17th Annual Emergency Medicine “Reality ED” Expert Panel

Michigan College of Emergency Physicians 46th Annual Emergency Medicine Assembly

Grand Hotel, Mackinac Island July 29, 2019

Distinguished Experts:

Abigail Brackney, MD, FACEP William Beaumont Hospital, Royal Oak Assistant Professor, Oakland University William Beaumont School of Medicine, Royal Oak

Adam Hunt, DO, MHS Covenant Healthcare, Saginaw Core Faculty, EM Residency, Central Michigan University, Saginaw

Diana Paratore, DO, MBA, M.Ed., FACEP, FACOEP Program Director, EM Residency, Beaumont Health-Farmington Hills Associate Professor, Michigan State University COM

Bradford L. Walters, MD, FACEP William Beaumont Hospital, Royal Oak Associate Professor, Oakland University William Beaumont School of Medicine, Royal Oak

Moderator: James C. Mitchiner, MD, MPH, FACEP St. Joseph Mercy Hospital, Ann Arbor University of Michigan/St. Joseph Mercy Hospital EM Residency

1 Objectives: the distinguished panel will discuss the management of actual Michigan cases that cover some of the interesting clinical aspects of contemporary emergency medicine. At the conclusion of this session, the audience will have a better understanding of how the experts would manage these challenging patients.

Audience participation is anticipated and highly encouraged!

Case Selection is generally based on meeting one or more of these criteria:

• Interesting and/or challenging • Occurred in Michigan • Unusual presentation of a common emergency • Typical presentation of a rare emergency • Administrative challenges you’re likely to encounter • Controversies in pre-hospital care • ‘Bounce backs’ • An occasional zebra

NOTE: these cases are provided for educational discussion and physician peer review only, and confidentiality is protected under applicable Michigan laws. Reproduction and further discussion outside of this venue is prohibited.

2 Case 1: Just Another Case of Weakness?

40-year-old male with acute illness of 4 days duration that started with low back pain, followed by paresthesias of both feet going up to his knees, then left arm paresthesias, followed by weakness in both legs on the day prior to his ED visit. Associated with headache, fatigue, but no visual symptoms. He was seen in the ED yesterday, had a negative head CT and a nonspecific mild leukocytosis along with mild elevation of his total CK and was discharged. He went home, took a bath, and noted worsening weakness, with inability to walk, and was brought back to the ED by his wife. Denies fevers, travel, recent vaccinations, recent infections, unusual food, URI symptoms.

Review of systems: Fatigue, no fever, no rash complained of fatigue but denied fever, rash, blurred vision, chest pain, shortness of breath, abdominal pain, nausea vomiting or diarrhea.

PMH: asthma, appendectomy Meds: ibuprofen, ProAir HFA Social History: married; denies alcohol, tobacco, or drug abuse.

Vital Signs: BP 139/111, P 97, R 18, T 98.2, O2 sat 100% (RA) Alert, no distress. HEENT: normal conjunctivae; oral mucosa moist. Neck: supple, no meningismus. CV: RRR, no murmur, normal pulses, no edema. Lungs: clear to auscultation, breath sounds equal, non-labored respirations. Abd: soft, non-tender, non-distended, normal bowel sounds. Neuro: AAOx3, strength 5/5 in both feet, ankles & wrists; 4/5 in elbows, hips & shoulders. Intact sensation to light touch in all 4 extremities. 1+ biceps reflexes bilaterally, absent L patellar reflex, Babinskis equivocal.

Labs: WBC 13,500, Hb 15.4, Plt 257K, Na 136, K 3.9, Cl 104, HCO3 22, Glu 147, BUN 17, Creat 0.84, Ca 9.2, LFTs normal except total protein 9.1, CK 546, ESR 23, C-reactive protein <0.5, TSH 0.78, UA negative

Imaging: CXR negative. MRI: no acute intracranial abnormality or spinal cord disease; multiple level minor disc protrusions.

A clinical diagnosis was made.

Question to Consider:

1. What is the most likely diagnosis?

2. How would you treat it?

3 Case 2: Follow those Labs!

53-year-old male with long-standing alcohol abuse, presents with 4-day history of intermittent melanemesis; now vomiting almost hourly. Denies abdominal pain, blood thinners, NSAIDs, dark-colored stools or visible rectal bleeding.

