follow up rounds
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FOLLOW UP ROUNDSAndrew Yoon, MD
Rhonda Forest, MD8/12/11
Case 1 Montefiore ED 7/29/11 Patient H.M. 01355124
CC: 89yo F BIBA from home for change of mental status as per home health aide
Case 1 EMS gave 1 amp of D50 Triage assessment: AAO X 1 Vitals in ED: T 99.8F (rectal), P 38-45, RR
14, BP 138/30, O2 99% on RA, Pain 0/10 PMH: DM, HLD, Depression, colostomy
from colon ca, chronic kidney disease (not on dialysis)
Meds: Citalopram, Glyburide, Zocor All: NKDA
History of Present Illness HHA reports patient was in her
wheelchair eating when she suddenly leaned backwards and became unresponsive. HHA checked patient who was breathing. She tried to wake her up but no response. Patient continued to slouch in her wheelchair for ~20 minutes before she vomited then awoke. Patient recalls eating dinner then waking up to her HHA and EMS surrounding her.
Review of Systems ROS: (-) fever, chills, malaise, CP, SOB,
cough, difficulty swallowing, decreased PO intake, nausea, diarrhea, constipation, hematochezia, melena, dysuria, hematuria, increased urinary frequency, vag bleeding, abnormal speech, HA, seizure like activity, blurry vision, new focal weakness
ROS: (+) vomiting x1, NBNB
Physical Exam General: NAD Skin: WNL Scalp/face: WNL Neck: WNL Heart: bradycardic, regular otherwise Lungs: clear, equal b/l Abd: WNL, colostomy bag in LLQ with healthy pink appearing
colonic tissue. Minimal amount of brown liquid in ostomy bag.
Back: No CVA tenderness Ext: WNL Neuro: Alert, AAO x2 (self, location), speech WNL, CNS 2-12
intact, sensation intact throughout body, motor WNL except 2/5 strength b/l LE, gait untested
EKG
Differential Diagnosis Syncope Vasovagal Myocardial Infarction Long QT syndrome Brugada Arrythmia Neurologic CVA Seizure Apnea/Hypoxia Aspiration Pneumonia Intracranial hemorrhage Hypovolemia Pulmonary Embolism Electrolyte Imbalance Hypoglycemia Deep Sleep Medication Induced Unexplained
Causes of Bradycardia Can be normal, especially in sleep and athletes Sick Sinus Syndrome Vagal activity Increased ICP Acute MI Heart block Obstructive sleep apnea Drugs (cholinergic drugs ie neostigmine, physostigmine,
beta blockers, reseperine, guanethidine, methyldopa, clonidine, cimetidine, digitalis, calcium channel blockers, amiodarone and lithium)
Other (hypothyroid, hyper/hypoK, hypothermia, prolonged hypoxia, strange infections ie babesiosas, Q fever, dengue fever, yellow fever, RMSF)
Labs Blood work resulted at 1835 Wbc 8.4, Hgb 12.1, Hct 36.1, Plts 254 Na 124, K hemo, Cl 94, CO2 15, BUN 80, Cr
3.2, Glu 211 Trop 0.07, CPK 144, CPK MB 1.7% Free T4 1.06 (No TSH sent)
Repeat BMP resulted at 2000 Na 128, K 6.3, Cl 99, CO2 15, BUN 78, Cr
3.2, Glu 180
Imaging CXR: clear lungs, heart enlarged but is an
AP view.
Head CT: chronic ischemic changes. No acute findings.
Treatment Calcium gluconate 1 amp IV Kayexelate 30g PO Bicarb 1 amp IV Insulin 10U IV, D50 1 amp NS 2L IV
Result Within 1 hour of administration of
medications patient’s heart rate increased to 50s, which is patient’s baseline heart rate based on previous two admissions.
No repeat EKG was done as patient was being prepared for transport to inpatient telemetry bed.
