20/ Location: E.R C.C: Severe shortness of breath Vitals: Pulse: 130/min,Temp: 99° F, B.P: 120/70 with pulsus paradoxus, R.R: 34/min
HPI: A 36-year-old asthmatic man is brought to the ED by his co-workers with complaints of severe shortness of breath, cough, wheezing, chest tightness, and diaphoresis. He is unable to speak in phrases and his speech is restricted to single syllables between breaths. He was doing his routine work when he developed breathless and wheezing. He used his prescribed as needed inhalers twice, but his condition deteriorated. The patient has never been intubated or mechanically ventilated for asthma. He denies any chest pain, fever, chills, and hemoptysis. His other ROS are unremarkable. PMH: Bronchial asthma. FH: Mother has H/O bronchial asthma and father is healthy. SH: Married for 12 years. No children. Smokes 10 cigarettes for the last 10 years and drinks alcohol occasionally. Allergies: Pollen and dust. Medications: Albuterol 2 puffs Q 4 hrs prn. Vaccinations: Up-to-date.
How would you approach this patient?
Dyspnea alone doesn ' t signify pulmonary disease; it may be present in cardiovascular and pulmonary diseases. This patient has severe dyspnea. The management in such patients depends upon identifying the cause of dyspnea. The patient is a known asthmatic. Start with a broad differential diagnosis. Dyspnea in a patient with known asthma may be due to:
- Asthma exacerbation
- Status asthmaticus
- Pneumonia
- Pneumothorax
And few causes in the context of any case of acute dyspnea;
- Pulmonary Embolism
- Cardiogenic pulmonary Edema
- Cardiac tamponade
- Upper airway obstruction (foreign body aspiration, anaphylaxis)
On the basis of history and vitals, we cannot rule out the possibilities of pneumothorax, or pulmonary embolism; however most likely cause of acute dyspnea in this patient is Asthma exacerbation.
Order:
- Pulse oximetry, stat, and continuous
- IV access, stat
- Oxygen inhalation, stat
- Head elevation
Results: Pulse oximetry showed 89% O 2 saturations on room air
Order examination:
General, HEENT, Chest/Lungs, Heart, Abdomen, Extremities
Results of Physical Examination: HEENT: WNL, no JVD; LUNG/CHEST: Patient is agitated and unable to recline. He is gasping for breath and using his accessory muscles. Respiratory rate is 34/min. Percussion note is resonant in all lung fields. On auscultation of lungs, air entry is bilaterally equal. Loud inspiratory and expiratory wheezing is audible in all lung fields. CVS: Decrease in systolic B.P. on inspiration is 20 mmHg (pulsus paradoxus). There is no pedal edema. The rest of the exam is normal.
How do you approach now?
Pneumothorax is unlikely in the presence of breath sounds in all lung fields. Cor pulmonale refers to acute right heart failure due to pulmonary disease. Pulmonary embolism is mostly responsible for the acute decompensation of right heart. Pulmonary embolism is unlikely in the absence of chest pain, any predisposing factor such as orthopedic surgery. Wheezing may be present in such patients due to reflex bronchospasm. Pulsus paradoxus again is non-specific for pericardial tamponade. It may be present in asthma and severe COPD. Pneumonia is unlikely in the absence of fever and productive cough. Respiratory examination didn ' t reveal any crackles or bronchial breath sounds.
Order review:
- Arterial Blood Gas (ABG), stat
- CBC with diff, stat (to determine infectious exacerbation of asthma)
- BMP, stat
- Peak expiratory flow rate, stat (Type – PEFR)
- EKG, 12 lead, stat
- CXR, PA, portable, stat (to determine infectious exacerbation of asthma and rule out other causes)
- Albuterol nebulization, stat and repeat for every 20 minutes
- Methyl prednisolone, IV, continuous
- *Examine the patient in 20 minutes
Results:
ABG shows pH 7.35 pO 2 60 mmHg pCO 2 40 mm Hg
PEFR 40% of the documented personal best
CXR shows hyperinflation, no infiltrate, no pneumothorax or effusions
EKG is unremarkable for new changes except sinus tachycardia
Results after 20 min: He is breathing better but still in distress (If he doesn’t respond give ipratropium inhalations as well).
Review orders:
- Admit to ward
- Vitals every 2 hours
- PEFR every 2 hours
- Regular diet
- Ambulation at will
- Fluid replacement may be necessary due to volume depletion secondary to diaphoresis
- Monitor the patient ' s condition frequently
Next day:
- D/C albuterol nebulization Start metered dose albuterol – type albuterol, inhalation, continuous
- D/C IV steroids Start oral steroids – type prednisone, oral, continuous (Usually we will taper but the option is not available in software)
- Start inhaled steroids – type beclomethasone, inhalation, continuous
- Counseling: Patient counseling Smoking cessation Limit alcohol Regular exercise Use of seat belt Safe sex No illegal drug use Medication compliance
- Change Location: Send home Follow-up in 1-week
Primary diagnosis: Acute exacerbation of bronchial asthma
Summary:
Carefully assess the patient for degree of severity
Use Beta agonists early
Monitor the patient frequently and assess the response
Recognize features of impending respiratory failure and act accordingly
Do not forget to taper steroids
Emphasis on post exacerbation care plan (medication compliance, use, follow-up, recognition and self-management of attack)
Who should be hospitalized? Patients who do not respond to initial treatment should be hospitalized. Generally patients who do not respond to 3 doses of bronchodilators are considered as non-responders. Other factors such as severity of attack, severity of airflow obstruction, duration of symptoms, and past history of such episodes
Response to initial treatment is a better predictor for the need of hospitalization in a patient than is a severity of an attack
What are the features of impending respiratory failure? Impending respiratory failure is very important to identify. Patient will become mute and respiratory muscle fatigue will lead to paradoxical respiratory efforts. Chest will be silent and there will be no wheezes due to reduced air entry. Patient will be confused. PEFR will be less than 50% of personal best
What is the role of antibiotics? In most cases, which are usually due to viral infection, antibiotics have no role. Antibiotics are prescribed to patients with fever, leukocytosis and pulmonary infiltrate on CXR.
Is there a role of anxiolytics? Anxiolytics are contraindicated in patients with status asthmaticus due to concomitant respiratory depressant action.
Is there a role of mucolytics? Mucolytics are not useful in asthmatic patients as it may worsen airway obstruction.
21/ Location: Office C.C: Constipation
Vitals signs: B.P: 110/70 mmHg; HR: 88/min, regular; Temp: 37.8 C; R.R: 16/minute. HPI: A 62-year-old Caucasian male, who has a 15-year history of Type 2 diabetes, taking insulin, presents for evaluation of recent onset of constipation. The patient reports that he has been having only one or two bowel movements per week for the last four to six weeks. He has been experiencing intermittent constipation for the last four or five years but usually has three to four bowel movements per week. He also reports abdominal bloating and distention, especially after eating meals, but denies abdominal pain. He denies any nausea, vomiting, history of abdominal surgery, trauma, weakness in the limbs, or prolonged immobility. He describes the stools as very hard, and he must strain to defecate. His diet consists primarily of red meat. He has no known allergies. PMH: Is significant for diabetes. He takes a total of 20 units of NPH and 10 units of regular insulin every day. He was diagnosed with congestive heart failure following an acute MI two years ago. At that time, lisinopril 10 mg QD, furosemide 80 mg BID, and isosorbide dinitrate were prescribed. He says that his blood sugar has been under control for the last 15 years. He admits to regular exercise. His other medications include aspirin 81 mg po QD, simvastatin 20 mg po QD, and KCL 40 mg PO QD. He never had colon checked. FH is significant for heart disease in his mother. SH: Quit smoking when he had an MI. Occasionally takes alcohol. Denies IV drug abuse.
