Case 1 Location: Office
Presenting complaint: A 25-year old white female presents with burning micturition.
Vitals: Pulse: 80/min, B.P: 130/80 mm Hg, Temp:99 0 F, R.R:14/min, Height: 67 inches (167.5 cm), Weight: 79 Kg (173.8 lbs).
HPI: A 25-year-old personal secretary at a local office presents with the complaints of three days of burning micturition, urgency, and frequency. She had to pass urine 10 times yesterday. She also complains of suprapubic discomfort. There is no vaginal discharge, fever, hematuria, or flank pain. She has no previous history of STD or UTI. ROS is unremarkable. She has no known allergies. Medications: None. SH: She is a personal secretary at a local office. She has been married for five years and has no children. She has been smoking 10 cigarettes for the last seven years and drinks alcohol on weekends. She is sexually active in a monogamous relation with her husband. They have not been practicing contraception. Her last menstrual period was 3 weeks ago.
1 – How do you approach this case? This young female has dysuria. Her dysuria may be due to acute pyelonephritis, acute cystitis, acute pelvic inflammatory disease, acute urethritis, or acute cervicitis. You should come up with the differential diagnosis of a dysuria in a young woman. Now, perform a focused physical examination on this patient.
Order physical examination:
Abdominal Genital/Pelvic exam
2 – Here are the findings: Suprapubic tenderness present Normal Pelvic examination No Urethral and vaginal discharge No costovertebral angle tenderness
This is probably a straightforward case of acute cystitis. The patient has no systemic signs of infection. So, she probably does not have acute pyelonephritis. A patient with pyelonephritis usually presents with a history of fever, chills, and flank pain. For acute uncomplicated pyelonephritis, oral ciprofloxacin for out-patients or IV ceftriaxone for hospitalized patients is appropriate therapy. The duration of treatment is usually 14 days. This patient is in a monogamous relationship with her husband and there is no history of vaginal discharge, so conditions like acute urethritis, cervicitis or acute PID are highly unlikely. A single oral dose of azithromycin or a 7-day course of doxycycline can be administered for chlamydial genital tract infections. For gonococcal genital tract infections, a single IM injection of ceftriaxone is the treatment of choice.
Begin therapy for acute cystitis after confirming the diagnosis of acute cystitis by demonstrating pyuria on urine analysis. Cultures are generally not required for acute uncomplicated cystitis. Treatment with 3-day TMP-SMZ is appropriate.
The most important part of this case is whether your order pregnancy test or not. This patient is not using contraception and her LMP was 3 weeks ago. She might be a pregnant from the past 5-7 days. So, order serum pregnancy test before prescribing antibiotics.
ORDERS:
UA, stat
Pregnancy test, qualitative, stat
3- RESULT: Serum pregnancy test is positive
Urine appearance Turbid/ yellow pH 5.6 (normal 4.1-8.0) Specific Gravity 1.016 (normal 1.003-1.030) Bilirubin Negative Ketones Negative Glucose Negative Blood Negative Leukocyte Esterase Positive Nitrite Positive Protein Negative Microscopic Analysis: Epithelial cells – Bacteria 20-30/hpf RBC/WBC Casts – WBC 30-40/hpf RBC 3/hpf Crystals – Mucus –
Review order:
Amoxicillin therapy, oral, continuous (for 7 days)
Follow-up for prenatal assessment
Prenatal vitamin, oral, continuous
Consider counseling about the following: Smoking cessation Limit alcohol Regular exercise Use of seat belt Medication compliance Patient counseling
Primary Diagnosis: Uncomplicated acute cystitis and Pregnancy
Treatment of uncomplicated cystitis:
Normal healthy women a 3 day TMP-SMZ
Diabetic women, symptoms for >7 days, recurrent UTI, >65 yrs age group a 7 day TMP-SMZ
Pregnancy a 7-day amoxicillin; allergic to penicillin – 7-day nitrofurantoin
Case 2 Location: office
Presenting complaint: A 75-year-old white male presents with forgetfulness.
Vitals: Pulse:75/min, B.P:110/75, Temp:98.6 F, R.R:16/min, Height:72 inches (180 cm), Weight:65kg (143 lbs).
HPI: A 75-year-old white male is brought to the outpatient clinic by his son with the complaint of forgetfulness for the last two years. He reports that his forgetfulness was mild initially but it has gradually worsened and now he cannot continue his routine activities of daily life. He has also developed paranoid features and accuses his son of mixing poison in his food. He eats and sleeps well, does not take any recreational drugs, smoke or drink alcohol. He has been sexually inactive since the death of his wife 15 years ago. There is no history of CAD or stroke. An older sister has a history of dementia. He has no known allergies. He takes docusate for constipation. FH: Father died of MI at 68 and mother died of breast cancer at 55. His rest of the ROS are unremarkable.
1 – How to approach this case? This patient has presented with progressive memory loss, which is most likely due to dementia. Complete physical examination to detect some occult/atypical medical illness should be performed. Neurological examination is of special consideration, which may help us detect focal neurologic deficits due to stroke; rigidity or tremors due to Parkinson ' s disease. Patient with Alzheimer ' s does not present with motor deficits.
Perform the physical examination:
Complete physical exam except breast exam.
2 – Results of the physical examination: General The patient is alert but appears poorly groomed. HEENT Thyroid gland is normal, no other abnormality found. Abdominal examination WNL Rectal examination
Discussion: The major dementia syndromes include Alzheimer ' s disease, Parkinson ' s and Lewy body dementia, vascular dementia, frontal lobe dementia, and reversible dementia.
DSM-IV criteria for the diagnosis of Alzheimer ' s disease:
Gradual impairment of cognitive function resulting in social or occupational dysfunction;
Impaired recent memory with one or more of the following: impaired executive function, impaired visual processing, impairment of skilled motor activities;
Absence of other psychiatric, neurologic or systemic diseases;
Occurrence of deficits not exclusively in the setting of delirium
Vascular dementia is suggested by the presence of abrupt onset of symptoms with stepwise deterioration, focal neurologic findings on examination, and presence of infarcts on CT scan. If dementia is due to Parkinson ' s disease, typical features like rigidity, tremor and bradykinesia will be evident. The recurrent graphic visual hallucinations and delusions are the most characteristic feature of associated dementia. In frontal lobe dementia there is impairment of executive function, behavior is disinhibited, and cognitive function is normal or minimally abnormal. These patients don ' t have insight of their problem. Many causes of dementia are reversible and they include the followings: medication induced; metabolic disorders like vitamin B12 deficiency, thyroid problems, hyponatremia, hypercalcemia; alcohol related; hepatic, and renal dysfunction; normal pressure hydrocephalus, and CNS disorders like tumors and hematomas.
The
Order routine:
CBC with differential, routine
BMP (Na, K, Cl, Co 2, BUN, Cr, Blood glucose, Ca), routine
LFT, routine
TSH, routine
Vitamin B12, serum, routine
Folic acid, serum , routine
CT scan of head, routine (non contrast)
3 – Result of Labs: CBC WBC count of 8,000/micro-L with 85% neutrophils BUN 11 mg/dL Serum creatinine 0.7 mg/dL Blood glucose 110mg/dL Serum calcium 9.5 mg/dL Serum TSH Normal Serum electrolytes WNL LFTs WNL CT scan of head Moderate to severe cortical atrophy
So based on the history, examination and lab results, the most likely diagnosis in this patient is Alzheimer ' s disease.
