Wednesday, September 14, 2011

The Lion's Roar

“Roooaaarrrrrrrrr!”

“What was that?” I said to the nurse sitting next to me.
“It sounded like it came from the patient behind you,” said the nurse.
I spin around in my chair. My eyes make contact with an elderly man lying in bed. His hair is white and reminds me of Albert Einstein, the way it sticks up from his head. He is covered in a white blanket. I walk over to find out more.
I check his chart. “Mr. Altman, what brings you to the hospital today?” I ask.
He responds after a 5-second delay. “My head. It is pounding. Right here,” Mr. Altman said as he pointed to a small spot on the right side of his forehead about 3 inches above his eyebrow. “I've never had pain like this before; never a migraine, not even a headache. I don't know what is wrong but I just don't feel well,” he says.
“What was that roar I heard before?” I asked.
“What roar?” he replies.
I decide not to pursue the issue.
I look at the man standing next to Mr. Altman. “Hi, I am Steve, Mr. Altman's son.”
“Hi, Steve. Can you tell me more about your father's headache?”
“Well, I noticed my father was not acting like himself this evening. He seemed confused. He forgot my name and didn't know the date. This is unusual. He never complains either. You know, he survived the Holocaust.”
I performed a quick physical exam on Mr. Altman, focusing on the neurological aspects. I asked him to smile, raise his eyebrows, puff out his cheeks, and stick out his tongue—looking for the slightest imperfection to signal a neurologic dysfunction. He performed all of these functions perfectly. Then I tested his motor skills. I asked him to push, pull, and raise various parts of his body against resistance. Again, all was normal. I cannot isolate a neurologic abnormality and therefore decide to order a head CT scan and alert the stroke team of a possible stroke.
I wheeled Mr. Altman across the hall to the CT scanner. The radiology technician positioned the stretcher next to the CT table. We slid Mr. Altman onto the table and strapped him in. We placed folded sheets on each side of his head so it does not move—careful to avoid streak artifact and degrade the quality of the scan. We double check to make sure everything is in place and leave the room.
The tech entered the orders into the computer and told Mr. Altman to hold still. “Don't move even an inch,” the tech says over the loudspeaker. The large mouth of the CT scanner swallows Mr. Altman. We all watch as the images appear slice by slice.
“Oh boy,” I say to myself. “That does not look good!”
Mr. Altman's brain was being compressed by an epidural hematoma. The blood is located exactly where Mr. Altman pointed to when we spoke just minutes ago. If this condition is not corrected, Mr. Altman's brain will start to herniate through the foramen magnum, leading to rapid decompensation and likely death. We don't have much time.
The tech walks over to open the door. I see him struggling with it so I ask what is happening. He says he cannot open the door. It is jammed. “What do you mean?” I ask. I push past him, and wiggled the handle and thrust my shoulder against the door. It doesn't budge. It's clear the door is not jammed, but locked.
“Who has the key?” I ask the tech.
“What key?” he replies, dead serious. “I never lock this door. I have never even seen a key ever used in this door.”
I peered into the room through the glass window and saw Mr. Altman lying on his back on the CT scanner table. He doesn't know we can't get him out.
“Call security,” I said. “Maybe they have a key.”
Security arrives minutes later with a ring of keys.
“Are you going to save the day?” I ask the guard. “Please tell me that one of those keys will open this door!” Five minutes and at least 20 keys later, I asked the clerk to call the fire department. “We need this door open now.”
While we waited for the fire department, we kept checking on Mr. Altman. We told him over the speaker not to worry, we are going to get him out soon. He doesn't respond. We can barely see his face because he is lying on his back inside the CT scanner. I started thinking about his brain filling with blood, pressure quickly building, causing his breathing to gradually slow and eventually stop. This man survived the Holocaust, I say to myself; he can hold out a few more minutes. I tried to see his chest rising but he is covered with so many sheets. I kept watching and waiting.
I decided not to wait any longer.
A security guard and I rammed our bodies into the door. It didn't budge. We took a few steps back to get some momentum, and then both of us hit the door at the same time. Nothing. I peer into the room and see Mr. Altman's face. His eyes are closed and I still can't tell if he is breathing. I look at the security guard and tell him we have to get this door opened. We raised our legs and kicked the door as hard as possible. I heard a crack. We kicked it again and again. Finally the door swung open. I rushed over to Mr. Altman's side. As I pulled down the blanket that partially covered his face all I hear is “Rooooaaaarrrrr,” coming from the mouth of Mr. Altman. Again, I am not sure what this is. I check his vital signs, which are unchanged.
We returned to the emergency department and called the neurosurgeons so that they could operate on Mr. Altman's hematoma. I explained the diagnosis to Mr. Altman's son and briefly discussed the next steps. I shook the son's hand and wished him luck. Just as I am about to walk away to see my next patient, I stopped and turned around. “Have you ever heard your father roar before?” I ask.
“Oh, his yawn,” the son said. “He's been doing that his whole life. He kind of sounds like a lion, doesn't he?”
I nod. He sure does.
[Ann Emerg Med. 2009;54:625-626.]

