Tuesday Advanced Cases

From the Archives: Acute Generalized Weakness by Dr. Aimee Parks

Case: A 35 year old Hispanic male presents to the Emergency Department for acute onset weakness, particularly in the bilateral upper and lower extremities. Symptoms started abruptly last night after a stressful work day. He denies any recent illnesses, insect bites, or rashes. Vitals are within normal limits. On exam, there is pronounced weakness in his proximal muscles with his lower extremities slightly weaker than his upper extremities. His grip strength is preserved. Reflexes are normal.

Differential diagnosis includes: thyrotoxic periodic paralysis, hypokalemic periodic paralysis, myasthenic crisis, Guillain-Barre syndrome, transverse myelitis, tick paralysis

Case continued: Labs are notable for a potassium 1.7, magnesium 1.5, TSH < 0.01, Free T4 5.9, Free T3 23.5. EKG showing sinus rhythm with prolonged QTc. Management included IV and PO repletion of potassium which improved the patient’s symptoms rapidly. He was also started on methimazole for hyperthyroidism. Finally, he was admitted to a telemetry monitored bed to check serial BMPs and monitor for rebound hyperkalemia.

Teaching Pearls:

  • Thyrotoxic periodic paralysis is a form of acquired hypokalemic periodic paralysis, often precipitated by rest after strenuous exercise or high carbohydrate load.
  • Treat with potassium repletion, continuous cardiac monitoring, and monitor potassium levels for rebound hyperkalemia.
  • For acute weakness episodes not responsive to potassium replacement, use Propranolol.
  • Treat hyperthyroidism – attacks should cease with euthyroid state.

Chaudhry MA, Wayangankar S. Thryotoxic Periodic Paralysis: A concise review of the literature. Curr Rheumatol Rev. 2016;12(3):190-194.

Kung AW. Clinical review: Thyrotoxic periodic paralysis: a diagnostic challenge. J Clin Endocrinol Metab. 2006 Jul;91(7):2490-5. Epub 2006 Apr 11.

Vijayaumar A, Ashwath G, Thimmappa D. Thyrotoxic periodic paralysis: clinical challenges. J Thyroid Res 2014;2014:649502

Monday Back to Basics

Let’s talk about Rehab with Dr. Katie Selman

Many facilities may have multiple services – often, the same facility will offer subacute rehab and long-term care and memory care services

Instrumental Activities of Daily Living (IADLs) = managing house, finances, transport, medications, shopping

Activities of Daily Living (ADLs) = walking, toileting, bathing, feeding, transferring

  • Is this a rehab-able condition?
    • Rehab-able condition examples: stroke, hip fracture, deconditioning after serious illness
    • Potentially not rehab-able examples: any progressive, gradual degenerative disease in which the patient is expected to continue to decline
  • Why does this matter?
    • Insurance will stop paying for rehab if patient is not improving or making progress based on their PT/OT/ST notes
    • There is a daily copay for patients after 21 days in rehab and the full cost is on the patient after 100 days
      • PT is amazing but cannot fully reverse a months-long decline in 21 days!
  • Will the patient be able to physically and cognitively participate in rehab?
    • Acute inpatient rehab = 3 hours therapy/day
    • Subacute rehab = 3 hours/week
  • Patients are not rehabbed until they can go home safely – patients are rehabbed until they can safely live in a one-story home.
    • So what is the goal after rehab? What is the backup plan if they still can’t go home after 21 days? Will they still need help?





Flint LA, David DJ, Smith AK. Rehabbed to Death. N Engl J Med. 2019;380(5):408-409. doi:10.1056/NEJMp1809354

Flint LA, David D, Lynn J, Smith AK. Rehabbed to Death: Breaking the Cycle. J Am Geriatr Soc. 2019;67(11):2398-2401. doi:10.1111/jgs.16128

Burke RE, Jones J, Lawrence E, et al. Evaluating the Quality of Patient Decision-Making Regarding Post-Acute Care. J Gen Intern Med. 2018;33(5):678-684. doi:10.1007/s11606-017-4298-1

Halifax E, Bui NM, Hunt LJ, Stephens CE. Transitioning to Life in a Nursing Home: The Potential Role of Palliative Care. J Palliat Care. 2021 Jan;36(1):61-65. doi: 10.1177/0825859720904802. Epub 2020 Feb 27. PMID: 32106767; PMCID: PMC8127871. 