How would you approach this patient?
He is a 62-year old man with a past medical history of Type 2 diabetes and congestive cardiac failure, presents with progressively worsening constipation. Consider the common causes of constipation.
The causes of chronic constipation include:
Irritable bowel syndrome IBS ; Approximately 10 to 20 percent of the general adult population report symptoms compatible with irritable bowel. Poor bowel habits; inadequate fiber or fluid intake;
Systemic diseases such as diabetes mellitus, neurologic gut dysfunction as seen in spinal cord injury, Parkinsonism, or Multiple Sclerosis.
Hypothyroidism or medications like narcotics, calcium channel blockers, antidepressants, and anticholinergics can be responsible for constipation. (This patient does not use any of these medications.)
The common causes of recent onset constipation are: colonic obstruction, which could be due to a neoplasm stricture; diverticular disease; anal sphincter spasm resulting from anal fissure, painful hemorrhoids or medications.
Other causes to consider are: chronic pseudo-obstruction due to slow colonic transit; megacolon, obstruction of rectal evacuation caused by Hirschsprung ' s disease; pelvic floor dysfunction; rectal mucosal prolapse; or rectocele.
Also, evaluate the patient for eating disorders and depression.
Order: Complete physical examination include rectal
Here are the results of your physical examination:
On general examination, the patient appears alert, awake, oriented times three, and not in any distress. No thyroid abnormalities. Heart examination is within normal limits. Abdomen is soft, but mildly distended. Bowel sounds are active in all quadrants. There is no guarding, rebound, or tenderness. Examination of the extremities does not reveal any edema or ulcerations. The neurological examination does not show any weakness or changes in sensation. Rectal examination shows normal prostate, normal sphincter tone, no fissure, but the rectal vault is empty.
How would you proceed from here?
Order the initial investigations on an outpatient.
This patient could have constipation because of electrolyte disturbances, especially hypokalemia, due to prolonged use of furosemide.
CBC with differential, routine
BMP including calcium, routine
TSH, routine
Magnesium, routine Phosphate, routine (Hypermagnesemia, hypercalcemia, and hypokalemia can all cause constipation)
Hemoglobin A1C, routine
Hem-occult
LFTs (He is on simvastatin, which can cause elevation of LFTs)
Advise the patient to:
Begin a high fiber diet; increase water intake; exercise regularly;
Do frequent Accu-Checks; keep tight control of blood sugar.
Ask him to return with the results of the lab tests.
Order:
High fiber diet Plenty of fluids Regular exercise
Metamucil 2 tsp 3 times a day
Accu-Checks QID (4 times a day)
Patient education
Return to clinic in one week
On return to your office, the rectal examination does not reveal any anal fissures, hemorrhoids, or an enlarged prostate. The rectal vault is empty. Thyroid function tests, magnesium level, CBC with differential, and BMP are all within normal limits. Hemoglobin A 1C is 6.
The patient has tried increased bulk and water intake. He is exercising and his blood sugar is under control. However, he is still constipated.
How would you proceed? This patient likely has an underlying GI problem that requires further evaluation. The next step for this patient should be colonoscopy. You could choose to do a barium enema with sigmoidoscopy but a colonoscopy is more appropriate, especially if you want biopsies of possible mucosal lesions.
Order:
NPO past midnight
GI consult: Reason ‘Colonoscopy’
Treatment:
First make sure that the patient does not have nausea, vomiting, abdominal pain or fecal impaction.
Docusate is used prophylactically to prevent constipation, especially when the patient is bedridden or on narcotic medications. Magnesium containing compounds (milk of magnesium or magnesium sulfate) can be used in patients without renal insufficiency. Osmotic laxatives, alone or in combination with fiber supplements, should be tried before more expensive nonabsorbable carbohydrates like lactulose or sorbitol are used. For nonresponsive patients consider giving enemas, either Fleets or tap water. Oral Lactulose 30 cc
In the initial investigations get abdominal and chest x-rays to rule out obstruction. Colonic transit studies, anorectal manometry, and pelvic floor studies are usually reserved for patients who have resistant constipation without any organic explanation.
Diagnosis: Constipation secondary to ?
22/ Location: Emergency room C.C: Shortness of breath Vitals: BP: 120/70, HR: 70/min, regular, RR: 28 min, Temperature: afebrile
HPI: A 64 yr old Caucasian male with a history of orthopnea and PND presented to the ER at 7 PM with a complaint of 2 months of progressively increasing shortness of breath. His condition has acutely become worse over the past 2 days such that he now has shortness of breath at rest. The SOB is slightly relieved when he sits upright. He denies any chest or abdominal pain. He complains of mild cough with deep inspirations that are associated with occasional pink frothy sputum. He has a 20-pound weight gain since the symptoms began. He is also complaining of easy fatigability, swollen legs, and decreased appetite. He denies any fever, chills, nausea, vomiting or headache. Bowel movements are regular and he denies urinary problems. PMH: He is a known hypertensive and diabetic of 19 yrs. He had a Q wave MI 6 yrs ago that was treated with thrombolytic therapy. He also has a history of hypercholesterolemia. Medications: He is on metoprolol, lisinopril, glyburide, simvastatin, aspirin, and isosorbide dinitrate. Allergic history: NKDA. SH: The patient has smoked 1 PPD for the past 40 years. Occasionally drinks alcohol on the weekends. He is retired and lives at home with his wife. FH: Father died of a heart attack at the age of 70. Mother died at the age of 68 from breast cancer metastasis.
How would you approach this patient?
Elevate head of bed
Pulse oximetry, stat and continuous
Oxygen, inhalation
IV access, stat
Cardiac monitor 12 lead
EKG, stat
Results:
Pulse oximetry shows oxygen saturation of 89% on 3 liters oxygen.
EKG shows an old Q wave in inferior leads with no significant changes from the old EKG.
Now do the physical examination:
General Heart Lungs Abdomen Extremities
Here are the results of the Examination:
Moderate JVD+, Mucosa is moist.
Lungs: Bilateral decreased breath sounds with bibasilar crackles.
Heart: Rate and rhythm is regular. S1 and S2 heard. S3 gallop present.
Abdomen: Soft, Right upper quadrant tenderness is present. Liver is 1 cm below the right costal margin. Bowel sounds are present. No free fluid clinically.
Extremities: 3 + bilateral pitting edema, no calf tenderness, no cyanosis
So how would you approach this case?
So basically the issue here is the differential diagnosis of progressive shortness of breath. Again in the CCS all cases are really straightforward. As we said this is a straightforward case of congestive heart failure, but you should consider 2 other things in this pt. One is renal failure due to diabetes and hypertension and liver failure due to some other reason (for example; alcoholism, hepatitis etc) even though they are unlikely.
So, always start with a relevant broad differential diagnosis and then work from there because the ECFMG (CCS) expect this from you. You should be considering why he is having CHF recently even though he had an MI 6 yrs ago. One possibility is another MI, which may be silent because he is a diabetic patient (autonomic neuropathy). The other possibilities are worsening hypertension leading to diastolic dysfunction or noncompliance with medication and diet resulting in decompensation of systolic dysfunction.
Order the following.
Furosemide (Lasix), IV, stat and continuous
Chest- X ray PA and lateral views, stat
CK-MB, stat, and every 8 hours x 2 Troponin I, stat and every 8 hours x 2
CBC with differential, stat
BMP, stat
Results:
Chest – X ray is consistent with bilateral pulmonary edema.
CK-MB and Troponin-I are normal.
CBC and differential is normal. BMP shows Na 134 (Dilutional hyponatremia), K – 4.0, Chloride, CO2 and Ca are WNL.
Blood glucose is 380.
