Question Of The Day #95

question of the day

Complete Blood Count

Result

(Reference Range)

WBC Count

16.2

4.0 – 10.5 X 103/mL

Hemoglobin

10.8

13.0 – 18.0 g/dL

Hematocrit

32.4

39.0 – 54.0 %

Platelets

220

140 – 415 x 103/mL

Which of the following is the most likely diagnosis for this patient’s condition?

This patient arrives to the Emergency department with bright red bloody stools and lower abdominal pain.  The exam shows fever, tachycardia, and left-sided abdominal tenderness.  The laboratory results provided show leukocytosis and anemia.  This patient likely has a lower GI bleed based on her signs and symptoms.  Please refer to the chart below for a list of causes of GI bleeding, GI bleeding signs and symptoms, and the initial Emergency Department treatment of GI bleeding. 

All choices provided are causes of lower GI bleeding and are possible in this patient.  However, that patient’s signs, symptoms, and risk profile make certain diagnoses less likely than others.  Diverticulosis (Choice A) is the most common cause of lower GI bleeding.  Diverticulosis often occurs in older patients and should not be associated with pain or fever, which support a diagnosis of an inflammatory or infectious etiology (i.e., diverticulitis, Shigellosis, ulcerative colitis, chron’s disease, etc.).  This patient is young and has fever and leukocytosis, making diverticulosis less likely.  Colon malignancy (Choice B) is also possible but is less likely given the patient’s young age, the presence of fever, and the acute onset of symptoms over 2 days.  Colon malignancy tends to cause slow GI bleeding over a longer period of time, rather than acutely over 2 days.  Ischemic colitis (Choice C), such as mesenteric ischemia, is less likely in a young patient without any cardiac risk factors or recent abdominal surgeries. 

Ulcerative colitis (Choice D) is the most likely diagnosis in this scenario.  Peak incidence for ulcerative colitis occurs in the second and third decades of life, and women are more likely than men to have this diagnosis.  Definitive diagnosis requires a biopsy and colonoscopy, but a CT scan of the abdomen and pelvis can show findings consistent with ulcerative colitis for a new diagnosis.  Treatment of an ulcerative colitis flare includes general supportive care, IV steroids, and IV antibiotics if there is concern for a concurrent infectious process.  Intestinal perforation and toxic megacolon also should be evaluated for with CT imaging.    

References

Cite this article as: Joseph Ciano, USA, "Question Of The Day #95," in International Emergency Medicine Education Project, July 1, 2022, https://iem-student.org/2022/07/01/question-of-the-day-95/, date accessed: July 7, 2022

Question Of The Day #94

question of the day

Complete Blood Count

Result

(Reference Range)

WBC Count

4.5

4.0 – 10.5 X 103/mL

Hemoglobin

5.3

13.0 – 18.0 g/dL

Hematocrit

15.9

39.0 – 54.0 %

Platelets

138

140 – 415 x 103/mL

Which of the following is the most appropriate next step in management for this patient’s condition?

This patient arrives to the Emergency Department with bright red bloody stools in the setting of warfarin use.  His exam shows hypotension and tachycardia.  The laboratory results show a low hemoglobin and hematocrit, but no INR or other coagulation studies are provided.  This patient is in hemorrhagic shock due to a lower gastrointestinal bleed.  This patient’s condition may be due to coagulopathy from his warfarin (i.e., supratherapeutic INR), diverticulosis, or other conditions.  Initial management of this unstable patient should include management of the airway, breathing, and circulation (“ABCs”).  This includes aggressive and prompt treatment of the patient’s hypotension and tachycardia and reversal of the patient’s anticoagulation.  Please refer to the chart below for a list of causes of GI bleeding, GI bleeding signs and symptoms, and the initial Emergency Department treatment of GI bleeding. 