After Treatment of Hyperkalemia
Hyperkalemia- EKG Changes
First changes: Peaked T waves Shortened QT interval
Then: Lengthening of PR interval Widening of QRS complex Disappearance of P waves
Finally: Sine wave pattern Asystole
Peaked T waves
QRS Widening
Sine Wave
Hyperkalemia- Cardiac Membrane Stabilization
Calcium gluconate or chloride if QRS widening or loss of P waves Calcium chloride has 3x concentration of
calcium as calcium gluconate Calcium gluconate: 1g or 10ml of 10% solution Calcium chloride: 500mg to 1g or 5 to 10ml of
10% solution Give calcium chloride through central line In patients taking Digitalis still can give Ca
Temporary Treatment Insulin 10U IV, D50 1 amp
Drives K intracellularly Peak effect at 30-60 minutes Drop K by 0.5-1.2 meq/L
Albuterol 10-20mg Nebulized Drives K intracellularly 4-8x concentration used for asthma Peak effect 90 minutes Drop K by 0.5-1.5 meq/L
Bicarb Drives K intracellularly Effects controversial even in setting of acidosis If given recommended to be given as infusion over 2-4 hours
Potassium Removal Loop or thiazide diuretics
Increase K loss through urine No data showing short term benefit
Kayexelate 1 dose is ineffective Requires at least TID for 1-5 days No short term benefit Intestinal necrosis believed to be due to sorbitol, which SPS
contains, but Kayexelate does not Dialysis
When above treatments are ineffective When hyperK is “severe” When expected to have continued release of K ie
rhabdomyolysis or tumor lysis syndrome
Case 2 Jacobi ED 8/10/10 Patient T.K. 2154687
CC: 21yo F 17 weeks pregnant with diffuse lower quadrant abdominal pain
Case 2 Vitals T 100.1 F, BP 129/79, HR 94, RR 16,
O2 100%, Pain 10/10 PMH: G2P1001, C-section 4/2010 Meds: None All: NKDA
History of Present Illness 21yo F 17 weeks by LMP p/w lower
abdominal pain since this morning associated with N/V. Pain started off in RLQ and is now also suprapubic area. No vag bleeding/discharge.
Review of Systems ROS: (-) HEENT, cough, CP, SOB,
diarrhea/constipation, dysuria, vag bleeding/discharge, HA, blurry vision
ROS: (+) fevers, chills, nausea, vomiting (non-bloody, +bilious),
Physical Exam HEENT: NCAT CV: RRR, No m/r/g Lungs: clear b/l Abd: soft, non-distended, TTP suprapubic region,
(+/-) RLQ TTP, (+/-) guarding, no rebound, +BS GYN: Normal external genitalia, white discharge
in vault, os closed, no blood, no lesions/masses, no CMT, no adnexal tenderness b/l
Back: No CVA tenderness b/l Ext: No c/c/e Neuro: AAOX3, normal gait
Labs WBC 14.9, Hgb 12.0, Hct 35.2, Plt 268,
0.2% bands Na 140, K 4.1, Cl 109, CO2 22, BUN 6, Cr
0.5, Glu 77, T bili 0.3, ALKP 83, SGOT 20, SGPT 14
Hcg 23,436 Lipase 20 UA: blood neg, LE neg, Nit neg, WBC
5/hpf, Epi 3-4/hpf, Bact trace
Imaging Bedside TVUS: +IUP w/ FHR 150s, no free
fluid in cul-de-sac, b/l ovaries small 2.5 x 3 x 3 cm with no adenexal masses.
Ovary
IUP
UltrasoundAppendicitis
Further Imaging MRI abd/pelvis: limited study, no
evidence of free fluid, gravid uterus, appendix cannot be identified therefore appendicitis cannot be excluded
MRI
Even More Money for the Radiology Department
CT abd/pelvis: normal appendix visualized, no free fluid, single intrauterine gestation
CT
Normal appendix Appendicitis
Results Admitted to Gen Surg s/p MRI results, but
discharged from ED after CT results
May 16, 2011 had C-section at 42 weeks gestational age. Healthy male infant with Apgar scores of 8 & 9. Male infant circumcised, tolerating breast and bottle.
