Friday Board Review

Board Review by Dr. Guo (Edited by Dr. Parikh)

A 40 year old female with a history of kidney stones with a left ureteral stent placed 2 years ago presents for urinary pain associated with increased urge and frequency. She denies fever or flank pain. It does not feel similar to her previous kidney stones. Vital signs are within normal limits. On exam, she is comfortable appearing and has mild suprapubic tenderness to palpation. Point-of-care pregnancy test is negative. Urinalysis results with 3+ leukocyte esterase, 2+ nitrites, and 105 WBCs/HPF. Which of the following is the appropriate management of this patient’s condition?

A: Admit for IV antibiotics

B: Consult urology for stent removal

C: CT of the abdomen and pelvis

D: Discharge with oral antibiotics

Answer: discharge with oral antibiotics

This patient is presenting with findings consistent with acute cystitis, a urinary tract infection localized to the bladder. Urinalysis findings with elevated leukocyte esterase, nitrites, and WBCs with clinical symptoms are supportive of the diagnosis. Treatment of minor urinary tract infections in patients with ureteral stents is oral antibiotics and do not require stent removal. If pyelonephritis or systemic infection with a ureteral stent is suspected, consultation with urology, IV antibiotics, and radiographic imaging to determine the location of the stent is warranted. 

References:

Askew KL. Urinary Tract Infections and Hematuria. 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.

Josephson EB, Azan B. Complications of Urologic Procedures and Devices. 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.

Friday Board Review

Board Review by Dr. Hilbmann (Edited by Dr. Parikh)

A 22 year old female G1P0 with no pmhx who presents to the Emergency Department with nausea and vomiting. The patient is 11 weeks pregnant and has experienced nausea and occasional vomiting throughout her pregnancy but for the past three days she has been progressively worse and has not been able to keep any food or liquids down without vomiting. You are given her ECG, what is a finding you are looking for due to her recent presentation?


A. Hyperacute T waves
B. Shortened PR Interval
C. Prolonged QT interval
D. ST-Elevation in aVR

Answer: C.
Due to this patient’s increased vomiting, most likely due to her pregnancy, it is possible that she may be experiencing electrolyte imbalances secondary to the loss of gastrointestinal contents. Most commonly hypokalemia, hypocalcemia, and hypomagnesemia can result from continuous vomiting. In addition to blood tests, which take time to result, the levels of these three electrolytes can be evaluated with ECG as well. Physicians should evaluate for increased p waves, prolonged PR interval, ST depression, u waves, and a prolonged QT interview.

References:
Mitchell SJ, Cox P. ECG changes in hyperemesis gravidarum. BMJ Case Rep. 2017;2017(bcr2016217158) doi: 10.1136/bcr-2016-217158.
Popa SL, Barsan M, Caziuc A, Pop C, Muresan L, Popa LC, Perju-Dumbrava L. Life-threatening complications of hyperemesis gravidarum. Exp Ther Med. 2021 Jun;21(6):642. doi: 10.3892/etm.2021.10074. Epub 2021 Apr 16. PMID: 33968173; PMCID: PMC8097228.
Image per @medicalce via Twitter

Friday Board Review

Board Review by Alex Hilbmann

Vital signs:

T: 37⁰C HR: 71 bpm O2 Sat: 100% BP: 112/92

A 29 year old female reports to the emergency department for abnormal scant vaginal bleeding. Initially, she believed that the bleeding was an early menstrual period but it has now persisted longer than her usual menses with less volume. She denies any other complaints, including pelvic pain, fevers, or vaginal discharge. Patient has attended OB/GYN appointments yearly and denies any previous history of sexually transmitted infections or abnormal pap smears. Pelvic exam reveals scant bleeding from the cervical os with no adnexal or cervical tenderness. No masses are appreciated upon palpation of bilateral adnexa. Transvaginal ultrasound reveals no intrauterine pregnancy or adnexal abnormalities. Point of care urine pregnancy test is positive. Quantitative beta-hcg results at 542 miU/mL. Vital Signs listed above. What is the next best step in management of this patient?

  1. Consultation to OB/GYN for concern of ectopic pregnancy
  2. Official transvaginal ultrasound read by Radiology
  3. Administration of methotrexate and discharge home
  4. Discharge home with 2 day OB/GYN follow up

Answer: D.