Order review:
Donepezil, oral, continuous (As cholinesterase inhibitors can improve cognitive function in patients with AD)
Vitamin E, therapy, continuous (Optional)
Olanzapine, oral, continuous for treatment of delusions in AD, atypical antipsychotics are preferred. The older low potency typical neuroleptics like chlorpromazine are highly sedating, and have anticholinergic side effects (May worsen memory). High potency neuroleptics like haloperidol are associated with high incidence of extra pyramidal side effects.
Counsel patient: Advance directives
Patient counseling No driving
Medical alert bracelet
Medication compliance
Also: SSRI (Fluoxetine) antidepressants if depression is present
Buspirone if patient has anxiety
Temazepam is the drug of choice if the patient has sleep problems.
Do not use short acting sedatives like triazolam as they exacerbate mental confusion. Primary Diagnosis: Alzheimer ' s disease
Case 3: Location: Emergency room
Vitals: Pulse: 80/min; B.P: 145/90 mm Hg ; Temp: 98.8 F; R.R : 16/min ; Height: 72 inches (180 cm); Weight: 72 Kg (158.4 lbs) .
CC: Severe chest pain HPI : A 60-year old white male comes to E.R with a two- hour history of severe central chest pain that began while relaxing on the couch at home. The patient denies any exertional activity prior to the onset of symptoms. The pain is constant, 9/10 in severity, crushing in quality, and radiates to the left side of the jaw and left shoulder. There is associated nausea without vomiting. Over the past two months he has experienced several episodes of exertional chest pain while at work. The pain is usually relieved with rest. He did not seek any medical attention thinking that the pain was work related muscle spasms. Medical problems include hypertension for which he has been taking hydrochlorothiazide the past 10 years. He has no known allergies. FH: His father died of MI when he was 55. Mother is 85 yrs old and healthy. SH: He has been married for 34 years and has two sons. He is not sexually active. He has a 30-pack per year smoking history. He drinks moderate amounts of alcohol on weekends, but denies the use of recreational drugs. He is a truck driver. ROS: Denies headaches, vision changes, tinnitus, or vertigo. Denies muscle tenderness, joint pain, stiffness, or weakness. Rest of ROS is unremarkable.
1 – How to approach this case?
This patient has come to the ED with chest pain of recent onset which has many causes and some of them may cause sudden death. Therefore, all such patients should be transported to ED immediately. Oxygen, IV access, cardiac monitoring, and EKG need to be done as soon as possible. Aspirin is given if MI is likely. Therefore, we should order the following:
Order:
Pulse oximetry, stat
Oxygen inhalation, continuous
Cardiac monitoring, continuous
IV access, stat
Cuff, BP monitoring, continuous
Aspirin, oral, continuous
Nitroglycerin, sub lingual, one time, stat (*Repeat every 5 minutes x 3 as needed for chest pain)
EKG, 12 lead, stat
The history and physical examination complemented by selected tests such as chest X-ray, EKG, cardiac enzymes allow the physician to accurately diagnose most causes of chest pain, especially CAD.
Therefore, we will also do the following
Physical Exam: General appearance HEENT/Neck Heart examination Lung examination Abdomen Rectal exam (As this patient may require Heparin for CAD) Musculoskeletal (for possible DVT)
2 – Results: 98% saturation on room air and 99% on 2-lit oxygen. Physical exam is completely normal. Rectal exam shows hem negative stools. EKG shows normal sinus rhythm with 3 mm ST depression and T wave inversion in lead II, III and AVF.
Order:
FOBT, stat
Heparin, IV, continuous
Metoprolol IV, bolus x 3 (5 minutes apart)
CBC with diff, stat and daily
BMP, stat and daily
Chest X-ray, PA, portable, stat
CK-MB, stat and every 8 hours x 2
Troponin-I, stat and every 8 hours x 2
PT/INR, stat PTT, stat
*Order brief history
3 – Results: Patient is still complaining of pain. His history, CAD risk factors such as smoking, HTN, family history, and the EKG findings of T wave inversion suggest the diagnosis of either unstable angina or non-Q wave infarction. In cases of unstable angina, troponins or CK-MB are not elevated but they are elevated in cases of non-Q wave infarcts. However, even in cases of non-Q wave infarcts, troponins levels may not be detectable at initial presentation. We will start heparin and anti-ischemic therapy in this patient.
Order review:
Shift to ICU
Bed rest, complete
NPO, as this patient may require emergency catheterization
Urine output
EKG, 12 lead, stat (repeat this to see the EKG changes)
Nitroglycerin, IV, continuous (blood pressure should be monitored as hypotension may develop) or nitro paste, topical, continuous
Metoprolol, oral, continuous
Simvastatin, oral, continuous
4 – Results: Cardiac enzymes are within normal limits. *Order brief history
Results: Now the patient is pain free; his second set of cardiac enzymes are negative. Order review:
Shift to ward after 24 hours and continue the above treatment
D/C intravenous nitroglycerine or nitro paste (once pain free)
Lipid panel, routine
LFTs (for baseline before you start statins), routine
Echocardiography, stat
Consult cardiology (for cardiac catheterization)
*Obtain TSH if the patient has abnormal lipids especially elevated triglycerides.
*Usually the case will end if you do this much.
If it continue then follow…
Order review:
Patient counseling Smoking cessation Limit alcohol Exercise program Medication compliance Relaxation techniques
Diet, low sodium Diet, low cholesterol (fat)
Follow up visit at two to six weeks
His discharge medications should be (aspirin, metoprolol, statin, Sub lingual nitroglycerine, and +/- clopidogrel)
Diagnosis: Unstable angina
Discussion: The guidelines for the management of USA/NSTEMI are:
Bed rest with continuous ECG monitoring in patients with ongoing rest pain.
NTG, sublingual, followed by intravenous administration, for the immediate relief of ischemia.
Aspirin should be given as early as possible. Clopidogrel is used in patients who are unable to take ASA because of allergic reactions or major gastrointestinal intolerance.
Pulse oximetry and/or ABG Supplemental oxygen for patients with cyanosis or respiratory distress
IV Morphine when the chest pain is not immediately relieved with NTG or when acute pulmonary congestion and/or severe agitation is present.
IV beta-blocker followed by a oral dose provided there are no contraindications. The goal of the treatment is to bring the heart rate down to 60-70/min. If there are any contraindications for beta blockers and the patient is having continuous or frequently recurring, a nondihydropyridine calcium antagonist (e.g., verapamil or diltiazem) can be used as initial therapy in the absence of severe
Routine use of ACEI to all patients with USA/NSTEMI is a class II recommendation. However, an ACEI is used when hypertension persists despite treatment with NTG and a beta-blocker, in patients with
Anticoagulation with LMWH or intravenous unfractionated heparin should be added to antiplatelet therapy with ASA and/or clopidogrel. Enoxaparin is the best studied of all. Heparin should be given for at least 2 days.
A platelet GP IIb/IIIa antagonist (Tirofiban or eptifibatide) should be administered, in addition to ASA and heparin, to patients in whom catheterization and PCI are planned.
Early invasive therapy is indicated for high-risk patients with UA. Patients with refractory ischemia, recurrent symptoms, ST segment depression, and hemodynamic instability are at high risks. These patients should be referred for angiography and revascularization. In the absence of these findings, either an early conservative or an early invasive strategy in hospitalized patients without contraindications for revascularization.
