Give me a case

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CrazyboyMD

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Yeah give me a case.
I'll respond within 5 minutes.
Make it easy since I'm in HS.
I'll order what I need to order.
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46F w a hx of HTN, hyperlipidemia, DM, PE, renal failure presents with constant, sharp right sided pain just below her right breast radiating to the back that is tender to palpation, as well as R flank pain. Pt says she was exercising vigorously with her husband at the on-set of the pain. Prior to coming to the ED, she took 324 mg ASA with no resolved pain. She also endorses hematuria, right sided pleuritic CP, SOB, and GW, claims she is sexually active and on birth control. Denies vomiting, diarrhea, neck/muscle stiffness, HA
Initial Vital Signs: HR 129, BP 143/92, SpO2 94%, RR 24, T 101.3
NKDA, no FHx
Social Hx: Fatty diet, smokes 4PPD, chronic alcoholic.

Here you go :) I'll reply with significant results from whatever you order to help you narrow down your DDx, I would like you to tell me why you're ordering whatever you order. (Hint: multiple diagnoses) At the end, state a disposition (OR, floor, DC home, etc.)

Shoot sorry I didn't see the make it easy part. I can revise?
 
Oh, also a Liver Enzymes to check bilirubin
 
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Creatinine and bilirubin levels are fine/insignificant tot his dx, however high Ca2+ levels

EDIT: High creatinine levels COULD be a factor with one of her dx, but her labs are not showing abnormality (perhaps too acute?)
 
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Ok, due to her sob then get me a CXR and spirometry
 
CrazyboyMD said:
Ok, due to her sob then get me a CXR and spirometry
Click to expand...
I'll be honest, I don't know much about spirometry, but she does have decreased Tidal volume if that helps.
CXR (no radiology interpretation) shows abnormality in descending aortic region. Consider further radiological studies
 
Ok with that, I want to further do some other labs

-Arterial Blood gas
-Tropinin levels
 
ABG normal, no indication of acidosis or alkalosis.
Troponin <.01 ng

With or w/o contrast? or both?
 
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Hey so repeat vital signs:
HR 130 RR 24 BP 84/50 SpO2 93% T:103.4

CT Chest shows Aortic dissection

Don't worry you're doing fine, I'm sure you know more than any other 16 year old lol. There's still a lot of things to do that should've been done immediately though, so keep crackin.
 
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CrazyboyMD said:
Give me both for contrast

@LucidSplash I'm only 16
Click to expand...

That's fine but I'm unclear what you're trying accomplish with this exercise. It won't be helpful to you in learning clinical medicine. Anyone can click boxes and order a bunch of tests and that's not what being a doctor is about. All seems a bit silly.
 
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Might wanna watch out for the tachycardia though
 
You're right though, these labs were useless due to the severity of the case
 
CrazyboyMD said:
Page Cardiothoracic surgery; go to the OR
Click to expand...

Might want to ask the location of the dissection. CT surgery and OR for ascending, ICU admit by medicine for medical management and consult to vascular if descending aorta.

This is my point, you don't have the foundation yet to really gain anything from this.
 
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I gotta ask, would you run sepsis protocol given the vital signs?
 
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haha you're right, he may not be gaining too much from it, but nonetheless it's a good challenge and boost to the morale. Here's how you should've gone about it:

Woman of child-bearing age with right sided pain below the breast. CP, SOB, on birthcontrol. hx of PE and HTN
So we see the risk factors of another PE are heightened, as well as the obvious acute myocardial infarction and aortic dissection.
STAT get a CXR, EKG, labs [CBC, CMP, Trop, D-dimer, Lactate (consider sepsis in a fever and tachycardia), CK-MB, and probably a PT/INR in if considering for dissection]
Results: elevated white count, lactate elevated (may be due to vigorous exercise as well, so not a very good indicator of sepsis, but may want to begin sepsis pathway), CXR was abnormal so would want a stat CT Chest/Abd with and without contrast or ultrasound, the CT would show aortic dissection as well as renal calculi in the right ureter (cause of UTI and fever? consider urosepsis with all other risk factors/sx). EKG normal, troponin normal, D-dimer elevated (PE ruled out by CT with contrast). INR adequate.
Medical Decision Making: start broad-spectrum ABx for indications of sepsis (tachy, hypo at second set of vitals which may also be due to hemodynamic instability, sx of GW, signs of UTI). Page cardiothoracic surgery immediately. Adequately oxygenate her prior to surgery. I think I hit everything. That'd be my work up personally.
 
