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Archive for the ‘What’s the Diagnosis?’ Category

What’s the Diagnosis #18

Tuesday, February 11th, 2014

An elderly patient with hypertension, hypothyroidism, and dementia is sent from the nursing home by ambulance for evaluation of a rash to her scalp. The patient’s nurse had noted the rash that afternoon while putting the beret in the patient’s hair and is sure that the rash wasn’t there two days ago when she last cared for the patient.

Scalp Rash BeforeThe patient was reportedly sleeping more than usual the day prior to her transport. The nursing director at the nursing home was concerned that the patient had developed shingles to her scalp.

A picture of the patient’s rash is to the right (unfortunately, not the best clarity).  What’s the diagnosis and what is the treatment for this condition?

Scroll down for the answer.

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Answer: Acute Lipstick Misapplication

Scalp Rash AfterThe “rash” happened to be the same color as the patient’s lipstick. There were initially two spots. Both were removed with an alcohol wipe.
Treatment: Discharge with close follow up.

Wait … not so fast.
Upon learning of the patient’s imminent return, the nursing director from the nursing home called back the emergency department and stated that no one had addressed why the patient had slept more than usual. After all, the patient reportedly slept past breakfast the day prior to her transport.
There was a bit of a discussion between the nursing director and the emergency department nurse which then escalated to a discussion between the nursing director from the nursing home and the nursing director from the hospital. Eventually, the patient had several lab tests performed in the emergency department to rule out anemia, electrolyte abnormalities, and hypothyroidism as a cause of the patient’s acute transient hypersomnolence.
When the labs all came back normal (except a mildly low sodium), the patient’s doctor had to be contacted in order to tell the nursing director from both facilities that it was permissible to send the patient back to the nursing home.
The nursing home then had its transport van come to pick up the patient.

Wait … not so fast.
The transport van was not available. It only runs between 8AM and 2PM. It was 4:30 PM.
So an ambulance had to be called to transport the patient back to the nursing home at a cost of roughly $400 plus $37.50 per mile.

The final result was an awful expensive bit of lipstick

Discharge instructions nearly included an order to set the patient’s alarm clock for 15 minutes prior to breakfast each day, but the emergency physician decided that there were enough phone calls made to hospital administrators regarding this patient for the day.

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This and all posts about patients may be fictional, may be my experiences, may be submitted by readers for publication here, or may be any combination of the above. Factual statements may or may not be accurate. If you would like to have a patient story published on WhiteCoat’s Call Room, please e-mail me.

Name That Rhythm

Wednesday, January 22nd, 2014

I’m posting this here today because I really don’t know the answer to the question and I wanted to get some opinions from the couple of you who still read this blog.

A patient in his 70′s comes in by ambulance with a complaint of dizziness. As part of his workup, we get an EKG which is noted below. I wasn’t able to figure out the rhythm. A cardiologist came down to the ED to evaluate the patient and wasn’t able to tell me what the rhythm was, either. He only stated that it “isn’t malignant” and it “isn’t what’s causing the patient’s dizziness.”

There is a P wave before every other QRS. The PR interval appears to be constant on those beats.
The R to R intervals appear to alternate and are regularly irregular.
The QRS morphology is narrow and seems to be constant, so it doesn’t appear to be bigeminy.
I guessed that it was a Mobitz II. The cardiologist said “no way.”

Your opinions? If you want to get a better look at the EKG, you can click on the picture. Also, a link to a .pdf copy of the EKG is here.

Undetermined Rhythm EKG

What’s The Diagnosis #17

Friday, November 22nd, 2013

A 26-year old female seeks your care for a bee sting to her thumb that occurred just prior to her arrival.

She states that she reached into her purse looking for her car keys and felt a sting to the pad of her thumb. She came directly to the emergency department after the incident because she is allergic to bees … and she always carries an EpiPen with her (shown below).

She’s currently having moderate pain in her thumb, but no other symptoms.

What’s your diagnosis and how would you treat this patient?
And take a guess how much it will cost the patient to refill her EpiPen.

Scroll below the pictures for the answer.

Thumb Sting

EpiPen

 

 

 

 

UPDATE NOVEMBER 28, 2013

The answer was more obvious than the treatment. This was obviously an epinephrine autoinjector injury and not a bee sting. After making the diagnosis, the question was what to do to treat the injury.

