Intern Report 8.27

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

 

Intern Report 8.26

 

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.

 

Answers & Discussion
1) Answer B – According to Michigan State law MCL 750.411 a physician or surgeon who is caring for a person suffering from a wound or other injury inflicted by means of a knife, gun, pistol, or other deadly weapon or means of violence, has a duty to report that fact immediately by telephone and in writing to the chief of police or head of the police force in that area they are practicing in. The report shall state the name and residence of the person if known, along with his or her whereabouts, the cause, character, and extent of the injuries and may state the identification of the perpetrator if it is known. So in this case the best answer would be B given the fact that you know the patient’s name and other pertinent information about the gun shot wounds. Answer D has more information than mandated by law and given the fact that HIPAA states that you are only allowed to give information if the patient is a victim of a crime, unless mandated by state law this may be too much information in the eyes of HIPAA.

2) Answer B – HIPAA states that you are only allowed to share protected health information for treatment, payment or healthcare operations. Treatment is defined as the provision, coordination, or management of healthcare or related services for an individual by one or more healthcare providers. Basically this states that information may be exchanged between anyone directly involved in the patient’s care or for any referral of care between providers. If the intern is not going to be involved in the patient’s care then they should not be in the patients medical record or other sensitive patient identifiers or information.

3) Answer C – Michigan state law states that the only time you are allowed to release protected health information in a legal arena is with a court order, which is a written order by a judicial officer or court of law. A subpoena may be issued from a lawyer and this may be for records or for an appearance in court. The only other time a physician is able to release protected health information without the patient’s consent is when the patient files or notifies the physician they intend to file a malpractice lawsuit MCLA 600.2157. Preferably you can refer the law office to medical records after the law office obtains the patient’s written consent.

Bonus) Answer C – MCL 400.11a states the healthcare providers are mandatory reporters for elder abuse. This report must include, under Michigan State law, name of the abused, description of the abuse, neglect or exploitation, the abused age, the name and address of the abused guardian or next of kin, and any information that might help determine why the abuse/neglect is occurring. Michigan statue voids the physician-patient relationship privilege in these situations.

 

Key Points

• When working in the ED you do not have the right to open up and look at anyone’s chart You must have a doctor patient relationship, in other words you are directly caring for the patient
  look over and review the states laws in the area you are practicing state laws will give more specific instruction while HIPAA provides a more overarching guideline
• When dealing with HIPAA specifically you’ll never be faulted for withholding/protecting a patients medical information
• In the end similar to medicine in general if you do what is best for the patient you will have at least at start of a defense if your decision is ever questioned.

 

References:

http://www.legislature.mi.gov/(S(tn13qcy04xk0b0aitgdcuqan))/mileg.aspx?page=getobject&objectname=mcl-750-411

http://www.michbar.org/journal/article.cfm?articleID=509&volumeID=38&viewType=live

http://www.hhs.gov/ocr/privacy/hipaa/faq/disclosures_for_law_enforcement_purposes/505.html

http://www.michbar.org/journal/article.cfm?articleID=509&volumeID=38&viewType=live

Click to access DHS-Pub-269_423962_7.pdf

Click to access APS_IA_LTCOP_Citations_Chart.authcheckdam.pdf

Intern Report 8.25

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:

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

Answers:

1. C

2. B

3. A

Discussion:

1) C

Remember that testicular torsion is a clinical diagnosis that required a high index of suspicion, even with ultrasound findings that show intact vascular flow. While symptoms such as abdominal pain, nausea and vomiting, history of trauma cannot accurately or reliably differentiate torsion from other causative disorders, the most common finding in patients with torsion is loss of the cremasteric reflex. Be careful as the reflex can still be intact in patients with torsion, and asymptomatic children younger than 30 months often have absent cremasteric reflexes. Ultrasound imaging for torsion has a sensitivity of 99-100 and specificity close to 90. False-negative findings occur if the testicle is examined early in the course of the disease or with intermittent torsion such as in this case.

