Question Of The Day #40

question of the day

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

This elderly patient presents to the emergency department with left lower abdominal pain, constipation, and anorexia. The exam shows fever, tachycardia, and marked left lower quadrant tenderness. Compared to younger patients, abdominal pain in an elderly patient has a higher likelihood of being due to a surgical emergency or from a diagnosis that carries higher mortality. Elderly patients may have more nonspecific associated symptoms that may make it difficult to confirm a dangerous diagnosis without advanced imaging. Additionally, elderly patients do not always have a fever or elevated white blood cells during an abdominal infection. The differential diagnosis of abdominal pain in an elderly patient should be broad and encompass conditions related to many body systems.

The most likely diagnosis for this patient is diverticulitis based on the location of the pain. Features of diverticulitis include left lower quadrant pain, nausea, vomiting, change in bowel habits (diarrhea or constipation), anorexia, fever, and leukocytosis. Right-sided diverticulitis is more common in patients of Asian descent, so these patients may alternatively present with right lower quadrant pain. Treatment for acute diverticulitis includes antibiotics, bowel rest, hydration, increased dietary fiber, and pain management.

Other potential diagnoses to consider for this patient include perforated diverticulitis, abdominal abscess, colitis, bowel obstruction, malignancy, AAA, urinary tract infection, ureterolithiasis, and soft tissue infections. The best next step in the management of this patient is to treat empirically for an abdominal infection with IV hydration, antipyretics, and antibiotics. Sepsis from a gastrointestinal source requires antibiotics that cover both gram-negative and anaerobic bacteria. IV Vancomycin (Choice A) is helpful for skin infections, soft tissue infections, MRSA (Methicillin-resistant Staph aureus) infections, or other infections from gram-positive organisms. Vancomycin would not include coverage for a gastrointestinal source. IV Metronidazole covers anaerobic bacteria, and Ciprofloxacin covers gram-negative bacteria. This makes Choice D the best antibiotic choice for this patient. Other options include IV ampicillin-sulbactam, ampicillin and metronidazole, piperacillin-tazobactam, ticarcillin-clavulanate, or imipenem. A CT scan on the abdomen and pelvis (Choice B) should be performed on this patient (ideally with PO and IV contrast). However, IV hydration and antibiotics are a more important initial step to address the patient’s sepsis. CT scanning is recommended for first-time diverticulitis episodes or if there are alternative diagnoses on the differential. Patients with a history of recurrent diverticulitis who present to the Emergency department with uncomplicated acute diverticulitis are able to be treated empirically with oral antibiotics in the outpatient setting. Ill-appearing patients, have no prior history of diverticulitis or have possible alternative diagnoses should get CT imaging. Emergent colonoscopy (Choice C) is not indicated as part of the Emergency department management of acute diverticulitis. In fact, colonic inflammation or inflamed diverticuli are contraindications to colonoscopy (increased risk of bowel rupture). Correct answer: D

References

Cite this article as: Joseph Ciano, USA, "Question Of The Day #40," in International Emergency Medicine Education Project, May 21, 2021, https://iem-student.org/2021/05/21/question-of-the-day-40/, date accessed: December 4, 2021

Question Of The Day #39

question of the day
Abnormal Right Upper Quadrant

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

This female patient presents to the Emergency department with atraumatic right shoulder pain, generalized abdominal discomfort, and vaginal bleeding.  She is found to have a positive urine pregnancy test and signs of shock on physical exam (hypotension and tachycardia).  The FAST exam (Focused Assessment with Sonography for Trauma) demonstrates free fluid around the liver.  This quick bedside sonographic exam evaluates the right upper quadrant (liver, right kidney, right lung base), left upper quadrant (spleen, left kidney, left lung base), suprapubic area (bladder), and subxiphoid area (view of heart).  The FAST exam is typically used in the setting of trauma to assess for intra-abdominal bleeding, or “free fluid”.  Fluid on ultrasound appears black, or anechoic.  In the setting of trauma or presumed hemorrhagic shock, free fluid is assumed to be blood.  The hepato-renal recess, also known as Morrison’s pouch, is the most common site for fluid to be seen on a FAST exam.  For this reason, the right upper quadrant should always be viewed first during a FAST exam if there is concern for hemorrhagic shock.  The patient’s right upper quadrant FAST view is annotated below.