Order:
Admit to ward
Telemetry
Ambulate at will
Low salt diet Low cholesterol diet Diabetic diet
Fluid restriction Urine output Daily weights (type – weight, every day)
Continue all his home medications
KCL, oral, continuous (as long as you give Lasix)
Digoxin, oral, continuous
DVT prophylaxis (type – Pneumatic compression stockings)
BMP, next day (to check K and other electrolyte abnormalities with Lasix)
HbA1C, routine
Lipid profile, routine
Accucheck, every 6 hours
EKG, repeat in the morning
Echocardiogram, routine (to assess the left ventricular function)
Make sure the patient is on following medications for heart failure:
Aspirin
Beta blocker (metoprolol)
ACE inhibitor (Enalapril or lisinopril)
Digoxin
Diuretic
Ok now we know that this most likely due to CHF. So what do you do for this pt?
Continue aspirin
Continue IV furosemide along with oral potassium because furosemide will cause hypokalemia. Order daily BMP.
Determine the
Beta blockers have clearly shown benefit in heart failure; so, they should be continued unless the patient is in acute pulmonary edema or has hypotension.
Continue lisinopril (ACE inhibitors should be added if the pt is not on ACEIs)
Digoxin is optional. It is particularly indicated if the patient is having atrial fibrillation or severely symptomatic.
Start insulin– order NPH and regular insulin
Continue simvastatin
.
You have admitted the patient. The next day is the day two. What is the plan?
Examine the patient
Consider converting IV to oral diuretics
Determine if the patient stable for discharge?
Assess the need for oxygen therapy. The goal saturation is 92 to 96%. Wean the oxygen if his pulse oxygen shows saturations of >92.
At the time of discharge consider the following: Patient education Cardiac rehabilitation program Smoking cessation program Alcohol cessation program Regular exercise Medication compliance Seat belt use
*Follow up in 2 weeks
Primary diagnosis: Exacerbation of CHF
23/ Location: Emergency Room Afebrile C.C: A 75 yr old nursing home patient with decreased urine out put and altered mental status
Vitals: BP: 102/68 in both arms , HR: 110/min regular rhythm , RR:16/minute ,.
HPI: A 75-year-old Nursing home patient is brought to ER for one day of altered mental status and decreased urine output. The patient is unable to give any history. The nursing home staff says that he has been having watery stools for the last 4 days. He has 7-10 loose bowel movements per day. Stools have no foul smell, no mucous or blood. He has been drinking fruit juices and oral formula for the last 3 days, but has not urinated in the last 12 hours. They denied any history of fever, chills, chest pain, shortness of breath and abdominal pain. PMH: His past medical history is significant for type II DM, hypertension and osteoarthritis. SH: The patient does not smoke or drink alcohol. FH: Father died at the age of 90 with Alzheimer ' s disease and mother died in motor vehicle accident. One brother has diabetes. Medications: Current medications are lisinopril 5mg once daily, NPH insulin 10 U in the morning and 15 U in the evening, metoprolol, simvastatin, aspirin, ibuprofen and multi vitamins. His vaccinations are up-to-date. Allergies: Iodine and shellfish.
How would you approach this case?
Based on the history you may consider decreased urine output secondary to acute renal failure. Also consider dehydration leading to acute prerenal failure, diabetes causing possible intrinsic renal cause (DM), and post-renal obstruction (BPH).
The other possible causes of altered mental status in this patient include DKA, hypoglycemia, hypertensive crisis, stroke etc.
Order: Complete physical examination
Results of the physical examination: HEENT:
Now how would you approach this patient?
This patient is dehydrated, so the primary things to order are:
Pulse oxy, stat STAT
IV line placement
Foley catheter, you are not sure of bladder residual volume in this elderly patient
12 lead EKG, stat
ABG, stat
CBC with differential, stat
Mg and Phosphate, stat
BMP (Na, K, Chloride, HCO3, BUN, Cr, Blood sugar, and Ca) stat and Q 8 hrs
Urine analysis, stat
Urine culture and sensitivity, stat
Urine sodium and creatinine, stat
The Foley is placed; 30 ml of residual volume is noted. NSS IV fluid is running.
What do you do now? Your initial assessment of the patient
1) What is the hemodynamic status? Dehydrated patient should be hydrated. A volume overloaded patient should be given diuretics. CVP (central venous pressure should be recorded by placing an order for central venous line in unstable patients)
2) What is the type of renal failure? Prerenal, renal or post renal – will decide the main mode of treatment.
3) Is there a need for urgent hemodialysis? The indications for urgent hemodialysis are refractory acidosis, refractory electrolyte disturbances, intoxicants, volume overload (pulmonary edema), pericardial rub, uremic encephalopathy, bleeding tendencies, and arrhythmias.
4) What is the most likely etiology? Labs reveal a BUN of 90, creatinine of 2.3, potassium of 5.6 and mild protenuria. So how would you proceed?
If the BUN (
If the patient is taking nephrotoxic drugs like NSAIDs, stop the drugs immediately. Ibuprofen is an NSAID and it aggravates the renal failure. ACEIs are indicated in DM type 2 for their renal protective effect, but in established renal failure with a creatinine of more than 2.0 to 2.5 their use should be restricted.
Now it ' s the time to determine the cause of the renal failure.
1 st determine whether the cause is low renal perfusion (prerenal) (or) disorders of parenchyma (renal) (or) obstructed urine flow (post renal). There are 3 ways to differentiate prerenal from renal causes. The best way of assessing is by calculating F E Na (Fractional Excretion of Sodium).
Prerenal: F E Na <1; urine sodium <20 meq/L; Disproportionate increase of BUN/Cr ratio >20:1
Renal: F E Na >1 ; urine sodium >20 meq/L; Proportionate increase of BUN/Cr ration < 20:1
A short explanation to understand the causes: Prerenal azotemia can lead to ATN, which is the most common cause of the acute renal failure. Two basic mechanisms: a) Decreased effective intravascular volume (includes third space loss) b) Decreased cardiac output. Renal causes have specific etiologies ranging from infectious to toxin mediated and can be treated with specific etiology directed therapy.
Post renal or obstructive must be promptly treated to avoid any damage to the kidney. Two most common are BPH and nephrolithiasis.
Here the case scenario is of a pre renal failure most probably due to dehydration resulting from diarrhea.
Order routine:
Discontinue lisinopril
Discontinue ibuprofen
Continue rest of his current medications
Diabetic and renal diet with 100% hand assistance (Only if the patient is awake
Transfer to the floor/ward
Vitals q2h 24hr urine protein
Daily weights Strict input and output
Complete bed rest until his mental status returns to baseline
Heparin 5000 U SQ Q12 hrs to prevent DVT
Renal ultrasound, routine. Stat order is placed only if you suspect an infective/renal/obstructive cause.
Acu checks (blood sugar), QID (4 times a day)
HBA1C levels, routine
Sliding scale insulin
Finally treatment: In prerenal the goal of the treatment is to increase the renal blood flow.
If the patient is dehydrated continue I.V hydration.
If the patient does not respond to fluids, start Lasix (furosemide) to increase the urine output.
If the cause of the renal hypoperfusion is heart failure you can start dobutamine and dopamine.
The use of sodium bicarbonate (type NaHCO) is rarely needed unless the patient is in severe acidosis i.e. pH of <7.2.
Review orders: Once the patient ' s mental status is improved
Discontinue (D/C) bed rest Out of bed to chair
D/C Foley catheter
Continue renal diet
Plenty of oral fluids
Other considerations:
Pericardial rub or rales – Chest X- ray (Both PA and lateral view)
Fever – Blood cultures, Immediate renal ultrasound, urine culture and start antibiotics (Ciprofloxacin)
Treat hypertension
Obstruction – order urology consult. Before getting a consult please order urgent renal ultrasound and don ' t forget to catheterize.