This patient’s platelet level is just below the lower limit of normal, so administration of a platelet transfusion (Choice A) would not be the next best step.  Platelet administration should be considered if the platelet count is below 50,000-100,000, or if a massive transfusion protocol is initiated to prevent coagulopathy.  No INR value is provided in the question stem, but prompt reversal of warfarin should not be delayed for an INR level (Choice D).  Reversal of warfarin should be promptly initiated when a patient is unstable (i.e., hypotensive GI bleed, traumatic wound hemorrhage, intracranial bleed, etc.).  Medication reversal in these settings includes both IV Vitamin K 10mg and IV Fresh Frozen Plasma 10-20cc/kg.  IV Vitamin K helps reverse the Vitamin K antagonistic effect of Warfarin, but it does not acutely provide new Vitamin K-dependent coagulation factors (Factors X, V, II, VII).  IV Vitamin K gives the liver the ‘materials’ needed to regenerate these coagulation factors, but this process takes time.  Fresh frozen plasma contains ‘ready-to-use’ coagulation factors that will help control the hemorrhage acutely.  For this reason, both Vitamin K and FFP are given together in an unstable patient.  An alternative to fresh frozen plasma (FFP) is prothrombin complex concentrate (PCC), which is a concentrated version of coagulation factors.  PCC is not broadly available in all countries, and is generally more expensive than FFP. 

The management of stable patients with a supratherapeutic INR includes holding warfarin doses and sometimes providing PO Vitamin K, depending on the INR level.  Administration of IV Vitamin K only (Choice C) is not the correct treatment in this scenario.  IV Vitamin K and IV Fresh Frozen Plasma (Choice B) is the best next step to reverse this patient’s anticoagulant. 

References

Cite this article as: Joseph Ciano, USA, "Question Of The Day #94," in International Emergency Medicine Education Project, June 24, 2022, https://iem-student.org/2022/06/24/question-of-the-day-94/, date accessed: July 7, 2022

Question Of The Day #93

question of the day

Which of the following is the most appropriate next step in management?

This patient arrives to the Emergency Department with bright red bloody stools and generalized abdominal pain.  His exam shows hypotension, tachycardia, a diffusely tender abdomen, and pale conjunctiva.  He also takes warfarin daily for anticoagulation.  This patient is in hemorrhagic shock due to a lower gastrointestinal bleed.  This patient’s condition may be due to coagulopathy from his warfarin (i.e., supratherapeutic INR), diverticulosis, ischemic colitis (i.e., mesenteric ischemia), and other conditions.  Initial management of this unstable patient should include management of the airway, breathing, and circulation (“ABCs”).  This includes aggressive and prompt treatment of the patient’s hypotension and tachycardia.  Please refer to the chart below for a list of causes of GI bleeding, GI bleeding signs and symptoms, and the initial Emergency Department treatment of GI bleeding. 

A CT Angiogram of the abdomen and pelvis (Choice A) may be helpful in clarifying the etiology and site of the patient’s bleeding, but this is not the best next step in management.  The patient’s shock state first should be managed prior to any imaging studies.  Gastroenterology consultation for colonoscopy (Choice B) may be important later in this patient’s management, but it is not the best next step in management. His shock state should be treated prior to calling any consultants. An IV Pantoprazole infusion (Choice C) is helpful in upper GI bleeds due to peptic ulcer disease.  Proton pump inhibitor medications, like pantoprazole, help reduce findings of ulcer bleeding during endoscopy.  Proton pump inhibitor use has been controversial in upper GI bleeds as there is no evidence that their use decreases mortality, decreases blood product requirements, or ulcer rebleeding, but these medications are often given due to their generally small risk profile.

 

The best next step for this patient in hemorrhagic shock is administration of packed red blood cells (Choice D).  He also should have reversal of his warfarin with IV Vitamin K and fresh frozen plasma to prevent continued bleeding.

References

Cite this article as: Joseph Ciano, USA, "Question Of The Day #93," in International Emergency Medicine Education Project, June 17, 2022, https://iem-student.org/2022/06/17/question-of-the-day-93/, date accessed: July 7, 2022

ICEM2022 and The First IFEM Medical Student Symposium

IFEM MSS

Dear medical students and EM community,

We invite you to the IFEM Medical Student Symposium, the first of its kind, to discuss the present and future of undergraduate emergency medicine education. The IFEM Medical Student Symposium will bring together speakers, facilitators, and attendees from seven regions of Africa, Asia, Central and South America, Europe, the Gulf, North America, and Oceania. You can find more details on the flyer below.

It will take place on June 14th, 2022, at 13:30 AEST (GMT +10). The symposium fee is 10 AUD. Thanks to IFEM leadership and the ICEM organising committee, participants intending to join the Medical Student Symposium only can use this link on the workshop page to register without an additional conference fee.

Please share this blogpost with your colleagues and trainees who might be interested in joining this conversation. We are looking forward to meeting you all virtually at the symposium.