Friday Board Review

Internal Medicine Board Review with Dr. Edward Guo

A 30 year old female with a history of type 1 diabetes and past hospitalizations for diabetic ketoacidosis presents via EMS for altered mental status. History is limited as patient is altered and not answering questions appropriately. Vitals include Temp 100.4F, HR 116, BP 102/70, RR 30, SpO2 98% on room air. Exam shows an ill-appearing female with Kussmaul respirations and a non-focal neurologic exam. Labs are notable for 20K WBCs and serum glucose of 400. A lumbar puncture is performed to assess for meningitis. For this patient, which of the following CSF glucose values is within normal limits?

A: 60 mg/dL

B: 100 mg/dL

C: 260 mg/dL

D: 400 mg/dL

Answer: 260 mg/dL

This patient is presenting with signs and symptoms of diabetic ketoacidosis. While it is critical for the emergency physician to treat the hyperglycemia with volume resuscitation and insulin, it is also paramount to investigate for underlying causes such as infection. The glucose level in CSF is proportional to serum glucose values and should correspond to approximately 60-70% of serum glucose values. Thus, a CSF glucose value of 60 or 100 mg/dL in this patient is lower than expected and concerning for bacterial CNS infection. Higher than expected CSF glucose levels are non-specific and generally do not exceed 300 mg/dL.


Lillian A. Mundt; Kristy Shanahan (2010). Graff’s Textbook of Routine Urinalysis and Body Fluids. Lippincott Williams & Wilkins. p. 237. ISBN 978-1582558752.

Seehusen DA, Reeves MM, Fomin DA (September 2003). “Cerebrospinal fluid analysis”Am Fam Physician68 (6): 1103–8. PMID 14524396

Wednesday Image Review

What’s the Diagnosis? By Dr. Ethan Anderson

A 19 year old female with a past medical history of autism and anxiety presents with right lower extremity swelling and pain. Two weeks ago, she developed right lower back pain with radiation into her right hip and leg which she describes as sore. She is sexually active and was started on hormonal contraception 2-3 months ago. Vital signs include BP 117/75, HR 108, RR 18, SpO2 99% RA, T 97.5F. The patient’s right lower extremity is neurovascularly intact with tenderness to palpation and swelling without color change. A right lower extremity ultrasound is shown below. What’s the diagnosis? How is this ultrasound performed?

Answer: Right Common Femoral and Popliteal DVT

DVT Ultrasound Evaluation: must evaluate at least 2 regions, typically femoral and popliteal veins

Femoral Vein

  1. Most often performed using the linear probe (curvilinear probe may provide greater penetration for larger body habitus)
  2. Start just distal to the groin where the iliac vein becomes the common femoral vein
  3. Follow common femoral vein down to where the common femoral splits off into greater saphenous, femoral, and the deep femoral vein (approximately mid-thigh) and continue to follow the femoral vein until at least the mid-thigh, compressing in 1 cm increments to ensure compressibility of veins throughout

Popliteal Vein

  1. Place probe on posterior aspect of the knee and look for popliteal vein (superficial to popliteal artery)
  2. Follow popliteal vein and compress in 1 cm increments to ensure compressibility until the vein divides into the fibular, posterior tibial and anterior tibial veins

DVT Ultrasound Pearls:

  • A vein is compressible if the walls touch with compression – if you are pushing hard enough to compress the artery but not the vein, there is likely a DVT!
  • Evaluation of femoral and popliteal regions is crucial because a DVT within either of these veins is considered “proximal” and requires medical management with anticoagulants and further evaluation for iliac/IVC involvement or pulmonary embolism.
  • Clinical diagnosis of DVT is typically unreliable due to the infrequency of classic findings (edema, warmth, erythema, pain, and tenderness) which are only present in 23 to 50 percent of patients
  • Venogram remains the “gold standard” for the diagnosis of deep venous thrombosis. However, ultrasound is the most accurate non-invasive test to diagnose deep venous thrombosis.

This patient received prompt anticoagulation in the ED and after being admitted, received a CT venogram revealing acute deep vein thrombosis in the infrahepatic inferior vena cava, bilateral common iliac, bilateral external iliac, bilateral internal iliac and bilateral common femoral veins requiring percutaneous mechanical thrombectomy!


Baker M, Anjum F, dela Cruz J. Deep Venous Thrombosis Ultrasound Evaluation. [Updated 2023 Aug 8]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2023 Jan-.



Tuesday Advanced Cases

DIC with Dr. Alyssa Sinko

Case: 64 M with no PMH presenting with continuous oozing from mass in posterior pharynx. Vital signs significant for: T 98.5, HR 72, BP 130/84, RR 16, SPO2 98%. Patient also found to have petechia on lower extremities. IV access established, and it is noted that there is bleeding from the IV sites.