Patient may take days to weeks to recover
Recovery diuresis should be treated with half (0.45%) NS and frequent electrolyte monitoring.
Primary diagnosis: Acute renal failure or prerenal azotemia
24/ Location: office CC: A 16-year-old girl presents with heavy menstrual bleeding.
Vitals: Pulse 86/min, Temp 98.7 F, R.R 16/min, Height: 162.5cm, Weight: 55 kg (12lbs) HPI: A 16-year-old girl presents with the complaints of irregular and heavy menstrual bleeding for the last two months. She started menstruating at 13 and her cycles have been regular until 2 months ago. She has been sexually active with her boyfriend for the last month and they have always used condoms. She denies any burning on urination or vaginal discharge. She uses no medications. Her appetite and weight are normal. She is doing well at school and has no emotional stressors. The rest of the ROS is negative. Allergies: Penicillin. Immunization history: Up to date. FH: Father is healthy at 43; mother is 38 and has asthma. Maternal grandfather died of colon cancer at 60. She has one younger brother who is healthy. SH: She does not smoke, drink alcohol or use recreational drugs. Recreational history: Attending parties and watching movies
How to approach this case: This young woman presents with abnormal uterine bleeding. In adolescent females and in perimenopausal women, dysfunctional uterine bleeding is in most cases due to anovulation thus it exposes the endometrial lining to unopposed estrogen stimulation. DUB is a diagnosis of exclusion, therefore other causes of abnormal uterine bleeding need to be ruled out. Any woman of reproductive age with DUB, pregnancy must be suspected. Reproductive tract problems like Leiomyoma, adenomyosis, endometriosis, PID and sexually transmitted diseases may be responsible. Polycystic ovary disease is another important cause. There may be endocrine causes like hypothyroidism, hyperthyroidism and hyperprolactinemia. Liver disease and other coagulation disorders may also be responsible. Therefore, careful history and examination as well as certain lab tests need to be performed before a diagnosis of DUB can be made.
ORDER Examination:
General HEENT (especially for thyroid enlargement and visual field defects)
Skin examination (especially for pallor, petechiae)
Heart exam Abdominal exam
Genital examination (for vaginal discharge, enlarged uterus, adnexal masses etc.) Extremity
Result of examination: Skin: no petechiae, no pallor, and no hirsutism HEENT: normal eyes, normal visual fields, normal vision, ears are normal set and normal hearing. Thyroid gland is normal. Genital: normal female genitalia, no vaginal discharge, no vaginal or cervical lesions, uterus is of normal size, no adnexal masses or adnexal tenderness. Rest of her exam is WNL.
Labs:
Pregnancy test, serum, qualitative, routine (for ectopic pregnancy, abortion)
Pap smear, routine (pap smear should be performed when sexual activity is initiated even in a female younger than 18)
Serum TSH, routine (hypo or hyperthyroidism)
Serum prolactin, routine
CBC with differential, routine (to determine platelet count as low platelet counts result in disorders of primary hemostasis, to look for anemia due to chronic blood loss)
PT, routine (for disorders of secondary hemostasis) PTT, routine (for disorders of secondary hemostasis)
There are other tests, which can be performed, in selected patients.
If alcoholic or viral hepatitis is suspected and other features of liver disease are found, LFTs need to be performed.
In perimenopausal women, endometrial biopsy must be performed to rule out endometrial cancer.
Pelvic ultrasound may be needed in cases of PCOS, in cases where pelvic examination is suboptimal due to obesity and in suspected cases of ovarian tumor.
Generally patients with DUB can be managed without imaging studies.
Result of Labs: Pregnancy test is negative Pap smear: normal Serum TSH: 1microU/mL Serum prolactin: 5ng/mL CBC with differential: WBC counts: 8,200/mm3 (normal differential); Hemoglobin: 10.9 g/dL; Platelet counts: 200,000/mm3; MCV: 78fl. Peripheral blood smear: Hypochromic and slightly microcytic erythrocytes; Leukocytes and platelets normal in number and morphology. PT: 10 sec PTT: 25 sec
*
Review order:
OCP, low estrogen, low progestin, continuous
Iron sulfate, oral, continuous
Iron enriched diet
Reassure the patient Safe sex counseling Medication compliance No smoking No alcohol No illegal drugs Regular exercise Seat belt use
Primary Diagnosis: Dysfunctional uterine bleeding
25/ Location: Emergency Room. HPI: The patient is a 16-month-old male who is accompanied by his mother who provides the history
Vitals: Temperature 38.0, respirations 30 per minute, blood pressure 101/68, heart rate is 90/min.. This patient began to get ill two days prior to coming to the Emergency Room with a runny nose and mild cough. The mother reports that she thought he had a low-grade fever because he felt subjectively hot; however, she did not take his temperature. The patient has continued with his regular activities and is eating, drinking and urinating as usual. However, on the evening of presentation, the patient began to have a more severe, harsh, barking-like cough that has increased in severity over the past ten hours. The patient has become increasingly hoarse and has, according to mother, " noisy breathing. "
REVIEW OF SYSTEMS is negative except for some complaints of sore throat, although it is difficult to determine because of the patient ' s age. Mother denies the patient getting into any small objects which he may have ingested. PMH: The patient was born by normal spontaneous vaginal delivery. He had a circumcision. He went home with his mother after 24 hours. He is up to date on all of his immunizations including DTaP, Haemophilus influenza B, and pneumococcal conjugate vaccines. He has had one episode of otitis media in the past year. Social history: He attends daycare three times a week. His lives with his mother, father, and seven-year-old sister. They have no pets in the house.
How do you approach this patient:
Pulse oxy, stat
Result: O2 saturation is 98% on room air,
Perform physical examination: General HEENT Lymph nodes Lungs Heart Abdomen Extremities Skin Neurologic
Here are the results: In general, the patient is in no acute distress. He is sitting on his mother ' s lap and is somewhat playful, although he does have a harsh barking cough. HEENT: Mucous membranes are moist. There is no perioral cyanosis. Oropharynx shows erythema without any exudate. The neck is supple. There are a few scattered shotty nodes on the anterior cervical chain. Conjunctivae are slightly injected. Coryza is present. Tympanic membranes are pale with normal light reflex bilaterally without any bulging of the tympanic membranes. Cardiovascular: The patient has a regular rate and rhythm without murmurs, rubs or gallops. Lungs are clear to auscultation bilaterally, although there is a harsh barking cough, and there are chest wall retractions. There is slightly diminished air entry bilaterally. No crackles, rhonchi or wheezes. Abdomen is soft, nontender, nondistended with positive bowel sounds in all four quadrants. Extremities show capillary refill of less than two seconds. The extremities are pink and well perfused with 2+ pulses in all four extremities. Neurologic: The patient is awake and alert. He gets upset during the exam but is easily consoled by his mother.
Discussion: The differential diagnosis for this patient ' s problem includes:
Viral croup. 1. Bacterial croup. 2. Spasmodic croup. 3. Epiglottitis. 4. Foreign body ingestion. 5. Bacterial tracheitis. 6. Angioneurotic edema. 7.
The case presentation and history are more consistent with a viral etiology for the patient ' s croup. The most common viruses are parainfluenza 1, 2, and 3, but croup can also be caused by adenovirus, respiratory syncytial virus, and influenza A and B viruses. Influenza A in particular can cause a fairly severe croup syndrome. Children with croup can also become secondarily infected and develop a bacterial tracheitis.