Monday, September 5, 2011

MH#4




Half of what you learn in medical school would prove to be wrong in ten years 


-Dr Sydney Burwell, Dean Harvard Medical School 

Monday, June 6, 2011

Intern Report Case Presentation 4.3

Case Presentation by Dr. Dan Helzer

HPI 
36 year old AA female presents to the emergency department complaining of “passing out.”  Pt states that she was sitting down watching TV when she stood up, became very dizzy and lightheaded but no vertigo and fell to the ground.  She stated that she remembers almost everything but could not stay standing up for some reason.  Family members stated that she was not arousable for a few seconds and then came too.  She felt uneasy as family members helped her up and needed assistance getting into the car to be brought to the ED.  She has felt a little weak over the last few days but has experienced nothing like this recently.  Pt also states that she has had heavy vaginal bleeding for the last 10 days, it began with her normal menses but never stopped.  Her last normal menstruation was a month and a half ago.  Typically she has heavy menses but it only lasts 3-4 days.  She says that currently she is passing large clots and goes through multiple pads daily.  She denies headaches, abdominal pain, chest pain, palpitations, and SOB.  She denies ever being told that she has an abnormal heart beat or problems with her heart.  Her family denies any bladder or bowel incontinence during the event.

Past medical history is significant for anemia and fibroid uterus.  Pt is G3P3 and is sexually active.  Her medications include Fe pills.

Past surgical history positive for C-section x 2.

Social Hx includes a 30 pack/year smoking history.

PE
Vitals:  108/55, HR 104, RR 16, Pulse Ox 99 % on RA, Temp 37.7

General:  Pt is in no acute respiratory distress, appears pale.

HEENT: Normocephalic/atraumatic, PERRLA, EOMI, no nystagmus, conjunctiva pale and non-icteric, mucous membranes moist and pale.  Fundoscopy demonstrated no pappiledema.  

Neck: No lymphadenopathy, no JVD, no masses

Respiratory and Lungs: Equal excursion bilaterally, CTAB, no wheezes, rales, rhonchi, or stridor.

Cardiovascular and Heart: Tachycardic rate and rhythm, S1/S2 auscultated, no murmurs, gallops, rubs, or thrills.  Pulses palpated in all 4 extremities. 

Gastrointestinal and Abdomen: BS +, Abdomen soft, non-tender, non-distended.  No masses.  No CVA tenderness. 
Neurological: Patient is alert and oriented to person place and time, CN II-XII intact, sensation to pinprick intact in all 4 extremities, strength 5/5 in all extremities.  No pronator drift was present. Reflexes are 2+.  Heal to shin was normal.  Upon standing pt became lightheaded and dizzy and felt the need to sit back down, therefore gait and Romberg were not properly evaluated. Dix-Hallpike test was normal.   

Genitourinary:  External genitalia were normal. Examination of the pelvis and vagina revealed active bleeding from the closed cervical os with pooling of blood and blood clots in the vaginal vault, no tissue like material was present.  The uterus was not enlarged.  CMT was absent.  The adnexa were non-tender and no masses were palpated. 

