Give me a case

[Levo]

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This is way more invasive than you need to be at this point, but OK, it gets done. Clean coronaries.

 

[CrazyboyMD]

Ok uhh
CT of the chest both with and without contrast

 

[Levo]

Ok uhh
CT of the chest both with and without contrast

OK, great, now we're getting somewhere! CT angiogram of the chest shows multiple pulmonary emboli.

 

[CrazyboyMD]

OH ok
Start patient on anticoagulation therapy (Ones I know are like heparin?)

 

[Levo]

OH ok
Start patient on anticoagulation therapy (Ones I know are like heparin?)

Correct! She needs a heparin drip to get her up to therapeutic range quickly. Good job!

 

[CrazyboyMD]

Thanks!

 

[Levo]

Not something you'll need to know for a while, but the big learning point of a case like this is that cancers (especially adenocarcinomas like the ones you get with breast, colon or pancreatic cancer) are a major risk factor for thrombotic or embolic events like deep vein thromboses and pulmonary emboli (that's called Trousseau's Syndrome). So if a patient with a history of cancer comes has a pulmonary embolism, their primary oncologist should be thinking about whether they've had a recurrence.

 

[Medic741]

Made me think of one of the bizarre critical patients I had a few years ago

High speed rollover MVC, patient self extricated.

Upon pt contact, pt relates drug use (non-specific, GCS 14). Skins pale, moist, tachy @ ~120 with BP 110/80.

Physical exam finds no life threatening hemorrhage... pt c/o being thirsty and loses consciousness as HR drops from 120s to 35, remains at 35 for 15 seconds and jumps back up to 120s. Patient experiences repeated brief episodes of severe bradycardia

what life threats should You be looking for? And what pathologies could be causing this?

This one's kinda cool - because what causes reflexive hypotension/bradycardia and may or may not be trauma?

Your dx tools are your hands, eyes, and a trusty stethoscope. Your thumb is on the plunger of a preloaded atropine syringe. Do you give the med? What are two reasons why atropine might be considered

 

[Levo]

Made me think of one of the bizarre critical patients I had a few years ago

High speed rollover MVC, patient self extricated.

Upon pt contact, pt relates drug use (non-specific, GCS 14). Skins pale, moist, tachy @ ~120 with BP 110/80.

Physical exam finds no life threatening hemorrhage... pt c/o being thirsty and loses consciousness as HR drops from 120s to 35, remains at 35 for 15 seconds and jumps back up to 120s. Patient experiences repeated brief episodes of severe bradycardia

what life threats should You be looking for? And what pathologies could be causing this?

This one's kinda cool - because what causes reflexive hypotension/bradycardia and may or may not be trauma?

Your dx tools are your hands, eyes, and a trusty stethoscope. Your thumb is on the plunger of a preloaded atropine syringe. Do you give the med? What are two reasons why atropine might be considered

You put a high-schooler in the trauma bay, and don't even give them an ultrasound machine? Dang, that's cold!

Edit: Just realized this is happening in the field. Nevermind.

 

[CrazyboyMD]

If anyone is out there, can you give me another case? 😀
Go easy on me I'm only 16

 

[longhaul3]

Edit: Deleted—too obscure. OP, give the motor vehicle accident posted above a shot.

 

[CrazyboyMD]

I'm late

I am suspecting cardiac tamp?
Cardiac Contusion?

I would push the atropine
-Increases HR
-Takes him out of brady

 

[CrazyboyMD]

Give me a case please
Go easy on me I'm only 16
I'll order what I need to
Thanks

 

[Levo]

Sure! 45 year old woman with no known health problems and no "bad habits" (non-smoker, no drug use, sexually active only with husband of 12 years, does drink but not huge amounts, like half a bottle of wine a week) comes in with abdominal pain centered on the right side, subjective fevers, and yellowing of the eyes. On exam she has a fast heart rate to 110, fast respiratory rate of 20, temp 102F, and jaundice of the eyes, face, and pallet. Her abdominal is diffusely tender to palpation, but worst in the right upper quadrant. BMI of 29. Rest of the physical exam is normal. Go!

 

[CrazyboyMD]

Get me a
-CBC
-Liver enzymes
-EKG

 

[Levo]

CBC: Normal hemoglobin with normal red cell size, normal platelet count. White count elevated to 15, with neutrophilic predominance on the differential
Liver enzymes: AST and ALT both slightly above normal range. Total bilirubin, alkaline phosphatase, and gamma glutamyl transpeptidase all markedly elevated.
EKG: Sinus tachycardia with no ischemic changes.

 

[CrazyboyMD]

I would like to order an abdominal ultrasound, possible free-fluid in the abdomen?

Elevated bilirubin is causing the jaundice

 

[CrazyboyMD]

Would you start antibiotics due to the elevated wbc?

 

[Levo]

Abdominal ultrasound shows dilation of both intrahepatic and extrahepatic bile ducts. No free fluid.