It is important to recognize which children have a benign viral picture compared to those who have a bacterial etiology necessitating antibiotics to cover for the most common pathogens, which are Strep. pneumoniae, Staphylococcus aureus, Haemophilus influenza, Moraxella catarrhalis as well as Streptococcus pyogenes. In general, the child with viral croup is going to look less toxic than the child who has bacterial croup or bacterial tracheitis. In the latter two disorders, fever is usually higher, the severity of respiratory symptoms is worse and the child may have a more toxic appearance. Since the introduction of the Hib vaccine, very few cases of epiglottitis have been seen in the
Laboratory workup: Croup is a clinical diagnosis and laboratory studies are usually not very helpful; however,
CBC may show an elevated white count around 10 with a predominance of polymorphonuclear leukocytes on the differential.
Pulse oximetry usually reveals normal oximetry as this is not a lower airways disease and air exchange is good.
Neck X rays can be obtained and they may show a classic steeple sign with subglottic narrowing (croup). However, in children in whom the tracheal cartilage is still soft, there can be a false steeple sign secondary to the respiratory phase as the trachea slightly collapses on expiration. Therefore, a good inspiratory film is necessary to evaluate steeple sign in children.
Treatment:
The first line of treatment is to start the child on cool humidified mist. This simple treatment can relieve airway edema and decrease the viscosity of tracheal mucus so that patients can clear their secretions better. Many children ' s croup will be relieved just with cool mist treatment. However, patients should be monitored during cool mist treatment because it may induce or exacerbate bronchospasm in susceptible children. In most cases, however, at least a trial of cool mist treatment is warranted and further treatment is warranted if there is no improvement.
The next line of treatment is oral or IV steroids. Decadron (Dexamethasone) is the most extensively evaluated corticosteroid used in the treatment of croup. The usual dose is 0.6 mg/kg of dexamethasone up to a maximum of 10 mg. This can be given orally or intramuscularly and clinical trials of dexamethasone have shown that it has improved symptoms of croup compared to placebo. The use of nebulized racemic or L-isomer epinephrine is also used to treat severe croup symptoms. Epinephrine is thought to increase fluid resorption in the airway vessels within the bronchial tree and reduce capillary leakage from interstitial space and therefore decrease mucosal edema. A predictable side effect, however, of epinephrine is tachycardia and therefore it should not be used in patients who have a history of congenital heart defects in whom tachycardia can be deleterious, including those children with tetralogy of Fallot or those with ventricular outlet obstruction.
Children with moderate to severe croup should be treated with the cool mist as well as nebulized epinephrine. There is some concern for rebound mucosal edema after nebulized epinephrine treatment and therefore children should receive a dose of Decadron prior to or shortly after receiving the epinephrine in order to decrease rebound edema. The patient should also be monitored for approximately four hours in the Emergency Room prior to discharge home. If they have no stridor at rest, normal air entry bilaterally, normal color and normal level of consciousness, and they have received their dose of Decadron, they can then be safely discharged from the Emergency Room.
Other management options for children with croup that is severe include heliox which is a mixture of helium and oxygen. This can be used in croup because the children usually do not have significant hypoxemia. Heliox can be used when the amount of oxygen being provided to the patient is 40% or less. The heliox mixture allows for laminar flow through the airways and provides better delivery of oxygen. It may be used in children who have laryngotracheitis which has extended into the bronchii and small airways causing a pneumonitis. These children are usually sicker and require inpatient management.
In those children in whom possible secondary bacterial infection is suspected, treatment should be directed at the most common pathogens which were noted above and initial treatment can be with a second generation cephalosporin such as cefuroxime or a combination of a semi-synthetic penicillin like Nafcillin or oxacillin and a third generation cephalosporin. Most cases of croup, however, are viral in nature and supportive therapy is all that is required.
Primary diagnosis: Viral croup
Location: Ambulatory Clinic. C.C: 6mo Vomitings and diarrhea
Vitals: Temperature 38 rectally, heart rate 155/min, blood pressure 95/55mm Hg. The patient ' s weight is 7.2 kg.
HPI: The patient is a six-month old white female who is brought in by her mother for evaluation of a three-day history of vomiting and profuse diarrhea and low-grade temperatures. Mother brings her to the clinic today because the infant has become increasingly irritable and fussy when she is awake and today has become much more somnolent and does not want to feed. She has not had any wet diapers since the evening before. However, she still is having bowel movements. Mother reports that the patient has had approximately eight to ten bowel movements a day for the past two days. She has been giving the infant an increased number of breast feeds at approximately three-hour intervals; however, the child frequently vomits the milk and also has runny diarrhea. The baby has refused to take any of the rice cereal which she has been introduced to for the past month. Mother reports that the vomiting is nonbilious. It mainly consists of partially digested milk. It is not projectile and it is nonbloody. The diarrhea is watery and yellow and there does not appear to be any blood or mucus in the stool. The mother reports that the baby ' s temperature has been as high as 101. The mother reports that at her visit to the doctor ' s about three weeks ago for her immunizations she was almost 8 kg. PMH: The patient was delivered at 40 weeks gestation by normal spontaneous vaginal delivery. She had no birth complications and was discharged home with her mother. This patient has been meeting her developmental milestones appropriately. She is able to roll over front to back and back to front. She babbles and coos and can sit upright for brief periods with minimum suppo! rt. IMMUNIZATIONS are up to date. She just had her six-month vaccinations about two and a half weeks ago. Social history: She lives with her mother and father and a three-year-old sibling (brother) who attends daycare one day a week. The parents are nonsmokers. There are sick contacts in the house as the older brother had a diarrheal illness earlier last week. The family has city water. They have not traveled. REVIEW OF SYSTEMS: is positive for irritability, decreased urine output, decreased
How do you approach this baby: General HEENT Neck Lungs Heart Abdomen Genitourinary Skin Extremities CNS
Here are the results: In general, the patient is a well-developed, well-nourished white female lying somewhat listlessly in her mother ' s arms. She does not fight against the examiner during the physical examination.
HEENT: Anterior fontanel is open and depressed. Posterior fontanel is closed. Mucous membranes are dry. Eyes are slightly sunken with dark circles underneath them. Tympanic membranes are pale with good light reflex bilaterally. Neck is supple. There is no evidence of meningeal irritation to neck flexion or extension. There is no cervical lymphadenopathy. Pupils are equal, round and reactive to light. Oropharynx is clear. Cardiovascular: Heart rate is regular rhythm but somewhat tachycardic. There is a II/VI systolic ejection murmur along the left sternal border. Lungs are clear to auscultation bilaterally. Abdomen is soft, nondistended and nontender. There are hyperactive bowel sounds in all four quadrants. Extremities: Pulses are +2 in all four extremities. Capillary refill is about 3-4 seconds. GU:
DIFFERENTIAL DIAGNOSIS for this child with acute diarrhea as well as vomiting: At the top of the list is an infectious gastroenteritis with the two main groups being viral gastroenteritis–with etiologies including rotavirus, enterovirus, adenovirus and Norwalk agent–and the bacterial enterocolitis agents including Shigella, Salmonella, Yersinia, Campylobacter, enteroinvasive E. coli, enteropathogenic E. coli, and C. difficile colitis. Other possible etiologies of acute diarrhea include extraintestinal infections such as otitis media and urinary tract infections, and GI causes including intussusception,
appendicitis, and hyperconcentrated infant formula. Other causes include antibiotic-induced diarrhea, vasculitides such has Henoch-Schonlein purpura, renal diseases including hemolytic uremic syndrome and toxic ingestions including iron, mercury, lead and fluoride ingestion.
This patient ' s clinical presentation includes
(1) a sick contact with a three-year-old sibling who had self-limited gastroenteritis symptoms the prior week,
(2) low-grade temperature,
(3) the lack of any preceding use of antibiotics, and
(4) nonbloody stools.
The most common cause for this picture is acute viral gastroenteritis.