Orthostatic Vital Signs:
-Supine BP 109/60, HR 103
-Sitting BP 100/59, HR 111
-Standing BP 88/52, HR 127  
Lab Results:
Urine pregnancy negative
WBC 11.3, Hemoglobin 2.9, Hematocrit 11.7, Platelets 35
Electrolytes all WNL 

Diagnostic Studies:

12 Lead ECG:  Sinus Tachycardia at 107 BPM.

Ultrasound showed?
 Version:1.0 StartHTML:0000000175 EndHTML:0000014694 StartFragment:0000003558 EndFragment:0000014658 SourceURL:file://localhost/Users/adamrosh/Desktop/Syncope%20Case.doc
Pelvic US with Duplex: 

Findings suspicious for adenomyosis.
Nabothian cyst in the cervix largest measuring 0.7 x 0.5 x 0.8 cm
Paraovarian cyst adjacent to left ovary.

Questions: 

1.     What is the most common cause of syncope in adults aged 18-65 who present to the ED?
A.   Postmicturation
B.    Orthostatic
C.    Psychogenic
D.   Unknown or Idiopathic
E.    Cardiac
2.     The same pt is brought in by family members who tell you that when she fell down after standing up her whole body started shaking for at least one minute and she was completely unresponsive during this time. They said it looked just like a seizure that the patient’s cousin with epilepsy has all the time.  Which clue in the HPI can often be the only distinguishing feature between syncope and seizure?
A.   The patient has never had a seizure before
B.    The patient remembers everything
C.    The patient has an abrupt and complete recovery to baseline
D.   The patient has generalized tonic/clonic movements during the episode.
E.    The patient ate 10 tacos from taco bell and drank a liter of cola earlier in the afternoon.
3.     Of the following, which pt with syncope should be discharged from the ED with follow up by PCP and not be admitted.
A.   A 17 year old male with exertional syncope and crushing chest pain. 
B.    A previously healthy 37 year old male with 5 seconds of asystole on carotid sinus massage.
C.    Our patient with a hematocrit of 11 and orthostatic hypotension
D.   A 90 year old female with an EF of 22% and enlarged heart borders on CXR
E.    A 52 year old male with SOB on initial presentation.

Please submit your answers as a comment. Your submission will not immediately post. Answers with a case discussion will post on Friday. If you have any difficulty, please contact the site administrator at arosh@med.wayne.edu. Thank you for participating in Receiving’s: Intern Report 

Intern Report Case Discussion 4.2


Case Presentation by Dr. Deepa Japra

Case Presentation


Answers: 1) c, 2) c, 3) c

Discussion:
The patient in this case is suffering from Pelvic inflammatory disease (PID) caused by Neisseria gonorrhoeae infection.  PID includes a spectrum of diseases of the female upper genital tract including endometritis, salpingitis, pelvic peritonitis, and tubo-ovarian abscess. It is an ascending infection most commonly caused by N. gonorrhoeae and Chlamydia trachomatis where the bacteria spread from the cervix and vagina to the upper portions of the female genital tract. PID is responsible for approximately 30% of female infertility and 50% of ectopic pregnancies.

Risk factors for PID include multiple sexual partners, STD status of the sexual partner(s), age, and history of previous PID. Numerous studies have shown that having multiple sexual partners resulted in increased risk of PID ranging from 4.6 to 20 fold. (Question 1c). In one study which compared 712 women hospitalized for PID to 2,719 controls, the risk of PID was increased 3.4 times in patients with four or more sexual partners during the previous six months, and 3.2 times in patients who had intercourse with one partner six or more times per week. Having a partner with symptomatic gonococcal infection including dysuria and urethral discharge also increases a woman’s risk of PID (Question 1e). PID is more common in the 15 to 25 year old age group, with the incidence in women greater than 35 years old being only one-seventh of that in younger women. (Question 1a). Women with previous PID have increased risk of subsequent episodes, with one study citing an increase by a factor of 2.3. (Question 1d). However, caution should be used in diagnosing a woman who presents with abdominal pain in the ED with PID based on a previous diagnosis of PID. IUD usage (Question 1b) causes minimal risk of PID, and risk is usually limited to the first 3 weeks after IUD insertion. There is no evidence indicating that an IUD should be removed in a patient with acute PID.

The clinical features of PID can vary widely, with lower abdominal or pelvic pain being the most common presenting symptom to the ED. Patients may also present with dyspareunia, abnormal bleeding, and/or vaginal/cervical discharge. Physical examination can demonstrate lower abdominal tenderness, cervical motion tenderness, unilateral or bilateral adnexal tenderness on bimanual exam, and/or fever (>38 C).  Though clinical examination has a low sensitivity for the diagnosis of PID, current recommendations by the CDC recommend empirical treatment based on clinical exam due to the long term sequelae, which include risk of ectopic pregnancy and infertility.