Best regards,
Dr Elif Dilek Cakal & Dr Erin Simon
IFEM Medical Student Symposium Co-leads
IFEM Core Curriculum and Education Committee

Question Of The Day #92

question of the day

Which of the following is the most likely cause of this patient’s condition?

This elderly patient arrives to the Emergency Department with painless hematochezia.  His exam shows borderline hypotension, tachycardia, and a normal abdominal exam.  This patient most likely has a lower gastrointestinal bleed based on his signs and symptoms.  A brisk (fast) upper GI bleed is also possible but is less likely.  Please refer to the chart below for a list of causes of GI bleeding, GI bleeding signs and symptoms, and the initial Emergency Department treatment of GI bleeding. 

All choices listed above are potential causes of bright red bloody stools.  Peptic ulcer disease (Choice C) is the most common cause of upper GI bleeding worldwide, not lower GI bleeding.  However, a profusely bleeding peptic ulcer can cause rapid blood transit through the GI tract to form hematochezia rather than melena.  The patient lacks any risk factors or symptoms of peptic ulcer disease, such as upper abdominal pain, hematemesis, NSAID use, or prior H. pylori infection.  Ischemic colitis, or mesenteric ischemia (Choice A), is often associated with abdominal pain and cardiac risk factors (i.e., atrial fibrillation).  Colon cancer (Choice B) is also possible, but typically colon malignancy causes slow, chronic bleeding, rather than acute large volume bloody stools with signs of shock as in this patient.  The most common cause of lower GI bleeding worldwide is diverticulosis (Choice D).  This is the most likely diagnosis in this patient with painless hematochezia.

References

Cite this article as: Joseph Ciano, USA, "Question Of The Day #92," in International Emergency Medicine Education Project, June 10, 2022, https://iem-student.org/2022/06/10/question-of-the-day-92/, date accessed: July 7, 2022

1 Week to ICEM2022 and The First IFEM Medical Student Symposium

1 week to IFEM MSS

Dear medical students and EM community,

We invite you to the IFEM Medical Student Symposium, the first of its kind, to discuss the present and future of undergraduate emergency medicine education. The IFEM Medical Student Symposium will bring together speakers, facilitators, and attendees from seven regions of Africa, Asia, Central and South America, Europe, the Gulf, North America, and Oceania. You can find more details on the flyer below.

It will take place on June 14th, 2022, at 13:30 AEST (GMT +10). The symposium fee is 10 AUD. Thanks to IFEM leadership and the ICEM organising committee, participants intending to join the Medical Student Symposium only can use this link on the workshop page to register without an additional conference fee.

Please share this blogpost with your colleagues and trainees who might be interested in joining this conversation. We are looking forward to meeting you all virtually at the symposium.

Best regards,
Dr Elif Dilek Cakal & Dr Erin Simon
IFEM Medical Student Symposium Co-leads
IFEM Core Curriculum and Education Committee

Question Of The Day #91

question of the day

Which of the following is the most likely cause of this patient’s condition?

This patient arrives to the Emergency Department with upper abdominal pain and hematemesis.  He occasionally takes ibuprofen, a non-steroidal anti-inflammatory drug (NSAID), which is a risk factor for GI bleeding. His examination shows tachycardia.  This patient likely has an upper gastrointestinal bleed given his signs and symptoms.  Please refer to the chart below for a list of causes of GI bleeding, GI bleeding signs and symptoms, and the initial Emergency Department treatment of GI bleeding.  

All choices listed above are potential causes of upper GI bleeding, with the exception of GERD (Choice D).  Erosive gastritis and esophagitis can cause an upper GI bleed, but GERD is not a cause of upper GI bleed.  The patient lacks risk factors for esophageal varices (Choice A), such as chronic liver disease, cirrhosis, or alcohol abuse.  Gastric malignancy (Choice B) is possible, but less likely given the patient’s young age and lack of risk factors mentioned in the question stem for gastric malignancy (i.e., prior H. pylori infection, tobacco smoking, chronic gastritis, weight loss, lymphadenopathy, etc.).  The most common worldwide cause of upper GI bleeding is peptic ulcer disease (Choice C).  For this reason, Choice C is the best answer.