Many options exist, but in most cases no treatment is needed.

Older studies recommended phentolamine injection for treatment of adrenaline autoinjector injuries.

A 2002 review of 28 autoinjector injuries showed that minimal treatment usually resulted in relief. Soaking the affected area in warm water resulted in symptomatic relief in most patients. This review also noted that injection of phentolamine is not without risk. Injecting phentolamine into an already closed space may increase the pressure and diminish blood flow to the affected digit. When administered parentally, phentolamine can cause hypotension and tachycardia.

A 2009 review of reported epinephrine autoinjector injuries showed that despite our best efforts, patients get better. Out of 69 reported cases, various treatments including observation, warming of the affected area, nitroglycerin paste application, phentolamine injection, and other unidentified treatments resulted in the same outcomes: No permanent sequelae were reported.

A 2007 review in the journal Hand reviewed all literature from 1900 to 2005 and found no instances of finger necrosis, but a few cases of neuropraxia and reperfusion pain. This study was interesting in that one of the study authors actually injected three of his own fingers with varying concentrations of epinephrine so that he could document the outcomes. The description of the symptoms was interesting, and the author had significant reperfusion pain in one of his fingers and developed neuropraxia lasting 10 weeks in the finger injected with 1:1000 epinephrine.

In this patient, we used an infant heel warmer to warm the finger and observed the patient for symptoms. Her pain resolved after about an hour and she was discharged with a new prescription for an EpiPen.

How much did that prescription cost?
One online pharmaceutical sales company lists the wholesale price for two epinephrine autoinjectors (0.6 mg total) and a trainer as $426.
A syringe of 1:10,000 epinephrine (1 mg) costs $7.69.
Ouch.

EpiPen Auvi-Q cost

Epinephrine 1mg cost

 

What’s the Diagnosis #16

Wednesday, April 3rd, 2013

A nursing home patient is brought by ambulance with a cough. Nursing home staff believe the patient may have aspirated lunch 30 minutes ago. The patient’s workup is normal except for his EKG which is shown below (you can click on it for a much larger/printable version).

What’s the diagnosis? What needs to be done with the patient? Does it make any difference whether this was a new finding or an old finding?

I’ll provide the answer in the comments section in a couple of days.

EKG Scenario

What’s the Diagnosis #15

Wednesday, January 16th, 2013

An elderly patient presents with leg weakness over the prior two days. The day of presentation he also notices pain in his upper back which seems to be fairly persistent. His medical history includes diabetes and renal failure. He was dialyzed the afternoon prior to his presentation and his glucose was 264. The patient’s daughter stated that he “wasn’t acting himself.”
The patient’s physical exam was fairly normal. Perhaps a little weakness in his legs, but he still moved all extremities.
His current EKG (dark background) and another EKG faxed from a different hospital done six months earlier (light background) are shown below. You can click on them for larger images. What’s the diagnosis and what’s the next step?
I’ll post the answer underneath the EKGs in a couple of days.

Previous EKG.

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What’s The Diagnosis #14

Wednesday, November 9th, 2011

A patient in her late 60′s comes in with vomiting and some vague abdominal pain over the previous 24 hours. Her husband states that her stomach looks swollen. It does. X-rays below can be clicked upon to give you a higher resolution image if you want one.

What is wrong with the patient? What’s the treatment?

I’ll post the answer in the comments section in a couple of days.

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What’s the Diagnosis #13

Wednesday, March 16th, 2011

A breast cancer patient presents with painful rash to her hands and feet for the past 24 hours. The palms and soles were warm and she had a horrible “burning” sensation that didn’t improve with pain medications. Putting ice on her hands and feet seemed to provide her with temporary relief.

She started several new medications recently including an an ACE inhibitor, prednisone, pyridoxine, and Vicodin. She had finished one round of chemotherapy and did not have a satisfactory response. Her oncologist had therefore started her on a different regimen several days prior to her emergency department visit.

Vital signs were stable. The rash stopped at the wrist creases and the ankles and was nowhere else on her body. CBC and basic chemistries were normal. She had mild relief with IV morphine. The dermatologist on call said that it sounded like contact dermatitis and that he would see the patient in his office the following day.

What’s the diagnosis?
Why does the rash occur?
What is the treatment?