Our patient is currently experiencing scant vaginal bleeding with no findings on transvaginal ultrasound, a positive pregnancy test, and a beta hcg below 1500 miU/mL.  1500 miU/mL is what is known as the “discriminatory zone” for transvaginal ultrasound (6,000 miU/mL for transabdominal). This discriminatory zone is a level of beta-hcg which an intrauterine pregnancy (IUP) would be expected to be seen on ultrasound. When beta-hcg is above the discriminatory zone, and therefore an IUP should be visible on ultrasound, the absence of an IUP on ultrasound suggests ectopic pregnancy until proven otherwise. With this patient however, we are below the discriminatory zone and therefore the absence of IUP (with no other findings suggesting ectopic pregnancy) does not make ectopic pregnancy a more likely diagnosis than pregnancy with implantation bleeding at this time. The beta hcg of an IUP should double by two days, whereas an ectopic pregnancy would decrease less than twofold. This can be assessed by the patient’s OB/GYN at her follow up, and given the patient’s stable condition she can be discharged home.

Tintinalli, J., Ma, O., Yealy, D., Meckler, G., Cline, D., Thomas, S. and Stapczynski, J., 2020. Tintinalli’s emergency medicine. 9th ed. [New York]: McGraw-Hill Education, pp.615-620.

Image:

Fadial, T., 2018. Differential Diagnosis of Ultrasound in Ectopic Pregnancy. [online] Differential Diagnosis of. Available at: <https://ddxof.com/ultrasound-in-ectopic-pregnancy/?sf_action=get_data&sf_data=all&_sf_s=ectopic> [Accessed 2 October 2022].

Friday Board Review

Infectious Disease Board Review with Dr. Edward Guo

A 65 year old male with no past medical history presents to the emergency department with a painful rash on his neck and left shoulder for 2 days. Vitals are within normal limits. Exam is notable for the skin findings shown below with no other abnormal skin findings elsewhere. He is currently being examined in a hallway stretcher. What is the appropriate level of infection control precaution for this patient?

A: airborne

B: contact

C: droplet

D: standard

Answer: standard

This patient is presenting with a vesicular rash on an erythematous base in a dermatomal distribution characteristic of herpes zoster (shingles). Immunocompetent hosts with no signs of disseminated herpes zoster infection should have their skin lesions covered and only require standard infection precautions which is the same for all patients. Immunocompromised patients with localized infection or any patient with signs of disseminated infection should initially be placed on airborne and contact precautions which involves a negative pressure room, gown, and respirator such as N95 mask.

References:

Takhar SS, Moran GJ. Serious Viral Infections. 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.

https://www.cdc.gov/shingles/hcp/hc-settings.html

Friday Board Review

Cardiology Board Review with Dr. Edward Guo

A 34 year old female with no past medical history that is 2 weeks post-partum from an uncomplicated vaginal delivery presents for acute chest pain that started while she was exercising. Vital signs are within normal limits. On exam, she appears uncomfortable but in no respiratory distress. There is no lower extremity edema. Her EKG demonstrates ST segment elevations in contiguous leads with reciprocal depressions. Based on the leading diagnosis, which coronary artery is most commonly involved?

A: left anterior descending (LAD)

B: left circumflex (LCx)

C: posterior descending (PDA)

D: right coronary (RCA)

Answer: left anterior descending (LAD)

This patient presentation is typical for spontaneous coronary artery dissection (SCAD) which predominantly affects young to middle aged females. Risk factors include pregnancy, postpartum period, and hormonal therapy. Physical stressors such as exercise or emotional stress are classically involved. Unlike acute coronary syndrome, the pathophysiology involves a dissection tear in the coronary artery wall, not an atherosclerotic plaque or embolization. The LAD is most commonly involved in about 32 to 46% of cases. It is diagnosed by coronary angiography. Management varies but is typically conservative with medical therapy. Invasive measures such as coronary stenting is considered in cases with ongoing ischemia or hemodynamic instability.

References:

Hayes SN, Kim ESH, Saw J, et al. Spontaneous Coronary Artery Dissection: Current State of the Science: A Scientific Statement From the American Heart Association. Circulation. 2018;137(19):e523-e557. doi:10.1161/CIR.0000000000000564

Friday Board Review

Gastrointestinal Board Review with Dr. Edward Guo

A 40 year old female who works as a nurse aide in a long term rehabilitation center presents for abdominal pain and diarrhea. She describes greater than 3 episodes of loose, watery stool for the past 2 days with no vomiting or fever. Her vital signs are within normal limits. A Clostridium difficile stool toxin PCR is sent and results positive. According to the 2021 Infectious Disease Society of America guidelines, what is the preferred treatment for her condition?

A: IV vancomycin

B: PO fidaxomicin

C: PO metronidazole

D: PO vancomycin

Answer: PO fidaxomicin

The most recent IDSA guidelines for the treatment of non-fulminant Clostridium difficile diarrhea is fidaxomicin. It has shown superiority in preventing recurrence of disease when compared to oral vancomycin. Oral vancomycin or oral metronidazole are acceptable alternatives in non-fulminant disease and generally cost less than fidaxomicin. IV vancomycin is not used in the treatment of C. difficile diarrhea.

