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

Shotgun Testing

Tuesday, April 27th, 2010

Part of a resident’s job is to learn the ropes in preparing for independent practice. While you’re a resident, you get the benefit of having someone looking over your shoulder to critique you as you determine how you are going to manage patients.

I frequently tell residents that different attending physicians practice medicine in different ways. Some practice defensive medicine more than others, some prescribe antibiotics more than others and some work harder than others. The resident’s job is to figure out whose practice they are going to emulate when they begin practicing on their own.

That being said, I usually practice conservatively. I don’t tend to shotgun a lot of cases. When residents present cases to me, I make them give me a differential diagnosis and justify why they order the tests that they order. If they can’t justify why they’re doing the tests, then I won’t approve the tests.

A resident rotating on the first day in our emergency department presented a case to me and his comments made me think.

A woman in her 40′s came in complaining of tender lymph nodes to her neck for the previous 36 hours. That was it. She had pain in her neck when she turned her head to one side and thought she had cancer.

The resident ordered a CBC, comprehensive metabolic panel, cardiac enzymes, coags, chest x-ray, urinalysis, influenza swab, and strep test. He wanted to know whether I wanted to do a soft tissue x-ray of the neck or a CT scan of the neck.

“So what do you think is causing the swollen glands?”
“Maybe strep, maybe cancer.”
“Why the cardiac enzymes and coags?”
“If it is cancer and she needs surgery, the surgeons require a baseline.”
“Any other symptoms besides the swollen glands?”
“Nope.”
“Why the urinalysis?”
“I figured they could do that while they’re getting the pregnancy test.”
“Why the pregnancy test?”
“She’s going to need x-rays, right?”
“We can’t do an abdominal shield?”
“Sure.”
“Is a $200 flu swab going to be worthwhile?”
“It could cause the swollen glands.”
“In a patient with no fever, no cough, no pharyngitis, and the incidence of influenza sporadic according to the CDC?”
“Didn’t think of that.” He was obviously getting annoyed. “Fine. What do you want me to order?”
“Anything else on the physical exam?”
“Not really. No nodes anywhere else. No signs of infection.”
“Let’s go look.”

I’m typing this case up on the fly and was going to finish describing the interaction, but then I thought that maybe you all would like to take a crack at guessing what was causing the bilateral tender lymphadenopathy in the patient’s neck.

I’ll give you a couple of hints, since the diagnosis was rather obvious on examination and therefore I can’t tell you what the exam showed. First, the resident didn’t perform a good physical examination and didn’t take a good history. Both of those would have led to the correct diagnosis.

Remember, the nodes were bilateral and the diagnosis was obvious.

What do you think?

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

UPDATE APRIL 29, 2010
The answer is posted in the comments section.
The point of the post was not to belittle the resident, but was more to make a statement about how another resident felt that residency training was lacking.

Another resident in our program lamented that most of their didactic teaching doesn’t involve close physical examination or a thorough history any more. She felt that the overwhelming teaching points during the residency program were to perform procedures and to work up patient complaints to avoid being sued: Take the patient’s chief complaint, order tests that can rule out all the things that doctors commonly get sued over, and have them follow up with their family physician. You make the diagnosis – great. If not – that’s why they have family practitioners. Patients with high risk complaints and any risk factors for bad outcomes get admitted.

I actually got pegged as someone the residents like working with because I make them think about what they’re doing  – although the resident above avoided me the rest of the day.

If defensive medical practice is as entrenched in our residency programs as this resident seems to believe, our system will get worse, not better with health reform. More “insured” patients will be dumped into the system, health care access will become more disjointed, and patient will end up bouncing from emergency department to emergency department getting shotgun testing that will rule out remote life threats and protect the physicians from lawsuits but that will never really get to the bottom of the patient’s problems.

This patient probably would have had a high WBC count if labs were ordered. Maybe she would have been discharged on antibiotics and improved without making the diagnosis. The cost to the system for the proposed workup, though, would have been immense. Is this the way we want to spend our health care dollars?

