Copyrighted Material Toy « Simon Takenaka ~ Baker © LivCase Files™: Emergency Medicine Lange Medical Books/McGraw-Hill MEDICAL PUBLISHING DIVISION New York Chicago San Francisco Lisbon London Madrid Mexico City Milan New Delhi San Juan Seoul Singapore Sydney Toronto EUGENE C.TOY, MD THE JOHN S$, DUNN, SENIOR ACADEMIC CHAIR AND PROGRAM DIRECTOR CHRISTUS ST, JOSEPH HOSPITAL OB/GYN RESIDENCY PROGRAM, HOUSTON, TX CLERKSHIP DIRECTOR, ASSISTANT CLINICAL PROFESSOR, DEPARTMENT OF OBSTETRICS AND GYNECOLOGY, UNIVERSITY OF TEXAS-HOUSTON MEDICAL SCHOOL HOUSTON, TX BARRY C. SIMON, MD ASSOCIATE CLINICAL PROFESSOR OF MEDICINE UCSF MEDICAL CENTER CHAIRMAN, DEPARTMENT OF EMERGENCY MEDICINE ALAMEDA COUNTY MEDICAL CENTER/HIGHLAND GENERAL HOSPITAL OAKLAND, CALIFORNIA KATRIN Y. TAKENAKA, MD. ASSISTANT PROFESSOR, CLERKSHIP DIRECTOR DEPARTMENT OF EMERGENCY MEDICINE UNIVERSITY OF TEXAS-HOUSTON MEDICAL SCHOOL HOUSTON, TEXAS BENTON BAKER Ill, MD DIRECTOR OF GRADUATE MEDICAL EDUCATION CHRISTUS ST. JOSEPH HOSPITAL PROFESSOR OF OBSTETRICS AND GYNECOLOGY UNIVERSITY OF TEXAS-HOUSTON MEDICAL SCHOOL HOUSTON, TEXAS TERRENCE H. LIU, MD ASSOCIATE CLINICAL PROFESSOR OF SURGERY UNIVERSITY OF CALIFORNIA, SAN FRANCISCO SCHOOL OF MEDICINE ATTENDING SURGEON AND PROGRAM DIRECTOR, UCSF-EAST BAY SURGERY RESIDENCY PROGRAM OAKLAND, CALIFORNIACase Files™: Emergency Medicine Copyright © 2005 by the McGraw-Hill Companies Inc. All right reserved. Printed in the United States of America, Except as permitted under the United States Copyright Act of 1976, no part of this publication may be reproduced or distributed in any form or by any means, or stored in a data base or retrieval system, without the prior written permission of the publisher. Case Files is a trademark of the McGraw-Hill Companies, Inc. 34567890 DOC/DOC 098765 ISBN 0-07-143795-9 This book was set in Times New Roman. The editor was Catherine A. Johnson. ‘The production supervisor was Catherine Saggese. The cover designer was Aimee Nordin. ‘The index was prepared by Pamela Edwards. RR Donnelly was printer and binder. This book is printed on acid-free paper. Library of Congress Cataloging-in-Publication Data Case files : Emergency medicine / Eugene C. Toy...[et al]. p. 5 cm, Includes index. ISBN 0-07-143795-9 1. Emergency medicine—Case studies, I. Title: Emergency medicine II. Toy, Eugene C. [DNLM: 1. Emergency medicine—Case Reports. 2, Emergencies—Case Reports. WB 105 C3365 2004] RC86.9.C38 2004 616.02'5—de22 2004048485¢ DEDICATION Case Files: Emergency Medicine is the sixth and last planned book in the Clinical Case Files series. It is fitting that we take this opportunity to dedicate this series to a great physician, Dr. Joseph A. Lucci, Jr., who has had a tremen- dous impact on the practice and education in medicine in Houston, particular- ly at CHRISTUS St. Joseph Hospital. Dr. Lucci was born in Morrone del Sannio, a province of Campobasso in Italy on August 21, 1921. “Dr. Joe” arrived in the United States in 1930 at the age of 9 years. He obtained his med- ical degree from the Medical College of Wisconsin in 1946. After finishing his internship in 1947, he served as an Air Force base surgeon in Germany during the Berlin Airlift. He then received residency training for 2 years at the Margaret Hague Maternity Hospital in Jersey City, New Jersey. Upon his arrival to Houston, Dr. Lucci received his further training in gynecologic sur- gery at the MD Anderson Cancer Center. He was appointed as the first aca- demic chair over the department of obstetrics/gynecology at St. Joseph Hospital, and had academic appointments at the MD Anderson Cancer Center, UTMB Galveston Medical School, and later at the University of Texas Houston Medical School. During his 31 years as academic chair, Dr. Joe trained more than 120 excellent residents, revolutionized the education of gynecologic surgery, developed innovative surgical techniques, markedly reduced the maternal mortality, and helped to coordinate the medical educa- tion throughout the Houston/Galveston region. He and his wife Joan have five children: Joe, Joan Marie, Jacqueline, Regina Marie, and James, and nine grandchildren. Currently, “Dr. Joe” is academic chief emeritus of the CHRIS- TUS St. Joseph Hospital Obstetrics-Gynecology Residency. Dr. Lucci has been a true pioneer in many aspects of medicine, touching the lives of thou- sands of people. We are greatly indebted to this extraordinary man.To Mabel Wong Ligh whose grace, love, and common sense bind our family together, and in the memory of John Wong, whose smile, integrity, and enthusiasm continue to warm our hearts. —ECT To my best friend and wife Zina Rosen-Simon and to my daughters Jamie and Kaylie for teaching me and always reminding me what is most important in life. I would aiso like to thank my faculty at Highland General Hospital and all the residents and students who have passed through our doors for helping make my career as an academic emergency physician challenging and immensely rewarding. —BCS To my parents, who continue to be my guiding light. Ta my other half, Mark, who knows how to make me smile. And to Clare, who remains my teacher & Jriend. —KYT To my grandchildren, Aidan, John, Joshua, Michael, Noah, Chloe... through whom I see the future! To Eugene Toy, MD who exemplifies why I became an educator. —BB To my wife Eileen for her continuous support, love, and friendship. To all the medical students and residents for their dedication to education and improving patient care. —THL“ CONTENTS CONTRIBUTORS ix INTRODUCTION xvii SECTION I How to Approach Clinical Problems 1 Part 1. Approach