Role of statin therapy is conflicting. However, in the acute setting the mechanism of benefit from statin therapy probably involves anti-inflammatory effects rather than the lipid lowering. The other added benefit is, studies have shown that the long term compliance is better if the statins are started before the discharge.
Thrombolytic therapy is not indicated in the treatment of USA/NSTEMI and should not be used.
Case 4
Location: Office
Presenting complaint : A 24-year-old married female presents with nausea and vomiting
Vitals: Pulse:82/min, Temp:98.6 F,R.R:15/min, B.P:130/70 mm Hg,Height:162cm, Weight:62 kg (136.4lbs)
HPI: A 24-year-old Asian female presents with complaints of nausea and vomiting for the last several days. She feels more nauseated in the morning and also complains of breast pain. Her last menstrual period was 7 weeks ago and before that her menstrual periods have always been regular with a 28-29 day cycle . She was married 8 months ago, is sexually active with her husband, and has never been pregnant . The patient denies abdominal pain, fever or vaginal discharge. She has been a one pack per day smoker since her teenage years . She is not on any medications, does not drink or use recreational drugs. The patient migrated to the
1 – How to approach this case?
This young sexually active female has presented with nausea, vomiting and amenorrhea, which are most likely due to pregnancy.
Therefore do complete physical examination, which should include abdominal, breast and genital examination to look for signs of pregnancy and order a pregnancy test .
2 – Here are the results: Breast examination: Mild breast tenderness bilaterally . Abdominal examination:
Labs:
Urinary beta-HCG, routine (or)
Pregnancy test, serum, qualitative, stat
The “gold standard” for diagnosis of pregnancy is the detection of the beta subunit of human chorionic gonadotropin (hCG) by immunologic techniques in blood or urine.
When performed in a clinical laboratory, the sensitivity and specificity for both blood and urine pregnancy tests are between 97 and 100 percent .
3 – Results: Urinary beta-HCG: positive
Discussion: There are many signs of pregnancy, which can be grouped into presumptive, probable and positive categories. Presumptive signs are associated with skin and mucous membrane changes. The dark discoloration of vulva and vagina noted in this woman is called Chadwick ' s sign. Probable signs are associated with changes in uterus. Globular shape and softer consistency of uterus is one of the probable signs. Positive signs of pregnancy are the detection of fetal heart sounds and the recognition of fetal movements. Doppler techniques enable us to detect fetal heart sounds as early as 9 weeks of gestation while the stethoscope can detect at 16 weeks. Recognition of fetal movements by an observer is possible at 20-24 weeks. Positive pregnancy testing coupled with findings on history and examination is suggestive of pregnancy. Next , confirm her pregnancy by ultrasound and start antenatal care. Ultrasound will also help us determine gestational age. A standard panel of laboratory tests should be obtained on every pregnant woman at the first prenatal visit. Additional testing of women at risk for specific conditions can augment this panel.
The initial laboratory tests recommended by the
Blood type Rhesus type
Antibody screen
CBC with differential
Basic metabolic panel
Pap smear
Rubella status
Syphilis screen
Urinary infection screen
Hepatitis B surface antigen
HIV counseling and testing
Chlamydia
Additional laboratory tests commonly performed in at-risk individuals include: Gonorrhea
Tuberculosis
Red cell indices to screen for thalassemia
Hemoglobin electrophoresis to detect hemoglobinopathies (e.g. sickle cell, thalassemias)
Hexosaminidase A
Cystic fibrosis carrier testing
Serum phenylalanine level
Toxoplasmosis screen
Hepatitis C antibodies
The first prenatal visit is a good time to discuss the patient’s responsibilities and the expected course of pregnancy and delivery. Patients should be given information regarding the general plan of management for the pregnancy.
Number and frequency of prenatal visits
Recommendations for nutrition, weight gain, regular exercise (limited), rest, and sexual activity
Routine pregnancy monitoring
Listeria precautions
Toxoplasmosis precautions
Abstinence from alcohol, cigarettes, and illicit drugs
Information on the safety of commonly used nonprescription drugs
Recommendation to continue wearing seat belts during pregnancy
Potential problems related to plans for travel, work outside of the home, or hobbies
Childbirth classes and breastfeeding recommendations
Confidentiality issues
Therefore, we will do order the following in this patient
Order Routine:
Blood type and Rh type, routine
Atypical antibody titer
CBC with differential, routine
BMP, routine
Transvaginal ultrasound, routine
Urinalysis, routine
Urine culture and sensitivity, routine
Pap smear, routine
Chlamydia , culture cervix, routine
Rubella antibodies, routine
RPR, routine
Hepatitis B surface antigen, serum
HIV test, ELISA, serum, routine
Medications:
Vitamin, prenatal, oral, continuous
Iron sulfate , oral, continuous
Folic acid, oral (0.4 mg), continuous
High calorie diet High fiber diet
Regular exercise Patient education Smoking cessation Safety plan Safe sex No illegal drug use No alcohol Drive with seat belt
Follow up in 4 weeks
U/A and Urine culture are very important because 5-10 % of pregnant patients may have asymptomatic bacteriuria and untreated patients may develop pyelonephritis.
Follow up visits: Every 4 weeks until 28 weeks Every 2 weeks between 28 to 36 weeks Every week between 36 to delivery Follow up visits: Complete physical examination Wt. Measurement Vitals especially BP Complete urinalysis Fundal measurement Fetal heart rate (110—160/min=N) measurement
Glucose screening: In the
Advise from 2 nd Trimester : Promotion of breast-feeding Childbirth classes Danger signs of pregnancy Preterm labor education
Primary Diagnosis: Pregnancy
Case 5
Location: Office
C.C: A 28-year-old white male presents with bleeding per rectum.
Vitals: Pulse:76/min, B.P:120/70 mm Hg, Temp:98.5 F, R.R:16/min, Height:72 inches (180 cm), Weight:72 Kg (158.4 lbs).
HPI: A 28-year-old white male presents with the complaint of having blood per rectum (BRBPR) for a week. His stools are streaked with blood. They are loose, watery, and contain mucus. He has mild colicky pain and a feeling of incomplete evacuation after defecation. He denies any history of nausea, vomiting, fever, weight loss, recent travel, or ill contacts with diarrheal illness. He has been smoking 20 cigarettes a day for the last seven years. He drinks alcohol occasionally and does not use illegal drugs. ROS are unremarkable. He has never been admitted to the hospital. He is not on any medications. He has no allergies. FH: Mother died at the age of 60 due to MI. An older brother has ulcerative colitis. Father is alive and healthy at the age of 65. SxH: Sexually active with his wife. He is a restaurant manager.
1 – Approach to the patient:
Differential diagnosis of rectal bleeding include ulcerative colitis, Crohn’s disease, infectious colitis, medication induced (NSAIDs, antibiotics), radiation colitis, ischemic colitis, internal hemorrhoid, anal fissure etc. The common infections include Campylobacter, Escherichia coli 0157:H7, Salmonella, Shigella etc. Consider CMV infections and Kaposi’s sarcoma in an immunocompromised patient. C.difficle can sometimes present with bleeding per rectum. It should be considered in all patients who have been on antibiotics. NSAIDs can exacerbate the underlying IBD. Whenever there is visible rectal bleeding in adults an evaluation, either in an inpatient or outpatient setting is necessary depending on the degree of risk. Low risk patients (e.g. self limited rectal bleeding in an otherwise healthy young patient is most likely due to an internal hemorrhoid) can be followed as outpatient. High risk patients, such as those with acute abdomen, hemodynamic instability, or persistent bleeding need to be resuscitated and hospitalized. GI consult should be obtained as soon as possible. After assessing the stability of the patient, the next step is to determine the source of the bleeding. When the left colon is the source, the blood is usually bright red. Dark maroon bleeding or blood mixed with stool is probably from the right colon. Some times the source of the hematochezia is upper GI (in about 11% of patients) and therefore nasogastric lavage should be done in all cases to rule out an upper GI source.