Review of systems: Notes general fatigue. Denies chest pain, shortness of breath, near-syncope, palpitations, abdominal pain, extremity pain

PMH: Hypertension Meds: Social history: drinks 2 10-ounce glasses of whiskey daily; denies smoking

Vital Signs: BP 219/119, P 112, R 34, T 97.9, O2 sat 100% (RA) Alert, no distress, no odors. HEENT: head atraumatic, normal conjunctivae; oral mucosa moist. Neck: supple. CV: tachycardic, RRR, no murmur, normal pulses, no edema. Lungs: clear to auscultation, breath sounds equal, non-labored respirations. Abd: soft, non-tender, non-distended, normal bowel sounds, stool guaiac positive but not grossly melanotic. Neuro: AAOx3, normal speech, normal motor & sensory, no focal neurologic deficit. Skin: warm & dry, no jaundice

Labs: WBC 11,300, Hb 12.1, Plt 205K, Na 130, K 3.5, Cl 87, HCO3 11, Glu 219, BUN 18, Creat 1.56, Ca 8.2, Alk Phos 145, ALT 53, AST 130, PT 12.1, INR 1.10, EtOH 43, lactate 3.9, venous pH 7.30, UA: 2+ ketones, 8 WBC, >175 RBC. LE neg, nitrite neg

ED Course: IV fluids started; repeat VS: BP 198/98, P 103, R 25. Patient started on pantoprazole drip. An additional lab test was ordered.

Questions to consider:

1. What is the differential diagnosis?

2. What was the additional lab test ordered?

3. What was the result?

4 Case 3: Syncope

51-year-old female found by her husband unresponsive in her bed today, with eyes open, noisy breathing, had brief jerky movements, possibly apneic. She was incontinent of urine. She denied headache, chest pain, shortness of breath, peripheral weakness or numbness, new medications, overdose, drinking alcohol, drug use or recent head trauma. No past history of seizures or syncope.

Review of systems: Denies fever, chills, jaundice, chest pain, shortness of breath, abdominal pain, vomiting, dysuria.

PMH: hypertension, hyperlipidemia, non-obstructive CAD, CHF (LVEF 30%), LBBB, asthma Meds: Cymbalta, Flonase, Norco, levothyroxine Social history: denies alcohol, tobacco or drug abuse

Vital Signs: BP 108/74, P 116, R 18, T 98, O2 sat 99% (RA) Alert, no distress. HEENT: PERRL, EOMs intact, normal conjunctivae; oral mucosa moist. Neck: supple. CV: tachycardic, RRR, no murmur, normal pulses, no edema. Lungs: clear to auscultation, breath sounds equal, non-labored respirations. Abd: soft, non-tender, non-distended, normal bowel sounds. Neuro: AAOx3, normal speech, CNs normal, normal motor & sensory, no focal neurologic deficit. Skin: warm, dry & pink

Labs: WBC 12,600, Hb 13.4, Plt 346K, Na 135, K 4.4, Cl 101, HCO3 23, Glu 125, BUN 19, Creat 0.91, Ca 9.4, LFTs normal, UA: negative

ECG: LBBB (old); see next page

ED Course: seizure precautions, IV fluids started, sent for non-contrast head CT which showed a calcified suprasellar mass (? pituitary origin).

Questions to Consider:

1. What is the historical clue to the most likely diagnosis?

2. What test would you order next?

3. Do you follow the San Francisco Syncope Rule?

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6 Case 4: Thinking Outside the Box

20-year-old woman with history of rheumatoid arthritis and asthma, presents with acute dyspnea, associated with anterior chest pain that started 1 week ago. Initially got better but became acutely worse last night. She also complained of tactile fever, upper respiratory congestion and cough. Her chest pain is worse when recumbent and improved by sitting up. No history of cardiopulmonary disease including PE or DVT, recent travel, leg pain, hormones, recent surgery or history of cancer.

ROS: positive for chills. Denies nausea, vomiting, diarrhea, dysuria, hematemesis, hematochezia PMH: RA, asthma Meds: albuterol, budesonide, loratadine, pantoprazole SH: denies alcohol, smokes marijuana daily

Vital Signs: BP 100/60, P 140, R 40, T 97.8, O2 sat 99% on RA

Exam: mild distress, tachypneic. HEENT: PERRL, conjunctivae normal. Neck: supple. Cardiac: tachycardic, regular rhythm, S1& S2 normal, no obvious murmur. Lungs clear to auscultation, mild increased work of breathing. Abdomen: soft, nontender, nondistended. Neuro: non-focal exam. Skin: warm & dry.

Labs: WBC 13,700, Hb 11.9, Hct 36.8, Plt 532K, Na 139, K 3.6, Cl 106, HCO3 22, Glu 110, Ca 8.7, BUN 7, creat 0.67, troponin 0.03, lactate 2.9, BNP 91, C-reactive protein 12.0, ESR 130, LFTs normal, PT 13.7, INR 1.25, D-dimer 2,630

Imaging: CXR interpreted as “cardiomediastinal silhouette that appeared mild to moderately prominent”; lungs clear.