to the Patient 3 Part 2. Approach to Clinical Problem Solving 9 Part 3. Approach to Reading 17 SECTION II Clinical Cases 23 Forty-seven Case Scenarios 25 SECTION III Listing of Cases 437 Listing by Case Number 438 Listing by Disorder (Alphabetical) 440 INDEX 443or = i=: iy =a oa“> CONTRIBUTORS Linda K. Barry, MD Clinical Fellow, Tumor & Endocrine Department of Surgery University of Southern California Los Angeles, California Clinical Fellow Hepatobiliary Division Department of Surgery LAC/USC Medical Center Los Angeles, California Approach to Septic Shock Terry J. Chong, MD General Surgery Resident General Surgery Alameda County Medical Center UCSF-East Bay Surgery Residency Program Oakland, California Approach to Hemorrhagic Shock Elizabeth Brand, MD Resident, Emergency Medicine Department Alameda County Medical Center/Highland Campus Oakland, California Approach to Syncope Wendy Cole, MD Co-Director of Medical Student Clerkships, Emergency Medicine Department Alameda County Medical Center/Highland Campus Oakland, California Approach to Meningitis Eileen T. Consorti, MD, MS Assistant Clinical Professor of Surgery Department of Surgery UCSF-East Bay Oakland, California Approach to Intestinal Obstruction Justin O. Cook, MD Chief Resident, Department of Emergency Medicine Alameda County Medical Center/Highland Hospital Oakland, California Approach to Pharyngitis/EpiglottitisBa CONTRIBUTORS Adam R. Corley, MD Resident, Emergency Medicine Department University of Texas-Houston Medical School Houston, TX Approach to Swallowed Foreign Body Approach to Headache Approach to Scrotal Pain Michael Cripps, MD Resident, Department of Surgery UCSF-East Bay Surgery Residency Program Oakland, California Approach to Drowning and Near-Drowning DeShawndranique Gray, MD Chief Resident, Obstetrics and Gynecology CHRISTUS St. Joseph Hospital Houston, Texas Approach to Frostbite Approach to Disseminated Gonococeal Disease Karen Dixon, MD Department of Emergency Medicine Inova Fairfax Hospital Falls Church, Virginia Approach to Atrial Fibrillation David K. English, MD Assistant Clinical Professor, Division of Emergency Medicine University of California, San Francisco San Francisco, California Informatics Director Department of Emergency Medicine Alameda County Medical Center Oakland, California Approach to Diabetic Ketoacidosis Juan M. Franco, MD Resident, Obstetrics and Gynecology CHRISTUS St. Joseph Hospital Houston, Texas Approach to Acute Urinary Retention Approach to NephrolithiasisCONTRIBUTORS xi Bradley W. Frazee, MD Attending Physician, Department of Emergency Medicine Alameda County Medical Center/Highland Campus Oakland, California Assistant Clinical Professor Department of Medicine University of California, San Francisco San Francisco, California Approach to Acute Chest Pain Rose B. Ganim, MD Clinical Instructor, Department of Surgery University of California, San Francisco, East Bay Oakland, California Approach to Penetrating Trauma Jocelyn Freeman Garrick, MD ALS Base Director, Emergency Medicine Department Alameda County Medical Center/Highland Campus Oakland, California Approach to the Child With a Limp Cherie Hargis, MD Faculty Physician, Emergency Medicine Department Alameda County Medical Center/Highland Campus Assistant Clinical Professor University of California, San Francisco Oakland, California Approach to the Red Eye Herbert Hern, MD Associate Residency Director, Emergency Medicine Department Alameda County Medical Center/Highland Campus Oakland, California Assistant Clinical Professor of Medicine University of California, San Francisco San Francisco, California Approach to Pharyngitis/Epiglottitis ‘Catherine A. Holt, MD Resident, Obstetrics and Gynecology CHRISTUS St. Joseph Hospital Houston, Texas Approach to Acute Pelvic Inflammatory Disease Approach to Ectopic Pregnancyxi CONTRIBUTORS Irfan Hydari, MD Attending Physician, Emergency Medicine Department Las Colinas Medical Center Irving, Texas Approach to Congestive Heart Failure Joseph Bram Johns, MD Department of Obstetrics and Gynecology CHRISTUS St. Joseph Hospital Houston, Texas Approach to Rabies and Animal Bites Anjali S. Kumar, MD, MPH Research Fellow Breast Care Center Department of Surgery University of California, San Francisco San Francisco, California Resident Physician, Department of Surgery University of California, San Francisco, East Bay ‘Oakland, California Approach to DVT/Pulmonary Embolism Dustin G. Mark, MD Resident, Department of Emergency Medicine Hospital of the University of Pennsylvania Philadelphia, Pennsylvania Approach to Acute Transfusion Reaction Jose Medina, MD Emergency Medicine Department University of Texas-Houston Memorial Hermann Hospital Houston, Texas Approach to Acetominophen Toxicity Approach to Heat-related Illnesses Approach to Sickle Cell Crises Amy Moore, BS, MD Resident Physician, Department of Medicine Highland General Hospital Oakland, California Approach to Drowning and Near-Drowning Nikole A. Neidlinger, MD Surgical Resident, Department of Surgery University of California, San Francisco San Francisco, California Approach to Lightning and Electrical InjuryCONTRIBUTORS xiii Christopher R. Newton, MD Critical Care Fellow, Department of Surgery Children’s Memorial Hospital Chicago, Illinois Approach to Pediatric Trauma Amanda Parker, MD Chief Resident Emergency Medicine University of Texas Medical School, Department at Houston Memorial Hermann Hospital Houston, Texas Approach to Acute Pneumocystis Pneumonia Approach to Acute Upper and Lower GI Bleeding Approach to Cerebrovascular Accidents and Transient