Until we address the fear of malpractice that drives defensive medicine (and I’ll even cede that some of that fear is irrational), we’ll never reduce our healthcare spending.

What’s The Diagnosis #9

Wednesday, April 14th, 2010

A patient presents with an itchy rash to the elbow that started a week prior to presentation. After initially becoming red, the rash developed small blisters then the blisters ruptured, leaving small sores. There is no warmth or fluctuance to the area.  The patient saw his primary care physician 5 days ago and was prescribed topical steroids which had no effect on the rash. He also notes that he has been having diarrhea and stomach cramping lately. WBC count and sed rate are normal.

What is the diagnosis, how is it treated, and what other disease is it associated with?

I’ll post the answer below the picture on Friday.

Answer: Dermatitis Herpetiformis
Kudos to anon for the perfect answer.
Dermatitis herpetiformis is associated with celiac disease. In fact, some clinicians assert that a diagnosis of dermatitis herpetiformis can be used as a “backdoor diagnosis” to celiac disease.
DH occurs most commonly in the extensor surfaces of the joints, on the buttocks, and on the back of the neck, but can occur anywhere on the body. It is often misdiagnosed, being confused with drug eruptions, contact dermatitis, dishydrotic eczema, and even scabies.
DH is diagnosed by skin biopsy, but multiple biopsies must be taken from diseased and healthy skin as at least one biopsy must show IgA deposits in the dermal layers under immunofluorescence in order to confirm the diagnosis.
Long-term treatment is a gluten-free diet, but dapsone (a drug used to treat leprosy – more in-depth information here) may be used to treat the rash in resistant cases or in flares.

Read more about dermatitis herpetiformis at the Celiac Sprue Association, eMedicine.com and Medline Plus.

What’s the Diagnosis #8

Tuesday, March 23rd, 2010

A 3 year old child is carried into the emergency department because of pain in her left hip. Her mother stated that she woke up with the pain and has refused to walk all day because of the pain. The patient has been running a low grade fever and “just wasn’t acting right.”

The mother brought the child to the pediatrician earlier in the day. The pediatrician diagnosed the patient with “double ear infections” and prescribed the child that powerful pink healing elixir otherwise known as amoxicillin. When the mother asked the pediatrician why the child’s hip was hurting, the pediatrician stated that the child “probably slept on it wrong.” The mother stated that the pediatrician never even examined the child’s leg.

The child didn’t seem like she was getting better, so the mother brought her to the emergency department for another exam.

When I examined the leg, the child held her hip in flexion and cried with any movement of the hip joint. Distal sensory, motor, and circulatory exams were intact to the extent that the patient would allow an exam to be done. There was no appreciable swelling over the joints. She wouldn’t even try to walk. Oh, and her otoscopic exam was within normal limits.

I decided to do a few labs. Her WBC was 13,000 with 91% segs. The sedimentation rate was 120.

What’s the diagnosis, how is the diagnosis made, and what’s the treatment?

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UPDATE MARCH 25, 2010
Final Diagnosis: Septic arthritis of the hip.
Culture showed staph aureus, which is the responsible organism in about half of all cases.
Nice summary of septic hip in pediatric patients is at Wheeless’ Online Orthopaedics
Kocher criteria include non-weight bearing on the affected side, sedimentation rate > 40, fever, and WBC count > 12,000. When all four criteria are present, septic arthritis has a 99% likelihood. When three criteria are present, the likelihood of septic arthritis is still 93%.
Diagnosis requires joint aspiration under either ultrasound or fluoroscopy.
Treatment requires surgical drainage and antibiotics. Preliminary treatment is usually a third generation cephalosporin – pending culture results.  Keep in mind that MRSA is a growing problem (no pun intended) and that IV vancomycin may be necessary. Also keep in mind that sickle cell patients are prone to salmonella infections in bone and joints.
Unfortunately, septic arthritis may lead to many long-term hip problems such as dysplasia, deformities in hip development, and postinfectious arthritis – even with appropriate care.