In this patient, who is clinically stable, there is no need for resuscitation. This patient is stable, and he is a potential candidate to have ulcerative colitis. So he needs a thorough physical examination including rectal.
Order: General, Skin, HEENT, Lungs, Heart, Abdomen, Rectal, and Extremities.
2 – Results of your exam: Physical examination is unremarkable except rectal examination, which is significant for blood stained stool.
*This patient is most likely suffering from ulcerative colitis based on his presenting complaints, family history and findings on examination. However, other similar conditions need to be ruled out.
Discussion: Typical history coupled with characteristic findings on endoscopy establish the diagnosis of UC, which is confirmed by a biopsy. The presence of ulcerative colitis, in a first-degree relative, is an extremely important clue. Flexible sigmoidoscopy documents the extent of inflammation as well as establishes the diagnosis. Colonic biopsy is particularly helpful when the findings on sigmoidoscopy are equivocal. A barium enema can confirm the diagnosis but is usually not necessary. Colonoscopy is usually not required unless the diagnosis is uncertain. The other problem with colonoscopy is it can cause perforation in a severely ill patient with extensive disease.
Order Routine:
CBC with differential, stat
BMP, stat
Liver function tests, routine
ESR, stat
PT/INR, stat PTT, stat
Stool ova and parasites, routine
Stool for white cells, routine
Stool culture, bacterial, routine
3 – Results of labs: CBC with differential, an BMP are within normal limits. Stool for ova and parasites is negative. Stool bacterial culture is pending. ESR is elevated at 60 LFTs are within normal limits. PT, and PTT are within normal limits.
Order:
Consent for procedure
Flexible sigmoidoscopy, stat
Rectal biopsy , stat
4 – Results: Sigmoidoscopy, and rectal biopsy are consistent with the diagnosis of ulcerative colitis involving the rectum, and distal sigmoid colon.
Management of ulcerative colitis: Treatment depends on the severity and extent of the disease.
Topical therapy with 5-ASA compounds is the treatment of choice (not steroid enemas) for mildly active proctitis or proctosigmoiditis. They are very effective in inducing and maintaining remission. For proctitis, 5-ASA suppositories are used and enemas are recommended for proctosigmoiditis. 5-ASA enemas are significantly superior in inducing remission and have less side effects compared with steroid enemas. Although the symptomatic improvement will be seen within a few days, treatment should be continued for at least four to six weeks. Doses should be tapered off during this time as complete healing takes place.
Oral therapy with sulfasalazine or with newer 5-aminosalicylates is the treatment of choice for moderately active proctosigmoiditis. Newer 5-aminosalicylates like mesalamine are more costly but have fewer side effects. Folic acid supplementation should be given to patients on sulfasalazine. Steroids are used when these 5-aminosalicylates compounds fail to induce remission. Steroids should not be used for maintenance of remission. Immunomodulator drugs like azathioprine or 6-MP are used when patient becomes steroid dependent or he is refractory to steroids.
Patients with severe disease need to be hospitalized and resuscitated with IV fluids and electrolytes. They are kept NPO and given parenteral nutrition.
It's very important to monitor the patient for complications that might develop. Abdominal examination, vital signs, and plain abdominal films are used for this purpose. IV steroids are the most important treatment modality.
Role of antibiotics is controversial in this patient population. However, many physicians consider giving broad spectrum antibiotics if the patient has fever, leukocytosis, or any indication of sepsis.
Surgery is considered for refractory cases. Antidiarrheal agents like loperamide may be used for symptomatic treatment of diarrhea, and anticholinergic agents for abdominal cramps. Antidiarrheal agents need to be avoided in severely ill patients. Antidepressants or anxiolytics may be required in some cases. Dietary counseling is important in all cases.
ORDER REVIEW:
5-ASA, rectal, continuous
Loperamide, oral, continuous
Dicyclomine, oral, continuous
Dietary consult, routine
Counseling: Patient counseling No alcohol No smoking Safe sex Seat belts use Regular exercise No illegal drug use Medication compliance
Primary Diagnosis: Ulcerative colitis, mild case involving rectum and distal sigmoid colon.
Case 6
Location: Office
Presenting complaint: A 28-year-old man presents with two months of abdominal pain, and altered bowel.
Vitals: Pulse:72/min, B.P:130/75 mm Hg, Temp:98.7 0 F, R.R:17/min, Height:70 inches (175 cm), Weight:70 Kg (154 lbs) HPI: A 28-year-old white male presents with the complaints of abdominal pain and altered bowel habits for the last three months. The pain is colicky in nature. It is located in the lower abdomen. The pain does not radiate, is 5/10 in severity, worsens postprandially, and relieves with defecation. For the last three months he has been suffering with diarrhea alternating with constipation. For the last three days, he has been having diarrhea. Stools contain mucus but not blood. Symptoms occur during the day and do not interfere with his sleep or work. His weight and appetite are normal. He is not taking any prescribed or recreational drugs. He smokes 10 cigarettes per day for the last 10 years and drinks alcohol only on weekends. He is currently sexually active with his wife and always uses condoms. He has no other medical problems or known allergies. He is not on any medications. FH: No H/O IBD or colon cancer in the family. SH: Married for 5 years and has a 2 year old daughter. Works at a local university. ROS are unremarkable.
1 – How to approach this case? This 28yo patient has alternating diarrhea and constipation. This may be due to infectious causes like amebiasis or giardiasis, which are very rare. Irritable bowel syndrome is another possible cause. Bowel obstruction may present with alternating diarrhea and constipation.
Order:
A complete physical examination, including rectal, is appropriate in this setting.
2 – Results: Completely normal physical examination
Now, order the following:
CBC with differential, routine
BMP, routine (diarrhea is associated with electrolyte abnormalities)
TSH, routine
ESR, routine
FOBT, routine
Stool for white cells, routine
Stool ova and parasites , routine
Stool cultures, bacterial, routine
72-hour stool fat, routine
*Schedule an appointment in one week.
3 – Results of labs: WBC count is 8,000/micro-L, hemoglobin is 15.6g/dL, and platelet count is 200,000/micro-L Serum TSH is 1 micro-U/L BMP is normal FOBT is negative Stool does not contain any ova, parasites, or white cells. Stool culture – No growth 72 hour fecal fat is WNL.
Order review:
Lactose free diet
High fiber diet
Loperamide, orally, continuous
Biofeedback, routine
Reassurance
Relaxation exercise
Counseling: Patient counseling
No smoking No alcohol Safe sex Seat belt use No illegal drug use
Counseling about cessation of cigarette smoking, limitation of alcohol intake, safe sex practices, and driving with seat belt
Follow up visit in 2 weeks
Discussion: Clinical features: Irritable bowel syndrome is a diagnosis of exclusion. Abdominal pain and altered bowel habits are the most characteristic features of this entity. Abdominal pain is crampy, located in lower abdomen, aggravated by stress, and relieved by defecation. Patients with IBS have diarrhea, constipation or diarrhea alternating with constipation. Stools contain mucus but no blood. Clinical features that suggest disease other than IBS include fever, weight loss, bloody diarrhea, large volume diarrhea, nocturnal diarrhea, nocturnal pain, anorexia and anemia.