Ischemic Accidents Dolar S. Patolia, MD Voluntary Faculty, Department of Obstetrics and Gynecology CHRISTUS St. Joseph Hospital Houston, Texas Approach to Herpes Zoster Approach to Bell Palsy Molly A. Phelps, MD Emergency Medicine Department Alameda County Medical Center Oakland, California Approach to Altered Level of Consciousness Steven G. Pilkington, MD Resident, Obstetrics and Gynecology CHRISTUS St. Joseph Hospital Houston, Texas Approach to Cocaine Intoxication Jason Quinn, BS, MD Resident, Emergency Medicine Department Alameda County Medical Center/Highland Campus Oakland, California Approach to Acute Chest Pain Approach to Anaphylaxis Andrea Richter-Werning, MD Resident, Obstetrics and Gynecology CHRISTUS St. Joseph Hospital Houston, Texas Approach to Preeclampsia/Malignant Hypertensionxiv CONTRIBUTORS Adam J. Rosh, MD Medical Resident Department of Emergency Medicine NYU/Bellevue New York, New York Approach to the Emergency Medicine Patient Amandeep Singh, MD Assistant Clinical Professor of Medicine, Emergency Medicine Department University of California, San Francisco San Francisco, California Staff Physician, Department of Medicine Highland General Hospital Oakland, California Approach to Asthma Eric R. Snoey, MD Program Director, Emergency Medicine Department Alameda County Medical Center Oakland, California Approach to Atrial Fibrillation John C. Stein, MD Assistant Clinical Professor, Emergency Medicine Department University of California, San Francisco ‘Oakland, California Approach to Syncope Michael Stone, MD Resident, Emergency Medicine Department Alameda County Medical Center/Highland Campus Oakland, California Approach to Meningitis Gary W. Tamkin, MD, FACEP. Assistant Clinical Professor of Medicine, Department of Emergency Medicine University of California, San Francisco San Francisco, California Attending Physician, Department of Emergency Medicine Alameda County Medical Center Oakland, California Approach to Seizure Disorder Alvin Tang, MD Physician, Emergency Medicine Department Alameda County Medical Center, Highland Campus Oakland, California Approach to the Child with a LimpCONTRIBUTORS xv Nicole N. Tran, MD Physician, Obstetrics and Gynecology Houston Women’s Care Associates The Women’s Hospital of Texas Houston, Texas Approach to Lyme Disease Jorge D. Trujillo, MD Director, Emergency Services CHRISTUS St. Joseph Hospital Houston, Texas Approach to Facial Lacerations Approach to Infectious Diarrhea Gregory P. Victorino, MD Assistant Professor of Surgery Department of Surgery UCSF-East Bay Oakland, California Trauma Director, Department of Surgery Alameda County Medical Center Oakland, California Approach to Hemorrhagic Shock Thomas G. Weiser, MD Resident, Department of Surgery UC-Davis Medical Center Sacramento, California Approach to DVT/Pulmonary Embolism Charlotte Wills, MD Clinical Instructor in Medicine, Division of Emergency Medicine University of California, San Francisco San Francisco , California Director of Medical Student Education Department of Emergency Medicine Alameda County Medical Center, Highland Hospital Oakland, California Approach to Anaphylaxis Robert Yetman, MD Professor of Pediatrics Director, Division of Community and General Pediatrics Department of Pediatrics University of Texas-Houston Medical School Houston, Texas Approach to Neonatal Sepsis7 -! 4 = = = "8 -s =e = 7 _ 7 7 ==. =o © “ 7 = @“% INTRODUCTION Mastering the cognitive knowledge within a field such as emergency medicine is a formidable task. It is even more difficult to draw on that knowledge, pro- cure and filter through the clinical and laboratory data, develop a differential diagnosis, and finally to form a rational treatment plan. To gain these skills, the student often learns best at the bedside, guided and instructed by experi- enced teachers, and inspired toward self-directed, diligent reading. Clearly, there is no replacement for education at the bedside. Unfortunately, clinical sit- uations usually do not encompass the breadth of the specialty. Perhaps the best alternative is a carefully crafted patient case designed to stimulate the clinical approach and decision-making. In an attempt to achieve that goal, we have constructed a collection of clinical vignettes to teach diagnostic or therapeutic approaches relevant to emergency medicine. Most importantly, the explana- tions for the cases emphasize the mechanisms and underlying principles, rather than merely rote questions and answers. This book is organized for versatility: to allow the student “in a rush” to go quickly through the scenarios and check the corresponding answers, as well as the student who wants thought-provoking explanations. The answers are arranged from simple to complex: a summary of the pertinent points, the bare answers, an analysis of the case, an approach to the topic, a comprehension test at the end for reinforcement and emphasis, and a list of resources for further reading. The clinical vignettes are purposely placed in random order to simu- late the way that real patients present to the practitioner. A listing of cases is included in Section III to aid the student who desires to test his/her knowledge of a certain area, or to review a topic including basic definitions. Finally, we intentionally did not primarily use a multiple choice question (MCQ) format because clues (or distractions) are not available in the real world. Nevertheless, several MCQ’s are included at the end of each scenario to reinforce concepts or introduce related topics. HOW TO GET THE MOST OUT OF THIS BOOK Each case is designed to simulate a patient encounter with open-ended ques- tions. At times, the patient’s complaint is different from the most concerning issue, and sometimes extraneous information is given. The answers are organ- ized in four different parts. PART I: 1. Summary—The salient aspects of the case are identified, filtering out the extraneous information. The student should formulate his/her summaryXviii INTRODUCTION from the case before looking at the answers. A comparison to the summa- tion in the answer will help to improve one’s ability to focus on the impor- tant data, while appropriately discarding the irrelevant information, a fundamental skill in clinical problem solving. 