The CDC criteria for empirical treatment of PID include a minimum of cervical motion tenderness or adnexal/uterine tenderness in the presence of lower abdominal or pelvic pain (Question 2c). Additional criteria which are used to support a clinical diagnosis of PID includes oral temperature > 38.3 C (Question 2e), abnormal cervical or vaginal mucopurulent discharge (Question 2a), the presence of numerous WBCs on microscopy of a vaginal sample (Question 2d), elevated erythrocyte sedimentation rate (ESR), and elevated C-reactive protein (CRP). These additional criteria, however, are not necessary for empirical treatment. A history of gonorrhea/Chlamydia infection in the past (Question 2b) is not part of the CDC criteria indicating empirical treatment for acute PID.

Findings which confirm a diagnosis of PID in a patient that presents with clinical signs and symptoms suggesting PID include endometritis or acute salpingitis on histological evaluation of a biopsy, demonstration of N. gonorrhoeae in the genital tract (Question 3c), gross salpingitis seen during laparoscopy/laparotomy, isolation of pathogenic bacteria from a clean specimen in the upper genital tract, or inflammatory/purulent pelvic peritoneal fluid without another source of infection.  A confirmed diagnosis of N. gonorrhoeae infection in the past does not confirm acute PID (Question 3a). Though a patient with a positive pregnancy test and clinical symptoms of PID is at increased risk for ectopic pregnancy, a positive pregnancy test or a vaginal ultrasound demonstrating an ectopic pregnancy does not confirm PID (Question 3e and 3b). An elevated serum WBC count may suggest acute inflammation/infection, but is not in the diagnostic criteria to confirm PID (Question 3d).
As discussed above, empiric treatment of acute PID in the ED should be initiated in patients with lower abdominal pain and cervical motion tenderness, uterine tenderness, or adnexal tenderness due to the potential adverse consequences of untreated PID, which include infertility and ectopic pregnancy. Currently, CDC outpatient recommendations include ceftriaxone 250mg IM PLUS doxycycline 100mg BID for 14 days, with or without metronidazole 500mg BID for 14 days. An alternative regimen includes: cefoxitin 2g IM AND probenecid 1g oral PLUS doxycycline 100 mg BID for 14 days with or without metronidazole 500mg BID for 14 days. Metronidazole should be administered in patients with pelvic abscess, proven or suspected infection with Trichomonas vaginalis or bacterial vaginosis, or history of gynecological instrumentation in preceding 2-3 weeks.

Approximately 10 to 25% of women with PID require hospitalization. CDC recommendations for hospitalization include pregnancy, failure to respond to outpatient treatment, inability to tolerate oral medications, nonadherence to outpatient therapy, presence of pelvic abscess, or severe clinical illness including elevated fever, nausea/vomiting, and severe abdominal pain.  Inpatient treatment options include cefoxitin 2g IV q6h OR cefotetan 2g IV q12h PLUS doxycycline 100mg q12h. An alternative regimen is Clindamycin 900mg IV q8h PLUS gentamicin (2mg/kg) loading dose with maintenance dose of 1.5mg/kg q8h.

Clinical Pearls:
-  Pelvic Inflammatory Disease includes a spectrum of diseases of the female upper genital tract including endometritis, salpingitis, pelvic peritonitis, and tubo-ovarian abscess
-  Empiric treatment of acute PID in the ED should be initiated in patients with lower abdominal pain and cervical motion tenderness, uterine tenderness, or adnexal tenderness due to the potential adverse consequences of untreated PID, which include infertility and ectopic pregnancy
- Male sexual partners of women with PID should be treated if they have had sexual contact with the patient during the 2 months prior to patient’s onset of symptoms
- Patients with PID should be tested for other sexually transmitted diseases, including HIV

Intern Report Case Presentation 4.2


Case Presentation by Dr. Deepa Japra


A 25-year-old woman presents to the emergency department with persistent nausea and vomiting for 6 days. She complains of pain in the lower chest and upper abdomen that she rates as a 6/10.  She describes the pain "like a heart beating real hard”, which is constant and throbbing in character. She is unable to tolerate a regular diet and states she vomits everything she eats.  The vomitus is described as white and yellowish without hematemesis.  The patient had a small bowel movement today, which was soft with no gross blood.  She denies any genitourinary symptoms including no polyuria, dysuria, or hematuria. She does describe a vaginal discharge X 6 days. She is sexually active with one partner, and does not use protection.  Her LMP ended 9 days ago. She has also had subjective fevers and chills, and lightheadedness, but without any syncopal episodes. 