2) B

In a patient who you strongly suspect testicular torsion, emergent urology consultation is necessary. About 90% of affected testicles can usually be saved within 6 hours of onset of symptoms, but by 24 hours nearly 100% of testicles are lost., Manual detorsion should be performed, but disposition without urologic consultation would be innappropriate. While standing at the feet of the patient, the testicle is twisted outward and laterally, as in “opening a book.” That is, the patient’s left testicle is twisted in a clockwise fashion and the right testicle is twisted in a counter-clockwise fashion. Analgesia should be given before the procedure such as parenteral or cord block. The testicle sometimes needs to be twisted 2-3x in order for complete pain relief. If it is difficult to detorse, or the pain worsens after rotation, you can attempt to rotate the testicle in the opposite direction and observe the results. Even with successful detorsion, patients still need to be evaluated by urology as the torsion can recur or there may have been irreparable damage to the testicle requiring further intervention, as well subsequent ultrasound after detorsion is necessary.

3) A

While epididymitis is uncommon in prepubertal children, the most likely cause is idiopathic unless the child has a congenital genitourinary anomaly that predisposes them to recurrent infections. Infants, on the other hand, more commonly have bacterial causes. As such, antibiotics should only be given after urine cultures are obtained and reveal causative bacteria, unlike other age groups where empiric treatment with antibiotics are usually given. Have a high suspicion for unreported sexual activity in adolescents and preadolescents.

References:

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

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

Senior Report 8.24

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

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

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

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

 

Answers:

1. A

2. D

3. A or B

 

Discussion:

Case 1: A
The patient in this case has herpes zoster ophthalmicus (HZO). Herpes zoster, or shingles, is reactivation of varicella zoster virus that follows dermatomes. In the case of HZO the affected dermatome is the ophthalmic branch of the trigeminal nerve (V1). The vesicle on the tip of her nose is referred to as Hutchinson’s sign.

The patient’s ocular manifestation in this case resembles conjunctivitis (red eye) and iridocyclitis (photophobia), but HZO can affect any number of structures including the sclera, retina, optic nerve, lids, and extraocular muscles.

The treatment for herpes zoster varies depending on the timing of symptoms and the severity of disease. Generally, treatment is supportive.

Acyclovir and other antivirals (choice A) are effective in shortening the duration of symptoms, preventing the occurence of further symptoms, treating complications and preventing post-herpetic neuralgia. In immunocompromised patients, IV acyclovir is the drug of choice. For more simple cases, a 7-21 day course of antivirals can be beneficial, especially in instituted in the preeruptive phase or within 72 hours of vesicle formation. Antibiotics, especially IV ones (choice B), have no indication in this case, although topical antibiotics (choice D) could be helpful in preventing superinfection.
Steroids (choice C) have been used in treating zoster. They have a potential to help with pain, decrease progression to post herpetic neuralgia and diminish severity of symptoms. Their use hasn’t been borne out in clinical trials and they would not be the treatment of choice in this case.

Case 2: D
This patient has CMV retinitis. Inspection of the fundus reveals retinal inflammation in a pattern consistent with CMV retinitis called a “cheese pizza” appearance. On examination of the fundus, some faint papilledema and blurred margins are visible, consistent with damage to the optic nerve (choice D).
A relative afferent pupillary defect (RAPD), or Marcus-Gunn pupil is a finding elicited with a ‘swinging flashlight test’. It’s much easier to explain with this link: https://www.youtube.com/watchv=HSYo7LhfV3A

 

Case 3: A or B
This question was poorly worded.
This patient has a constellation of symptoms that point to an orbital mass lesion, and the main item on the differential should be an ocular tumor. HIV/AIDS is a risk factor for CNS lymphoma and ocular lymphoma can be a manifestation of it. The ocular component can either be primary or a site of metastasis.
The workup of suspected intracranial/CNS pathology in the ED typically starts with a non-contrast CT scan of the head (choice A), however, in this case, there is good reason to consider ordering the CT with contrast initially to evaluate for a tumor.
The patient has diplopia as a result of proptosis (which is why is it binocular diplopia). He has an elevated intraocular pressure, papilledema and a prolonged course of symptoms. This should strongly point to the presence of an ocular mass.