2. A straightforward answer is given to each open-ended question. 3. The Analysis of the Case, which is comprised of two parts: a. Objectives of the Case—A listing of the two or three main principles that are crucial for a practitioner to manage the patient. Again, the student is challenged to make educated “guesses” about the objectives of the case upon initial review of the case scenario, which help to sharpen his/her clinical and analytical skills. b. Considerations—A discussion of the relevant points and brief approach to the specific patient. PART II: Approach to the Disease Process, which has two distinct parts: a. Definitions or pathophysiology—Terminology or basic science cor- relates pertinent to the disease process. b. Clinical Approach—A discussion of the approach to the clinical problem in general, including tables, figures, and algorithms. PART III: Comprehension Questions—Each case contains several multiple-choice questions that reinforce the material, or introduce new and related concepts. Questions about material not found in the text will have explanations in the answers. PART IV: Clinical Pearls—A listing of several clinically important points, which are reiterated as a summation of the text and to allow for easy review such as before an examination.& ACKNOWLEDGMENTS The curriculum that evolved into the ideas for this series was inspired by two talented and forthright students, Philbert Yau and Chuck Rosipal, who have since graduated from medical school. It has been a pleasure to work with Dr. Barry Simon, a wonderfully skilled and compassionate emergency room physician, and Dr. Kay Takenaka, who is as talented in her writing and teach- ing as she is in her clinical care. It has been like a dream to once again work with my mentor, friend, and colleague, Dr. Benton Baker III, who in addition to being an excellent obstetrician-gynecologist is also well-versed in emer- gency and trauma care. Likewise, I have cherished working together with my friend since medical school Terry Liu, who initially suggested the idea of this book. I am greatly indebted to my editor, Catherine Johnson, whose exuber- ance, experience, and vision helped to shape this series. | appreciate McGraw- Hill’s believing in the concept of teaching through clinical cases, At CHRISTUS St. Joseph Hospital, I applaud the finest administrators I have encountered: Jeff Webster, Janet Matthews, Michael Brown, and Dr. Benton Baker III for their commitment to medical education, and Dorothy Mersinger for her sage advice and support. I thank Adam Rosh MS IV for his excellent review of the manuscript. Without my dear colleagues, Drs. Que Tranvan, Jacqueline Brown, Sterling Weaver, Michael Leung, Carl Lee, and Robert Hilliard, this book could not have been written. Most of all, | appreciate my ever-loving wife Terri, and four wonderful children, Andy, Michael, Allison, and Christina for their patience, encouragement, and understanding. Eugene C. ToySECTION I How to Approach Clinical Problems PART 1. Approach to the Patient PART 2. Approach to Clinical Problem Solving PART 3. Approach to Reading= t* 955 OEO-opgrs --! Front apareloel Nii = =. - - _ & = 7 Fi | 7HOW TO APPROACH CLINICAL PROBLEMS 3 PART 1. APPROACH TO THE PATIENT Applying “book learning” to a specific clinical situation is one of the most challenging tasks in medicine. To do so, the clinician must not only retain information, organize the facts, and recall large amounts of data but also apply all of this to the patient. The purpose of this text is to facilitate this process. The first step involves gathering information, also known as establishing the database. This includes taking the history, performing the physical exami- nation, and obtaining selective laboratory examinations, special studies, and/or imaging tests. Sensitivity and respect should always be exercised during the interview of patients, A good clinician also knows how to ask the same question in several different ways, using different terminology. For exam- ple, patients may deny having “congestive heart failure” but will answer affir- matively to being treated for “fluid on the lungs.” CLINICAL PEARL od Sa The history is usually the single most important tool in obtaining a diagnosis. The art of seeking this information in a nonjudgmental, sensitive, and thorough manner cannot be overemphasized. History 1, Basic information: a. Age: Some conditions are more common at certain ages; for instance, chest pain in an elderly patient is more worrisome for coronary artery disease than the same complaint in a teenager. b. Gender: Some disorders are more common in men such as abdominal aortic aneurysms. In contrast, women more com- monly have autoimmune problems such as chronic immune thrombocytopenic purpura or systemic lupus erythematosus. Also, the possibility of pregnancy must be considered in any woman of child-bearing age. c. Ethnicity: Some disease processes