Past medical history is significant for genital herpes infection.

VS: BP: 122/75, P: 59, R:18, T: 36.5, O2 saturation 100% on RA

GENERAL:  Pt is conscious, alert, and cooperative
HEENT:  Conjunctivae are pink without pallor, sclera anicteric. Mouth without intraoral lesions.  Pharyngeal soft tissues are normal.
NECK:  Supple. Trachea midline. No thyromegaly or lymphadenopathy.
RESPIRATORY:  Clear symmetric breath sounds. Good air exchange in all lung fields. No accessory muscle use.
CARDIOVASCULAR:  Normal S1 and S2.  No S3 or S4 gallops.  No murmurs or rubs.  CHEST WALL:  Nontender.
ABDOMEN:  Soft, nondistended, bowel sounds present. mild discomfort to palpation in the epigastric and suprapubic areas, but there is no guarding, masses or rebound tenderness. 
BACK:  No spinal or paraspinal tenderness. No CVA tenderness.
MUSCULOSKELETAL:  FROM, symmetrical strength, no acutely inflamed joints. SKIN:  No rashes or lesions.
NEUROLOGIC:  No gross focal motor or sensory deficits.
PELVIC EXAM: External genitalia are normal. Slight discharge in vaginal vault, cervical os is closed. Positive cervical motion tenderness. Mild uterine and adnexal tenderness, no masses.

Laboratory Studies are as follows:
CBC: Hb 15.5, Hct 43.1, WBC 9.2, Pl 234
Electrolytes: Na 139, K 3.7, Cl 101, HCO3 26, BUN 21, Cr 1.0, Glu 90, Ca 9.5
Lipase 294
ALT 30, AST 19, Alk Phos 77, TBili .8, DBili .2,
Urine Pregnancy negative
UA: trace glucose, 3+ ketones, 1+ blood, 1+ protein, Positive nitrite, 1+ leukocyte esterase, RBC 2-5, WBC 5-10, 1+ mucus, 1+ bacteria
Rapid HIV negative
Gonorrhea PCR positive, Chlamydia PCR negative

Questions:

Question 1
Which of the following is the greatest risk factor for development of pelvic inflammatory disease?
a.     age
b.     intrauterine device usage
c.     multiple sexual partners
d.     previous PID
e.     sexually transmitted disease status of sexual partner

Question 2:

According to CDC guidelines, which of the following is essential in the diagnostic criteria for empirical treatment of PID?
a.     abnormal cervical or vaginal mucopurulent discharge
b.     history of Gonorrhea/Chlamydia infection
c.     lower abdominal or pelvic pain with cervical motion tenderness or uterine/adnexal tenderness
d.     numerous WBCs on microscopy of vaginal secretions
e.     oral temperature > 38.3 C

Question 3:
In addition to clinical symptoms and physical exam findings, which of the following criteria suggests a confirmed case of PID?
a.     confirmed N. gonorrhea infection in the past
b.     confirmation of ectopic pregnancy on vaginal ultrasound
c.     demonstration of N. gonorrhea in the genital tract
d.     elevated serum WBC count
e.     positive Pregnancy test

Please submit your answers as a comment. Your submission will not immediately post. Answers with a case discussion will post on Friday. If you have any difficulty, please contact the site administrator at arosh@med.wayne.edu. Thank you for participating in Receiving’s: Intern Report

Intern Report Case Discussion 4.1


Case Presentation by Dr. Sarah Hyatt


Case Presentation


Answers: 1. D, 2. B, 3. E
Discussion:
This patient has a Valsava retinopathy. Immediately following a Valsava maneuver, a sudden rise in intraocular pressure causes retinal capillaries to spontaneously rupture. The prognosis for Valsava retinopathy is generally good.