As far as antibiotics, yes, this patient will definitely receive antibiotics during this case. But you can't just say "due to elevated WBCs." One has to consider what the organism most likely is, what the route of infection is, and what the severity of illness is, as that would dictate your choice of antibiotics, dose, timing, route of administration etc. I obviously don't expect you to know the names of particular bugs, antibiotics and their dosing. That's like 3rd year medical student level knowledge. But you should tell me what you think the unifying diagnosis is so I can help you with antibiotics selection. So, wanna take a guess, or order some more tests?

 

[CrazyboyMD]

I was thinking of possible cirrhosis or hepatic failure? Possible malignancy on the liver? i don't know so I would like to order one more scan:

CT of the abdomen with and without contrast

 

[Levo]

It's not cirrhosis. The abdominal ultrasound can tell you what the echo-texture of the liver is, so you would have known that by now. Likewise, if it were a liver cancer that's big enough to cause biliary obstruction, you'd have also seen it on the ultrasound.

CT is not the imaging of choice to confirm the diagnosis you're looking for here (should have been magnetic resonance cholangiopancreatography), but in this case, it pays off! You see a 5mm stone completely obstructing the common bile duct.

 

[CrazyboyMD]

Haha you're right

To treat it would I need to put the patient on some type of diuretic? (I don't know)
I would need to consult general surgery and would possibly remove the stone via endoscope

Follow up Liver function panel

 

[Levo]

Close enough lol. The idea behind this case is that you have a patient with a gallstone obstructing the common bile duct. That causes elevation of the liver enzymes alkaline phosphatase and gamma-glutamyl transpepitdase, both of which are found in cells in the common bile duct. You get much lower elevations of the enzymes AST and ALT because while there is still some damage to the liver cells themselves from bile backing up into the liver, it's not that significant. You get a huge elevation in bilirubin, since the liver can't excrete bilirubin through the clogged duct. You also get the fever and elevated white count because bacteria grow in the backed-up bile (cholangitis).

The proper approach to this case would be to do magnetic resonance cholangiopancreatography (MRCP) to find the level of the obstruction. You then call gastroenterology (not general surgery, this is GI's turf) to do a procedure called an ERCP (endoscopic retrograde cholangiopancreatography) where they advance and endoscope into the small intestine, then us it to stick a wire up the common bile duct to dislodge the stone. While all of this is happening, you should start an antibiotic that would cover the gut bacteria that grow in the backed-up bile to "cool off" the patient. After the stone has been removed through ERCP and the patient is doing well, you can then call general surgery to remove the gallbladder. This is not urgent, but the gallbladder was the likely source of the stone, so you take the patient's gallbladder to keep this from happening again.

No need for diuretics.

 

[da8s0859q]

To add to Levo's case presentation: if you're really that curious, go read up on ascending cholangitis. He gave you a classic set of symptoms called Charcot's triad (the belly pain, fever, and jaundice, which isn't actually all present at the same time in a majority of cases). The more worrisome version is when you add a certain kind of physiologic shock called septic shock and confusion to the mix -- "Reynolds' pentad". Even less common to have all five.

Regardless of pedantry: bad news with significant morbidity and mortality risk. Some of the details will be beyond your level if you read from a reputable source. That's okay. I get the fascination.

Have taken care of many common bile duct stone patients and a few ascending cholangitis patients as a resident and now as an EM attending.

 

[CrazyboyMD]

Thank you both this is some interesting information

 

[mmmcdowe]

Merging threads

 

[CrazyboyMD]

Hey, can anyone give me an easy case? Please remember I am only 16.

 

[CrazyboyMD]

Hey, is anyone out there? May I have a case

(I am 16 go easy on me)

 

[Toutie]

Hey, is anyone out there? May I have a case

(I am 16 go easy on me)

Honestly, what is the point of this?

 

[Medic741]

Honestly, what is the point of this?

Right?!

Go enjoy summer amigo

 

[CrazyboyMD]

Damn, lol.

 

[CrazyboyMD]

Wait, school isn't over yet...anyone care to give me an easy case for a 16 year old?

 

[longhaul3]

.

 

[CrazyboyMD]

Get me a CBC, Chem-7, and TSH levels for labs

 

[longhaul3]

.

 

[CrazyboyMD]

Before that, I need a thorough neurological exam

I'm going to be honest, I'm a little stumped

After that, an ultrasound of the neck

 

[hopefulERdoc251]

Here's a real easy basic one.

34 year old female presents to the ED for L flank pain + hematuria that's been ongoing for the past 24 hours. Has associated nausea, no vomiting, no diarrhea.

In the ED, vitals are: Temp - 102.2, Pulse - 100, RR - 17, O2 sat - 99%, BP - 140/96.

What do you want to ask her?
What labs would you do?
What imaging would you do?
What is your differential diagnosis?

 

[frosted2]

CBC and Chem-7 are normal. TSH undetectable.

Thyroid storm?

 

[longhaul3]

.

 

[frosted2]

Neurological exam notable for hyperreflexivity and biceps strength iv/v. Ultrasound shows diffuse goiter with hypervascularization.



This isn't an emergency, but you're on the right track. Thyroid storm is life-threatening and she would present with acute illness. She has Graves' Disease. You can start her on a medication called methimazole, which inhibits the synthesis of thyroid hormone.

I knew it was some type of endocrine problem, I just was not sure which one 🙂
Thanks!