Treatment of Clostridium Difficile Diarrhea in Adults
Initial, non-fulminantFidaxomicin preferred
PO vancomycin alternative
Recurrent, non-fulminantFidaxomicin or PO vancomycin
FulminantPO vancomycin or via NG tube and IV metronidazole

References:

Stuart Johnson, Valéry Lavergne, Andrew M Skinner, Anne J Gonzales-Luna, Kevin W Garey, Ciaran P Kelly, Mark H Wilcox, Clinical Practice Guideline by the Infectious Diseases Society of America (IDSA) and Society for Healthcare Epidemiology of America (SHEA): 2021 Focused Update Guidelines on Management of Clostridioides difficile Infection in Adults, Clinical Infectious Diseases, Volume 73, Issue 5, 1 September 2021, Pages e1029–e1044, https://doi.org/10.1093/cid/ciab549

Friday Board Review

From the Archives: Acute Signs Board Review with Dr. Christine Collins

A 50 year old male presents with 4 weeks of diarrhea and associated abdominal pain described as cramping. He reports multiple episodes of pale, loose and malodorous stools daily. He recently went fishing. His vitals are as followed: 70 bpm, BP: 125/80, RR 18, PO2: 98%. Temp 37.2. What vitamin deficiency would you worry about in this patient?

A. Vitamin

B. Niacin

C. Vitamin C

D. Riboflavin

Answer: Riboflavin

This patient is presenting with signs and symptoms consistent with giardiasis. Patients can have malabsorption and steatorrhea, and chronic infection can result in deficiency of fat soluble vitamins A, D, E, and K.  Malabsorption can also lead to deficiency in Vitamin B12 and folate.

Giardiasis is the most common cause of parasitic diarrheal infection in the US and is transmitted by fecal-oral route. It is associated with streams and daycares. Classic symptoms include, colicky abdominal pain and pale, loose, malodorous stools. Treatment is metronidazole.  

References: 

Singh KD, Bhasin DK, Rana SV, et al. Effect of Giardia lamblia on duodenal disaccharidase levels in humans. Trop Gastroenterol 2000; 21:174.

Bjoernsen, L. P., & Ebinger, A. (2016). Chapter 159 Foodborne and Waterborne Diseases In Tintinalli’s Emergency Medicine: A Comprehensive Study Guide (8th ed). New York, NY: McGraw-Hill Education.

Friday Board Review

Toxicology Board Review with Dr. Edward Guo

A 45 year old male with a history of autism, depression, and epilepsy presents for an overdose. He was found in his bedroom obtunded by family with empty pill bottles. His medication list includes valproic acid and fluoxetine. He was intubated by EMS for airway protection. His vital signs include Temp 98.0F, HR 108, BP 100/60, RR 16, SpO2 99% on 40% FiO2. On exam, he has a GCS of E1 V1T M4 with minimal sedation. Pupils are equal and reactive to light. There is no rigidity or clonus. Labs are notable for elevated LFTs and ammonia. Which of the following medications should be used for the treatment of this patient’s suspected overdose?

A: Cyproheptidine

B: Levo-carnitine

C: Meropenem

D: B & C

Answer: B & C (Levo-carnitine & Meropenem)

This patient’s presentation is consistent with valproic acid overdose. The most common exam finding is CNS depression which can range from drowsiness to coma. Serotonin syndrome classically presents with hyperthermia and clonus. Treatment of serotonin syndrome typically includes supportive care with benzodiazepines and cyproheptadine with consultation of a toxicologist. Treatment of valproic acid toxicity includes GI decontamination and levo-carnitine as it can increase metabolism of valproic acid, hasten resolution of coma, and prevent hepatic dysfunction. Newer studies have shown that concomitant use of carbapenems (specifically meropenem) with valproic acid causes drug-drug interactions that lead to decreased serum valproic acid concentrations. Dialysis can be considered for severe overdoses with hemodynamic instability or acidosis that does not respond to initial therapy.

References:

LoVecchio F. Anticonvulsants. 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. 

Al-Quteimat O, Laila A. Valproate Interaction With Carbapenems: Review and Recommendations. Hosp Pharm. 2020;55(3):181-187. doi:10.1177/0018578719831974Al-Quteimat, O., & Laila, A. (2020). Valproate Interaction With Carbapenems: Review and Recommendations. Hospital pharmacy55(3), 181–187. https://doi.org/10.1177/0018578719831974

Special shoutout to our ED pharmacists that educated us on this topic!

