Intern Report 8.20

Case Presentation by Khoa Nguyen, MD

CC: “fever and runny nose”

 

HPI: 9-day-old full term female born via C-section who presents with cough, rhinorrhea, and tactile fever. Patient’s mother stated that the patient had rhinorrhea 3 days ago who then developed a cough the following day. The mother then felt that the patient was warm in the back but did not measure any temperature. The patient was not given any anti-pyretic or antibiotics. There had been green discharges from the eyes. Patient had 2 episodes of non-bloody nonbilious emesis that looked like her feeds. Patient had been sleeping more than normal. On further questioning, the patient’s mother had GBS and Chlamydia with this pregnancy and had HSV during the previous pregnancy.   There were no changes in the number of wet diapers and no changes in PO intake.

 

ROS:

Constitutional: positive for tactile fever

HEENT: positive for rhinorrhea, green discharges from eyes, and congestion

CV: neg

Pulmonary: positive for coughing

GI: positive for 2 episodes of NBNB emesis. No changes in appetite and PO intake.

GU: no change in number of wet diapers

The rest of the ROS were negative

 

PMH/PSH: none

Allergies: NKDA

Immunizations: UTD

Birth history: 39 wks, repeat c-section

Family history: Mother was treated for GBS and chlamydia with this pregnancy

 

Physical Exam:

Vital signs: Temperature 37, HR 160, RR 30, BP 67/41, 98% on RA

General: patient is alert and responsive to touch

HEENT: NC/AT, anterior fontanelle is open, soft, and flat. There is bilateral eye discharge with crusting. No chemosis. Eyelids appear normal. TMs are clear. Oropharynx within normal limits

Neck: supple

CV: RRR, S1 S2, no notable murmurs

Lung: Clear to auscultation bilaterally

GI: soft, nontender, non distended, no masses

MSK: moving all extremities

Skin: no rashes, bruising

Neuro: normal moro, rooting, grasp

 

Questions:

1. What is the workup for this patient?

A. Patient does not need a workup.

B. Full sepsis workup: LP, CBC, CXR, LP, UA with culture, blood culture, RSV/Flu.

C. UA with culture, CBC, Chest x-ray

D. Rapid Viral antigen testing

 

2. What is the management?

A. PO challenge and discharge home after reassuring the mother that this is likely a viral infection and that she needs to follow-up with PMD.

B. Ampicillin, ceftriaxone, and acyclovir

C. Ampicillin and acyclovir

D. Ampicillin, cefotaxime, and acyclovir

 

3. Which of the following is true?

A. Management of pediatric fever is the same throughout all ages.

B. Defervescence after acetaminophen administration has been shown to reliably exclude bacteremia in children of any ages.

C. The absence of fever does not eliminate the possibility of serious bacterial illness.

D. A thorough history and physical exam can exclude a serious bacterial illness in a patient less than 28 days old.

 

Answers:

1. B
2. D
3. C

 

Pediatric patients from 0-28 days of age who present with a fever are at a high risk for bacterial illness. Fever may be the only clinical manifestation of a potentially life-threatening disease. However, in this age group, the absence of fever does NOT eliminate the possibility of serious bacterial illness because more than half of neonates with meningitis are afebrile.

The physical exam in this age group is insensitive to exclude serious bacterial illness.

Here are some of the findings to suggest bacterial meningitis:

Vital signs – apnea, tachypnea, hypothermia, hyperthermia, bradycardia, tachycardia. The absence of fever does not rule out the possibility of serious bacterial illness.
Behavior – listless, restless, irritable, lethargy, change in sleeping pattern
Neurologic – high pitch cry, nystagmus, vacant stare, seizure, altered tone, absence of cry
Dermatologic – cyanosis, petechiae, purpura, livedo reticularis
GI – altered feeding, diarrhea, vomiting, abdominal distention, jaundice

 

B – Although the patient has symptoms to suggest a viral infection, she needs a thorough workup given her age. A change in sleeping pattern, cough, eye discharges, and tactile fever must be taken seriously. Additionally, the patient’s mother has a history of GBS, chlamydia, and HSV which all put the patient at risk of a serious infection. For these reasons, the patient needs a complete sepsis evaluation.
D – The patient should be treated empirically with broad spectrum medications in the ED given her risks of a serious infection. Ceftriaxone should be avoided in patients younger than 28 days because of a hypothetical risk of causing bilirubin encephalopathy since this medication causes bilirubin to be displaced from protein binding sites.
C – Management of pediatric fever depends on the age of the patient. Defervescence of a fever after Tylenol ingestion does not exclude bacteremia in children of any ages.