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SunnyDO said:
I gotta ask, would you run sepsis protocol given the vital signs?
Click to expand...
I would personally from an ED perspective run the sepsis pathway because of the tachycardia and fever. The blood pressure is high, but that could be associated with compensated shock. Elevated white count and signs of UTI, I would think urosepsis is a possibility. Considering all the hell going on, I felt it would be a safe approach. I of course could be wrong but that'd be how I would go about it until proven otherwise. A lot of unreliable labs however given the circumstances. Maybe I'd even leave it up to the admitting physicians before initiating the ABx
 
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shaheene87 said:
I would personally from an ED perspective run the sepsis pathway because of the tachycardia and fever. The blood pressure is high, but that could be associated with compensated shock. Elevated white count and signs of UTI, I would think urosepsis is a possibility. Considering all the hell going on, I felt it would be a safe approach. I of course could be wrong but that'd be how I would go about it until proven otherwise. A lot of unreliable labs however given the circumstances. Maybe I'd even leave it up to the admitting physicians before initiating the ABx
Click to expand...

Just from a learning standpoint, if the dissection is descending only, do not bother CT surgery, they won't care. If ascending only go ahead. If BOTH you'll need both services (but the vascular consult isn't as urgent as the CT consult). But if you suspect dissection that heavily get the CTA all the way into the abdomen to see the distal extent of the dissection. The hematuria could also be from a kidney that is malperfused if the dissection extends that far because it is coming off the false lumen.
 
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LucidSplash said:
Just from a learning standpoint, if the dissection is descending only, do not bother CT surgery, they won't care. If ascending only go ahead. If BOTH you'll need both services (but the vascular consult isn't as urgent as the CT consult). But if you suspect dissection that heavily get the CTA all the way into the abdomen to see the distal extent of the dissection. The hematuria could also be from a kidney that is malperfused if the dissection because it is coming off the false lumen.
Click to expand...
Thank you for that, all good information to know and to be aware of, especially the last part:thumbup:
 
LucidSplash said:
Just from a learning standpoint, if the dissection is descending only, do not bother CT surgery, they won't care. If ascending only go ahead. If BOTH you'll need both services (but the vascular consult isn't as urgent as the CT consult). But if you suspect dissection that heavily get the CTA all the way into the abdomen to see the distal extent of the dissection. The hematuria could also be from a kidney that is malperfused if the dissection extends that far because it is coming off the false lumen.
Click to expand...

from real world standpoint,though, if someone has a thoracic dissection of any kind then i'm calling CT surgery. as a non-surgeon, I'm not going to make the call about medical vs surgical management. i'm going to make them come see the patient, and review the images, and if they don't want to surgerize after that, then so be it. But i'm not going to be a GP or ER doc making that call on my own...
 
sonofva said:
from real world standpoint,though, if someone has a thoracic dissection of any kind then i'm calling CT surgery. as a non-surgeon, I'm not going to make the call about medical vs surgical management. i'm going to make them come see the patient, and review the images, and if they don't want to surgerize after that, then so be it. But i'm not going to be a GP or ER doc making that call on my own...
Click to expand...

Do what you like I suppose. But CT surgery doesn't manage descending dissections. So it will be a wasted call because they will tell you to call someone else.
 
sonofva said:
from real world standpoint,though, if someone has a thoracic dissection of any kind then i'm calling CT surgery. as a non-surgeon, I'm not going to make the call about medical vs surgical management. i'm going to make them come see the patient, and review the images, and if they don't want to surgerize after that, then so be it. But i'm not going to be a GP or ER doc making that call on my own...
Click to expand...

Additionally it should be noted that "in the real world," knowing the appropriate service to consult is important. No one "makes me" come see consults. If it isn't an appropriate consult then the ED doc and I have an adult discussion and I'm happy to provide education to them on the subject; that's part of my job anyway. Everyone is better off for it. I've never had a situation where an ED doc refused to accept that for something as cut and dry as ascending vs descending dissection because I work with generally decent ED docs who are amenable to being educated about specialty-specific consulting. I will frequently review the images for them remotely if necessary but I can guarantee that our CT guys (who don't have residents or fellows but PAs and NPs instead) are just going to tell you to call the appropriate service as soon as they confirm with you there isn't an ascending component to the dissection.
 
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LucidSplash said:
Additionally it should be noted that "in the real world," knowing the appropriate service to consult is important. No one "makes me" come see consults. If it isn't an appropriate consult then the ED doc and I have an adult discussion and I'm happy to provide education to them on the subject; that's part of my job anyway. Everyone is better off for it. I've never had a situation where an ED doc refused to accept that for something as cut and dry as ascending vs descending dissection because I work with generally decent ED docs who are amenable to being educated about specialty-specific consulting. I will frequently review the images for them remotely if necessary but I can guarantee that our CT guys (who don't have residents or fellows but PAs and NPs instead) are just going to tell you to call the appropriate service as soon as they confirm with you there isn't an ascending component to the dissection.
Click to expand...
All the hospitals i have worked in have bylaws
LucidSplash said:
Additionally it should be noted that "in the real world," knowing the appropriate service to consult is important. No one "makes me" come see consults. If it isn't an appropriate consult then the ED doc and I have an adult discussion and I'm happy to provide education to them on the subject; that's part of my job anyway. Everyone is better off for it. I've never had a situation where an ED doc refused to accept that for something as cut and dry as ascending vs descending dissection because I work with generally decent ED docs who are amenable to being educated about specialty-specific consulting. I will frequently review the images for them remotely if necessary but I can guarantee that our CT guys (who don't have residents or fellows but PAs and NPs instead) are just going to tell you to call the appropriate service as soon as they confirm with you there isn't an ascending component to the dissection.
Click to expand...