ECG: see next page

ED Course: A diagnostic test was then ordered.

Questions to Consider:

1. What is the Differential Diagnosis?

2. What was the diagnostic test?

3. What did the test show?

7 Case 4:

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Case 5: Confusion, with Unexpected Lab Results

79-year-old male with history of type 1 diabetes, brought to the ED for confusion. Patient himself is delirious and unable to provide a history. His friend, who accompanied him, states that the patient called him today and sounded confused about his insulin dosage so the friend went over to find the patient was confused and brought him to the ER. Friend last saw the patient 1 week ago. No further history available.

Review of Systems: unable to obtain

PMH: DM1, CAD, GERD Medications: Family history: unknown Social history: single, occasional alcohol use

Vital Signs: BP 149/71, P 82, R 15, T 98, O2 saturation 98% on RA

Exam: awake, alert but somewhat confused, no distress Skin: warm, dry, pink Head: normocephalic, atraumatic Neck: supple, no tenderness Eyes/ENT: normal conjunctivae, oral mucosa moist Cardiovascular: regular rate and rhythm, no murmur, normal peripheral perfusion, No edema. Respiratory: respirations non-labored, breath sounds clear and equal Abdomen: mild distension, mild diffuse tenderness; Musculoskeletal: normal ROM, normal strength, no tenderness, no swelling, Neurological: no focal neurological deficit, normal speech observed.

Labs: WBC 5,300, Hb 11.6, Na 133, K 4.8, Cl 100, HCO3 25, BUN 16, creatinine 0.82, glucose 347, Ca 8.8 Venous blood gas: pH 7.58, pCO2 24, pO2 36, HCO3 23, lactate 2.4

Imaging: CXR: no acute disease. CT head: No hemorrhage, extra-axial fluid, mass effect or infarct

ED Course: IV fluids started. An additional test was ordered.

Questions to Consider:

1. What is your Differential Diagnosis for confusion?

2. What test would you order next?

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Case 6: Putting It All Together

19 year-old female, with history of chronic back pain, otherwise healthy.

ED Visit #1: she presented with complaint of acute left eye redness with photosensitivity. Denied eye or head pain, history of trauma, FB sensation, discharge, changes in acuity or URI symptoms. Symptoms started after placing eyelash extensions on lids. Denies similar problems with OD. On exam, her vital signs were stable. Exam showed grossly normal acuity with conjunctival injection, PERRL, intact accommodation, EOM’s intact. SLE w/ fluorescein negative for corneal injury or foreign body. Diagnosed with viral conjunctivitis and discharged with Rx for flurbiprofen eye drops.

ED Visit #2: returned 3 days later with persistent eye irritation and redness, no better. No fever, headache or neck pain. SLE again negative. Everted eyelid exam negative. Erythromycin ointment added and referred to ophthalmology clinic in AM, where she was seen and diagnosed with acute uveitis. Started on steroid eye drops and referred back to her PCP for ongoing issue of back pain.

ED Visit #3: returned 17 days later with complaint of non-traumatic knee swelling x 2 days, with additional complaints of pain in her jaw, left hip and right great toe. Denies fever, chills, but endorses night sweats. No history of rheumatologic disease.

ROS: No fever or chills. Has had night sweats. Denies dyspnea, cough, chest or abdominal pain, nausea, vomiting, diarrhea, dysuria, diarrhea. PMH: chronic back pain Meds: cyclopentolate eye drops, Durezol (steroid) eye drops, Aleve SH: single; denies alcohol, uses marijuana

Vital Signs: BP 117/70, P 108, R 16, T 98.1, O2 sat 99% on RA Exam: moderate distress, tachycardic. Normocephalic. L pupil dilated (on cyclopentolate drops), conjunctivae normal. ENT: tender over right TMJ w/ pain on opening jaw. Neck: supple. Cardiac: tachycardic, regular rhythm, no murmur. Resp: non-labored, lungs clear to auscultation. Abdomen: soft, nontender, nondistended. Neuro: non-focal exam. Musculoskeletal: swelling, warmth, tenderness in R knee; no erythema, painful ROM, R great toe unremarkable, L hip nontender. Skin: warm & dry.

ED Course: X-rays of L-spine and SI joints were negative. Given IM Toradol with some improvement. Results of a blood test ordered by her ophthalmologist, and a urine test from her PCP, were then obtained. The diagnosis was then made.

Questions to Consider:

1. What were the additional tests?

2. What would you do next?

10 3. What was the ultimate diagnosis?

