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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, September 03, 2014

A 21-year-old woman came in to the ED in the middle of the night after hitting her hand with a hammer. She had swelling and tenderness over the dorsal first metacarpal. Two linear hypodense lines disrupting the normal trabecular pattern were seen, but there was no cortical break noted. Fracture?

 

 

Here is another view that shows the same lines.

 

 

 

The radiology read: Two parallel curvilinear hypodensities in the distal and midshaft of the first metacarpal, which are new since the prior exam and most consistent with nondisplaced, possible trabecular microfractures, which do not appear to extend to the cortex.

 

She was placed in a thumb spica and given the number for orthopedics, so does it matter whether these were noted? Maybe not medically because this was likely a severe crush injury, but it can make a difference.

  • Missed fractures are one of the more common complaints with malpractice against emergency physicians.
  • We had the patient view the images on the computer so she could see the barely perceptible abnormality. That might help with the ever-elusive patient satisfaction.
  • The next morning there was no annoying, disruptive, time-stealing callback from radiology that had to be followed up by a colleague.

Tips to Remember:

1. Pay attention to the trabecular pattern because linear abnormalities can be subtle clues to a fracture.

2. Look for prior comparisons.


Wednesday, August 20, 2014

A man in his mid-50s with intermittent nosebleeds was sent in by his primary doctor for “abnormal labs.” The CBC sent from the office revealed a hemoglobin of 5.9 mg/dL. He had no past medical history and no sites of bleeding except for nosebleeds. Labs were sent to confirm the anemia as well as for potential admission.

 

His lab results were WBC 5.5; HGB 5.0; platelets 160; NA 124; K 3.4; Cl 99; CO2 23; BUN 16; Cr 1.8; glucose 71; anion gap 2; calcium 9.3; and albumin 2.1.

 

What is his diagnosis?

 

With the pressure on wait times and length of stay, I think much more often we put patients on the "admit train" to get them out of the ED. We put them in their "boxcar" with the hope that they will get off at the right stop. This patient was put on the severe anemia boxcar: Send appropriate labs, get consent for transfusion, admit, and move on. Seeing patients quickly is often given higher regard than taking the time to reflect critically on a patient's condition. A little more attention can make a difference in getting the patient on the best track.

 

Here is the biggest red flag. How often do you see a 50-year-old man with a hemoglobin of 5? How often do you see it in any man who doesn't have cancer, sickle cell, or a GI bleed? Um ... never. Sure, we see it all the time in women with heavy periods. A severely anemic male, however, is an anomaly worthy of deeper scrutiny.

 

The other unusual anomaly — an anion gap of 2. Recalling deeply buried bits of minutiae for the boards, a low anion gap goes along with multiple myeloma. From these two odd factors, the workup for multiple myeloma was started in the ED.

 

That was, in fact, his diagnosis. The very astute physician might have recognized the renal insufficiency as an additional concerning clue. The skeletal survey was more revealing, showing innumerable lytic lesions. The bone marrow biopsy confirmed the diagnosis: a hypercellular marrow with 62 percent monoclonal plasma cells consistent with multiple myeloma.


Wednesday, August 06, 2014
Have you ever picked up a chart, glanced at the chief complaint, and immediately thought, "Really! How do they know that?"
 
If you practice long enough, you will hear chief complaints such as "feels like spiders are crawling inside me," "feels like my muscles are falling off my bones," or something equally improbable. Yes, some might be delusional, but others just may be trying to give you the best clues they can.
 
"I Feel Blood Draining Inside My Head"

A 19-year-old man with no active medical conditions was brought to the emergency department five days after an assault during which he was knocked unconscious by a blow to the right side of his head. He has had a headache, nausea, and vomiting since that time, although he had not vomited since the day before.
 
The patient's father was concerned that his son was having difficulty walking and was just not himself. The teen attributed his ambulatory difficulties to knee abrasions sustained when he fell. He did complain of headache and felt "blood streaming" down the right side of his head. The patient denied confusion, diplopia, vision changes, focal weakness, or paresthesias. The neuro exams before and after his CT were reported as normal, including his mental status.
 
Here is the CT.

Epidural hematomas occur in different locations:
• Temporal/temporoparietal: 70%
• Frontal: 10%
• Parieto-occipital:10%
• Infratentorial/posterior fossa: 10%

The prognosis and presentation may be different depending on the brain real estate that the epidural inhabits.

Infratentorial epidurals can be rapidly deadly in that tight space. The supratentorial brain tolerates anterior-posterior compression more than lateral compression. Patients with frontal epidural hematomas (like this patient) may present days out with few neurologic signs beyond headache and perhaps irritability. In fact, they might not even report having a loss of consciousness.

Tips to Remember:
1. When parents (and wives) say their family member isn't right, they usually know. It is often wise to err on the side of trusting that this is true.
2. Not all epidurals present the same way or the way that you might think.



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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