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.

Treatment of Cluster Headache

Case: 29 year old male presents with new onset gradually worsening pain located behind R eye. Associated sweating and Nasal Congestion.

Tapa: When working up headaches, the H&P can help separate out the benign from the concerning.

Concerning signs & symptoms include:

• Fever, Meningeal signs, Photophobia, AMS, Syncope, Sudden Onset/Worst HA of life, Trauma, HTN with DBP > 120, unilateral neck pain, signs of glaucoma, or neuro deficits

In this case, the patient has some classic presenting symptoms of a Cluster Headache. Although Cluster Headaches typically present in men in their 40s, they have been reported in both infants and the elderly. Classic signs & symptoms include sudden onset unilateral pain behind the orbit with associated lacrimation.

If you suspect a Cluster Headache, start the patient on Oxygen before presenting the case. The risks and expense of giving oxygen are relatively low. By starting the patient on O2 you will potentially decrease the time of their ED stay (not to mention you will impress your attending/resident)!

If the Headache resolves with oxygen, this is sufficient for diagnosis of a cluster headache. The patient should follow up with a neurologist as an outpatient. If the symptoms do not resolve, consider other therapeutic medications, or consider re-addressing your differential diagnosis.

Indications for Head CT in Minor Pediatric Head Trauma

Case Presentation:

HPI: 6 yo male presents s/p un-helmeted fall from bicycle. Fall unwitnessed, mom reports child came running inside immediately, crying, holding head. Applied ice to developing hematoma, child back to playing with siblings in 15-20 minutes. Pt presents to ED 6 hours after fall- urged to seek treatment by NP over phone when mom called concerned that child "acting funny" at bedtime. Asking to "wear shoes in bed," claiming he saw "pasta in his sister's hair," that it "was time to wake up." Per mom, no change in level of alertness, no nausea/vomiting, no complaints of HA or changes in vision.

Exam: VS- 110/65 76 12 37.1 99%RA
Gen- AAO x3, NAD, laughing, smiling, answers questions appropriately
HEENT- 2cm boggy hematoma above R eye, PERRL, EOMI, no nystagmus, no papilledema, TMs benign, no Battle's sign, nares and oropharynx benign
Neck- supple, full ROM, no spinous process tenderness
Neuro- CN II-XII intact, no focal deficits, finger-nose-finger with no dysmetria, able to run up and down hall without difficulty


Clinical Question: Should this child receive a head CT?

l

Evidence:

Osmond, M et al. CATCH: a clinical decision rule for the use of computed tomography in children with minor head injuries. CMAJ 2010 Mar 9;182(4):341-8

Prospective study conducted at 10 Canadian Pediatric EDs
-3866 subjects age 0-16 with minor head trauma
-Identified key variables of hx and exam associated with abnormal findings on head CT and/or need for neurosurgical intervention
-CATCH rule 98.1% sensitive and 50.0% specific for CT findings/need for intervention
-requires additional prospective validation

Radial Head Fracture in the Adult

Case: 62 year old woman presents after tripping on sidewalk and falling on outstretched hand. No LOC. Left elbow hurts to move. No other injuries or complaints.

Tapa: Radial head fractures are common in adults falling on outstretched hands, but can be difficult to detect on x-ray.

A focused physical exam should include:

• Distal skin examination, capillary refill, radial/ulnar pulses.
• Upper extremity sensation, motor, strength testing
• Upper extremity nerve function can be tested as follows: A-OK (median), crossed fingers (ulnar), thumbs up (radial)
• Active/Passive ROM testing including: pronation/supination, wrist & elbow extension/flexion
• Palpation feeling for point tenderness and/or displacement in entire upper extremity (a rule of thumb with orthopedic injuries is to always check the joints proximal and distal to the site of suspected injury).

At this point you will most likely need an x-ray to confirm your suspicions. Radial head fractures can be classified into three types radiographically. For the purposes of this conversation we will focus on Type 1 fractures, as they are non-displaced, and often the most difficult to detect.

Here you can see a "normal" lateral film of the elbow. The fat pad lines the sinovial fluid in the joint. After trauma to the elbow, the synovial fluid can cause this area to expand, and thus the fat pad can be an indirect marker of type 1 radial head fractures (especially if no fracture in the bone can be appreciated).

Here is an example of displacement of the anterior fat pad, otherwise known as the "sail sign". Remember, this is an indirect sign of trauma, and does not confirm a diagnosis of radial head fracture. Use wisely with your clinical suspicion!












In this example, you can again see the "sail sign". Additionally, you can see a posterior fat pad (marked with arrow). Presence of a posterior fat pad is always abnormal and is the most sensitive radiographic finding for a radial head fracture.













Any suspicions of distal radial/ulnar injuries should warrant wrist films as well.

After examination and radiographs you may still be unsure as to whether the patient has a type 1 radial head fracture or not. Rest assured, the treatment is the same. The patient should be given medication for their pain, placed in a sling, and instructed to mobilize their arm with range of motion exercises after 1 week. They should follow up with an orthopedist, and if any suspicion lingers as to whether or not their is a fracture, radiographs can be repeated at this time as evidence of a fracture will be more apparent.

(Images courtesy of: http://www.wikiradiography.com/)

Assessing the Intoxicated Patient

Case: 40 year old male presents via EMS after being found "sleeping" on the sidewalk. Smells of EtOH, difficult to arouse, disheveled appearance. Electronic records show 7 recent visits related to EtOH with no hospital admissions.

Tapa: Awakening this man could agitate him, creating a difficult scenario for the entire ED staff. In a busy environment, it would be easy to let this man "sleep it off", but the responsibility is on the Emergency Physician to ensure there is no underlying pathology. It is imperative to attempt an initial examination, at the very least so as to have a baseline to compare to on later exams.

At a minimum, intial examination should include:

• Vital Signs and Fingerstick Blood Glucose
• A+O and Glasgow Coma Scale
• If possible, asking what/how much the person had to drink and if other substances were used as well (i.e. cocaine, prescription meds, etc.). Ask questions related to pain.
• Undress patient and examine completely for lacerations, abrasions, obvious deformities, and trauma (especially craniofacial).
• Check for PERRL.
• Perform Cardiac, Respiratory, Abdominal exams (note epigastric tenderness: think pancreatitis work-up)
• Make sure patient can move all 4 extremities, either by command or in response to pain.

If the above examination is unremarkable and you are fairly confident based on the clinical picture that the patient's altered mental status is secondary to Alcohol, the mainstay of treatment is observation & reassessment. IM Thiamine/Folate can be considered, but in general, labs, tox screens, and IV Fluids are unnecessary.

Alcohol is metabolized in the liver via Zero-Order Kinetics at a rate of approximately 1 drink/hour (faster in chronic alcoholics). Reassess the patient in several hours. If the patient is showing improved mentation, continue with your history & physical. If the patient has not improved, further workup including Head CT may be warranted.

The patient can be discharged when they are A+O x3, have a steady gait, and have no new complaints.