternating movements all normal. Patient had a slow shuffling gait, but no loss of balance

 

Labs:

BMP: Na 146mmol/L, K 4.2 mmol/L, CL 99 mmol/L, HCO3 24 mmol/L, BUN 25 mg/dl, Creatinine 1.3 mg/dl, Glucose 101 mg/dl

ALT 55, AST 24

CBC: WBC 9.4 Hemoglobin 12.3 g/dL, Hematocrit 40.1%, Platelets 250

PT >12.5 seconds

INR: unable to calculate (INR was 9.7 one week ago at outpatient clinic, pt said he was restarted on warfarin two days later).

UDS: positive for benzodiazepine, and opiates

EKG: NSR, no ST segment elevations or depressions, normal intervals, normal axis, no heart block

 

Questions:

1) You begin scrolling through the non-contrast CT of the head you ordered and note the following. What is your diagnosis?

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A) Epidural hematoma

B) Brain Mass

C) Subdural hematoma

D) Subarachnoid hemorrhage

 

2) What is the next appropriate step in management for this patient?

A) Oral Vitamin K

B) Fresh frozen plasma

C) Prothrombin complex concentrate

D) Immediate neurosurgery evacuation of hematoma

 

3) How long does it take for fresh frozen plasma to work?

A) 5-15mins

B) 1-4hr

C) 12-24hr

D) 24-48hr

 

Answers: 1) C 2) C 3) B

Discussion:

1. C. The patient has a subdural hematoma with mass effect causing a midline shift. You can tell that it is a subdural hematoma because of the crescent shape pattern of the blood. You can also tell that there is a midline shift, as the ventricles are shifted to the left. (A) If the blood was in the shape of a lens/convex, this type of hemorrhage this would be indicative of an epidural hematoma. (D) If the blood was displayed in a star like pattern and the patient had a sudden severe (thunderclap) headache you would suspect a subarachnoid hemorrhage. (B) If the CT showed a brain tumor one would expect to find a lesion on CT that would not follow the borders of dura matter or sulci of the brain. What is known in this patient is that he has an elevated INR which could be from inappropriate dosing, low vitamin K, unknown drug interaction or a combination of all of the above. However, we are unable to ascertain the whether the cause of the subdural hematoma was spontaneous or traumatic.

2. C. For this patient given the patient’s supratheraputic INR and unsure onset of symptoms it was decided by neurosurgery and us to immediately reverse this patient’s anticoagulation state with PCC. The reason the patient was given PCC was that his INR was greater than 8 and he was experiencing midline shift. (B) Fresh frozen plasma is indicated if the patient has an PT or APTT that is greater than 1.5X its normal value and if the patient has ongoing liver disease, if the patient is on vitamin K antagonist in the presence of major hemorrhage or intracranial bleeding in preparation for surgery that cannot be postponed and PCC is not available, or correction of microvascular bleeding in patients that are undergoing massive transfusion and experiencing microvascular bleeding. (A) Vitamin K can be given on its own if the patient has an elevated INR with no significant bleeding. If the patient is experiencing significant bleeding and has an elevated INR, PCC or FFP is indicated for immediate reversal, and vitamin K is given to stabilize the INR. (D) Indications for immediate neurosurgical intervention are if there is a midline shift that is greater than 5mm, the subdural hematoma has a thickness greater than 10cm (we did not measure hematoma thickness), or the patient’s GCS is below 9.

It is also important to know the signs and symptoms of elevated intracranial pressure which could signal impending herniation and necessitate prompt neurosurgical intervention. The signs and symptoms of elevated intracranial pressure are:

Headache

Vomiting without nausea

Ocular palsies

Altered level of consciousness

Papilledema

Pupillary dilatation

Cushing’s triad (increased systolic pressure, widened pulse pressure, bradycardia, and abnormal respiratory pattern).

If you suspect impending herniation intubate the patient immediately, begin hyperventilating them, elevated the head of the bed, and call neurosurgery for possible evacuation of the hematoma. For patients that are showing midline shift on CT, but no signs neurological dysfunction it is best to proceed with anticoagulation reversal prior to neurosurgery intervention, if indicated.

3. B. (A) The time of onset of PCC is 5-15mins and lasts 12-24hr. Use this in combination with vitamin K. The PCCs contain coagulation factors II, IX, and X in concentrations 25X that of FFP. Prothrombin complex concentrates are made from fresh frozen plasma; however these complexes are lyophilized which means that it can be reconstituted as opposed to thawed saving time. frozen plasma requires one hour to thaw delaying reversal of anticoagulation. Another advantage of PCC as opposed to fresh frozen plasma is the volume associated of fresh frozen plasma equal to one unit of PCC. This volume is 2000ml, which could cause a fluid overload state in the frail, elderly, and CHF patients. Fresh frozen plasma contains all of the coagulation factors II, VII, IX, and X but in diluted and inactive form compared to PCC. Thus, a large volume may be required for adequate anticoagulation reversal. The time of onset is 1-4hr depending on magnitude and dose of anticoagulation (B). The duration of effect is less than or equal to 6hr. If vitamin K is used to reverse anticoagulation, it can substantially reduce a patients elevated INR within 24hr (C&D).