 

References:

Marx, JA, Hockerberger R, Walls RM. Rosen’s Emergency Medicine: Concepts and Clinical Practice (8th edition), Mosby 2013.

Senior Report 8.19

 Case Presentation by Laura Smylie, MD

A 14 year old girl who presents with nausea and vomiting for one day and an abrupt onset of chest pain.
Vitals: BP 100/67, HR 121, RR 25, Temp 36.7, 100% on room air.

 

Questions:
1. What is the diagnosis based upon the above x-rays?
a) Foreign body
b) Pneumothorax
c)Pneumomediastinum
d)Apical pneumonia

2. What is the likely etiology of the radiographic finding?
a) alveolar rupture secondary to forceful retching
b) esophageal rupture secondary to forceful retching
c) acute PE
d) no abnormality on chest x ray.

3. What is the most appropriate initial management of this patient?
a) place on continuous pulse oximetry, place a left sided chest tube
b) place on continuous pulse oximetry, 4mg ondansetron, NPO.
c) place on a continuous cardiac monitor, start heparin drip, consult cardiology.
d) send blood cultures, start antibiotics, encourage PO intake.

 

Answers and discussion:

1) C
2) A
3) B

1) C – Pneumomediastinum. You can see air tracking in the soft tissues of the neck and the upper aspects of the mediastinum. Although there could potentially be a pneumothorax (B) associated with this this, no pneumothorax can be seen in this study. No foreign body (A) is present and there is no infiltrate to suggest pneumonia (D).

 

2) A – Alveolar rupture secondary to forceful retching is the most likely etiology of the pneumomediastinum, although you should also be concerned for possible esophageal rupture secondary to forceful wretching (B) also known as Boerhaave’s esophagus. Review of the literature shows that in similar presentations, esophograms are typically negative for tears in the esophagus. Acute PE (C) has not been shown to present with free air. On a chest xray, the most concerning (and classically pimped) findings for acute PE are Hampton’s Hump and Westermark’s sign. Hampton’s Hump, represented in the first image below, shows a wedge shaped area of hyperdensity along the lung parenchyma periphery, indicative of an infact/PE. Westermark’s sign, as shown in the second image below, shows a focal peripheral hyperlucency secondary to oligemia, with or without dilation of the central pulmonary vessels.

 

3) B – Although there is no obvious pneumothorax on the initial chest x ray, you must keep a high level of suspicion for a small pneumothorax. This would not necessitate chest tube placement (A), but a nonrebreather and continuous pulse oximetry are appropriate if a small pneumothorax is present. Given that the retching led to the pneumomediastinum, treat her nausea with ondansetron. She should be kept NPO until an esophagram can be obtained (as an inpatient or in the observation unit) to definitively rule out Boerhaave’s esophagus. As an inpatient, the chest x ray should repeated in 6-8 hours. C is the treatment for a non-massive PE or NSTEMI; D is the treatment for pneumonia, neither of which applies in this case.

The percentage of pneumothorax will guide therapy. This picture illustrates that 2 cm pneumo is typically the cut off point for inserting a chest tube with a spontaneous pneumo but not necessarily with a traumatic pneumo.

 

References:

Spontaneous pneumomediastinum: diagnostic and therapeutic interventions. Al-Mufarrej F, Badar J, Gharagozloo F, Tempesta B, Strother E and Margolis M. Journal of Cardiothoracic Surgery 2008, 3:59 doi:10.1186/1749-8090-3-59

BMJ Case Rep. 2012 Oct 10;2012. pii: bcr0320091647. doi: 10.1136/bcr.03.2009.1647.

http://radiopaedia.org/articles/westermark-sign

https://www.tumblr.com/usmlepathslides/53392063709/westermarks-sign-cxr-note-the-area-of

Gantner J, Keffeler JE, Derr C. Pulmonary embolism: An abdominal pain masquerader. J Emerg Trauma Shock [serial online] 2013 [cited 2015 Mar 26];6:280-2. Available from: http://www.onlinejets.org/text.asp?2013/6/4/280/120376

Senior Report 8.18

 Case Discussion by Erin Ge, MD

 

CC: “Nausea”

HPI:

This is an 80 year old female who presents with nausea. She states she has been feeling nauseated and generally unwell for the past week. She denies any significant abdominal pain, vomiting or diarrhea. She has not had any fevers or chills. She reports feeling like she has no energy. She has been refusing to eat. Her family states she has seemed progressively more confused and has been “seeing double”. Today, she started complaining of some episodes of “heart racing” so her family brought her in for evaluation. She denies chest pain or shortness of breath.