are more common in certain ethnic groups (such as type II diabetes mellitus in the Hispanic population). CLINICAL PEARL The possibility of pregnancy must be entertained in any woman of child-bearing age.CASE FILES: EMERGENCY MEDICINE 2. Chief complaint: What is it that brought the patient into the hospital? Has there been a change ina chronic or recurring condition or is this a completely new problem? The duration and character of the com- plaint, associated symptoms, and exacerbating/relieving factors should be recorded. The chief complaint engenders a differential diagnosis, and the possible etiologies should be explored by further inquiry. CLINICAL PEARL The first line of any presentation should include Age, Ethnicity, Gender, and Chief Complaint. Example: A 32-year-old white male complains of lower abdominal pain of 8 hours duration. 3. Past medical history: a. Major illnesses such as hypertension, diabetes, reactive airway disease, congestive heart failure, angina, or stroke should be detailed. i. Age of onset, severity, end-organ involvement. ii. Medications taken for the particular illness including any recent changes to medications and reason for the change(s). iii. Last evaluation of the condition (example: when was the last stress test or cardiac catheterization performed in the patient with angina?). iv. Which physician or clinic is following the patient for the disorder? b. Minor illnesses such as recent upper respiratory infections. c. Hospitalizations no matter how trivial should be queried. 4, Past surgical history: Date and type of procedure performed, indica- tion, and outcome. Laparoscopy versus laparotomy should be distin- guished. Surgeon and hospital name/location should be listed. This information should be correlated with the surgical scars on the patient’s body. Any complications should be delineated including, for example, anesthetic complications, or difficult intubations. 5. Allergies: Reactions to medications should be recorded, including severity and temporal relationship to medication. Immediate hyper- sensitivity should be distinguished from an adverse reaction. 6. Medications: A list of medications, dosage, route of administration and frequency, and duration of use should be developed. Prescription, over-the-counter, and herbal remedies are all relevant.HOW TO APPROACH CLINICAL PROBLEMS 5 If the patient is currently taking antibiotics, it is important to note what type of infection is being treated. Social history: Occupation, marital status, family support, and ten- dencies toward depression or anxiety are important. Use or abuse of illicit drugs, tobacco, or alcohol should also be recorded. Family history: Many major medical problems are genetically trans- mitted (e.g., hemophilia, sickle cell disease). In addition, a family history of conditions such as breast cancer and ischemic heart dis- ease can be a risk factor for the development of these diseases. Review of systems: A systematic review should be performed but focused on the life-threatening and the more common diseases. For example, in a young man with a testicular mass, trauma to the area, weight loss, and infectious symptoms are important to note. In an elderly woman with generalized weakness, symptoms suggestive of cardiac disease should be elicited, such as chest pain, shortness of breath, fatigue, or palpitations, Physical Examination 1. General appearance: Is the patient in any acute distress? The emer- gency physician should focus on the ABCs (Airway, Breathing, Circulation). Note cachectic versus well-nourished, anxious versus calm, alert versus obtunded. Vital signs: Record the temperature, blood pressure, heart rate and respiratory rate. An oxygen saturation assessment is useful in a patient with respiratory symptoms. Height and weight are often placed here. Head and neck examination: Evidence of trauma, tumors, facial ede- ma, goiter and thyroid nodules, and carotid bruits should be sought. In patients with altered mental status or a head injury, pupillary size, symmetry, and reactivity are important. Mucous membranes should be inspected for pallor, jaundice, and evidence of dehydration. Cervical and supraclavicular nodes should be palpated. Breast examination; Inspection for symmetry and skin or nipple retraction, as well as palpation for masses. The nipple should be assessed for discharge, and the axillary and supraclavicular regions should be examined. Cardiac examination: The point of maximal impulse (PMI) should be ascertained, and the heart auscultated at the apex as well as the base. It is important to note whether the auscultated rhythm is regular or irreg- ular. Heart sounds (including $3 and $4), murmurs, clicks, and rubs should be characterized. Systolic flow murmurs are fairly common inCASE FILES: EMERGENCY MEDICINE pregnant women because of the increased cardiac output, but signifi- cant diastolic murmurs are unusual. Pulmonary examination: The lung fields should be examined sys- tematically and thoroughly. Stridor, wheezes, rales, and rhonchi should be recorded. The clinician should also search for evidence of consolidation (bronchial breath sounds, egophony) and increased work of breathing (retractions, abdominal breathing, accessory mus- cle use). Abdominal examination: The abdomen should be inspected for scars, distension, masses, and discoloration. For instance, the Grey-Turner sign of bruising at the flank areas may indicate intraabdominal or retroperitoneal hemorrhage. Auscultation should identify normal versus high-pitched and hyperactive versus hypoactive bowel sounds. The abdomen should be percussed for the presence of shifting dull- ness (indicating ascites), Then one should carefully palpate, begin- ning away from the area of pain and progressing to include the whole abdomen to assess for tenderness, masses, organomegaly (i.