Diagnosis: When a clinical presentation is typical of IBS, only a few investigations are ordered. They include CBC and routine chemistry panel in all; thyroid hormones, and stool for ova, parasites, and leukocytes in patients with diarrhea; and flexible sigmoidoscopy in patients over 40, and in patients who have persistent diarrhea. When all the fore mentioned studies are normal, symptomatic treatment is started and patient is reevaluated after 4-6 weeks. If symptoms progress, more detailed studies are warranted.
Treatment: A lactose free diet and high fiber diet are considered. A diet that produces gas is discouraged. Anticholinergic drugs for abdominal pain and loperamide for diarrhea are given on a ‘as needed basis’. Prokinetic drugs may be used for constipation. Benzodiazepines are used only in cases of acute situational anxiety. Behavioral treatment is a consideration for patients who have some sort of stressor.
PRIMARY DIAGNOSIS: IBS
Case 7
Location: Emergency room
Presenting complaint: A 65-year-old male presents with a chief complaint of severe breathlessness .
Vitals: Pulse: 88/min , regular, B.P: 120/70 mm Hg, Temp: 100.5 F, R.R: 25/min , Height: 72 inches (180 cm), Weight: 72 Kg (158.4 lbs).
HPI: A 65-year-old white male, with a two-year history of COPD, presents to the ER with an acute onset of severe breathlessness, wheezing, and chest tightness. He also states that his cough has become more severe the past two days and the sputum production has increased in quantity and become yellowish. Other complaints include fever and malaise. He denies any chest pain and does not use supplemental oxygen at home. He continues to smoke 2-5 cigarettes/day. He does not drink alcohol or use illegal drugs. He has no allergies. His current medications are albuterol 2 puffs as needed for SOB. He has no other medical problems. Vaccinations are up to date. He was admitted once in the hospital for exacerbation of COPD. REVIEW OF SYSTEMS: Skin No complaints HEENT No vision changes, epistaxis, or sore throat Musculoskeletal Easily fatigued, chronic left knee pain Cardio respiratory Frequent productive cough, wheeze, and dyspnea Genitourinary No history of STD or UTI. Neuropsychiatric Not asked Abdominal Occasional heartburn, denies nausea, vomiting, or diarrhea
1 – How to approach this case? Based on his history, this is most likely an exacerbation of COPD. Features suggestive of COPD exacerbation include increase in the severity of dyspnea, and a change in the color and quantity of sputum. To assess the severity of exacerbation, ABGs and pulmonary function tests are performed. CXR is done to rule out disorders that mimic COPD exacerbation. ECG is done to detect RVH, arrhythmia and ischemia. CBC is performed to detect polycythemia or bleeding. Serum chemistry may point towards some metabolic cause of COPD exacerbation. Sputum gram staining, culture, and sensitivity are indicated when COPD exacerbation with a purulent sputum fails to respond to empiric antibiotic treatment. PaO2 of < 60 mm Hg and/or SaO2 <90 on room air indicates respiratory failure. PaO2 <50 mm Hg, PaCO2 >70 mm Hg, and pH <7.30 indicate a life-threatening respiratory failure and requires mechanical ventilation with ICU management. A PEF <100 L/min or an FEV1 <1.00 L also indicates a severe exacerbation. Start with the physical examination:
General HEENT Neck Heart examination Lungs examination Abdomen Extremities
2 – Results of your examination: The patient is in obvious respiratory distress, sitting upright and using his accessory muscles of respiration. Increased AP diameter of chest, decreased air entry on both sides, and generalized bilateral rhonchi and wheezing. Heart exam: Regular rate, and rhythm,; loud P 2 but no murmurs. There is no edema, calf tenderness, or Jugular venous distension. Rest of the examinations is within normal limits.
Routine Orders:
Sit upright (Head elevation)
Pulse oximetry, stat and continuous
Oxygen inhalation, continuous
IV access, stat
Cardiac monitor, continuous
FEV1, stat and every hour
PEFR, stat and every hour
EKG, 12 lead, stat
CXR, PA, lateral, stat
ABG, stat
CBC, with differential, stat
BMP, stat
3 – Lab results: PEFR: 0.9L/min FEV1: 0.85L Oxygen saturation: 86% on room air and 94% on 2-litre oxygen via nasal cannula CXR shows hyperinflation of both lung fields and a small infiltrate on the right lower lobe EKG is within normal limits.
Start treatment:
Nebulized albuterol, continuous
Nebulized ipratropium, continuous
Prednisone, IV, continuous
Levofloxacin, oral, continuous
4 – Lab results: ABG: · pH: 7.38 · PaO2: 53 · PaCO2: 53 mm Hg CBC shows WBC count of 12,000/micro-L with 8% bands. BMP are normal Patient is feeling better and his pulmonary function has improved now after 4 hours of therapy.
Review orders:
Shift to floor/ward
Urine output
Vitals Q 4 hours
Ambulate as tolerated
Regular diet
Serum theophylline levels if patient is on theophylline
Pulmonary toilet (suction upper airway): If the patient is having lot of secretions and is unable to clear them
Diuretics are given in cases of cor pulmonale Low sodium diet in cases of cor pulmonale
Phlebotomy (> 50 hematocrit)
Discontinue the cardiac monitor if the patient’s vitals are stable and the acute episode is over
DISCUSSION: Pharmacological agents used to treat acute exacerbation of COPD include inhaled beta-adrenergic agonists, inhaled anticholinergics, antibiotics, and steroids.
Inhaled beta-adrenergic agonists like albuterol are the main stay of treatment for acute exacerbation of COPD and are given via a nebulizer or MDI. Anticholinergic bronchodilators like ipratropium are sometimes used along with beta-agonists when more bronchodilation is required. Even though there is no clear evidence, parenteral corticosteroids may be used in hospitalized patients for severe exacerbation. Methylxanthines like theophylline are used for patients who fail with inhaled bronchodilators. It may improve dyspnea, airway function, mucociliary clearance, and central respiratory drive. However, theophylline has narrow therapeutic window and may cause tachyarrhythmias. Antibiotics are indicated when COPD exacerbation is caused by infection. Empiric treatment is done with levofloxacin, amoxicillin, TMP-SMZ or doxycycline. Gram staining and culture of sputum is required in refractory cases. Adequate oxygenation must be maintained by giving supplemental oxygen with goal arterial oxygen tension of >55-60 mmHg and the oxygen saturation of above 88-90%. Noninvasive positive pressure ventilation (NIPPV) should be tried initially in selected patients with respiratory failure. However, it is contraindicated in patients with hemodynamic instability (eg, hypotension, serious cardiac arrhythmias). Criteria to use NIPPV include moderate to severe dyspnea, PaCO2 of > 45 mmHg or pH of < 7.35 or RR of >25/minute.
5 – Review order: Patient is asymptomatic and his pulmonary function tests have reached his personal best after 2 days of inpatient therapy.