References

Cite this article as: Joseph Ciano, USA, "Question Of The Day #91," in International Emergency Medicine Education Project, June 3, 2022, https://iem-student.org/2022/06/03/question-of-the-day-91/, date accessed: July 7, 2022

IFEM Medical Student Symposium – Team Oceania

Dear medical students and EM community,

We invite you to the IFEM Medical Student Symposium, the first of its kind, to discuss the present and future of undergraduate emergency medicine education. The IFEM Medical Student Symposium will bring together speakers, facilitators, and attendees from seven regions of Africa, Asia, Central and South America, Europe, the Gulf, North America, and Oceania. You can find more details on the flyer below.

It will take place on June 14th, 2022, at 13:30 AEST (GMT +10). The symposium fee is 10 AUD. Thanks to IFEM leadership and the ICEM organising committee, participants intending to join the Medical Student Symposium only can use this link on the workshop page to register without an additional conference fee.

Please share this blogpost with your colleagues and trainees who might be interested in joining this conversation. We are looking forward to meeting you all virtually at the symposium.

Best regards,
Dr Elif Dilek Cakal & Dr Erin Simon
IFEM Medical Student Symposium Co-leads
IFEM Core Curriculum and Education Committee

 

 

 

 

Question Of The Day #90

question of the day
366 - pneumonia-middle lobe

Which of the following is the most likely cause of this patient’s condition?

Shortness of breath, also known as dyspnea, is a common reason for patients to visit the Emergency Department.  Dyspnea is often caused by a pulmonary or cardiovascular condition, but it is important to remember that dyspnea can be due to endocrine conditions, toxicologic conditions, neurologic conditions, hematologic conditions, musculoskeletal conditions, and psychiatric conditions. 

The initial approach to all patients with shortness of breath involves the primary survey, or “ABCs” (Airway, Breathing, Circulation).  This first involves checking the patient for a patent airway.  A simple method to assess the airway is to ask the patient to speak and listen for the voice.  A muffled voice, the presence of stridor, hematemesis, or a lethargic patient are clues that a patent airway may not be present.  Problems with the airway, such as an obstructing foreign body, inflammation (i.e., epiglottitis, anaphylactic shock), or vocal cord dysfunction can certainly cause shortness of breath.  Endotracheal intubation may need to be performed before moving forward.  Breathing is assessed by evaluating the function of the lungs.  Steps include looking at how the patient is breathing (fast or slow), measurement of an SpO2 level, and auscultation of both lungs for wheezing, crackles, rhonchi, or distant or absent sounds.  A low oxygen level should be immediately addressed with supplemental oxygen before moving forward.  The patient’s breathing rate and lung sounds can be very helpful in discovering the diagnosis and guiding treatment.  Lastly, circulation should be assessed.  Check the heart rate, blood pressure, peripheral pulses, skin color and temperature, and evaluate for any sites of hemorrhage.  The presence of hypotension or tachycardia should be addressed appropriately based on the presumed cause.  After the primary assessment (“ABCs”) and initial treatment actions, a more detailed history and physical exam should be conducted. 

Pertinent causes of shortness of breath for the emergency practitioner to know are outlined in the chart below. 

 

Select Causes of Shortness of Breath (Dyspnea)

Pulmonary

 

Tension pneumothorax, pneumonia, empyema, pleural effusion, pulmonary edema, asthma, COPD

Cardiovascular

 

Acute coronary syndrome (i.e., STEMI), pulmonary embolism, cardiac tamponade, Decompensated Congestive Heart Failure (acute pulmonary edema)

Endocrine

 

Diabetic ketoacidosis (Kussmaul breathing)

Toxicologic

 

Salicylate overdose, or any ingestion that causes a severe metabolic acidosis

Neurologic

 

Intracranial hemorrhage, Stroke, Spinal cord injury, Guillain-Barre syndrome, Myasthenia Gravis crisis (myasthenic crisis)

Hematologic

 

Severe anemia (i.e., GI bleeding, trauma, miscarriage, post-partum hemorrhage, ruptured ectopic pregnancy)

Musculoskeletal

 

Rib fracture, flail chest

Psychiatric

 

Anxiety, Panic attack

Airway Problem

Foreign body, epiglottitis, anaphylactic shock (laryngeal swelling), expanding neck hematoma

This patient arrives to the Emergency department with shortness of breath, productive cough, and fever for 5 days.  On exam, the patient is febrile, tachycardic, and has a low SpO2 on room air.  The lung exam demonstrates focal rhonchi at the right base.  The chest X-ray demonstrates a consolidation at the right middle lobe that obscures the right heart boarder.  The consolidation is highlighted with a red star in the patient’s X-ray below.