As an aside, I was completely blown away by the number of thoughtful responses and differential diagnoses for this case. I intended it to be just a relatively straightforward case to jog the memories of the attendings and to teach the young grasshoppers. You guys came up with several things that even I hadn’t considered.
I’ll have to post these cases more often.
Thanks for the education!

What’s the Diagnosis #6

Thursday, November 19th, 2009

A 39 year old male with a 1 pack per day smoking habit presents with acute onset of shortness of breath and right-sided chest pain. You obtain an x-ray that is shown below. What is the diagnosis?

CXR

If you said “pneumothorax”, you’re right.
You decompress the pneumothorax using a Cook catheter and Heimlich valve. You hear a rush of air through the needle as the patient breathes out. You obtain a second chest x-ray to confirm that the lung is re-expanded. The result is shown below. Now what is your diagnosis?

CXR 2

Scroll down for the answer.
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Bullous Emphysema with Pneumothorax
When I initially saw the second x-ray, I was going to put in a second chest tube, suspecting that part of the pneumothorax had become walled off or loculated. Then I saw small septations in the right lung field and conferred with the radiologist who agreed that there was no further pneumothorax present.

Absence of lung tissue is noted in the right lower lung field in the first x-ray.
In the second chest x-ray, a small catheter can be seen in the right lateral 5th interspace. The remaining lung tissue is expanded, but multiple large bullae remain in the upper lung field, simulating a persistent pneumothorax.

See additional information about bullous emphysema here: Link #1, Link #2, Picture link

What’s The Diagnosis #5

Friday, October 23rd, 2009

An intoxicated 68 year old male involved in a car accident is brought in by ambulance in full spinal immobilization. No complaints of pain, but since the patient is intoxicated you do trauma films, including this c-spine x-ray series.

What’s the diagnosis and the treatment? Scroll down after the three x-rays for the answer.

Xray-1

Xray-2

Xray-3

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Answer: C2 Odontoid Fracture – Type II
In addition to the lucency on the odontoid view, if you look close, you can also see that the ring of C2 on the lateral x-ray is disrupted.
Read about C2 fractures at Maitrise Orthopedics (best explanation), Wheeless’ Textbook of Orthopedics, LearningRadiology.com, Medscape

Xray-3-2CT-1

What’s The Diagnosis #4

Friday, July 17th, 2009

A 13 year old boy comes in after being thrown from an ATV while riding in a field. His arm is painful and deformed at the elbow. He has numbness in his thumb, index, and middle fingers.

What is the diagnosis? What problems do you have to worry about? What should you monitor? What is his prognosis?

Scroll down for the answer.

Supracondylar Fracture

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Answer: Type III Supracondylar Elbow Fracture

With sensory deficit in the first three fingers of the hand, the patient likely has a median nerve injury. Also note the darker grey fat pad immediately posterior to the distal fracture segment.

Gartland Classification of Supracondylar Fractures includes
Type I: non-displaced
Type II: displaced, but with intact posterior cortex
Type III: displaced with complete dissociation of fracture segments

Vascular compromise occurs in up to 20% of children with supracondylar fractures. If missed, can develop compartment syndrome or ischemic contractures.
Compartment syndrome occurs infrequently and may be difficult to diagnose in presence of an associated median nerve palsy since the pain associated with compartment syndrome is diminished. May consider applying a continuous pulse oximeter to help monitor perfusion.
Median nerve injury can occur in up to half of patients with Type III supracondylar fractures.
Radial nerve injury can occur in up to 25% of patients with Type III supracondylar fractures.
Supracondylar fractures can often be fixed by percutaneous pinning, but may require open reduction and/or exploration if vascular injuries or if unable to achieve satisfactory reduction using closed manipulation.
Neurologic deficits often, but not always, resolve in 3-6 months.
Range of motion in joint may not return for up to 12 months.