Well im not going to physically come carry you, but most hospitals have bylaws requiring on call consultants to arrive within a certain time frame for all reasonable consults. And if a consultant did refuse to come see a patient with dissection, you better believe that im putting this in bold on the chart, along with their name and time called. For me its not a matter of knowing or not knowing, because i do know. its a matter of diffusing medicolegal responsibility in a condition that most people would consider high risk.

Sent from my SM-G930V using SDN mobile
 
I don't understand why you are unwilling to understand that this is about the appropriateness of the consult. I'm just trying to educate you on who is the right person to talk to about your hypothetical patient's problem and that can be done over the phone in this setting. I mean maybe go ask in the EM forum? They might tell you that CT surgery doesn't manage descending dissections and that should go to vascular. I'm just trying to help you understand that. CT can't tell you if the patient needs surgery for a descending dissection because they don't manage them.

If you threatened CT and they came, they would write that in their note "consulted to see patient for descending dissection. This is not an appropriate consult, patient requires vascular surgery consult. Recommend vascular consult."
 
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Why don't you guys give this 16 year old another case (common)
 
LucidSplash said:
I don't understand why you are unwilling to understand that this is about the appropriateness of the consult. I'm just trying to educate you on who is the right person to talk to about your hypothetical patient's problem and that can be done over the phone in this setting. I mean maybe go ask in the EM forum? They might tell you that CT surgery doesn't manage descending dissections and that should go to vascular. I'm just trying to help you understand that. CT can't tell you if the patient needs surgery for a descending dissection because they don't manage them.

If you threatened CT and they came, they would write that in their note "consulted to see patient for descending dissection. This is not an appropriate consult, patient requires vascular surgery consult. Recommend vascular consult."
Click to expand...


It's better to have more people to carry the coffin.
 
CrazyboyMD said:
Make an easy one if you are willing to give me one :D
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Patient is a 40 year old female coming in with 30 hours of abrupt onset right sided and substernal chest pain with associated shortness of breath. She says the pain is constant since onset, worse when she takes a deep breath. Pain does not radiate anywhere, she has never had anything like this before. She has no other medical problems excepting gallstones. She only takes oral birth control pills. She drinks socially, smokes 1 ppd cigs, and denies street drug use. She has no surgical history.
Pulse 105, O2 92%, RR 20, Temp 100.0F, BP is 110/70, D-stick is 90.

Before you start rattling off tests, list top 5 items in your differential, and what you are looking for on physical exam to confirm your primary diagnosis.
 
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sonofva said:
Patient is a 40 year old female coming in with 30 hours of abrupt onset right sided and substernal chest pain with associated shortness of breath. She says the pain is constant since onset, worse when she takes a deep breath. Pain does not radiate anywhere, she has never had anything like this before. She has no other medical problems excepting gallstones. She only takes oral birth control pills. She drinks socially, smokes 1 ppd cigs, and denies street drug use. She has no surgical history.
Pulse 105, O2 92%, RR 20, Temp 100.0F, BP is 110/70, D-stick is 90.

Before you start rattling off tests, list top 5 items in your differential, and what you are looking for on physical exam to confirm your primary diagnosis.
Click to expand...
This is good, I'm sure he'll get this one. Dang 30 hours though haha
 
For differential I am thinking an CHF, AA, PE, Pneumo? Possible Myocarditis or Pneumonia due to the fever

When doing physical exam for the primary, I am looking for murmurs when I ausucltate heart sounds
Patient will appear cyanotic
Diminished lungs sounds
 
For labs I would like to order a CBC, ABG, Troponin

Also I would get an EKG done

For radiology:

CXR
Chest CT
 
Was given a case last time
Willing to answer as soon as I see the notification
I'll order what I need to order
Make it easy as I am still in HS, and 16
 
Sure, 56 year old lady with a history of breast cancer that was surgically removed 3 years ago comes in with shortness of breath and chest pain that is worse with respiration. Physical exam is pretty unremarkable, except for oxygen saturation of 85%. Go!
 
I would like to order a CBC and Arterial Blood gas for labs
 
CrazyboyMD said:
I would like to order a CBC and Arterial Blood gas for labs
Click to expand...

CBC shows increased white blood cells (neutrophilic predominance). ABG shows pH 7.5, low pCO2, low pO2.
 
I am worried for possible infection due to increased WBC, or possible reoccurrence of the cancer?
Ok so might want to start the patient on o2
EKG and CXR will be needed
 
CrazyboyMD said:
I am worried for possible infection due to increased WBC, or possible reoccurrence of the cancer?
Ok so might want to start the patient on o2
EKG and CXR will be needed
Click to expand...

Reasonable. EKG shows sinus tachycardia, chest x-ray looks normal.
 
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