Discharge:
Send the patient home
D/C nebulization of albuterol and ipratropium (Switch to metered dose inhalers)
Ipratropium inhalation, continuous
Albuterol inhalation, continuous
Oxygen therapy at home (when PaO2 is less than 55 mm Hg or SaO2 is less than 88 percent, oxygen therapy and cessation of cigarette smoking improves prognosis)
Oral Levofloxacin for total of 10 days
Influenza vaccine
Pneumococcal vaccine
Smoking cessation Alcohol, advice the patient to limit intake Counsel patient, no illicit drugs Patient counseling
Follow-up visit at 2 weeks
Primary diagnosis: ACUTE EXACERBATION OF COPD
Case 8
Location: office
Presenting complaint: A 40-year-old female with complaints of insomnia, easy fatiguability, and feelings of worthlessness presents to the outpatient medicine clinic.
Vitals: Pulse:75/min, B.P:110/75mm Hg, Temp:98.6 F, R.R:16/min, Height:72 inches (180 cm), Weight:55kg (121 lbs).
HPI: A 40-year-old female comes to the clinic with the complaint of insomnia, easy fatiguability, and feeling worthless. She states that she has been " feeling low " for the last two months. She no longer finds pleasure in any of her normal activities. She can ' t sleep. There is loss of appetite. Her weight has decreased by 20 pounds in two months. The patient has feelings of guilt, hopelessness, and inability to concentrate. She is finding it difficult to continue her job as a librarian and has decided to take a leave of absence. Prior to the onset of symptoms, she was doing well, both at home and in the office. She is married, has two children, and her husband is very loving. Because of her lack of interest in sex, they have been sexually inactive for the past two months. Generally, the patient has always been in good health. She doesn ' t smoke, drink alcohol, or use drugs. She has a history of cluster headaches. Her last cluster headache was six years ago. ROS are unremarkable. FH: Mother is 65 and has HTN. Father is 70 and healthy. Vaccinations are up-to-date. She is not on any medications. She has no known allergies.
1 – How do you approach this case? This patient has classic clinical features of depression. A number of medical conditions may present with depression, including stroke, diabetes, dementia, cancer, hypothyroidism, chronic fatigue syndrome (see Fatigue below), fibromyalgia, systemic lupus erythematosus (SLE), coronary heart disease, corticosteroid use, anxiety and panic disorders, hypercalcemia, Sjögren’s syndrome, increased bone loss, and seizure disorders in older adults. Perform a complete physical and psychiatric examination. An assessment of the presence of suicidal ideation is essential in all depressed patients.
Physical examination: Complete physical examination
2 – Results of PE: General: Well developed, well nourished, middle aged female, in no acute distress. HEENT, lungs, heart, abdomen, and the rectal exam is completely normal. No lymph nodes palpable. Neuro/psychiatric examination: Neurological examination is non-focal. She is alert and oriented though her speech is somewhat slow. She expresses feelings of worthlessness and lack of energy. She denies having delusions or hallucinations. There are no suicidal ideations. Her cognitive functioning is normal.
How would you approach this patient? In cases of depression, limited laboratory testing that may help rule out associated disorders includes measurement of thyroid function (TSH), serum electrolytes/basic metabolic panel, folate, vitamin B12, and an electrocardiogram. Other tests may be ordered based on the findings of history and physical examination include: ANA when SLE is suspected 1. HIV testing and VDRL in cases of high risk sexual behavior 2. Urine and blood toxicology screening in cases of suspected substance abuse 3. Dexamethasone suppression test for suspected Cushing ' s disease 4. Cosyntropin stimulation test for suspected
Order review: In this case, no associated medical illness is suspected based on history and examination.
Routine Orders:
CBC with differential, routine
BMP, routine
TSH, serum, routine
EKG, 12 lead, routine
Vitamin B 12, serum, routine
Folate, serum, routine
3 – Result of Labs: EKG: normal rate, rhythm and axis, no evidence of ischemia or hypertrophy. Serum TSH: 1microU/mL BMP: Na is 140 meq/L, K is 4.0 meq/L, Cl is 100 meq/L; calcium, CO 2 , BUN, creatinine, B 12 and Folate are normal.
Discussion: Based on the history and examination, this patient is likely suffering from major depression.
There are four major types of depression: adjustment disorder with depressed mood; depressive disorders; bipolar disorders; and mood disorders secondary to illness and drugs. These need to be differentiated from grief and bereavement, which are normal responses to a loss. The DSM-IV criteria for major depression: At least five of the following symptoms should present for a period of two-weeks. One of the symptoms must be depressed mood or loss of interest. The symptoms should not be the result of an organic factor or substance. The disturbance should not occur within 2 months of the loss of a loved one. Depressed mood most of the day 1. Markedly diminished interest or pleasure in almost all activities nearly every day (anhedonia) 2. Significant weight loss or weight gain 3. Insomnia or hypersomnia 4. Psychomotor agitation or retardation 5. Fatigue or loss of energy nearly every day 6. Feelings of worthlessness and/or excessive or inappropriate guilt 7. Impaired concentration or indecisiveness 8. Suicidal ideation 9. A history of a prior manic episode in addition to these criteria suggests the diagnosis of bipolar disorder. Dysthymia is defined as mild, chronic depression which lasts for at least two years or longer. It is characterized by poor appetite, insomnia, low energy or fatigue, low self-esteem, impaired concentration, and anhedonia.
Long-term psychotherapy is frequently helpful. Mild to moderate major depression is treated with either psychotherapy or pharmacotherapy.
Moderate to severe depression should be treated initially with either pharmacotherapy or ECT. SSRIs are the drugs of choice.
Patients should have a follow-up appointment at least every one to two weeks for six to eight weeks during the initiation phase of treatment. Patients with severe depression should be seen weekly. Less severely ill patients should be seen every 2 weeks.
Patients with associated anxiety symptoms and difficulty sleeping should be offered a short acting benzodiazepine like lorazepam for 1-2 weeks with tapering doses.
Patients with suicidal behavior and severe functional impairment should be admitted in the hospital and treated with ECT.
Psychiatric consultation is needed When the first line medication produce no improvement in 6-8 weeks period; Patients with severe suicidal ideation; Patients with associated psychiatric or medical or substance abuse disorders
When to add antipsychotics? If the patient experiences the associated psychotic symptoms with depression, a small dose of atypical antipsychotics like risperidone can be added.
As this patient has moderate to severe depression and she does not reveal any history of suicidal ideation, psychotic symptoms and anxiety, we can treat her with antidepressants alone.
Order review:
Fluoxetine, oral, continuous
Suicide contract
Seat belt use Patient education No smoking No alcohol Seat belts use Regular exercise No illegal drug use
Follow up visit after 10 days
Primary Diagnosis: MAJOR DEPRESSION
09/ Location: Emergency room
Presenting complaint: A 55-year-old male presents with recent onset confusion, blurry vision and headache.
Vitals: Pulse:75/min, B.P:215/150 mm Hg, Temp:98.8 F, R.R: 16/min, Height:72 inches (180 cm), Weight:72 Kg (158.4 lbs)
HPI: A 55-year-old white male comes to the E.R with a 2-hour history of confusion, blurred vision, headache, / nausea, one episode of vomiting, and breathlessness. He was doing his routine office job when symptoms developed. The headache started this morning, was 1-2/10 in severity but now it is 6-7/10. He denies weakness, sensory disturbances, dysphasia, dysarthria, leg swelling, chest pain or palpitations. Bowel and bladder functions are intact. Diagnosed 5 years ago with hypertension, he was prescribed atenolol, however he is poorly compliant. There is no history of DM, CAD or hyperlipidemia. He has a 25-pack-year smoking history and rarely drinks alcohol. He has no known allergies. FH: Mother is 80 and is hypertensive, father died of MI at 65. One brother is diabetic. SH: Married 30 years, has two sons and one daughter. He is a business executive. SxH: he is sexually active with his wife and does not use condoms. ROS are unremarkable.
