Grand Rounds Recap 11.14.18
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R4 Case Follow-up: Aseptic Fever WITH DR. Whitford
case
The patient is an elderly female with a history of COPD, lung cancer with lobectomy, hypertension presents to the ED with altered mental status. She is brought in by family who report that over the last week the patient has been complaining of significant dental pain and using prescribed Vicodin for pain control.
Vitals: Febrile to 103 F but other vitals within normal limits
Initial assessment showed that patient was somnolent, found to have pinpoint pupils, and with the history provided that she has been taking increased amounts of Vicodin for dental pain control the concern was for opioid overdose and she was administered Narcan. The patient had a robust response; however, became markedly agitated and was never found to be oriented at that time. She ultimately required haloperidol for chemical sedation.
Initial work-up showed a leukocytosis with WBC of 15 with the rest of her blood work being unremarkable. EKG, CXR, and non-contrast head CT were are unremarkable. Empiric antibiotics were initiated with concern for sepsis.
Reassessment of the patient showed that she now had myoclonus of the right arm, a right gaze deviation, and was obtunded. This prompted concern for seizure possibly due to meningitis/encephalitis. Attempts with benzos to control her seizures were unsuccessful and the decision was made to place the patient in the resuscitation bay for intubation and ultimately propofol drip for seizure control.
Intubation was successful and repeat vital signs were now remarkable for a temperature of 106 F. Patient was cooled down to 101.7 but now was found to be hypotensive. A central line was placed, the patient was rapidly managed with pressors. A LP was performed and the patient was admitted to the ICU.
Her hospital course showed the LP to be negative for infection. Her blood culture x1 was positive. She improved dramatically over hospital day 1 and 2 such that she was extubated on day 2, transferred to the floor on day 3, and discharged from the hospital on day 4.
discussion
Non-infectious causes of fever:
Serotonin syndrome / NMS
Malignant hyperthermia
Anticholinergic vs. Sympathomimetic
Thyrotoxicosis
Withdrawal syndromes: EtOH, benzos, baclofen
Pontine stroke
CPC: Septic arthritis WITH DR. Koehler and dr. betz
case
The patient is an elderly male with a history of chronic back pain, hep C, poly-substance abuse, presents with altered mental status. He was brought to the ED when family found him not acting normally at home.
Vitals: Temp: 101 HR: 111 BP: 173/88 RR: 20 SpO2: 96% on 2L
EMS reports that he had a normal fingerstick glucose and that he was hypoxic with SpO2 of high 80s on arrival so they placed him on 2L by nasal cannula.
Physical Exam: Notable for sluggish but reaction pupils without miosis, bruising over the right shoulder and a frontal cephalohematoma. He was oriented only to person and place but not time, and his exam was otherwise unremarkable.
Labs: notable for mild hyponatremia, mild hyperkalemia, mild luekocytosis, and acute kidney injury.
Imaging/Studies: Head CT, EKG, CXR unremarkable
Test Ordered: Shoulder Arthrocentesis
Diagnosis: Septic Arthritis
discussion
Summary of arthrocentesis approaches can be found HERE
Risk Factors for Septic Arthritis:
Pre-existing joint disease (Rheumatoid arthritis, Osteoarthritis)
Diabetes
End Stage Renal Disease
IV drug use
Most common infectious organism: S. aureus (45%)
Most commonly affected joint: Knee (45%)
Treatment Options:
Medical management: Repeated joint aspirations + antibiotics
Surgical management: Open or arthroscopic I&D
Pediatric vomiting WITH DR. edmunds
case 1
3 month old male with vomiting x 1 week. Spits up after every bottle feed. Emesis looks like contents from bottle. Mother is concerned because it appears to her as if the child is throwing up everything she tries to feed him.
Vitals: T: 37.3 C HR: 155 RR: 36 BP: 96/52 SpO2: 100% on RA
Well appearing, well hydrated. Evaluation of the electronic medical record shows a reassuring growth chart.
discussion:
This is a case highlighting reflux. These patients are often called the “Happy Spitter”. Reflux typically peaks at ages 3-4 months. Presents as effortless, non-projectile vomiting. Appropriate weight gain (30 grams per day) is a reassuring sign on chart review. Management is mainly reassurance and education for the parents. There is not great data to support initiation of medications such as Zantac; however some primary pediatricians will initiate this in the outpatient setting.
case 2
6 week old male presents as a referral from the primary care physician for dehydration. Mother reports that the patient has been ‘‘spitting up’’ with feeds that has been attributed to reflux.
Vitals: T: 35.1 C HR: 151 RR: 18 BP: 88/76 SpO2: 100% on RA
Appears lethargic and cachectic. Noted to have periods of apnea. On exam found to have a sunken anterior fontanelle, dry lips, soft abdomen without distention.
Labs are notable for metabolic alkalosis with hypochloremia and hyponatremia.
The patient ultimately requires intubation for their periods of apnea. Ultrasound is performed showing evidence of pyloric stenosis. The patient is admitted to the PICU with surgery consulted.
discussion
This is a case highlighting pyloric stenosis. These patients are often called the “Hungry Vomiter”. They classically present with projectile vomiting after feeds are often displaying signs of hunger immediately after. Occurs in approximately 2-3 infants per 1000 live births with a male predominance. Physical exam will often show a soft, non-distended abdomen and occasionally you can palpate the hypertrophied pylorus with deep palpation. Classic laboratory findings are a hypochloremic, hypokalemic, metabolic alkalosis. Management typically involves rehydration with IVF and consultation of surgery for definitive management. Most patients will not present as sick as the patient highlighted in this case because this diagnosis is often made earlier in the course of the illness.
case 3
7 month old female presenting with vomiting for one week. 7-8 episodes of emesis per day. Initially the emesis was described as non-bloody, non-bilious; however, more recently has become more bilious appearing. No fevers or diarrhea but has been constipated without a bowel movement for the past four days.