References:

1) Rosen Emergency Medicine

2) http://www.ucdmc.ucdavis.edu/anticoag/pdf/AnticoagReversal.pdf

3)https://www.braintrauma.org/pdf/protected/Surgical_Guidelines_article_2.pdf

 

 

 

Senior Report 8.2

Case Presentation by Andrew Sweeny, MD

History:

The patient is a 79-year-old female with a history of hypertension and atrial fibrillation who presents to the emergency department via EMS after falling at a social event. The patient reports that she fell stepping off the curb hitting her left face. She denies any preceding lightheadedness, shortness of breath, or chest pain. The patient denies any loss of consciousness. She denies using any alcohol, illicit drugs, or sedating medications. Currently, the patient complains of mild occipital headache and pain to her left periorbital region. She denies pain to her neck or extremities. The patient is on warfarin for her atrial fibrillation and has her INR checked regularly.

 

Physical Exam:

Vitals: Blood pressure was 157/95, heart rate 80, respiratory rate 18, temp 36.2, pulse ox 100 on room air

General: awake/alert/no apparent distress

HENT: Normocephalic, no icterus, no cervical midline tenderness, full active range of motion at the neck without pain, large contusion/ecchymosis to left orbit, small abrasion to bridge of nose without gross deformity/crepitus/intranasal hematoma, no facial crepitus, no hemotympanum

Eyes: EOMI, PERRL, large temporal subconjunctival hematoma occupying 40% of conjunctiva of left eye, significant periorbital ecchymosis/edema to L eye, patient unable to open L eyelids due to edema, no hymphema, patient able to read name badge at distance 12” bilaterally, unable to conduct full Snellen eye chart exam as patient requires assistance to hold L eyelid open due to edema

Cardio: Irregularly irregular rhythm, normal rate, no murmurs

Respiratory: clear to auscultation bilaterally

Abdomen: soft/non-tender/non-distended

Neuro: Normal speech, moving all extremities, strength 5 out of 5 and symmetric to hand grip, elbow flexion/extension, knee flexion/extension, hip extension/flexion, dorsi/plantar flexion

Extremities: No contusion/abrasion/ecchymosis/bony tenderness to upper/lower extremities

 

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Questions:
1. When performing this patient’s physical exam, what finding would indicate need for an emergent procedure?

a. Inability abduct or adduct the injured eye

b. Hyphema occupying greater than50% of anterior chamber

c. Significant loss of visual acuity of injured eye when compared to uninjured eye

d. Proptosis of injured eye
2. What physical exam finding has the highest incidence of underlying facial fracture in minor head injury?

a. Periorbital ecchymosis

b. Subconjunctival hemorrhage

c. Epistaxis

d. Decreased skin sensation
3. What is the most commonly injured portion of the orbit in a blow-out fracture?

a. Superior

b. Medial

c. Inferior

d. Lateral

 

Answers:

C – This patient has a medial and lateral blow out fracture with proptosis and evidence of orbital edema. If this patient had either increased intraocular pressure or significant loss of vision, a lateral canthotomy is indicated to save patients vision. Ideally, the patient’s vision should be tested using his/her glasses, or if the glasses were broken during the injury, use a pinhole card. (A) Extraocular nerve palsy is not an indication for an emergency department procedure, and rather, requires consultation with ophthomology/ENT for possible intervention in the OR. (B) Hyphema drainage is not an emergency department procedure. Hyphema greater than 50% is associated with formation of synechia (iris adhesions), but an anterior chamber wash out is a procedure that is performed in an OR. (D) Proptosis alone is not an indication for a lateral canthotomy.

A – retrospective study by Buttner et al found that in a cohort of 1676 patients with minor head trauma and black eye had a 68.3 incidence of underlying facial fracture. (B-D) All other physical exam findings where specific for facial fracture in the setting of black eye but had low sensitivity varying from 10-22%. The authors of this study recommend maxillofacial CT for every patient with periorbital ecchymosis in the setting of minor head injury.

C – Inferior blow-out fracture is the most commonly fractured portion of the orbit due to the relatively weak bony structure separating the orbit from the maxillary sinus when compared to the rest of the orbit. Special consideration in an inferior blow out fracture is a trap door fracture where a portion of the inferior rectus muscle becomes entrapped in the fracture leading to reduced ability to look upwards (supraduction). This type of fracture is more common in pediatric populations and is clinically important because of improved outcomes with early surgical intervention. (A) Superior blow out fractures are uncommon. They are associated with CSF leaks and increased risk for meningitis. (B) Medial blow out fractures are second most common and frequently occur in conjunction with inferior blow out fractures. Medial blow out fractures occur commonly due to the weak bony structure of the lamina papyracea. Radiographically, blood in the ethmoid cells is commonly seen. Medial rectus prolapse may occur in these fractures. (D) Lateral blow out fractures are the most uncommon because the bony structure is strongest along the lateral orbit.
References:

1. Is a black eye a useful sign of facial fractures in patients with minor head injuries? A retrospective analysis in a level I trauma centre over 10 years
Büttner, Michael et al.
British Journal of Oral and Maxillofacial Surgery , Volume 52 , Issue 6 , 518 – 522

2. Zilkha A. Computed tomography of blow-out fracture of the medial orbital wall. AJR Am J Roentgenol. 1981;137 (5): 963-5. AJR Am J Roentgenol (citation)[pubmed citation]

3. Curtin HD, Wolfe P, Schramm V. Orbital roof blow-out fractures. AJR Am J Roentgenol. 1982;139 (5): 969-72. AJR Am J Roentgenol (citation) [pubmed citation]

4. Linden JA, Renner GS. Trauma to the globe. Emerg Med Clin North Am 1995;13(3):581-605.

5. Samples JR, Hedges JR. Ophthalmologic procedures. In: Roberts JR, Hedges JR, editors. Clinical procedures in emergency medicine. 3rd ed. Philadelphia: W.B. Saunders Co; 1998. p. 1089-119.