Clinical Assessment of Appendicitis
Most widely used is the modified Alvarado scale Migratory right iliac fossa pain (1 point) Anorexia (1 point) Nausea/vomiting (1 point) Tenderness in the right iliac fossa (2 points) Rebound tenderness in the right iliac fossa (1 point) Fever >37.5 degrees C (1 point) Leukocytosis (2 points) Score <3 home, 4-6 admit for observation, >7 OR
(male) Sensitivity 95%, Specificity 83% Much less reliable in women
Imaging Modalities for Diagnosing Appendicitis
Ultrasound Sensitivity 86%, Specificity 81%
MRI Sensitivity 91%, Specificity 98%
CT w/ IV and PO contrast Sensitivity 91-98%, Specificity 93%
CT w/ rectal contrast only Sensitivity 98%, Specificity 98%
CT w/ no contrast Sensitivity 88-96%, Specificity 91-98%
Radiation to Fetus < 5 rads
NO increased risk of fetal anomalies or pregnancy loss
CXR < 1mrad, Abd xray 2-3 rads, CT abd 2-3 rads
5-10 rads Inconclusive data IV pyelogram 4-9 rads, L-spine xray 4-6 rads
> 10 rads Increased risk of fetal anomalies and
pregnancy loss Barium enema 7-16 rads
Bathe in Radiation Round trip flight from NY to LA
3 mrem CXR
10 mrem Natural radiation from living on Earth for
1 year 300 mrem
Blaming Mother Earth for child’s MR Priceless
Fetal Periods of Vulnerability
First 2 weeks after conception “All or none” 100 rads will kill 50% of embryos
2-16 weeks after conception Death is rare Anomalies occur with 10-20 rads
20-25 weeks and beyond after conception Relatively resistant to teratogenic effects of
radiation
References1. Hong JJ, Cohn SM, Ekeh AP, et al. A prospective randomized study of clinical assessment versus
computed tomography for the diagnosis of acute appendicitis. Surg Infect (Larchmt). 2003;4(3):231.
2. Denizbasi A, Unluer EE. The role of the emergency medicine resident using the Alvarado score in the diagnosis of acute appendicitis compared with the general surgery resident. Eur J Emerg Med. 2003;10(4):296.
3. Lee SL, Walsh AJ, Ho HS. Computed tomography and ultrasonography do not improve and may delay the diagnosis and treatment of acute appendicitis. Arch Surg. 2001;136(5):556.
4. Ceydeli A, Lavotshkin S, Yu J, Wise L. When should we order a CT scan and when should we rely on the results to diagnose an acute appendicitis? Curr Surg. 2006;63(6):464.
5. Gaitini D, Beck-Razi N, Mor-Yosef D, et al. Diagnosing acute appendicitis in adults: accuracy of color Doppler sonography and MDCT compared with surgery and clinical follow-up. AJR Am J Roentgenol. 2008;190(5):1300.
6. Terasawa T, Blackmore CC, Bent S, Kohlwes RJ. Systematic review: computed tomography and ultrasonography to detect acute appendicitis in adults and adolescents. Ann Intern Med. 2004;141(7):537.
7. Rao PM, Rhea JT, Novelline RA, et al. Helical CT combined with contrast material administered only through the colon for imaging of suspected appendicitis. AJR Am J Roentgenol. 1997;169(5):1275.
8. Bentur, Y. Ionizing and nonionizing radiation in pregnancy. In: Maternal-fetal toxicology, 2nd ed, Koren, G (Ed), Marcel Dekker, New York, 1994, p. 515.
9. ACOG Committee Opinion. Number 299, September 2004. Guidelines for diagnostic imaging during pregnancy. Obstet Gynecol. 2004;104(3):647.
10. CDC. http://www.bt.cdc.gov/radiation/pdf/measurement.pdf
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