Pathophysiology of DIC:

Causes of DIC:
– Most common: Sepsis
– Carcinomas, leukemias, TBI, pancreatitis, snake bites, ARDS, transfusion reactions, transplant rejection, crush injuries, burns, fat embolism, liver disease
– Pregnancy associated: Placental Abruption, Amniotic Fluid Embolism, Septic Abortion, HELLP syndrome, Acute fatty liver of pregnancy

Laboratory Testing:

PT used for monitoring over course

Bleeding Differential Diagnosis:

– Treat to treat underlying trigger
– If purpura fulminans present, treat with protein C concentrate
– Consider heparin if thrombosis is primary symptom
– Repletion to be considered if significant bleeding or impending procedure

  • Fibrinogen < 100 = Cryoprecipitate
  • Platelets <50K with bleeding, <10K without bleeding = Platelets
  • PT/PTT over 1.5x normal limit = FFP
  • Vitamin K and Folate


Tintinalli’s Emergency Medicine Manual, 8e Eds. Rita K. Cydulka, et al. McGraw Hill, 2018


Friday Board Review

Infectious Disease Board Review with Dr. Edward Guo

A 74 year old male with a past medical history of advanced dementia and type 2 diabetes presents via EMS from his long term advanced care facility for cough and shortness of breath. Patient is AOx1 and intermittently follows commands at baseline. EMS reports that the facility nurse noticed that he was hypoxic and had a “nasty cough.” Vitals include Temp 100.6F, HR 110, BP 126/80, RR 22, SpO2 89% on room air. Exam shows a chronically ill, pale appearing older male in mild respiratory distress with a productive cough. Lung sounds are notable for crackles in the lower right lung. A chest x-ray demonstrates focal consolidations of the right middle and right lower lobes with a moderate sized pleural effusion above the right hemidiaphragm. Which of the following laboratory values is NOT part of the diagnostic criteria for an empyema?

A: pleural gram stain of culture

B: pleural LDH

C: pleural pH

D: pleural protein

Answer: pleural protein

This patient is presenting with pneumonia demonstrated by imaging results consistent with the clinical findings of fever, cough, and hypoxia. Pneumonia is the most common cause of an empyema which has specific diagnostic criteria distinct from the Light Criteria for pleural effusions. Approximately 40% of cases have negative cultures. Treatment is drainage and broad spectrum antibiotics with anaerobic coverage.

Diagnostic Criteria for EmpyemaLight Criteria for Exudative Pleural Effusion (requires 1 of the following)
Aspiration of grossly purulent fluid plus one of the following:Pleural protein/serum protein > 0.5
     Positive gram stain or culturePleural LDH/serum LDH > 0.6
     Pleural fluid glucose < 40Pleural LDH > 2/3 upper limit of normal serum LDH
     Pleural pH < 7.2 
     Pleural LDH > 1000 

Mace SE, Anderson E. Lung Empyema and Abscess. In: Tintinalli JE, Ma O, Yealy DM, Meckler GD, Stapczynski J, Cline DM, Thomas SH. eds. Tintinalli’s Emergency Medicine: A Comprehensive Study Guide, 9e. McGraw Hill; 2020.

Birkenkamp  K, O’Horo  JC, Kashyap  R,  et al: Empyema management: a cohort study evaluating antimicrobial therapy. J Infect 72: 537, 2016.

Wednesday Image Review

What’s the Diagnosis? By Dr. Carlos Cevallos

A 62 year old male with a history of coronary artery disease s/p recent cardiac stents, atrial fibrillation on Plavix and Eliquis presents to the ED with sudden onset headache, aphasia, and right sided facial deficits. A stroke alert is immediately activated, and non-contrast head CT imaging reveals the image below. What’s the diagnosis?

Answer: Subdural Hematoma

The patient’s anticoagulation was reversed with andexanet alfa. He additionally was provided with one unit of platelets and Keppra for seizure prophylaxis. Ultimately, the patient underwent embolization of the middle meningeal artery with significant clinical improvement of symptoms and was able to be discharged several days later.

Subdural Hematoma Pearls:

  • Crescent shaped hematoma on CT
  • Elderly and alcoholic patients at much higher risk due to brain atrophy
  • Most commonly caused due to acceleration-deceleration injuries with tearing of the bridging veins

Eliquis reversal pearls:

  • Traditionally 4-factor prothrombin complex concentrate (4Factor-PCC) has been used
    • Contains Factors II, VII, IX, and X
  • More recently, andexanet alfa has been developed which functions by binding and inhibiting factor Xa inhibitors


Cline, David, et al. “Head Trauma.” Tintinalli’s Emergency Medicine: A Comprehensive Study Guide, McGraw-Hill Education, New York, 2020.