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Lions and Tigers and Bears

Dr. Loice Swisher’s daughter had five episodes of unexplained vomiting without a fever in just one month during 1999. Thinking through the files in her mind, she was unable to shake the memory of a young child with the same complaint 12 years before. The well-looking child had been bounced out of the ED four times with "viral syndrome" and "gastroenteritis." The diagnosis was a posterior fossa tumor.

“How did this happen?” she asked. The attending shrugged, offering up various possibilities. It was a difficult diagnosis because the symptoms at first are nonspecific. It is uncommon. The prior docs probably didn't get her up to walk or look in her eyes. They probably didn't think of it. He concluded, "To an ER doc, unexplained vomiting is a brain tumor until proven otherwise."

That single phrase altered the course of her life. A "reassurance MRI" showed a 5 cm brain cancer, a medulloblastoma. Her daughter navigated a course of radiation, chemotherapy, and multiple complications, and Dr. Swisher started an entirely new medical education in the art of diagnosis.

Amal Mattu, MD, reminds those of us in emergency medicine to be on the lookout for lions and tigers and bears, not horses and zebras, Dr. Swisher explained. As an emergency physician and mother, she knows the profound impact this approach has on a patient's life. Using real cases, this blog aims to expose the lions and tigers and bears out there ready to bite.

Wednesday, July 23, 2014
Some might say it would be better to be lucky than good.

Others might say it is crucial to maintain a high index of suspicion.

In emergency medicine, clearly both are true.
Here is a humbling case of a fortunate diagnosis made by a colleague.
A 42-year-old woman with a history of hypertension and schizophrenia presented to the emergency department with a day of left flank pain. She had a decreased appetite and didn't remember her last bowel movement, but had no fevers, chills, vomiting, or vaginal or urinary symptoms. She had left upper quadrant tenderness, perhaps with some guarding. The urine dip was unremarkable. The WBC was 14.3. An uncontrasted, abdominal CT scan was obtained.
Surgery consultation was obtained for the suspected 3 cm foreign body in her proximal descending colon. An impaled fishbone was removed during colonoscopy.
I will concede, ingested foreign body would be listed on an exhaustive differential diagnosis list for abdominal pain, but it isn't one that I tend to consider. Fortunately, most ingested foreign bodies traverse the GI tract without problems. When an ingested foreign body causes problems in the bowels, the inciting object is usually long, sharp, and double-pointed. Toothpicks are most commonly reported. A PubMed search pops up a couple non-toothpick impacted bowel foreign body case reports — two with fishbones and one with a lollipop stick! Reading these cases can be frightening.
Keep in mind:
• It isn't uncommon that patients are either unaware or unwilling to provide this key historical information.
• The physical exam is nonspecific.
• Imaging is only helpful in a small fraction of the cases.
• Complications have included perforation, obstruction, and migration, which can cause liver abscesses and bacterial pericarditis!

The deck is stacked against an emergency physician to make this diagnosis on the very first visit. Even if he asked the question, "Do you think you swallowed anything unusual? Maybe a fishbone or a toothpick or something?" the answer from this patient would have been no. How is an EP going to protect himself against the odd and unusual?

I tell patients that sometimes problems are like a photograph. I will know everything I am going to know about a diagnosis right then. Other times problems are more like movies. Events may progress to the expected ending. On the other hand, unanticipated twists can completely alter the conclusion. I give them a predicted timeframe when they should be better. I also give them a signpost, which should make them wonder if they are going in a different direction. I want them to come back to the ED if they see these signposts (symptoms).
Whether by luck or wisdom, the CT scan made this patient's experience more like a photograph.

Wednesday, July 02, 2014

Another patient pops up on the electronic medical record tracking board: a 52-year-old man with back pain who had run out of pain medication. A pink box indicates the lowest possible triage severity. A quick look at prior visits reveals that this diabetic, hypertensive smoker with high cholesterol was admitted for weakness and numbness of the right lower extremity just two months ago. His stroke workup, including head CT, brain MRI, and MRA, was normal. A lumbar MRI was also was relatively unremarkable.

With an empty bottle of Tramadol in his hand, the (fully dressed) patient recounted that the pain medicine initially seemed to help but didn't by the end. Perhaps, he said, he needed "something stronger." He also wondered if he was getting too old for his job because he and his coworkers race down the stairs at the end of the shifts. Now he has pain in his read end and down his legs. He just can't do it anymore.

A CT was ordered, almost inexplicably. Perhaps it was a slow night. Something really just didn't add up. Maybe a scan would give a clue.

The radiologist provided the diagnosis readily apparent by an impeccable exam: atherosclerosis obliterans of the aortoiliac vessels.

Embarrassingly, this patient had classic Leriche syndrome. Not only did he have four of the four risk factors — hypertension, diabetes, high cholesterol, and smoking — he also had the full triad of symptoms: claudication of the lower extremities, decreased lower extremity pulses, and impotence.

Yes, had someone asked, the patient would have quietly acknowledged "claudication a la troisieme member," as the French surgeon Rene Leriche described it more than a century ago. He also had, in fact, bilateral mid-abdominal bruits, bilateral femoral bruits, diminished femoral pulses, and barely palpable pedal pulses on retrospective physical exam. Certainly ABIs (ankle-brachial index) would have been markedly abnormal, had they been performed.

A few days later after stopping his metformin, the arteriogram revealed a pinpoint stenosis of the left common iliac artery with a complete or near-complete stenosis of the origin of the left internal iliac artery and a pinpoint stenosis of the mid-right common iliac artery with a patent internal iliac artery on that side.

After stent angioplasty of the left and right common, his pedal pulses and capillary refill returned to normal. Just as with Leriche's first published case, I expect that this patient again walks without pain and maintains an erection.

Tip to Remember: Always meticulously check the vascular status of the extremities when a patient has neurologic complaints.

About the Author

Loice Swisher, MD
Loice Swisher, MD, graduated from the Medical College of Pennsylvania emergency residency program after an educational fellowship in the early 1990s. She has been the nocturnist in the ED at Mercy Philadelphia Hospital since 1997.

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