1 – How to Approach this case: This hypertensive male presents with recent onset of confusion, blurred vision and headache. He is most likely suffering from hypertensive encephalopathy, a hypertensive emergency. Other possible causes include subarachnoid hemorrhage, intra-parenchymal brain hemorrhage, acute MI or migraine. Hypertensive emergency or hypertensive crisis is characterized by very high blood pressure with impairment of end organs like CNS, heart or kidney. CNS manifestations include confusion, blurring of vision, headache, weakness and fatigue. CVS involvement results in congestive heart failure, angina, MI or aortic dissection. Renal manifestations are hematuria and/or proteinuria and impaired renal function.
Immediate examination is crucial in this patient,
Order: General, HEENT/Neck, Heart, Lungs, Abdominal, Extremities, Neuropsychiatric.
2 – Results: Patient is disoriented and neurological examination is otherwise non-focal. Fundoscopy shows arteriolar narrowing and AV nicking. There is mild papilledema, and soft exudates. There is no neck stiffness. CVS examination is significant for S4 gallop. Lungs are clear to auscultation bilaterally. Abdominal examination is normal. Extremities show no evidence of edema.
Order:
IV access, stat
Oxygen inhalation, continuous
Pulse oximetry, stat and continuous
Cardiac monitor, continuous
Continuous BP cuff
STAT Order: CT scan of head, stat
12 Lead EKG, stat
*Before starting treatment, rule out the possibility of stroke. Treating high BP is detrimental in patients with stroke especially those who with increased intracranial pressure, i.e. papilledema. First order CT scan of the head without contrast.
( without contrast to look for edema, hemorrhage, infraction)
3 – Results: CT is negative for stroke. Pulse oximetry is 97% on 2 lit. Vitals are same as before. 12 lead EKG has evidence of Left ventricular hypertrophy.
Now start treatment:
Nitroprusside, IV, continuous (monitor the patient for hypotension)
After starting treatment, order basic labs to assess the end organ involvement.
*Shift the patient to ICU
NPO
Bed rest, complete
Urine output
CBC with differential, stat (for microangiopathic hemolytic anemia)
BMP, stat (for possible renal involvement)
Urinalysis, stat (for possible renal involvement)
CXR-PA view, stat (to look for the evidence of pulmonary edema)
4 – BP is under control and patient is symptom free. Always check the BP frequently (in the exam) as continuous infusion of nitroprusside can cause hypotension and try to wean nitroprusside and add an oral agent.
*Shift the patient to the ward/floor
D/C cardiac monitor, oxygen, pulse oxy,
NPO,
bed rest
Vitals Q 6 hours
Lipid profile, routine
Metoprolol or hydrochlorothiazide, oral, continuous
Low salt diet
*Once the blood pressure is controlled with oral antihypertensive agents, the patient can be sent home with the following orders
Order review:
Patient counseling
Regular exercise Medication compliance Smoking cessation Alcohol, advice patient to limit intake Seat belt use No illegal drugs
Discussion:
Diastolic blood pressure of more than 120 is considered as hypertensive crisis. The presence of end organ damage further classifies it as hypertensive emergency and lack of end organ damage classifies it as hypertensive urgency.
• The most common cause of hypertensive crisis is inadequately treated essential hypertension. The other common causes include renovascular hypertension and renal parenchymal diseases and rarely form pheochromocytoma or primary hyperaldosteronism.
• Careful physical exam to differentiate hypertensive urgency from emergency should be done. The main components of the exam are funduscopy, CVS, CNS and BP in both upper extremities and at least one lower extremity.
• Basic labs, which include CBC with peripheral smear, U/A, BUN, Cr, EKG, and CXR, should be ordered.
Treatment:
• In hypertensive emergency blood pressure should be lowered within one hour to limit the end organ damage. In hypertensive urgency the aim is to reduce the diastolic blood pressure to about 100-105 mm hg with in a period of 2-6 hours. The maximum initial fall should not be more than 25 mm Hg. More aggressive reduction of BP decreases the blood pressure below the auoregulatory range and may cause ischemic events like stroke. Once the goal is reached, the patient should be switched to oral medications. The diastolic pressure should be lowered to 85-90 over a period of 2-3 months.
• IV nitroprusside is the drug of choice for hypertensive crisis. It acts within seconds and it has a very short half-life. The patient BP should be monitored with intra-arterial line. Prolonged infusion i.e. >48 hrs may cause cyanide toxicity, especially in patients with renal insufficiency. It is not a first line medication in pregnant women. The other good alternatives to nitroprusside are IV labetalol and hydralazine. Hydralazine is the drug of choice in pregnant patients.
• IV phentolamine is the drug of choice in pheochromocytoma.
• Esmolol is an IV beta-blocker and is effective in acutely lowering BP when used in conjunction with a vasodilator. Myocardial ischemia is an important indication for its usage.
Management of hypertension varies in certain situations:
• Rapid reduction for blood pressure is detrimental in patents with cerebrovascular accident. These patients can be differentiated from hypertensive emergency by the abrupt onset of focal neurological findings.
• Patients with acute pulmonary edema are best treated with combination of nitroprusside or nitroglycerine and loop diuretic. Drugs like hydralazine or beta-blockers or labetalol should be avoided.
• Patients with acute coronary syndromes are best treated with IV nitroglycerine or IV labetalol or IV nitroprusside.
• Aortic dissection: The primary goal is to decrease both the systemic BP and cardiac contractility. The best regimen is a combination of IV nitroprusside and an IV beta-blocker either a labetalol or metoprolol. Nitroprusside alone should not be used without a beta-blocker.
• Rebound hypertension secondary to abrupt withdrawal of short acting sympathetic blockers such as clonidine is best treated by re-administration of the discontinued rug and if necessary with IV phentolamine.
• The rare causes include 1. Pheochromocytoma 2.Cocaine intoxication 3. Interaction of MACI and tyramine containing foods can also cause hypertensive crisis. This is best treated with IV phentolamine.
10/ Location: Emergency room
presenting complaint: A 7-month-old boy presents with severe breathlessness of sudden onset
Vitals: Pulse: 100/min, B.P: 80/55 mm Hg, Temp: 98.7 0 F, R.R: 40/min, Weight: 6.8 kg (15lbs), Height: 53 cm
HPI: A 7-month-old boy is brought to the ER with severe cough, stridor, and breathlessness. His 6-year-old brother went to school leaving peanuts near him. Mom found the child in respiratory distress and rushed him to the hospital. There is no family history of asthma. The infant was healthy prior to this incident. Developmental milestones are being achieved at the appropriate ages. He has no allergies. Vaccinations are up-to-date. FH: Father is 32 and healthy; mother is 28 and has DM. He has one elder brother who is healthy. ROS are unremarkable.
1 – How to approach this case: This child presents with acute dyspnea due to upper airway obstruction. Stridor is one of the important clinical signs of upper airway obstruction. There are a number of causes of upper airway obstruction in the pediatric population. Etiologies vary according to the age of the patient. Careful history, and examination as well as lateral and PA chest X-rays should be done in all such patients.