References:
Wheeless’ Textbook of Orthopaedics
Orthopaedia.com

What’s the Diagnosis #3

Tuesday, June 23rd, 2009

WARNING – GROSS PICTURE BELOW

You probably know what this is, but can you spell it? What are risk factors for it? And how do you manage it?

Think about it for a minute and then scroll down for the answer.

Wound dehiscence

Answer: Wound dehiscence with evisceration (the bulge from the wound at the 1:00-2:00 position is bowel)

A good nursing article about wound dehiscence is here.

The following are excerpts about wound dehiscence taken from Sabiston’s Textbook of Surgery, 18th ed.

Wound dehiscence occurs in approximately 1% to 3% of patients who undergo an abdominal operation – usually 7 to 10 days postop.
It may be related to technical errors in placing sutures too close to the edge, too far apart, or under too much tension.
A deep wound infection is one of the most common causes of localized wound separation.
Many factors contribute to wound dehiscence including technical errors in fascial closure, emergency surgery, advanced age, wound infection, obesity, chronic steroid use, previous wound dehiscence, malnutrition, radiation therapy, and other systemic diseases such as diabetes or renal failure.

Dehiscence may occur without warning. Evisceration, such as in this case, makes the diagnosis obvious. Serosanguinous drainage precedes wound dehisence in 25% of patients. Probing the wound with a sterile, cotton-tipped applicator or gloved finger may also detect the dehiscence.

Treatment depends on the extent of fascial separation and the presence of evisceration or significant intra-abdominal contamination (intestinal leak, peritonitis). A small dehiscence may be managed by packing the wound with saline-moistened gauze and using an abdominal binder. If evisceration occurs, cover the intestines with a sterile, saline-moistened towel and contact the surgeon immediately. The patient will require urgent surgical closure of the wound.

Management of wound dehiscence may involve placing absorbable mesh, skin grafts, and/or flaps to reconstruct the abdominal wall.
Wound vacuums remove interstitial fluid, lessen bowel edema, decrease wound size, reduce bacterial colonization, increase perfusion, and improve healing. Successful closure of the fascia can be achieved in 85% of cases of abdominal wound dehiscence.

What’s the Diagnosis #2

Wednesday, May 6th, 2009

A 27 year old patient has had a sore throat for the past 10 days. He received antibiotics from his primary care physician without a lot of improvement. He comes in on a Saturday because he is out of antibiotics and wants a refill.
He doesn’t appear uncomfortable. He doesn’t have any problems swallowing. No fever. He does have pain on the left side of his neck along a swollen lymph node. It hurts for him to turn his head to the left. On exam, his throat is red, but there is no pus and his airway is patent. There are several swollen and tender lymph nodes in the neck. He complains of pain turning his head to the left side. He doesn’t have any signs of meningitis. Nothing else seems abnormal on his physical exam.

Think about what your differential diagnosis would be and what you’d do to work the patient up … if anything.

Now look at the x-ray below. What is the calcified foreign body in the front of his neck? Are there any other abnormalities? What other test(s) would you do and who would you call?

Scroll down for answers and other pictures.

xray-lateral

The calcified foreign body in the front of the neck is actually the hyoid bone. Coroners look to see whether this bone is intact during autopsy since a broken hyoid bone suggests that strangling took place.

The neck x-ray shows prevertebral soft tissue swelling. Remember 7 mm at C2 and 22mm at C7. Got the diagnosis now?

Answer is retropharyngeal abscess. More about the diagnosis here and here.

CT scans of the neck below.

retropharyngeal-abscess-ct-1

retropharyngeal-abscess-ct-2

What’s The Diagnosis?

Sunday, April 19th, 2009

25 year old patient presents with the rash below for the previous two weeks. Started on Acyclovir for herpes by primary care physician, but not getting better.  Mouth was sore previous week but no lesions noted. Now no mouth symptoms.
What’s the diagnosis? (Picture used with patient’s permission)
Answer here and here.

dyshidrotic-eczema

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