¢., spleen or liver), and peritoneal signs. Guarding and whether it is voluntary or involuntary should be noted. Back and spine examination: The back should be assessed for sym- metry, tenderness, or masses. The flank regions particularly are important to assess for pain on percussion that may indicate renal disease, Genital examination a. Female: The external genitalia should be inspected, then the speculum used to visualize the cervix and vagina. A bimanual examination should attempt to elicit cervical motion tenderness, uterine size, and ovarian masses or tenderness. b. Male: The penis should be examined for hypospadias, lesions, and discharge. The scrotum should be palpated for tenderness and masses. If a mass is present, it can be transilluminated to distinguish between solid and cystic masses. The groin region should be carefully palpated for bulging (hernias) upon rest and provocation (coughing, standing). c. Rectal examination: A rectal examination will reveal masses in the posterior pelvis and may identify gross or occult blood in the stool. In females, nodularity and tenderness in the uterosacral ligament may be signs of endometriosis. The poste- rior uterus and palpable masses in the cul-de-sac may be identi- fied by rectal examination. In the male, the prostate gland should be palpated for tenderness, nodularity, and enlargement.HOW TO APPROACH CLINICAL PROBLEMS “N 10. Extremities/ skin: The presence of joint effusions, tenderness, rash- es, edema, and cyanosis should be recorded. It is also important to note capillary refill and peripheral pulses, 11. Neurological examination: Patients who present with neurological complaints require a thorough assessment including mental status, cranial nerves, strength, sensation, reflexes, and cerebellar function. In trauma patients, the Glasgow Coma Score is important (Table I-1). Table I-1 GLASGOW COMA SCALE ASSESSMENT AREA SCORE Eye Opening Spontaneous 4 To speech 3 To pain 2 None 1 Best motor response Obeys commands 6 Loealizes pain 5 Withdraws to pain 4 Decorticate posture (abnormal flexion) 3 Decerebrate posture (extension) 2 No response 1 Verbal response Oriented 5 Confused conversation 4 Inappropriate words 3 Incomprehensible sounds 2 None 1CASE FILES: EMERGENCY MEDICINE CLINICAL PEARL A thorough understanding of anatomy is important to optimally interpret the physical examination findings. Laboratory Assessment 1. 2. Laboratory assessment depends on the circumstances CBC (complete blood count) can assess for anemia, leukocytosis (infection) and thrombocytopenia. Basic metabolic panel: Electrolytes, glucose, BUN (blood urea nitro- gen) and creatinine (renal function). Urinalysis and/or urine culture: To assess for hematuria, pyuria, or bac- teruria, A pregnancy test is important in women of child-bearing age. AST (aspartate aminotransferase), ALT (alanine aminotransferase), bilirubin, alkaline phosphatase for liver function; amylase and lipase to evaluate the pancreas. Cardiac markers (CK-MB [creatine kinase myocardial band], tro- ponin, myoglobin) if coronary artery disease or other cardiac dys- function is suspected. Drug levels such as acetaminophen level in possible overdoses. Arterial blood gas measurements give information about oxygena- tion, but also carbon dioxide and pH readings. Diagnostic Adjuncts lL. Electrocardiogram if cardiac ischemia, dysrhythmia, or other cardiac dysfunction is suspected. Ultrasound examination: useful in evaluating pelvic processes in female patients (e.g., pelvic inflammatory disease, tubo-ovarian abscess) and in diagnosing gall stones and other gallbladder disease. With the addition of color-flow Doppler, deep venous thrombosis and ovarian or testicular torsion can be detected. Computed tomography (CT): Useful in assessing the brain for mass- es, bleeding, strokes, skull fractures. CT of the chest can evaluate for masses, fluid collections, aortic dissections, and pulmonary emboli. Abdominal CT can detect infection (abscess, appendicitis, divertic- ulitis), masses, aortic aneurysms, and ureteral stones. Magnetic resonance imaging (MRI) helps to identify soft tissue planes very well, In the emergency department (ED) setting, this is most commonly used to rule out spinal cord compression, cauda equina syndrome, and epidural abscess or hematoma.HOW TO APPROACH CLINICAL PROBLEMS 9 PART 2. APPROACH TO CLINICAL PROBLEM- SOLVING Classic Clinical Problem-Solving There are typically five distinct steps that an ED clinician undertakes to sys- tematically solve most clinical problems: 1. Addressing the ABCs and other life-threatening conditions 2. Making the diagnosis 3. Assessing the severity of the disease 4. Treating based on the stage of the disease 5. Following the patient’s response to the treatment Emergency Assessment and Management Patients often present to the ED with life-threatening conditions that necessi- tate simultaneous evaluation and treatment. For example, a patient who is acutely short of breath and hypoxemic requires supplemental oxygen and pos- sibly intubation with mechanical ventilation. While addressing these needs, the clinician must also try to determine whether the patient is dyspneic because of a pneumonia, congestive heart failure, pulmonary embolus, pneu- mothorax, or for some other reason. As a general rule, the first priority is stabilization