This patient is in shock with free fluid in her right upper quadrant FAST view.  In the setting of a pregnancy of unknown origin, shock, and abdominal free fluid, a ruptured ectopic pregnancy is assumed to be the diagnosis.  A cystic adnexal structure and a uterus without a gestational sac can also be noted on ultrasound.  Ectopic pregnancy can present with mild symptoms ranging from abdominal pain and vaginal bleeding to signs of shock with hemoperitoneum as in this patient.  Risk factors for ectopic pregnancy include prior ectopic pregnancies, prior tubal surgeries, prior sexually transmitted infections, tobacco smoking, and use of an intrauterine device (IUD).  Initial Emergency department treatment should include volume resuscitation with blood products, pre-operative laboratory testing, and prompt OB/GYN consultation (Choice C).  Patients who are unstable, show signs of shock, or have large ectopic pregnancies are treated operatively.  Patients with stable vital signs, small ectopic pregnancies, and minimal symptoms are treated medically with Methotrexate (Choice A).   This patient’s hemodynamic instability makes Methotrexate contraindicated in her treatment course.  The patient’s atraumatic shoulder pain is likely from free fluid in the right upper quadrant, causing referred pain to the shoulder from diaphragmatic irritation.  A shoulder X-ray (Choice B) is not indicated in this patient.  Rho(D) immune globulin (RhoGAM) (Choice D) is an important treatment to provide in Rh-negative mothers with ectopic pregnancy.  RhoGAM is indicated in maternal-fetal hemorrhage in order to prevent the maternal immune system from attacking fetal Rh-positive cells in future pregnancies.  RhoGAM is indicated in Rh-negative mothers, not Rh-positive mothers.  The question does not indicate the mother’s blood type or Rh status, however, RhoGAM is not the best initial treatment.  Treatment of the hemorrhagic shock and OB/GYN consultation are the best next steps.  Correct Answer: C

References

Cite this article as: Joseph Ciano, USA, "Question Of The Day #39," in International Emergency Medicine Education Project, May 14, 2021, https://iem-student.org/2021/05/14/question-of-the-day-39/, date accessed: December 4, 2021

Question Of The Day #38

question of the day
251 - Gallbladder stone with thickened wall
Which of the following is the most likely cause for this patient’s condition?

This patient presents to the emergency department with upper abdominal pain, nausea, and vomiting. The physical exam demonstrates fever, tachycardia, and focal right upper quadrant abdominal tenderness. Differential diagnoses to consider include cholecystitis, choledocholithiasis, cholangitis, hepatitis, pancreatitis, and ruptured peptic ulcer. The ultrasound image provided shows a thickened gallbladder wall (>4mm) and a gallstone present. See the labeled image below.

Signs of acute cholecystitis on ultrasound include a thickened gallbladder wall, pericholecystic fluid (anechoic (black) fluid around gallbladder), the presence of a gallstone (hyperechoic (white) with posterior shadowing), sonographic Murphy sign (tenderness when the transducer is pressed into gallbladder), and a dilated gallbladder. This patient has some but not all sonographic signs of cholecystitis. However, the age, obese body habitus, fever, and location of the pain support a diagnosis of acute cholecystitis (Choice B). Treatment of acute cholecystitis involves IV hydration, parenteral pain management and antiemetics, IV antibiotics, and surgical consultation for cholecystectomy. Biliary colic (Choice A) is less likely given the ultrasound findings and fever on exam. If the patient’s vital signs were normal and the ultrasound showed gallstones with no other sonographic signs of cholecystitis, biliary colic would be more likely. Gastritis (Choice C) does not cause fever or the sonographic signs illustrated above. Gallstones are the most common cause of pancreatitis (Choice D), but there is focal tenderness over the gallbladder in the right upper quadrant. Additional findings, such as an elevated lipase level, pain that radiates to the back, or a history of alcohol abuse would make pancreatitis a more likely diagnosis. Correct Answer: B

References

Cite this article as: Joseph Ciano, USA, "Question Of The Day #38," in International Emergency Medicine Education Project, May 7, 2021, https://iem-student.org/2021/05/07/question-of-the-day-38/, date accessed: December 4, 2021

Question Of The Day #37

question of the day
25.1 - obstruction volvulus coffee bean 1

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

This elderly male patient presents to the emergency department with generalized abdominal pain and distension. Compared to younger patients, abdominal pain in an elderly patient has a higher likelihood of being due to a surgical emergency or from a diagnosis that carries higher mortality. Elderly patients may have more nonspecific associated symptoms that may make it difficult to confirm a dangerous diagnosis without advanced imaging. Additionally, elderly patients do not always have a fever or elevated white blood cells during an abdominal infection. The differential diagnosis of abdominal pain in an elderly patient should be broad and encompass conditions related to many body systems.