Lung consolidations have multiple causes, including pneumonia, malignancy, heart failure, pulmonary emboli, and septic emboli from endocarditis.  Septic pulmonary emboli (Choice A) can present with cough, fever, and difficulty breathing, but often have multiple foci of consolidations on chest X-ray.  This patient has a single area of consolidation.  This patient also lacks the typical risk factors for septic emboli, like IV drug use, recent dental procedures, structural heart disease, or prosthetic heart valves.  An infected pleural effusion (Choice B), also known as an empyema, is shown as a blunted or hazy right costo-diaphragmatic angle.  This patient’s X-ray shows no fluid in both costo-diaphragmatic recesses to indicate the presence of a pleural effusion.  A pulmonary embolism (Choice D) often presents with clear lungs on auscultation and a normal chest X-ray.  However, if the pulmonary embolism progresses to a pulmonary infarct, a wedge-shaped opacity can be seen on the X-ray.  This patient’s X-ray lacks this finding.  The most likely cause for this patient’s symptoms is a right middle lobe pneumonia (Choice C).  She should receive IV fluids, antipyretics, supplemental oxygen, and IV antibiotics.

References

Cite this article as: Joseph Ciano, USA, "Question Of The Day #90," in International Emergency Medicine Education Project, May 27, 2022, https://iem-student.org/2022/05/27/question-of-the-day-90/, date accessed: July 7, 2022

IFEM Medical Student Symposium – Team Gulf

Dear medical students and EM community,

We invite you to the IFEM Medical Student Symposium, the first of its kind, to discuss the present and future of undergraduate emergency medicine education. The IFEM Medical Student Symposium will bring together speakers, facilitators, and attendees from seven regions of Africa, Asia, Central and South America, Europe, the Gulf, North America, and Oceania. You can find more details on the flyer below.

It will take place on June 14th, 2022, at 13:30 AEST (GMT +10). The symposium fee is 10 AUD. Thanks to IFEM leadership and the ICEM organising committee, participants intending to join the Medical Student Symposium only can use this link on the workshop page to register without an additional conference fee.

Please share this blogpost with your colleagues and trainees who might be interested in joining this conversation. We are looking forward to meeting you all virtually at the symposium.

Best regards,
Dr Elif Dilek Cakal & Dr Erin Simon
IFEM Medical Student Symposium Co-leads
IFEM Core Curriculum and Education Committee

 

 

 

IFEM Medical Student Symposium – Team North America

Dear medical students and EM community,

We invite you to the IFEM Medical Student Symposium, the first of its kind, to discuss the present and future of undergraduate emergency medicine education. The IFEM Medical Student Symposium will bring together speakers, facilitators, and attendees from seven regions of Africa, Asia, Central and South America, Europe, the Gulf, North America, and Oceania. You can find more details on the flyer below.

It will take place on June 14th, 2022, at 13:30 AEST (GMT +10). The symposium fee is 10 AUD. Thanks to IFEM leadership and the ICEM organising committee, participants intending to join the Medical Student Symposium only can use this link on the workshop page to register without an additional conference fee.

Please share this blogpost with your colleagues and trainees who might be interested in joining this conversation. We are looking forward to meeting you all virtually at the symposium.

Best regards,
Dr Elif Dilek Cakal & Dr Erin Simon
IFEM Medical Student Symposium Co-leads
IFEM Core Curriculum and Education Committee

 

 

IFEM Medical Student Symposium – Team Central and South America

Dear medical students and EM community,

We invite you to the IFEM Medical Student Symposium, the first of its kind, to discuss the present and future of undergraduate emergency medicine education. The IFEM Medical Student Symposium will bring together speakers, facilitators, and attendees from seven regions of Africa, Asia, Central and South America, Europe, the Gulf, North America, and Oceania. You can find more details on the flyer below.

It will take place on June 14th, 2022, at 13:30 AEST (GMT +10). The symposium fee is 10 AUD. Thanks to IFEM leadership and the ICEM organising committee, participants intending to join the Medical Student Symposium only can use this link on the workshop page to register without an additional conference fee.

Please share this blogpost with your colleagues and trainees who might be interested in joining this conversation. We are looking forward to meeting you all virtually at the symposium.

Best regards,
Dr Elif Dilek Cakal & Dr Erin Simon
IFEM Medical Student Symposium Co-leads
IFEM Core Curriculum and Education Committee