Dealin' with Dysuria and Discharge

Case: 20 yo female with 4 day history of dysuria, burning, vaginal itchiness/tenderness. Physical exam reveals multiple 5-10 mm ulcerated lesions, significant mucopurulent discharge, and extreme tenderness.

Tapa: Hearing the words painful ulcerated lesion should trigger every medical student to think about Herpes (and also H. ducreyi). Although we have been clasically taught that diagnosis is confirmed with a Tzank smear, in clinical Emergency Medicine practice, Herpes can be diagnosed clinically.

An important point to remember is that patients can often have more than one disease process occurring at the same time. In this case, the patient's vaginal discharge is likely secondary to gonorrhea and/or chlamydia. Due to vaginal tenderness, an accurate cervical examination could not be performed to assess for PID. If unsure, always ere on the side of treating for PID, rather than vaginitis.

Finally, never forget a pregnancy test!

Work-up: UPT, UA, GC/Chlamydia swabs, Wet prep swabs for trichomonas/BV

Treatment:
Primary Herpes - Acyclovir 400 mg, 5 times/day for 5-10 days
PID (always cover GC and Chlamydia) - Ceftriaxone 250 MG IM x1, Doxycycline100 mg PO x10 days

Anaphalyxis Considerations

Case: 65 yo man presents after being stung by a bee. Complains of wheezing, shortness of breath and tightness in his throat. SBP 95, O2 sat 97%, tachypneic and tachycardic. PMHx HTN treated with atenolol. Management?

Initial Considerations/Tapas:
-ABCs- pts prone to rapid airway compromise, sensation of "lump" or "fullness" in throat is omnious sign, consider definitive airway mgmt
-Epi is mainstay of treatment- 0.3mg of IM epi (1:1000 concentration) q15 minutes as needed for mgmt of hypotension, edema (DO NOT give IV epi unless you are coding the pt(i.e. they are not "alive")- if IV dosing required, 1mg of 1:10,000 epi IV)
-pt's on B-blockers may have blunted response to epi- administer 1g IV glucagon
-antihistamines (H1 and H2 blockers) 50mg IV push of diphenhydramine (H1) and raniditine (H2); use cimetidine with caution, as can increase 1/2 life of B-blockers)
-steroids (onset 4-6 hours after administration); methylpred 125mg
-pt should be observed 4-6 hours (can rarely have phenomenon of relapse 4-6 hours after initial event)

General Anaphalyxis Pearls:
-Anaphalyxis caused by IgE mediated type I hypersensitivity rxn. Preformed antibodies cross-linked by exposure to antigen, results in massive mast-cell degranulation, release of histamine and leukotrienes.
-Common precipitants of anaphalyxis include bee/insect stings, food allergies (particularly nuts), drug allergies (PCN, sulfa drugs), radiocontrast agents (anaphalactoid rxn- not IgE mediated)

Disposition and Patient Expectations

Case #1: 48 year old female presents with chest tightness, palpitations, and SBP > 200. Work-up is negative, including Cardiac Enzymes x 2, symptoms have resolved, and BP has "normalized". The patient asks the student (me), if she can go home.

Case #2: 31 year old female with history of surgically operated prolactinoma presents with recurrence of headaches, galactorrhea, possible bitemporal hemianopia, and dysmenorrhea (remember prolactinoma should cause amennorhea). A prolactin level is 3,900, MRI shows a 3 cm tumor pressing on the optic chiasm, and transvaginal ultrasound revealed endometrial polyps. The patient asks the student how soon before she moves to a room upstairs.

Tapa: Creating patient expectations for disposition before a definitive plan has been finalized can give patients false hope. In the aforementioned scenarios, the patient in the first case was kept overnight for observation with a stress echo in the morning, and the patient in the second case was discharged home with follow-up to Neuroendocrinology clinic and her gynecologist.

It is important to have an open relationship with your patients, and be honest about their disposition status. If you are unsure of a patient's disposition, do not offer them a definitive plan until you have discussed it with the primary (admitting/consulting) team.

Another important take home message can be gained from these examples. Mistakes will happen. They are inevitable in the learning curve of medicine. As doctors/students we must recognize these humbling moments and be honest and open with our patients. Numerous studies have shown that patient's value honesty in their physicians, and that patient care is not just about doing what's right for the patient, but also admitting when we are wrong.

Shoulder Dislocation

Case: 29 year old female dislocated L shoulder while swimming at lake.

Tapa: When assessing dislocations, you want to make sure you document neurovascular function prior to any therapeutic measures. With a shoulder dislocation it is important to check axillary nerve function. Sensation can be assessed over the deltoid, and motor function can be attempted with abduction.

X-Rays in at least 2 planes should be taken to ensure you have localized the dislocation correctly (over 90% of shoulder dislocations are anterior).

Left: Scapular Y-View showing an anterior dislocation.

There are numerous techniques used to for anterior shoulder reductions. The following video link from the good folks at Vanderbilt University illustrates a few of them: http://vimeo.com/8605660

After you believe the shoulder has been reduced, a simple test you can perform is to see if the patient can use their affected arm to reach across and touch their opposing shoulder. If they are successful, there is a good chance their arm has been successfully reduced. Post-reduction x-rays may be obtained to confirm placement.

The patient's arm should be placed in a sling, and the patient should follow up at an orthopedic clinic. It is important to instruct the patient that without physical therapy or surgery, the shoulder becomes easier to dislocate each time thereafter.

Ottawa Ankle Rule

Case: 32 year old biker hit by slow moving car. Walking with limp and pain at L ankle/foot.

Tapa: The often referred to Ottawa Ankle/Foot Rule can help guide clinical decision making on whether or not imaging is needed.

Ottawa Ankle Rule:

Pain in malleolar zone and (any of the following)

• bone tenderness along distal 6 cm of posterior tibia
• bone tenderness along distal 6 cm of posterior fibula
• Cannot weight bear for 4 steps in Emergency Department

Ottawa Foot Rule:

Pain in midfoot and (any of the following)

• bone tenderness at base of 5th metatarsal
• bone tenderness at navicular bone
• Cananot weight bear for 4 steps in Emergency Department

Miscellaneous notes:

• Ottawa Ankle/Foot Rule is far more sensitive than specific. Therefore, if patient does not fit any criteria in Ottawa Ankle/Foot Rule, they likely do not need an x-ray
• The rule cannot be applied to pregnant women, children <>
• It is also worthwhile to palpate the proximal fibula after ankle injury, checking for a Maisonneuve fracture, and to palpate between the 1st and 2nd MTP checking for a Lisfranc Fracture/Dislocation.
• In 5th metatarsal injuries it is important to recognize the difference between a Jones and Pseudo-Jones fracture, (the former being > 1.5 cm), as this distinction will change the course of management.