I will post the answer in the comments section in a couple of days.

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What’s the Diagnosis #12

Wednesday, February 23rd, 2011

A 15 year old girl goes to a pharmacy chain’s walk in clinic with a nonproductive cough and nasal congestion. She is diagnosed with “bronchitis” and is of course given antibiotics.

Two days later, she presents with joint pains and the rash below.

What’s the diagnosis?
What is/are the likely cause(s)?
What is the treatment?
What two clinical findings are most likely to predict an increased risk of death from this disease?

Answers in the comments section in a couple of days.

What’s The Diagnosis #11

Monday, August 23rd, 2010

A 55 year old patient comes in with itching to her scalp – so bad that it is setting off her migraine headaches.

She’s been to her family physician twice already and was first prescribed antibiotics for a scalp infection, then was prescribed steroid lotion for the inflammation. She was feeling worse.

When I examined her, she had several bite marks to the base of her neck and over the ears. You could also see the dried hydrocortisone cream in her hair. Then I saw movement and I pulled out the insect pictured.

What is the diagnosis and what is the treatment?

UPDATE AUGUST 25, 2010

OK, you all are too smart. Head lice, it is.
I had never seen a live head louse before and had to look it up on the internet. I knew it wasn’t a bedbug and suspected it was a louse because of the couple of lice nits on the patient’s hair.
Treatment recommendations vary.
Shaving the head is a radical but curative approach.
The American Academy of Pediatrics recommends copious amounts of amoxicillin, then Augmentin if that doesn’t work just came out with an excellent clinical report on head lice last month (.pdf format).
Pediculicides (chemicals) such as “Quell,” “Nix” and “Rid” are still the mainstay of treatment according to this paper. Benzyl Alcohol also works well. While oils have been used to remove lice, the report states that their effect is not reproducible. Occlusive agents such as petroleum shampoos, mayonnaise, and herbal oils “have not been evaluated for effectiveness in randomized, controlled trials.”
A dessicator can be used to blow hot air on the lice to kill them – with good results. Using a blow dryer to try this at home will cause live lice to become airborne and spread all over your house. Don’t do it.

What’s the Diagnosis #10

Wednesday, June 16th, 2010

A 26 year old female comes in complaining of chronic neck pain for the past 6-8 months. She was seen in the emergency department 4-5 months ago for the same pain and was diagnosed with a neck strain. Since that time, she has had intermittent pain.
She states that the pain is worse when she tilts her head forward or backward and also worse when she coughs.
There is no history of trauma. She has had no fevers or difficulty swallowing. Her vital signs are normal. Her teeth are in good shape with no signs of abscess. Oropharynx is also normal. No meningeal signs are present. She can move her head about fairly easily, but does notice some pain when flexing her head forward. Neurological examination is normal.
She came to the emergency department this time because when she woke up, the pain was worse and she had tingling down her back and into her fingertips when she was bending over to tie her shoes.
Xrays of her cervical spine are below (the AP view was unremarkable).
What is the abnormality on the x-rays? What is the name of the clinical sign that she was demonstrating? Given these two pieces of information, what was her diagnosis?

I’ll post the answers under the x-rays in a couple of days.

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Final Answer:

The patient was indeed exhibiting Lhermitte’s Sign. More common in multiple sclerosis, it can also be caused by other etiologies, including trauma. The presence of this sign and her pain with coughing were what prompted me to order a c-spine x-ray.

Scanman hit the x-ray results right on the nose. Atlantoaxial instability with posterior fusion of C2 and C3. The predental space (between the posterior arch of the atlas and the anterior surface of the dens) should be no more than 3mm. See more about interpreting C-spine x-rays in this AAFP article. In this patient, the predental space was 7 mm. The instability and the patient’s symptoms resulted in a sphinchter tightening moment while we scurried around to find a cervical collar.

Final diagnosis from our ED was shown on CT scan below – odontoid fracture. Probably subacute, but a fracture nonetheless. This occurred in the rural ED where I moonlight, so she was shipped to a tertiary care center.

By the way – I remember from my trauma training that coughing exacerbates the pain of a c-spine fracture, but was unable to find a name to go along with this sign. Anyone know of it? This is the third time I have caught an occult c-spine fracture because the patient complained of pain in the neck with coughing.

 

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