How do you proceed: LABORATORY STUDIES: Depending on how dehydrated the patient appears clinically, one might forego any laboratory studies and just treat her symptomatically with either oral electrolyte replacement solutions or IV rehydration in the clinic setting. However, based on her change in weight, it appears that she has lost about 7-10% of her body weight and is showing clinical signs that she is significantly dehydrated. Therefore, appropriate labs to obtain would be a basic metabolic panel and a CBC with differential. Stool should be heme checked and if it is positive, then stool samples could be sent for culture. If there had been a past history of antibiotic use, then a C. difficile antigen could be sent to rule out C difficile colitis. If the patient is being seen during the winter months, then stool can be sent for rotazyme assay since rotavirus can cause up to 65% of infant diarrhea during winter months. Stool can also be sent for fecal leukocytes, which also help to indicate that it is an infectious or inflammatory process. Because this child is moderately dehydrated, a urinalysis should also be sent to look for urinary tract infection.
The patient should be given a fluid bolus with normal saline 20cc/kg IV until the labs come back. A repeat fluid bolus can be given as well. The patient should be allowed to feed as tolerated. In this case, the patient is breast-fed so orders for breast-feeding ad lib would be appropriate. It can be helpful if the mother can feed the infant in smaller more frequent feedings whether breast-fed or bottle-fed. In addition, bottle fed infants can also be given an oral electrolyte solution; again small frequent feedings are preferable to decrease stomach irritation and reflex vomiting.
Review orders:
IV access
CBC with diff, stat
BMP, stat
Urine analysis
Stool heme check Stool for leukocytes Stool culture
Breast-feeding ad lib
Here are the results: Laboratory studies return. CBC shows a white blood count of 11, hemoglobin 14, hematocrit 42.1, platelets 370, differential shows segmented cells 52%, lymphocytes 20%, monocytes 5%, eosinophils 10%. Basic metabolic panel shows a sodium of 131, chloride 106, potassium 3.2, CO2 18, BUN 22, creatinine 0.6, calcium 9.8, glucose 87. A catheterized urine specimen yielded a scant amount of dark amber clear fluid. Specific gravity 1.032, negative for esterase, negative nitrates, no blood, 1-5 white blood cells, 0 red blood cells, no casts. Culture eventually is negative.
· DISPOSITION: This patient should be admitted to the hospital for IV fluid rehydration because she is greater than 5% dehydrated, not taking enough oral fluids to meet her maintenance needs, and showing a declining mental status with irritability and listlessness.
Review orders:
Admit in ward/floor
IV Potassium
Vitals Q 4 hours Recheck the BMP next day
Repeat physical exam for every 4-6 hours
Once the patient is adequately hydrated and the BMP is normal, discharge the patient to home.
DISCUSSION:
· Acute gastroenteritis is a very common pediatric problem and because many of the etiologies are self-limited, the clinician should direct attention to the patient ' s overall fluid and electrolyte status as top priorities in management. Attention should be paid to the patient ' s vital signs looking for tachycardia and evidence of weight loss.
· The physical exam should focus on hydration status by looking at mucous membranes, sunken eyes, skin turgor and capillary refill, which in normal children is less than two seconds. Abdominal exam should focus on whether there is any distention, tenderness or masses; frequently bowel sounds are hyperactive in viral or bacterial gastroenteritis. Direct inspection of the stool can be helpful as bloody or mucous stool is more often associated with bacterial pathogens and would direct investigations towards those etiologies. One would send a stool culture for Shigella, Campylobacter, Salmonella and Yersinia as well as the enteroinvasive E. coli.
· Pathogens that will require more than just supportive treatment with fluids and electrolytes include Campylobacter jejuni infection, which is treated with erythromycin; C difficile colitis, which is treated with metronidazole; and systemic salmonellosis, which is treated with fluoroquinolones or azithromycin or third generation cephalosporins such as ceftriaxone or cefotaxime. Bactrim may also be started empirically, but there is increasing resistance of Salmonella to Bactrim. In those children whose diarrhea is due to Giardia, a variety of drugs are used: metronidazole, furazolidone, or quinacrine, for example.
· History taking should include questions about travel, well water (since Giardia can contaminate well water), immunization status, sick contacts, and daycare attendance (since Campylobacter outbreaks have been found in daycare centers). One should also ask about the duration of symptoms, fever, and the number, character, and color of the stools, particularly whether there is any blood or mucus in the stools.
Primary diagnosis Acute gastroenteritis
27/ Location: Emergency department HPI: The patient is a nine-year-old African-American male who presents to the ER with his mother with a 16-hour history of fever, poor eating, and abdominal pain.
Vitals: Temperature 38.4, blood pressure 101/62 mm Hg, heart rate 95/min, and respirations 14/min. The mother reports that the patient only picked at his dinner the night before and then went to bed early. During the middle of the night, she noted that he was hot to the touch but she did not take his temperature. In the morning, the patient had emesis one time, did not eat any breakfast and complained to his mother of abdominal pain. She then made an appointment to bring him to the clinic for further evaluation. You see the patient walking down the hallway of the clinic to go to his room and note that he is slightly bent forward and walking very carefully without lifting his feet very far off the ground. He looks ill. The history from the patient reveals that he has abdominal pain which he poorly localizes and points to the center of his stomach as to the site of the pain. He had one loose bowel movement this morning but otherwise denies any diarrhea, constipation, melena, bright red blood per rectum, dysuria, and frequency. He also denies sore throat, cough, rashes and joint complaints. Mother reports that the patient had been in his usual state of health until about suppertime the prior evening.
REVIEW OF SYSTEMS is as above and otherwise negative. PMH: The patient is a healthy nine-year-old boy with no past medical history. He attends the fourth grade. His immunizations are up to date. He has never been hospitalized. Past surgeries only include circumcision which was uncomplicated. Development: He is in fourth grade, a B student. He does well socially and plays Little League baseball. SH: The patient lives with his mother and five-year-old sister. There are no sick contacts in the house. There are no smokers in the house. They have city water.
How do you approach this patient?
General HEENT Neck Heart Lungs Abdomen Rectal Extremities Skin Genitourinary
Here are the results: PHYSICAL EXAM: In general, the patient is alert and oriented, in moderate distress, lying very still on the exam table with both knees bent up. He ' s cooperative with the exam, but appears apprehensive. HEENT: No abnormalities detected. Cardiovascular exam shows regular rate and rhythm without murmurs, rubs or gallops. Lungs are clear to auscultation bilaterally. Abdomen: Decreased bowel sounds. No hepatosplenomegaly. The patient has voluntary guarding during the exam. He points to the periumbilical area when asked to define where the location of the pain is. On palpation of the left lower quadrant, he complains of pain on his right lower quadrant.
He has moderate voluntary guarding over the right lower quadrant. There is no distention and no tympany. Upon palpation of the right lower quadrant, there is rebound tenderness. Extension of the right leg from its flexed position where the patient has kept it elicits increased pain and the patient resists the extension manuever. GU: Tanner I circumcised male. Testes are descended bilaterally. There are no hernias appreciated. Femoral pulses are +2. Rectal is heme negative. No masses are palpated nor does exam elicit any further tenderness. Extremities reveal +2 pulses in all four extremities with good capillary refill. Skin is without rashes or signs or trauma.