of the ABCs (see Table 1-2). For instance, a comatose multi-trauma patient first requires intubation to protect the airway. See Figures I-1 through I-3 regarding management of air- way and breathing issues. If the patient has a tension pneumothorax (breathing problem), (s)he needs an immediate needle thoracostomy. If (s)he is hypoten- sive, large-bore IV access and volume resuscitation are required for circulato- ry support. Pressure should be applied to any actively bleeding region. Figures 1-4 through I-6 outline the key algorithms for cardiac dysthythmias. Once the ABCs and other life-threatening conditions are stabilized, a more complete history and head-to-toe physical exam should follow. CLINICAL PEARL Because emergency physicians are faced with unexpected illness and injury, they must often perform diagnostic and therapeutic steps simultaneously. In patients with an acutely life-threaten- ing condition, the first and foremost priority is stabilization— the ABCs, Making the Diagnosis This is achieved by carefully evaluating the patient, analyzing the information, assessing risk factors, and developing a list of possible diagnoses (the differen-10 CASE FILES: EMERGENCY MEDICINE Table 1-2 ASSESSMENT OF ABCs ASSESSMENT MANAGEMENT Airway Assess oral cavity, patient Head-tilt and chin-lift color (pink vs. cyanotic), If cervical spine injury suspected, patency of airway (choking, stabilize neck and use jaw thrust aspiration, compression, If obstruction, Heimlich maneuver, foreign body, edema, blood), | chest thrust, finger sweep (uncon- stridor, tracheal deviation, scious patient only) ease of ventilation with bag Temporizing airway (laryngeal mask and mask airway) Definitive airway (intubation [naso- tracheal or endotracheal], cricothy- roidotomy) Breathing Look, listen, and feel for air Resuscitation (mouth-to-mouth, movement and chest rising mouth-to-mask, bag and mask) Respiratory rate and effort Supplemental oxygen, chest tube (accessory muscles, diapho- (pneumothorax or hemothorax) resis, fatigue) Effective ventilation (bron- chospasm, chest wall deform- ity, pulmonary embolism) Circulation | Palpate carotid artery If pulseless, chest compressions Assess pulse and blood. pressure Cardiac monitor to assess thythm Consider arterial pressure monitoring Assess capillary refill and determine cardiac rhythm (con- sider epinephrine, defibrillation) Intravenous access (central line) Fluids Consider SHs and STs: Hypovolemia, Hypoxia, Hypothermia, Hyper-/Hypokalemia, Hydrogen (aci- dosis); Tension pneumothorax, Tamponade (cardiac), Thrombosis (massive pulmonary embolism), Thrombosis (myocardial infarction), Tablets (drug overdose). Source: Reprinted, with permission, from Roman AM. Noninvasive airway management. In: Tintinalli JE, Kelen GD, Stapezynski JS, eds, Emergency medicine, 6 ed, New York: McGraw- Hill, 2004:102-8; and Danzl DE, Vissers RJ. Tracheal intubation. In: Tintinalli JE, Kelen GD, Stapezynski JS, eds, Emergency medicine, 6" ed, New York: MeGraw-Hill: 2004, 108-24. tial), Usually a long list of possible diagnoses can be pared down to a few of the most likely or most serious ones, based on the clinician’s knowledge, experience, and selective testing. For example, a patient who complains of upper abdominal pain and who has a history of nonsteroidal antiinflammatory drug (NSAID) use may have peptic ulcer disease; another patient who has abdominal pain, fattyHOW TO APPROACH CLINICAL PROBLEMS Il Figure I-1. Determination of breathlessness. The rescuer “looks, listens, and feels” for breath. Figure I-2. Jaw-thrust maneuver. The rescuer lifts upward on the mandible while keeping the cervical spine in neutral position. food intolerance, and abdominal bloating may have cholelithiasis. Yet another individual with a 1-day history of periumbilical pain that now localizes to the right lower quadrant may have acute appendicitis. CLINICAL PEARL ‘The second step in clinical problem solving is making the diagnosis.12 CASE FILES: EMERGENCY MEDICINE Figure I-3. Chest compressions. Rescuer applying chest compressions to an adult victim. Assessing the Severity of the Disease After establishing the diagnosis, the next step is to characterize the severity of the disease process; in other words, to describe “how bad” the disease is. This may be as simple as determining whether a patient is “sick” or “not sick.” Is the patient with a urinary tract infection septic or stable for outpatient thera- py? In other cases, a more formal staging may be used. For example, the Glasgow coma scale is used in patients with head trauma to describe the sever- ity of their injury based on eye-opening, verbal, and motor responses. CLINICAL PEARL The third step is to establish the severity or stage of disease. This usually impacts the treatment and/or prognosis.HOW TO APPROACH CLINICAL PROBLEMS 13 Treating Based on Stage Many illnesses are characterized by stage or severity because this effects prog- nosis and treatment. As an example, a formerly healthy young man with pneu- monia and no respiratory distress may be treated with oral antibiotics at home. An older person with emphysema and pneumonia would probably be admitted to the hospital for [V antibiotics. A patient with pneumonia and respiratory failure would likely be intubated and admitted to the intensive care unit for fur- ther treatment. CLINICAL PEARL The fourth step is tailoring the treatment to fit the severity or “stage” of the disease, Following the Response to Treatment The final step in the approach to disease is to follow the patient’s response to the therapy. Some responses