Appears lethargic with a tender, distended abdomen.
Labs including CBC, BMP, Amylase/Lipase, Lactic acid, and urinalysis are all within normal limits.
Upper GI is ordered showing no contrast crossing over to left side of abdomen.
discussion
This is a case highlighting malrotation and volvulus. Malrotation is where the cecum is abnormally positioned in the right upper quadrant and is fixed to the lateral abdominal wall by peritoneum. This malrotation makes the patient predisposed to bowel twisting on the mesentery defining volvulus. Classic presentation is that of an acute small bowel obstruction. Management is with resuscitation with IV fluids, placement of an NG/OG and preparing the patient for surgery.
r1 clinical diagnostic: hypertension in pregnancy WITH DR. roblee
Hypertension in Pregnancy: SBP >= 140 mmHg or DBP >= 90 mmHg
Gestational Hypertension: diagnosed after 20 weeks gestation or in the immediate postpartum period
Preeclampsia: above blood pressure elevation + Proteinuria (>300mg/24 hr, urine protein /Cr ratio >= 0.3, or 1+ protein on urine dipstick)
Preeclampsia with severe features: Preeclampsia + 1 or more of the following
SBP>= 160 or DBP >=110
Platelets < 100,000
LFTs >2x upper limit of normal
Pulmonary edema
visual changes or mental status disturbance
Eclampsia: presence of seizures
HELLP Syndrome: Hemolysis, Elevated Liver enzymes, Low Platelets
case 1:
31 year old female G1P0 at 10 weeks pregnant based upon last menstrual period/ultrasound with confirmed IUP presents with 2 days of a headache. She has not tried anything for her pain due to not wanting to take medications during pregnancy. Headache is described as 6/10 frontal, squeezing, made worse with loud noises. No fever, focal weakness, recent head trauma, neck stiffness, or photophobia/visual changes. She is nausea/vomiting and has been for the past few weeks. She does not have any history of significant headaches.
PMH/PSH: none
Social Hx: no drug/tobacco, EtOH use
Meds: prenatal vitamin
Vitals: BP: 146/94 HR: 80 RR: 14 SpO2: 99% on room air Temp: 98.5
Physical Exam: notable for dry mucous membranes but otherwise unremarkable including a normal neurological exam.
Management: Symptoms can be secondary to tension headache. Many providers would acquire a urinalysis and BMP and manage her symptomatically. Prior to 20 weeks gestation so not concerned for preeclampsia.
case 2:
24 year old female G2P1 at 34 weeks pregnant presents with 3 days of worsening abdominal pain. Pain is located in the right upper quadrant, non-radiating, aching 8/10, worse with palpation, not affected by eating/drinking. She denies any abdominal trauma.
PMH: none
PSH: none
Social Hx: No history of drug, tobacco, or EtOH use
Meds: prenatal vitamin
Vitals: BP 135/88 HR: 75 RR: 15 SpO2 97% on room air Temp: 98.3 F
Physical Exam:
Gen: uncomfortable appearing, nontoxic
HEENT: normal
Pulm: normal
CV: normal
Abdominal: soft, non-distended with right upper quadrant tenderness without guarding, no hepatomegaly
MSK: normal
Neuro: A&O x 4, no focal neurological deficits
Bedside Biliary Ultrasound: normal
Management: Labs including CBC, BMP, LFTs, LDH. They result showing thrombocytopenia, transaminitis, and elevated LDH. This patient has HELLP syndrome. Provide Magnesium and engage OBGYN with plan to transfer for definitive care.
case 3:
33 year old female G1P0 at 24 weeks gestation with a history notable for hypertension presents with fatigue, nausea/vomiting and headache. Symptoms have been worsening for the past 4-5 days. Headache is mild-moderate, occipital and peri-orbital, throbbing, similar to prior migraines, with associated photophobia. She feels nauseated and vomited non-bloody, non-bilious emesis x 1 yesterday. She feels tired/fatigued but denies significant dyspnea with exertion. ROS positive for mild hand/feet swelling but is otherwise negative. BP is normally well controlled on home labetalol dose. Chart review shows most BPs 130/75 while on medication. She took her medication today.
PMH: HTN, Migraines
PSH: none
Meds: Labetalol
Social Hx: prior smoker before pregnancy, social drinker before pregnancy, no illicit drugs
Vitals: BP 169/105 HR 65 RR: 14 SpO2: 97% on room air Temp: 98.7 F
Physical Exam:
Gen: Uncomfortable appearing, nontoxic
HEENT: photophobia, otherwise normal
CV: normal
Resp: normal
GI: normal
MSK: subtle symmetric swelling of fingers/feet
Neuro: A&O x 4, moves all extremities spontaneously and symmetrically, PERRLA, EOMI
Management: Laboratory analysis as in case 2 to evaluate for preeclampsia. Concern for preeclampsia with severe features given markedly elevated blood pressure.