Unilateral manifestations are most commonly seen, but bilateral findings have been reported. Sudden decreased vision occurs in the affected eyes, ranging from complaints of floating spots to complete loss of central vision. Vision often improves over weeks to months, depending on the severity of the retinal findings.

Risk factors for Valsava retinopathy are a history of vascular disease, diabetes, hypertension, sickle cell disease, anemia, idiopathic thrombocytopenic purpura.
Ocular findings are usually described as preretinal hemorrhages. Valsava retinopathy has a predilection for the macula. The ruptured vessels in the perifoveal capillaries usually cause a sudden and painless loss of central vision.

Causes: coughing, weight lifting, vomiting, bungee jumping, aerobic exercise, sexual activity, end-stage labor, colonoscopy procedures, constipation, and blowing musical instruments.

Medical care: patients should be advised to avoid anticoagulants and strenuous activities to prevent a rebleed. Patients should be instructed to sleep in a sitting position to promote blood settling, which may improve visual acuity, stool softeners may need to be considered for those with constipation. A diet rich in fiber is advisable. Physical activity should be limited until the retina has sufficiently healed. The patient should always try to limit activities that cause sudden increases in intrathoracic pressure against a closed glottis. Consultation to ophthalmology is recommended and needed for follow up.
Vision usually returns to normal over a short time period from weeks to months.

Key points:
When testing visual acuity use a Snellen chart at a distance of 20 feet or a Rosenbaum chart at a distance of 14 inches.  If the patient is unable to do this test visual acuity by testing  ability to count fingers (CF), if unable to do this test ability to perceive hand motion (HM), if unable to do this test  ability to perceive light (LP). The result may be recorded as “patient able to count fingers at 5 feet”

Acute angle-closure glaucoma: Pt has a narrow anterior chamber angle; folds of the peripheral iris can block the angle, which prevents aqueous humor outflow. The rapid elevation of intraocular pressure causes optic atrophy if not treated promptly. Patient often complains of nausea, vomiting, and pain. Emergent ophthalmologic consultation is indicated. Acute glaucoma is treated with IV mannitol or glycerol to decrease intraocular pressure by osmotic dieresis, topical miotics (i.e., 2% pilocarpine or 0.5% timolol) to decrease pupil size and increase aqueous outflow, and acetazolamide IV to decrease aqueous production

Vitreous hemorrhage: Suspect if sudden painless monocular loss of vision, more common in diabetics with an obscured red reflex and retinal details. Patients often report seeing flashing lights.  Patients also complain of seeing dark floating spots or floaters, which reflect benign vitreous separations
Central retinal artery and vein occlusion: both occur in middle-aged atherosclerotic patients or elderly hypertensive patients and present as sudden painless loss of vision. Occlusion of the retinal artery or its branches results in a dilated nonreactive pupil with an APD on the affected side. The retina is pale with a cherry-red spot on the macula. Occasionally amaurosis fugax precedes central retinal artery occlusion.
The fundoscopic examination of a central retinal vein occlusion is described as a “blood and thunder fundus” because of the presence of multiple large hemorrhages. Prognosis for both CRAO and CRVO is poor.

Common causes of nontraumatic loss of vision
Transient monocular
Amaurosis fugax
Temporal arteritis
Migraine

Persistent monocular
Central retinal artery occlusion
Central retinal vein occlusion
Retinal detachment or hemorrhage
Vitreous or macular hemorrhage
Optic or retrobulbar neuritis
Internal carotid occlusion

Acute binocular
Migraine
Vertebral basilar insufficiency
Cerebrovascular disease
Toxins (methanol, salicylates, quinine, ergot)
Optic or retrobulbar neuritis
Hysteria
Malingering

Sudden painless loss of vision
Central retinal artery occlusion
Central retinal vein occlusion
Vitreous hemorrhage
Retinal detachment
Ischemic optic neuropathy
Nonarteritic ischemic optic neuropathy
Valsava retinopathy
Functional visual loss, hysterical conversion or malingering

References: 
1.Retinopathy, Valsalva, eMedicine http:emedicine.medscape.com/article/1228106
2.Emergency Medicine Secrets, fourth edition, 2006, pages 117-121, Markovchick