Order:
Pulse oxy, stat CBC with diff, stat BMP, stat LFTs, stat
PT/INR, stat PTT, stat
FOBT
NS Abdominal ultrasound, stat
Abdominal x-ray, stat
NPO IV fluids,
Next order: Surgery consult, stat
Analgesia, stat (once the diagnosis is confirmed)
IV cefazolin, stat IV metronidazole, stat
Discussion: This patient ' s presentation is strongly suspicious for acute appendicitis. However, in some children a Strep throat infection can also cause abdominal symptoms. In the absence of any history of sore throat and with this patient ' s presentation, one probably does not need to order a rapid Strep test. Any child who does have any complaint of sore throat, however, probably should have a rapid Strep done before going to surgery for an appendicitis. Other labs to order include basic metabolic panel, CBC with differential, heme check the stool, plain film of the abdomen. A urinalysis is frequently obtained to rule out a urinary tract infection. Results can be confusing since the inflamed appendix is often in close proximity to the bladder and ureter; as a result, microscopic hematuria and pyuria are found in up to one-third of patients with acute appendicitis. Pelvic cultures may be useful in sexually active, menstruating women. A beta-HCG is mandatory to rule out an ectopic pregnancy. Further imaging studies depend on what the initial laboratory results show and include an abdominal ultrasound to see if there is any fluid collection. However, ultrasound on pediatric patients is sometimes difficult to interpret because of the lack of qualified technicians to perform the study.
DISCUSSION: The most common age range for appendicitis in children is between the ages of 10 and 15 years of age. This child is nine years old and a little bit outside of the range. Less than 10% of children with appendicitis are under five years of age and those children who are under two years of age are frequently missed and often have a perforated appendix before they are diagnosed. Other causes of abdominal pain that can mimic an appendicitis include enterocolitis caused by Campylobacter and Yersinia. They both can have right lower quadrant abdominal pain and tenderness.
Here are the results: A basic metabolic panel may just show an elevated BUN, suggesting some dehydration. A CBC may show an elevated white blood count with a left shift, although the white count usually is not above 20,000. The plain film of the abdomen may show a fecalith, although this is not very frequent. An abdominal ultrasound may sometimes show the inflamed appendix. CT of the abdomen with oral contrast may show the enlarged dilated
appendix.
DISCUSSION: For any child in whom one suspects appendicitis, an early surgical consult should be obtained as these patients need to be taken to surgery expeditiously. The risk for perforation increases markedly after 24 hours and those who are not diagnosed prior to 36 hours have a very high risk of perforation. Perforation carries with it the increased risk of abscess formation and diffuse peritonitis with higher morbidity and mortality. The role of antibiotics for an unperforated appendix just includes perioperative antibiotics (We prefer a combination of cefazolin and metronidazole; Postoperative antibiotics are unnecessary); for those who have perforated, triple antibiotics with ampicillin, gentamicin and metronidazole would be appropriate.
Primary diagnosis: Acute appendicitis
28/ Location: Outpatient clinic HPI: The patient is a three-month-old infant with two to three day history of runny nose with congestion, low-grade fever, and poor eating
Vitals: His temperature 37.8, pulse 145, respiratory rate 33, blood pressure 88/52.. He also vomited several times and the emesis is usually mucus mixed with some of his feeds. He is more irritable and has difficulty feeding but appears to be still taking in his usual amount of formula. Mother reports, however, instead of feeding the formula over 15 minutes, it is taking the baby 35-40 minutes to finish his usual bottle of formula. The patient ' s temperature has been a maximum of 100.6. He has two older school age siblings who had upper respiratory infections during the past week. Mother is concerned because the baby ' s breathing is much more noisy. ROS: Somewhat increased irritability but consolable. Urine output is normal. No diarrhea. No constipation. Vomiting as noted above. No episodes of cyanosis or apnea episodes or rashes. PMH: The patient was born via normal spontaneous vaginal delivery. He was circumcised and had no bleeding diathesis. He went home with his mother after 48-hour hospital stay. He has had his two-month immunizations including DTAP, HIB, second hepatitis B, pneumococcal conjugate vaccine, and IPV. Development: He has been meeting his milestones. His eyes track to 180 degrees bilaterally. He moves all of his arms and legs well. He does not yet roll over. He has a fair degree of head control. He has a social smile and interacts well with his family. SH: He lives with his parents and two older siblings. They have two cats in the house. They have well water. The patient does not attend any daycare. There is no smoking in the home. FH: Family history is positive for allergic rhinitis and is otherwise negative. Mother was Group-B Streptococcal infection positive an! d received prophylactic antibiotics intrapartum.
How do you approach the baby?
Pulse oximetry, stat
Result: O2 saturation is at 95% on room air,
Order physical exam:
General HEENT Neck Lungs Heart Abdomen Extremities Skin
Here are the results of physical exam: The patient weighs 6.3 kg and is in the 75 th percentile for length and 50 th percentile for head circumference. In general, the patient is awake, alert, and in no acute distress. HEENT: Pupils are equal, round and reactive to light. Extraocular eye movements are intact. The patient follows past the midline. His mucous membranes are moist. Neck is supple without lymphadenopathy. There is occasional nasal flaring. Nares are patent bilaterally but the mucosa is edematous. There is a profuse clear rhinorrhea. Tympanic membranes are pale with good light reflex bilaterally. Anterior fontanel is open, flat and soft. Heart is within normal limits (WNL). Lungs show bilateral diffuse wheezes and rhonchi in all lung fields. There are mild subcostal retractions but no paradoxical abdominal movement with breathing. Abdomen is within normal limits. Extremities show +2 pulse in all four extremities. The capillary refill is about two seconds. GU:
Orders:
Admit the patient in ward/floor
Continuous cardiorespiratory monitoring
Pulse oxy, Q 1hour
ABG, stat (for baseline)
Chest X-ray ( Mainly to rule out any coexisting pneumonia, which requires antibiotics)
Humidified oxygen (40%), continuous
Epinephrine, nebulization, prn (as needed)
Albuterol, nebulization, Q 2-4hours
Suction, Q 1 hour (Nasal and posterior pharyngeal)
Chest PT, Q 2 hours
Discussion:
· This is a classic presentation of bronchiolitis and it should be suspected in any child who presents with coryza, cough, dyspnea, prominent wheezing, and hyperinflation of lungs. Evaluation should include assessment of hydration and respiratory distress. Management of bronchiolitis respiratory infections in children is somewhat controversial. Agreed upon therapy includes oxygen therapy for those children who are hypoxic and severely distressed as well as inpatient monitoring for worsening respiratory distress. Children who cannot maintain good fluid intake or who do not have reliable caretakers to monitor their status should also be admitted to the hospital for observation. The role of bronchodilators and corticosteroids is not fully clear in these patients. Most clinicians will give a trial of bronchodilators to see if it improves the patient ' s wheezing. These nebulizers such as albuterol can then be continued to improve wheezing and hypoxemia associated with bronchoconstriction. Judicious use of epinephrine nebulizers can also help temporize the patient ' s symptoms probably by decreasing edema and allowing better airflow. The use of corticosteroids is not clear. Aggressive pulmonary toilet is necessary for these children with frequent nasal and posterior pharyngeal suctioning, frequent chest percussion therapy to help relieve the congestion secondary to excessive secretions. Nasal washings for respiratory syncytial virus and viral culture for parainfluenza and adenoviruses should be part of one ' s work up.
· Etiologies for this patient ' s bronchiolitis are mainly viral in origin and include respiratory syncytial virus, parainfluenza viruses 1, 2, and 3, influenza viruses A and B and adenovirus.
· For infants who need to be hospitalized, orders should include continuous cardiorespiratory monitoring, supplemental oxygen, frequent nasal suctioning and chest percussion therapy and, if they show benefit, albuterol nebulizer treatments. Continuous cardiorespiratory monitoring is warranted especially for very young infants with respiratory syncytial virus bronchiolitis because frequently their presentation involves apnea and, in fact, they may have very few wheezes on physical exam and have apnea as their sole presentation of RSV. Ribavarin is indicated for those with respiratory failure, immunosppression or severe coexisting medical condition.