11 Case 7: A Classic Case of Appendicitis

23 year-old female presents to ED with acute abdominal pain for about 20 hours. Pain described as sharp and shooting, “like being stabbed with a poker”, initially periumbilical but now localized to the RLQ, worse with movement, including walking. Pain exacerbated while driving and riding over bumps in road. Associated with nausea without emesis. Denies urinary symptoms, vaginal discharge, fever, chills, sweats, chest pain, cough, wheezing or shortness of breath. Had normal bowel movements x 2 but still feels constipated.

ROS: all negative, except as noted above. PMH: negative. Has never been pregnant; LMP started 26 days earlier, normal Meds: none SH: student, single, lives with parents. Occasional alcohol, non-smoker

Vital Signs: BP 111/88, P 118, R 18, T 98.1, O2 sat 100% on RA, weight 89 kg Exam: moderate distress. Normocephalic. Eyes: PERRL, EOM’s intact, conjunctivae normal. ENT: oral mucosa moist, TM’s normal. Neck: supple, non-tender. Cardiac: regular rate and rhythm, no murmur, normal pulses. Resp: non-labored, lungs clear to auscultation, breath sounds equal. Abdomen: soft, non-distended, normal bowel sounds, markedly tender in RLQ with rebound + referred rebound tenderness from palpation of LLQ. Neuro: non-focal. Musculoskeletal: unremarkable. Skin: warm & dry.

Labs: WBC 10,500, Hb 11.5, Plt 276K, Na 134, K 3.5, Cl 104, HCO3 20, BUN 6, creat 0.83, glucose 80, Ca 9.0, Alk Phos 188, other LFTs normal, lipase not done

ED Course: IV fluids started, given Dilaudid and Zofran. MDM says “symptoms and physical findings are classic for acute appendicitis”

An imaging study was ordered to confirm the diagnosis, and a consultant was called.

Questions to Consider:

1. What is your Differential Diagnosis?

2. Do you use a scoring system for appendicitis, e.g., Alvarado Score?

3. What imaging study was ordered, and what did it show?

4. What did the consultant do?

12 Case 8: Face Pain + Headache

ED Visit #1: 35 year-old male presents with headache x 5 days, gradual onset, getting worse. Has had URI symptoms with nasal/sinus congestion, myalgias and generalized weakness. Denies fever, recent head trauma, dizziness, nausea, vomiting, visual changes, focal weakness/numbness or neck pain. No relief after taking Excedrin.

ROS: no cough, chest pain, shortness of breath, dysuria, abdominal or back pain. Other systems negative except as noted above. PMH: depression, anxiety, GERD Meds: Paxil, Prilosec, trazodone SH: smokes cigarettes, occasional alcohol, uses marijuana (last time today)

Vital Signs: BP 150/84, P 100, R 22, T 98.8, O2 sat 97% on RA Exam: mild distress, anxious. Normocephalic. Eyes: PERRL, EOM’s intact, conjunctivae normal. ENT: oral mucosa moist. Neck: supple, non-tender. Cardiac: regular tachycardia, no murmur. Resp: non-labored, lungs clear to auscultation. Abdomen: soft, non-tender. Neuro: AOx4, non-focal, normal motor and speech, normal coordination. Musculoskeletal: unremarkable. Skin: warm & dry.

Labs: WBC 19,300 (18,200 neutrophils), Hb 15.6, Plt 291K, Na 132, K 4.2, Cl 96, HCO3 28, BUN 15, creat 1.24, glucose 107, Ca 9.2, UA normal CXR: no infiltrates.

ED Course: IV fluids started, given Toradol and Reglan, with significant improvement in headache. Developed fever (100.7), but no neck stiffness or neuro deficit. Given Tylenol and Afrin nasal spray. Tachycardia persisted, believed to be secondary to fever and Excedrin (caffeine). Discharged home, improved, with diagnosis of acute sinusitis, Rx for Atrovent Nasal spray. ******************************************************************************

ED Visit #2: Returned 16 days later with complaint of persistent headache, despite finishing a course of prednisone and amoxicillin, prescribed by his PCP. Headache frontal, throbbing, non- radiating, and associated with photophobia and nausea; no recurrent fever, chills, vomiting, vision changes, dizziness or peripheral weakness/numbness. No relief from NSAIDs or Tylenol.

ROS: nasal congestion and sinus pain; denies sore throat

Vital Signs: BP 131/93, P 71, R 18, T 98.7, O2 sat 98% on RA Eyes: EOM’s intact, normal conjunctiva. ENT: bilateral maxillary & frontal sinus tenderness Remainder of exam unchanged from before

Labs: WBC 17,200. Influenza A&B negative

ED Course: IV fluids started. A diagnostic test was ordered.

Questions: What test was ordered? What was the diagnosis?

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