3.Rosen’s Emergency Medicine, seventh edition, 2010, pages 870-873, Marx
4.Uptodate, Approach to the adult with acute persistent vision loss, 2010, Leaveque

Intern Report Case Presentation 4.1


Case Presentation by Dr. Sarah Hyatt




Case
Chief complaint: “I can’t see”
28 year old female comes to the ER for loss of vision for 2 days, patient states that this happened suddenly after she was vomiting.  Patient is 6.5 months pregnant and has hyperemesis gravidarum that has persisted through her entire pregnancy. She denies any eye pain and the vision has not improved.  She says she is unable to see anything from the left eye. Previous to this she has not had any trouble with her vision, other than wearing reading glasses.  She decided to come to the ER because her vision still has not improved. She has history of hypertension but no longer requires medication. Denies any headache, fever, chills, chest pain, palpitations, shortness of breath, abdominal pain diarrhea, constipation, dysuria, vaginal bleeding or discharge, no recent travel, no sick contacts.

ROS: negative except as noted per HPI.
PMH:  Hx of Hypertension no longer on medication
Surg hx: none
Gyn: G1P0, good prenatal care
Meds:  Prenatal vitamins 
Allergies: Vicodin causes “throat to close”
FH: Hypertension and diabetes run in the family
SH: No tobacco/alcohol/drugs

PE:  vitals: T 98.7, HR 76, BP 110/56, RR 18, pulse ox 100% RA,  weight 231, 5’5’’
General:  28 year old, African American female, sitting converses without difficulty
Skin: No rashes or scars
Head: normocephalic, atraumatic
Eyes:  EOMI, PERRLA constricting from 6 to 3 mm bilaterally with light, no afferent pupillary defects, Pt has 20/20 VA in right eye,  left eye able to finger count correctly at 5 ft. In her left eye her vision is more clear in her peripheral fields than centrally, intraocular pressure R eye 12, L eye 13, peripheral fields are intact by confrontation, on fundoscopy there were no distinct optic discs visualized, no pallor, no icterus
Nose: symmetric, no discharge
Mouth, throat: No erythema or exudates
Neck: No tracheal deviation or masses
Heart: RRR, S1, S2 heard no murmurs rubs or gallops
Respiratory: CTA BIL
Abd: gravid uterus above the umbilicus consistent with 26 week gestation, soft NT ND,
CNS: Alert and oriented x 3, cranial nerves:  II, III, IV, and VI  see eye exam above, good eyelid opening bilaterally; V, corneal reflex intact bilaterally facial sensation intact bilaterally in V1,V2, V3, good jaw opening, and bite strength; VII, eyebrow raise, eyelid close, smile, frown, pucker, and taste all intact and equal bilaterally; VIII equal auditory acuity to finger rub bilaterally; IX good swallow reflex, positive gag reflex; XI good lateral head rotation, neck flexion, shoulder shrug bilaterally; XII midline tongue protrusion and equal strength on lateral deviation bilaterally. Equal strength in the upper and lower extremities bilaterally, speech and gait are normal.
Extremities: no peripheral edema, all peripheral pulses are felt, good range of motion, no weakness
Labs:       136    101    5      Glucose 82, Ca 9.1, ALT 13, AST 21, total protein 7.1, albumin 3.4, uric acid 4.2                   4.0     23       0.7   Alkaline phosphatase 166, negative UDS and UA 
      10.2
13.5        451  MCV 81.7       Fetal heart tone 150’s
          32.6



Questions

1.     After you dilate the pupil this is your fundoscopic exam. Your diagnosis is?
A. acute glaucoma
B. vitreous hemorrhage
C. central retinal vascular occlusion
D. valsava retinopathy
E. central retinal vein occlusion

2. The patient should be advised which of the following?
A. use aspirin
B. sleep in a sitting position
C. decrease fiber intake
D. resume normal physical activity
E . all of the above

3.Which of the following are risk factors for the above diagnosis?
A.diabetes
B.hypertension
C.anemia
D. idiopathic thrombocytopenic purpura
E. all of the above

Please submit your answers as a comment. Your submission will not immediately post.  Answers with a case discussion will post on Friday.  If you have any difficulty, please contact the site administrator at arosh@med.wayne.edu. Thank you for participating in Receiving’s: Intern Report