Primary diagnosis: Bronchiolitis
29/ Location: Office C.C: Knee pain with swelling, and fever
Vitals: Temperature 39.1C, Blood pressure 118/80 mm Hg, Heart rate 98/min, regular, and Respiratory rate is 20/minute.
HPI: A 40-year-old white male with no significant past medical problems presents to your office with two-day history of fever, chills, and pain in his left knee associated with swelling. The patient reports that the fever and chills started two days ago. Last night he noticed moderate to severe pain and swelling in his left knee. The patient is unable to ambulate well due to the severity of the pain. There is no history of trauma to the joint. He denies any previous episodes of these symptoms. He also denies IV drugs use or insect bites. The patient ' s mom has a history of rheumatoid arthritis. ROS are unremarkable. He has no allergies. He is not taking any medications. PMH: No past medical history, no history of hospital admissions. SH: He is sexually active with his wife and denies having multiple sex partners. He does not smoke or drink alcohol.
How would you evaluate this patient?
First list the patient problems: 40-year-old healthy male presented with two-day history of fever, chills, and sudden onset of pain and swelling in the knee, without a history of trauma or any prior joint disease. The differential diagnosis of bacterial arthritis includes gout, pseudogout, Reiter’s syndrome, RA, and Lyme disease, each of which can present with acute involvement of one or a few joints. Always obtain a detailed history and physical examination. In this patient, examine the skin, joints and extremities, abdomen, heart, and lungs. This patient may have infective endocarditis, anemia, or murmurs as part of a diffuse septic process.
Order: General HEENT /Neck Heart Lungs Abdomen Extremities Skin
Here are the results of the physical examination: GENERAL EXAMINATION: The patient appears ill and is in obvious pain. He is awake, alert, oriented to time, place and person. The skin is without rash or any pustular lesions. The lungs are without crackles, wheeze, or rhonchi. The heart is within normal limits. There are no audible murmurs, rubs, or gallops. His abdomen is soft and non tender. Bowel sounds are present in all quadrants. His left knee is erythematous, tender, swollen, and has limited range of motion (ROM). The rest of his exam is unremarkable.
Order:
Admit in floor/ward
Vitals Q 4 hours NPO
Blood cultures, stat
CBC with diff, stat
Basic metabolic panel, stat
ESR (Optional, non specific)
PT/INR, stat PTT, stat
Consent for procedure Aspirate joint fluid, stat Joint fluid for Gram stain, culture & sensitivity, GC culture, cell count and differential, crystals (all are stat)
X-ray knee, stat Acetaminophen, oral, continuous
Once you draw the blood and aspirate the joint Ceftriaxone, IV continuous
Morphine, IV, one time, stat
How would you continue?
This patient is clearly ill and in severe pain. He needs to be hospitalized to confirm the diagnosis, rule out endocarditis, start treatment including joint aspiration and to monitor the clinical response. Admit the patient to the general medicine floor. The next step should be joint aspiration. The fluid should be sent for gram stain, culture and sensitivity, cell count with the differential and examined for crystal microscopy. Synovial fluid total protein, lactic dehydrogenase, and glucose level are not required because they are nonspecific in making the diagnosis. Obtain blood cultures from at least two sites. Also, order a CBC with a differential, ESR, and basic metabolic panel. Serological testing for Lyme disease may be indicated if suspicion is high. Radiographs should be taken but are usually normal early in the disease process. Culture the skin if there are any skin lesions. Infectious arthritis can be separated into either nongonococcal or gonococcal. Usually, nongonococcal infectious arthritis occurs in adult patients with previous joint damage or in compromised host. Gram-negative bacilli should be considered in a compromised host. For example, those with malignancies , immunosuppression, HIV, or IV drug abusers. Staph aureus is the single most common cause of nongonococcal bacterial arthritis in the adult population. It is also, the most common organism associated with underlying rheumatoid arthritis. Gonococcal arthritis occurs in patients between the age of 15-40 who are otherwise healthy and sexually active. Staphylococcus epidermidis should be cons! idered if the patient has a prosthetic joint infection. Lyme disease should be considered if the patient has a history of rash or insect bites. Gonococcal arthritis commonly presents as a migrating polyarthritis accompanied by tenosynovitis and erythematous pustular skin lesions. Cutaneous lesions and articular findings are believed to be the consequence of immunoreaction to circulating gonococci and immunocomplex deposition in tissues. However, culture is positive in less than half of the cases and gram stain in 25 percent of cases. Leukocyte counts average 10,000 per microliter. In gonococcal septic arthritis, blood cultures are almost always negative and gonococcus is only occasionally evident on gram stain smears. X-ray of the involved joint is indicated primarily to rule out osteomyelitis.
· Empirically administer broad-spectrum antibiotics while awaiting lab results . The drug of choice is ceftriaxone, given intravenously. It is a broad-spectrum third generation cephalosporin and covers gram-negative diplococci (Neisseria, gonorrhea), gram-negative bacilli, as well as Lyme disease. If the initial gram stain of the synovial fluid shows gram-positive cocci, IV nafcillin or cefazolin are the drugs of choice. Vancomycin is considered for penicillin allergic patients or if it is a hospital or nursing home-acquired infection. If the initial Gram stain shows gram-negative bacilli, treatment should be started with a third generation cephalosporin such as ceftriaxone. If the suspecting organism is a Pseudomonas, such as in patients with H/O IV drug abuse, the treatment should be started with Ceftazidime along with an aminoglycoside, such as gentamicin. Treatment should be changed according to the culture results. If the patient is on vancomycin and the culture showed methicillin sensitive S. aureus, vancomycin should be discontinued and nafcillin should be started. Patients should be treated with at least 10-14 days of IV antibiotics, followed by an additional 14 days of oral therapy.
· Analysis of synovial fluid usually reveals most of the important diagnoses . Normal synovial fluid contains less than 180 cells per microliter with mostly mononuclear cells. Synovial fluid cell count of 25,000 to 50,000 per microliter with more than 90% neutrophils, is most likely due to bacterial infection. Crystal-induced, rheumatoid, and other noninfectious inflammatory arthritis are usually associated with a count of less than 30,000 to 50,000 cells per microliter. The presence of positively birefringent calcium pyrophosphate crystals indicates pseudogout. The presence of negative birefringent monosodium urophosphate crystals indicate gouty arthritis.
RESULTS: WBC count reveals 15,000/dl with 12% bands. Blood cultures are pending. Because it is very difficult to isolate gonococcal from synovial fluid and blood cultures, specimens for culture should be obtained from mucosal surfaces, especially urethral discharge, oropharyngeal mucosal surface, and rectal cultures. X rays of the joint revealed no osteomyelitis, but there is a joint effusion and soft tissue swelling. Synovial fluid analysis revealed WBC count of 120,000 with 85% polymorphs and gram stain smear showed gram-positive cocci in clusters. Synovial fluid culture is pending. There are no visible crystals on microscopy.
How do you approach now ?
This patient clearly has an infectious process of the knee joint. The most likely organism is Staphylococcus aureus. IV antibiotics should be started. If the patient is allergic to penicillin or the organism is methicillin resistant then the drug of choice is vancomycin. Repeated joint aspiration may be necessary. When response to antimicrobial therapy has been demonstrated, NSAID ' s or Cox 2 inhibitors can be used to reduce pain. Splinting can be used but septic joints usually do not require immobilization. For recurrent gonococcal arthritis, complement deficiencies must be ruled out.
Order:
D/C ceftriaxone
Nafcillin, IV, continuous
Consult orthopedic surgery, stat (Reason: Patient with septic arthritis and needs incision and drainage)
*Patient is accepted for surgery
Primary Diagnosis: Septic Arthritis
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