First General examination HEENT/Neck Chest/lungs CVS
2 – Results of PE General examination: The baby is crying, and in obvious respiratory distress. child is tachypneic with nasal flaring, suprasternal, and intercostal retraction. Inspiratory stridor is noted. Air entry is reduced, and percussion note is resonant bilaterally. Normal S1 and S2. No murmurs, rubs, or gallops. Pulses are normal. No jugular venous distension. Blood pressure is equal in both arms.
Review orders:
Oxygen inhalation, stat
IV access, stat
Pulse oximetry, stat and continuous
Cardiac monitoring, stat
CBC with differential, stat
CXR-PA/lateral views, portable, stat
X-ray neck lateral views, portable, stat
3 – Results of Labs: CBC: normal. CXR PA and lateral views: No abnormality found. Pulse oxymetry: oxygen saturation is 91 percent on room air, and 97% on 2-lit oxygen. Cardiac monitoring: no abnormality of rate or rhythm.
Discussion
This child has sudden and dramatic onset of symptoms. He had peanuts in the vicinity before he developed symptoms. Based on these findings, symptoms are most likely due to aspiration of a foreign body. The next step in this case would be bronchoscopy, which will confirm the diagnosis and aid in the removal of aspirated foreign body. Before bronchoscopy, IV steroids and IV antibiotics may be used to help reduce the chances of edema and infection. Other important causes of upper airway obstruction include croup, laryngitis, epiglottitis, retropharyngeal abscess, angioedema, peritonsillar abscess, and laryngeal papilloma. Croup is common in children aged 6 months to three years and it develops insidiously as an upper respiratory tract infection. Patients with croup have a characteristic barking cough. Laryngitis occurs in children aged greater than five, the voice is hoarse, and there is no stridor. Epiglottitis is more frequent in children aged 2-6 years. There is a short prodrome, drooling is noted, and the patient feels better when leaning forward. Patients with retropharyngeal abscess are usually younger than 6 years, and they do not have stridor. The voice is muffled and they are found to be drooling. Angioedema can occur at any age, onset is sudden, and clinical features of stridor, retractions of intercostal muscles, and facial edema are found. Peritonsillar abscess occurs in children greater than 10 years of age, onset is gradual but with sudden worsening, and there is no stridor. Laryngeal papilloma is encountered in patients of ages 3 months to 3 years, onset is chronic and voice is hoarse. The majority of foreign bodies are not visible by plain films. So, a normal radiograph can! never rule out aspirated foreign body in a highly suspicious patient like this.
STAT orders:
IV methylprednisolone, one dose
IV cefazolin, one dose
Bronchoscopy, stat
Surgery consult. Reason: Confirmation and removal of aspirated foreign body by bronchoscopy)
Primary Diagnosis: FOREIGN BODY ASPIRATION
11/ Location: Office
Presenting complaint: A 40-year old female patient presents with lump in her left breast.
Vitals: BP:130/80 mm Hg, Pulse:86/min, Temp: 98.7 0 F, R.R:16/min, Height:162.5cm, Weight:55 kg (12lbs).
HPI: A 40-year-old white female presents with mass in the upper outer quadrant of her left breast. She first noted this mass two months ago, the mass is painless and its size does not change pre or post-menstrually. There is no nipple discharge. She does not give a history of breast lumps. There is no family history of breast cancer. She is a 10-pack year smoker and drinks alcohol socially. She is married and uses oral contraceptives. The patient denies recreational drug use. Her age at menarche was 13 and her menses have always been regular. LMP was 10 days ago. She is gravida 2, para 2, one at the age of 23 and the other at 27. Both deliveries were spontaneous vaginal. Her mother is 65 and is diabetic; her father is 70 and has angina. The rest of her ROS are unremarkable.
1 – How to approach this case: This 40-year old female has presented with a lump in her breast. Careful examination of breasts and lymph nodes especially supra clavicular and axillary should be performed when any woman presents with a breast lump.
First order the physical examination: General examination HEENT/Neck Heart examination Lung examination Abdomen examination Breast examination Lymphnode examination
2 – Here are the results of examination: General, HEENT/Neck, heart, lung, and abdomen examination is WNL.
Breast examination: There is a 2 cm size solid, mobile, firm, non-tender mass with distinct margins, located in the left upper and outer quadrant. There is no nipple discharge. There are no skin changes. Lymphnode examination: There is no palpable lymphadenopathy.
Discussion: Based on the history and examination, this patient most likely has benign breast disease. There are multiple causes of benign breast disease. Fibroadenoma: Typically a 15-30 yr old female presents with firm, painless, mobile, (breast mouse) and well-circumscribed lumps. Fibrocystic changes: Multiple and bilateral cystic breast swellings, which are noted to be particularly painful and tender premenstrually. Papillomas: C/O bloody nipple discharge (Non-bloody nipple discharge is usually benign). Duct ectasia: Presents with fever, greenish cheesy discharge, pain, and tenderness. Mastitis: Patients complain of the sudden onset of pain, fever, chills, and local erythema, tenderness, and induration. Breast cancer: Consider risk factors first – elderly age, family history of breast cancer, early menarche, late pregnancy, nulliparity, and late menopause. On examination you have to look for the characteristics of cancerous lesion (Single, hard, immobile lumps with irregular borders and a size of more than 2cm).
The best way of making the diagnosis is by using a combination of physical examination, mammography, and fine needle aspiration cytology/biopsy (triple diagnosis).
Interpretation should be followed as.
If all three, suggest a benign lesion – Follow the patient with 3 to 6 monthly physical exam for 1 year to make sure the mass is not enlarging.
If all three, suggests malignancy – Refer to definitive therapy.
If any one of the three suggests malignancy – Perform excisional biopsy.
Women younger than age 35: Mammogram is not useful in this age group, as the breast tissue is very dense. However, it can be done in very high-risk patients. If you find a lump and appears to be cystic, perform FNAB/FNAC. If the aspirated fluid is non-bloody, the patient can be reassured and followed in four weeks to check for recurrence. If it recurs then the patient should be referred to surgical specialty. If the fluid is bloody, send it for cytology. If the mass is not cystic, obtain an ULTRASOUND. If ultrasound shows a solid mass, the patient should undergo biopsy (Core biopsy or excisional biopsy).
Women age 35 and older: The only difference from the above age group is all these patients should undergo bilateral mammogram along with clinical exam. Management is similar to the above group. Upto 15% of palpable breast cancers will not be visualized by mammogram. So, a negative mammogram doesn’t eliminate the need for biopsy in a patient with palpable mass. We will follow triple diagnostic approach here, and will perform mammography and FNAB.
Order Review:
Mammography, routine
FNA, breast, routine (Software will ask you general surgery consult)
*Schedule an appointment in one week
3 – Results: Mammography and FNAB are consistent with the diagnosis of fibroadenoma. In this patient, the fibroadenoma is small; therefore it does not need to be excised. The patient can be followed every three to six months for one year to assess the size of the mass.
Order review:
Reassure the patient
Follow up visit at 3 months
Screening of cervical cancer by Pap smear
Counsel the patient Patient counseling Contraception advise Safe sex Smoking cessation Limit alcohol intake Safety plan Seat belt use Regular exercise
Diagnosis: FIBROADENOMA OF THE LEFT BREAST
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