ROS:

General: Positive for generalized weakness

Neurological: Positive for confusion

Ear, Nose and Throat: No congestion

Eyes: Positive for diplopia

Cardiovascular: Positive for palpitations

Pulmonary: No shortness of breath

Abdomen: See HPI

Genitourinary: No polyuria

Musculoskeletal: No back pain

Skin: No rashes

 

Past Medical History: Congestive heart failure, hypertension, coronary artery disease

Past Surgical History: Cardiac catheterization, total hysterectomy

Family History: Hypertension

Social History: Lives with her daughter, history of tobacco use but quit over 20 years ago, denies alcohol or illicit drug use

Medications: Aspirin, Lisinopril, Lasix, digoxin, omeprazole

Allergies: NKDA

 

Physical Exam:

General: Overweight, nontoxic

Vitals: Blood pressure 125/92, heart rate 80, respiratory rate 16, temperature 36.8, pulse oximetry 98% on room air

HENT: Normocephalic, atraumatic, mucous membranes moist, trachea midline

Eyes: Sclerae noninjected and nonicteric, pupils 3mm, equal, round and reactive to light, EOMI

Cardiovascular: rate and rhythm regular, normal S1, S2, no murmurs, no JVD, 1+ bilateral lower extremity edema

Respiratory: Clear to auscultation bilaterally with good air entry and equal chest rise

Gastrointestinal: Soft, nontender, non distended, no rebound tenderness, negative Murphy sign, no CVA tenderness

Musculoskeletal: No obvious deformities, extremities nontender, moves all extremities equally

Skin: No erythema, rashes or ulcerations

Neurologic: Alert, oriented x 3, responds slowly, no facial asymmetry, no speech dysarthria, sensation intact to light touch bilateral upper and lower extremities, 5/5 strength bilateral upper and lower extremities

 

EKG:

 

Laboratory Studies:

CBG – 97

CBC:

5.1           12.0        122

36.0

BMP:

138         97            24            103

6.0           20            2.1

Troponin <0.017

SDS: neg

UDS: neg

Digoxin level: 4.0 ng/mL (nml 0.5-2.0)

 

Questions:

1. In the initial management of an acute digoxin overdose, which of the following should be considered:

A. Gastric lavage

B. Emergent dialysis

C. Activated charcoal

D. High dose insulin

 

2. You are informed by nursing staff that the patient is now tachycardic and a new EKG is obtained:

What next intervention is indicated?

A. Lidocaine

B. Transvenous pacing

C. Quinidine

D. Procainamide

 

3. What is the appropriate treatment for this patient’s hyperkalemia?

A. Insulin/glucose, sodium bicarbonate, calcium gluconate and kayexalate

B. Fab fragments

C. Emergent dialysis

D. Isotonic fluid hydration

 

Answers:

1. c

2. a

3. b

Digoxin toxicity typically presents with nonspecific symptoms. Generalized weakness, nausea and decreased appetite are often reported.  Visual symptoms are also often seen with the classic being xanthopsia where patients describe yellow halos around lights (think van Gogh’s Starry Night) or other distortions in colors particularly yellow and green. Cardiac dysrhythmias are also typical and the life threatening complications of this overdose.  The patient’s initial EKG should lead the clinician to be suspicious of a dig overdose even prior to receiving the elevated level. The “scooped” appearance of the ST segment or the so called “Salvador Dali” moustache indicates use of digoxin (NOT toxicity).  The multiple PVCs should increase a clinician’s suspicion for toxicity as this is the most common early sign.

1.    The correct answer is C. Activated charcoal.  This can prevent systemic absorption of the drug, although more likely useful in an acute overdose as opposed to a chronic.  Gastric lavage (a.) is contraindicated in this overdose as it can lead to increased vagal stimulation which can produce fatal arrhythmias in this patient.  Emergent dialysis (b.) is also incorrect as digoxin has a wide nonvascular distribution and therefore dialysis does not effectively remove a significant amount of the drug.  High dose insulin is used to treat beta blocker and calcium channel blocker overdoses and does not have a role in digoxin overdose.