are clinical such as improvement (or lack of improvement) in a patient’s pain. Other responses may be followed by testing (e.g., monitoring the anion gap ina patient with diabetic ketoacidosis). The cli- nician must be prepared to know what to do if the patient does not respond as expected. Is the next step to treat again, to reassess the diagnosis, or to follow up with another more specific test? CLINICAL PEARL ga 6 The fifth step is to monitor treatment response or efficacy. This may be measured in different ways—symptomatically or based on physical examination or other testing. For the emergency physician, the vital signs, oxygenation, urine output, and mental status are the key parameters.14 CASE FILES: EMERGENCY MEDICINE V FIB, Pulseless V Tach Primary ABCD Survey Focus: basic CPR and defibrillation * Check responsiveness * Activate emergency response system * Call for defibrillator A Airway: open the airway B Breathing: provide positive-pressure ventilations C Circulation: give chest compressions D Defibrillation: assess for and shock VF/pulseless VT, up to 3 times (200 J, 200 to 300 J, 360 J, or equivalent biphasic) if necessary Rhythm after first 3 shocks? Persistent or recurrent VF/VT? Secondary ABCD Survey Focus: more advanced assessments and treatments A Airway: place airway device as soon as possible BB Breathing: confirm airway device placement by exam plus confirmation device B Breathing: secure airway device; purpose-made tube holders preferred B Breathing: confirm effective oxygenation and ventilation C Circulation: establish IV access ¢ Circulatior lentify rhythm > monitor Circulation: administer drugs appropriate for rhythm and condition D Differential Diagnosis: search for and treat identified reversible causes * Epinephrine 1 mg IV push, repeat every 3 to 5 minutes or + Vasopressin 40 U IV, single dose, 1 time only Resume attempts to defibrillate 1 x 360 J (or equivalent biphasic) within 30 to 60 seconds Consider antiarrhythmics: * Amiodarone (\lb for persistent or recurrent VF/pulseless VT) + Lidocaine (Indeterminate for persistent or recurrent VF/pulseless VT) |* Magnesium (Ilb if known hypomagnesemic state) * Procainamide (Indeterminate for persistent VF/pulseless VT; llb for recurrent VF/pulseless VT) Ei ‘ Resume attempts to defibrillate Figure 1-4. Algorithm for Ventricular Fibrillation, Pulseless Ventricular Tachycardia. With permission from American Heart Association, ECC Guidelines, 2000. VF = Ventricular Fibrillation; VT = Ventricular Tachycardia.HOW TO APPROACH CLINICAL PROBLEMS is Primary ABCD Survey Focus: basic CPR and defibrillation * Check responsiveness * Activate emergency response system + Call for defibrillator A Airway: open the airway B Breathing: provide positive-pressure ventilations C Circulation: give chest compressions C Confirm true asystole D Defibrillation: assess for VF/pulseless VT; shock if indicated Rapid scene survey; is there any evidence that personnel should not attempt resuscitation (eg, DNAR order, signs of death)? Secondary ABCD Survey Focus: more advanced assessments and treatments A Airway: place airway device as soon as possible B Breathing: confirm airway device placement by exam plus confirmation device B Breathing: secure airway device; purpose-made tube holders preferred B Breathing: confirm effective oxygenation and ventilation C Circulation: confirm true asystole C Circul : establish IV access C Circulation: identify rhythm > monitor C Circulation: give medications appropriate for rhythm and condition D Differential Diagnosis: search for and treat identified reversible causes. Transcutaneous pacing If considered, perforr mediately Epinephrine 1 mg |V push, repeat every 3 to 5 minutes Atropine 1 mg lV, repeat every 3 to 5 minutes up to a total of 0.04 mg/kg Asystole persists Withhold or cease resuscitative efforts? * Consider quality of resuscitation? * Atypical clinical features present? + Support for cease-efforts protocols in place? Figure 1-5. Algorithm for asystole. With permission from American Heart Association, ECC Guidelines, 2000.16 CASE FILES: EMERGENCY MEDICINE Pulseless Electrical Activity (PEA = rhythm on monitor, without detectable pulse) Primary ABCD Survey Focus: basic CPR and defibrillation * Check responsiveness * Activate emergency response system * Call for defibrillator A Airway: open the airway B Breathing: provide positive-pressure ventilations C Circulation: give chest compressions D Defibrillation: assess for and shock VF/pulseless VT Secondary ABCD Survey Focus: more advanced assessments and treatments A Airway: place airway device as soon as possible confirm airway device placement by exam plus confirmation device ecure airway device; purpose-made tube holders preferred infirm effective oxygenation and ventilation establish |V access C Circulation: identify rhythm > monitor C Circulation: administer drugs appropriate for rhythm and condition C Circulation: assess for occult blood flow (“‘pseudo-EMD”) D Differential Diagnosis: search for and treat identified reversible causes Review for most frequent causes * Hypovolemia * “Tablets” (drug OD accidents) * Hypoxia * Tamponade, cardiac * Hydrogen ion-acidosis * Tension pneumothorax © Hyper-/hypokalemia * Thrombosis, coronary (ACS) * Hypothermia * Thrombosis, pulmonary (embolism) Epinephrine 1 mg |V pust repeat every 3 to 5 minutes Atropine 1 mg IV (if PEA rate is slow), repeat every 3 to 5 minutes as needed, to a total dose of 0.04 mg/kg Figure I-6. Algorithm for Pulseless Electrical Activity. With permission from American Heart Association, ECC Guidelines, 2000.