Friday Board Review

Pediatrics Board Review with Dr. Edward Guo

A 13 year old male presents to the emergency department for 2 days of abdominal pain and diarrhea. He has no past medical or surgical history other than a tooth extraction for which he recently completed a week of clindamycin. The abdominal pain is generalized and associated with greater than 5 episodes of watery diarrhea daily. He denies any vomiting or recent travel. Vitals signs are: HR 120, BP 108/60, T 38.3 C, RR 20, SpO2 99% RA. On exam, he is tired but non-toxic appearing and not in acute distress. Mucous membranes are dry, and his cap refill is between 2 to 3 seconds. His abdomen is minimally tender to palpation diffusely with no guarding or rigidity. IV access is obtained and fluid resuscitation is started. What is the appropriate antibiotic treatment for this patient’s suspected condition?

A: IV vancomycin and cefepime

B: PO metronidazole

C: PO vancomycin

D: PO vancomycin and IV metronidazole

Answer: PO metronidazole

This patient’s fever, abdominal pain, and profuse diarrhea in the setting of recent antibiotic use is worrisome for Clostridium difficile (C. Diff) infection. Oral metronidazole is the treatment of choice in mild to moderate cases of pediatric C. Diff colitis. It is first-line due to being less expensive than vancomycin and avoids the potential risk of developing vancomycin-resistant enterococci. IV vancomycin and cefepime are broad spectrum agents commonly used in sepsis but are not preferred for suspected C. Diff colitis. In addition, the combination lacks anaerobic coverage for gastrointestinal infections. PO vancomycin with or without IV metronidazole is reserved for recurrent or severe infection which includes hypotension, ileus, or inability to tolerate PO antibiotics. 

Pediatric Clostridium Difficile Colitis Treatment
All patientsFluid resuscitation and electrolyte repletion
Discontinue offending antimicrobial agents if possible
Mild to moderate diseasePO metronidazole
Severe diseasePO or rectal vancomycin + IV metronidazole

References:

Freedman S.B., & Thull-Freedman J (2020). Vomiting, diarrhea, and dehydration in infants and children. Tintinalli J.E., & Ma O, & Yealy D.M., & Meckler G.D., & Stapczynski J, & Cline D.M., & Thomas S.H.(Eds.), Tintinalli’s Emergency Medicine: A Comprehensive Study Guide, 9e. McGraw Hill.

Friday Board Review

Internal Medicine Board Review with Dr. Edward Guo

A 60 year old male with a history of poorly controlled type 2 diabetes, hypertension, and hyperlipidemia presents for right foot pain. He noticed a few weeks ago that he developed a wound on the sole of his right foot which hurts with pressure. He denies any injury to the area or fevers. Vitals are within normal limits. Exam is notable for a shallow based ulcer with clean margins and no active drainage on the sole of his right foot. Which of the following positive physical exam findings, laboratory test, or imaging study has the highest positive likelihood ratio for osteomyelitis in this patient?

A: ESR > 70

B: MRI

C: probing to bone

D: ulcer area > 2 cm2

Answer: ESR > 70

This patient is presenting with a diabetic foot ulcer, a common complication of poorly controlled diabetes. While many physical exam features such as fever, pain, or purulence may be suggestive of osteomyelitis, an accurate diagnosis remains a challenge especially with co-existing diabetic neuropathy and blunted immune responses from diabetes. Although it is a non-specific marker of inflammation, an ESR > 70 mm/h has the highest likelihood ratio of osteomyelitis compared to other exam, laboratory, and imaging investigations as shown in the table below. This emphasizes the sensitivity and diagnostic utility of obtaining an ESR level in the emergency department to investigate for osteomyelitis in patients with diabetic foot ulcers. The gold standard test to diagnose osteomyelitis is a bone biopsy.

Positive FindingPositive LR (95% CI)Negative LR (95% CI)
Ulcer area > 2 cm²7.2 (1.1 – 49)0.48 (0.31 – 0.76)
“Probe to bone”6.4 (3.6 – 11)0.39 (0.20 – 0.76)
ESR > 70 mm/h11 (1.6 – 79)0.34 (0.06 – 1.90)
Plain radiograph2.3 (1.6 – 3.3)0.63 (0.51 – 0.78)
MRI3.8 (2.5 – 5.8)0.14 (0.08 – 0.26)
Table adapted from Tintinalli’s Emergency Medicine: A Comprehensive Study Guide, 9e Table 224-2

References:

Jalili M, Niroomand M. Type 2 Diabetes Mellitus. 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.

Mandell  JC, Khurana  B, Smith  JT, Czuczman  GJ, Ghazikhanian  V, Smith  SE: Osteomyelitis of the lower extremity: pathophysiology, imaging, and classification, with an emphasis on diabetic foot infection. Emerg Radiol 2017 Oct 20. doi: 10.1007/s10140-017-1564-9. [Epub ahead of print] [PubMed: 29058098]