2.   A. One the classic (and terrifying looking!) arrhythmias which may be induced by dig toxicity is bidirectional ventricular tachycardia which is demonstrated in the EKG.  The QRS complex axis shifts 180 degrees with each beat (see green arrows).  This is a rare tachyarrhythmia, but classically associated with dig toxicity.  Lidocaine (a.) is the correct answer and has been shown to effectively treat this arrhythmia along with phenytoin. Pacing (b.) or cardioversion should be avoided if possible as they can induce worsening dysrhythmias and if used, low energies are to be used. Both quinidine (c.) and procainamide (d.) are class IA antidysrhythmics and can lead to worsening of the arrhythmia. Quinidine, in particular, has been shown to increase levels of digoxin and therefore worsen toxicity.

3.   B.  The treatment of hyperkalemia in the setting of dig toxicity is treatment of the toxicity itself with administration of digoxin immune Fab (b.). The hyperkalemia itself in this patient would be an indication for use of this, but also the significant dysrhythmia would obviously be another indication. Traditional hyperkalemia treatment (a.) can be used with the exception of calcium.  The “stone heart” theory is the reason calcium in contraindicated in these patients.  Dig toxicity itself causes an elevation of the intracellular calcium concentration and the theory states that further increases in calcium can lead to a “stone heart” or an irreversible noncontractile state.  This is based on case reports and recent studies show evidence that this is likely a false theory, however, the board exam answer is still to avoid calcium in these patients (sorry). Neither emergent dialysis (c.) or IV fluid hydration (d.) are significantly effective in reducing dig levels which is the underlying cause of the hyperkalemia.

As a side note, hyperkalemia is more likely in an acute ingestion (think healthy toddler who got into Grandma’s meds), and less likely in this patient who fits a chronic ingestion picture (known history of taking this medication, potentially induced by decreased renal clearance with an elevated creatinine, although baseline is unknown).

Sources:

Cadogan, Mike, and Nickson Chris. “Life in the FastLane.” Web. http://www.lifeinthefastlane.com

Goldfrank, Lewis R. Goldfrank’s Toxicologic Emergencies. New York: McGraw-Hill Medical Pub. Division, 2002.

“Hippo EM.” Emergency Medicine Board Review, LLSA, & More. Web. <http://www.hippoem.com&gt;

 Mahadevan, Swaminatha V., and Gus M. Garmel. An Introduction to Clinical Emergency Medicine. Cambridge: Cambridge UP, 2005.

Marx, John A., Robert S. Hockberger, Ron M. Walls, James Adams, and Peter Rosen. “Cardiovascular Drugs.” Rosen’s Emergency Medicine: Concepts and Clinical Practice. Philadelphia: Mosby/Elsevier, 2010.

Intern Report 8.17

Case Presented by Jeff Butler, MD

Chief Complaint: abdominal pain, diarrhea, weakness

HPI: An otherwise healthy 6yo boy presents with three days of abdominal pain, nausea, vomiting, and diarrhea. His symptoms started with nausea and vomiting, and were followed by fever and epigastric, cramping abdominal pain. By Day 2 of his illness he was having frequent loose stools up to 15 times per day. The mother decided to bring the child in after he developed some weakness and difficulty walking prior to arrival. The vomiting occurred around 2-4 times per day and was characterized as nonbloody and nonbilious. There was also no blood noted in the stool. The child has had a poor appetite in the last two days and has been refusing meals after two episodes of post-prandial emesis. The mother thinks the child may have been urinating less frequently since this morning. The fever is being treated with alternating motrin and Tylenol last given 2 hours prior to arrival. The child had multiple sick contacts with similar symptoms at daycare and there was no history of recent travel.

ROS:
Constitution: positive for fevers, negative for weight change
HEENT: negative for ear pain, sore throat
Cardiac: negative for chest pain, palpitations
Pulm: negative for wheezing, cough
GI: positive for abd pain, diarrhea, vomiting
GU: positive for decreased urination
MSK: negative for joint pain, swelling, myalgia, positive for weakness
Neuro: positive for dizziness, HA

PMHX: none

PSHx: none

Allergies: NKDA

Meds: Motrin, Tylenol PRN fever

SocHx: no tobacco use in the home, patient attends school and daycare, lives with mom, dad, two brothers.

PE:
Vitals: T37.1, HR140, BP100/60, R20, SpO2 99% RA
General: Ill-appearing male child sitting on the exam table in mild distress due to weakness
Eyes: PERRL, EOM, no pallor
HENT: Normal tympanic membrane without erythema or purulent drainage, dry oral mucous membranes, neck supple and nontender without LAD
CV: Tachycardic regular rate with normal hearts sounds, pulses 2+ at radial and dorsalis pedis bilaterally, cap refill 2 seconds
Pulm: Normal work of breathing with clear breath sounds bilaterally
Abd: Soft, mildly tender to palpation over epigastrium, no rebound tenderness or guarding, normoactive bowel sounds
Skin: No rashes, bruises, or petechiae
Neuro: Normal mentation, no facial droop, tongue midleine, smiles symmetrically, 4/5 strength with hip flexion bilaterally, 4/5 strength with leg flexion and extension bilaterally, 5/5 strength otherwise throughout, sensation intact to light touch throughout, no clonus

You begin IV hydration with a 20cc/kg bolus and start weight-based maintenance fluids. Lab tests were ordered as follows:

 Labs:
CBC
WBC- 9.4
Hgb- 13.5
Plts- 278

BMP
Na- 134
Cl- 105
K- 1.9
HCO3- 19
BUN- 20
Cr- 1.1
Glu- 89

Questions:
Q1. Which of the following is a spurious cause of hypokalemia?
A) Recent fluid administration in the IV site
B) Sample deterioration
C) Hemolysis
D) Cold storage

Q2. What EKG finding can be found with hypokalemia?
A) Peaked T waves
B) U waves
C) J waves
D) QRS prolongation

Q3. What is the best method for replacing this patient’s electrolyte abnormalities?
A) No replacement needed
B) PO potassium
C) IV potassium
D) Yes, supplement with magnesium and IV potassium

Bonus Question:
Q4. What is the most likely acid-base disorder this patient will have? Maybe make this the bonus questions but clinically not as important as the next question
A) Respiratory acidosis
B) Metabolic alkalosis
C) AG metabolic acidosis
D) NAG metabolic acidosis

 

Answers: 1. A, 2. B, 3. D, 4. D

Discussion:

There are a couple important causes of spurious hypokalemia, most of which will be due to elements outside of your control except by thinking ahead and, for example, asking nursing staff to hold IV fluids before drawing labs. If you think the hypokalemia is spurious due to white cell consumption as in the case of the high leukocytosis usually associated with sepsis or leukemia you can call the lab and try to determine whether there were delays in analysis.
However, if the hypokalemia is clinically significant such that you suspect the need for IV supplementation you may be able to quickly verify the result based on EKG findings that include flattened T waves and U waves. Peaked T waves and QRS prolongation are more typical of hyperkalemia.
For a potassium > 2.5 mmol/L it is appropriate to replete with an oral dose of 0.5 mmol/kg for kids age < 5, and 1 mmol/kg in younger kids. However, repletion of severe hypokalemia is complicated by the fact that potassium is an irritant to peripheral veins and higher IV doses result in transiently increased cardiac concentrations that can cause cardiac arrest. This patient will likely require ICU admission for potassium repletion, cardiac monitoring, and q4-6h electrolyte checks where it will be appropriate to calculate a total body potassium deficit but a dose of 0.3 mmol/kg/h can be started in the ED through a peripheral vein. Magnesium should also be supplemented because depletion often coexists with hypokalemia, low magnesium impairs renal potassium reabsorption, and patients are at higher risk for a ventricular arrhythmia as described below.
Diarrheal stool contains a relatively high potassium content and diarrhea is the main cause of hypokalemia worldwide. The stool also contains a significant amount of bicarb, the loss of which is adjusted for by the kidneys with the H+/K+ antiporter, exchanging intracellular potassium for extracellular protons. Thus, the sufficient loss of bicarbonate ionically balanced through shifts in potassium result in a non-anion gap metabolic acidosis. The low serum potassium in the setting of this regulatory mechanism by the kidneys indicates an even more profound degree of total body potassium loss that should prompt repletion. Clinically, hypokalemia is most likely to affect the heart and muscles with severe cases of hypokalemia (< 2.5 mmol/L) resulting in complete muscle paralysis, rhabdomyolysis, and torsades or ventricular fibrillation. However, hypokalemia by itself rarely causes the cardiac complications just mentioned, and instead potentiate other causes of these like hypomagnesemia.
References:
Marx, JA, Hockerberger R, Walls RM. Rosen’s Emergency Medicine: Concepts and Clinical Practice (8th edition), Mosby 2013.

Nickson, C. Life in the Fast Lane (http://lifeinthefastlane.com/pediatric-perplexity-010/). 2010.

Welfare, W, Sasi P, English M. Challenges in managing profound hypokalmia. BMJ. 2002. Feb 2; 324(7332): 269-70.