The abdominal X-ray demonstrates a “coffee bean sign” and dilated loops of the large bowel (note haustra of the large bowel). The image supports the diagnosis of sigmoid volvulus, a type of large bowel obstruction that necessitates prompt surgical consultation in the Emergency department. Risk factors for sigmoid volvulus are elderly age, constipation, poor mobility, and residence in a long-term care facility. If left untreated, volvulus can result in intestinal ischemia, necrosis, perforation, and peritonitis. Sigmoid volvulus is most often treated with manual intestinal detorsion through flexible sigmoidoscopy or rectal tube. Cecal volvulus is more common in younger patients, and requires surgical bowel resection or cecopexy (fixing the cecum to the abdominal wall).

The abdominal X-ray provided is sufficient to make the diagnosis of volvulus. A CT scan of the abdomen and pelvis (Choice A) is not necessary for this patient. Surgical consultation is the next best step. IV antibiotics (Choice D) are indicated in volvulus if there are signs of intestinal perforation, necrosis, or peritonitis. The question stem indicates that although the abdomen is tender and distended, the abdomen is soft. This makes peritonitis and the need for antibiotics less likely. Surgical consultation for colectomy (Choice B) would be correct if the patient had cecal volvulus or if there were signs of bowel necrosis. Surgical consultation for bowel detorsion (Choice C) is the best next step for this patient with sigmoid volvulus. Correct Answer: C

References

Cite this article as: Joseph Ciano, USA, "Question Of The Day #37," in International Emergency Medicine Education Project, April 30, 2021, https://iem-student.org/2021/04/30/question-of-the-day-37/, date accessed: December 4, 2021

Question Of The Day #36

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

A hernia is an abnormal defect in the abdominal wall through which intra-abdominal contents (i.e., bowel) can protrude. About 10% of the population experiences hernias at one time during their lifetime. Hernias can cause symptoms that range from mild discomfort to severe pain with signs of bowel obstruction, perforation, necrosis, or peritonitis. The most common type of hernia is the inguinal hernia located along the inguinal crease. Other hernias include the femoral hernia, obturator hernia, Richter hernia, internal hernias, and ventral hernias (umbilical, incisional, Spigelian hernia types). Hernias are further classified as reducible, incarcerated (firm, painful, nonreducible), or strangulated (firm, severely painful, nonreducible, overlying skin redness or crepitus, signs of bowel necrosis or obstruction).

This patient has a right inguinal hernia on exam with overlying skin redness, severe tenderness, and signs of intestinal obstruction (vomiting, constipation, abdominal distension). This should raise concern over a strangulated hernia, which is a surgical emergency. Treatment includes IV hydration, IV antibiotics, and prompt surgical consultation for operative management. The patient’s inguinal hernia is not incarcerated (Choice A), the hernia is strangulated. A Spigelian hernia (Choice B) is located along the lateral ventral abdomen along with the rectus abdominal muscle. Spigelian hernias have a high rate of incarceration compared to other hernias. This patient’s hernia is located along the inguinal crease, not the ventral abdominal wall. Fournier’s gangrene is a severe necrotizing fasciitis of the perineum. Although early Fournier’s gangrene may lack subcutaneous emphysema and marked skin redness, the location and other historical details make a strangulated inguinal hernia a more likely diagnosis. Choice D is the correct answer.

Correct Answer: D

References

Cite this article as: Joseph Ciano, USA, "Question Of The Day #36," in International Emergency Medicine Education Project, April 23, 2021, https://iem-student.org/2021/04/23/question-of-the-day-36/, date accessed: December 4, 2021

Question Of The Day #35

question of the day
qod35
29.2 - small bowel obstruction 2
Which of the following is the most likely cause for this patient’s condition?

This patient presents to the emergency department with generalized abdominal pain, nausea, vomiting, and constipation. The physical exam demonstrates tachycardia and a distended and diffusely tender abdomen. The patient has three prior abdominal surgeries. The upright abdominal X-ray shows multiple dilated loops of small bowel with air-fluid levels. The information provided by the history, physical exam, and diagnostic imaging collectively supports a diagnosis of small bowel obstruction.

Small bowel obstruction (SBO) is a mechanical blockage to forward flow through the intestines. The majority of SBOs are caused by post-operative scar tissue formation (adhesions), but other causes include hernias, intra-abdominal malignancies, foreign bodies, and Crohn’s disease. Symptoms include intermittent colicky abdominal pain, abdominal distension, nausea and vomiting, and constipation. Some patients may be able to pass stool and flatus early in the timeline of an SBO or if the obstruction is partial, rather than complete. Typical exam findings in SBO are a diffusely tender abdomen and high-pitched bowel sounds. Findings of abdominal rigidity, guarding, or fever should raise concern about possible intestinal perforation, peritonitis, or intestinal necrosis. Diagnosis is made clinically in combination with diagnostic imaging, such as abdominal X-rays, CT scanning, or ultrasound. CT scans have better sensitivity and specificity in diagnosing an SBO than Xray. Abdominal ultrasound is more sensitive and specific in diagnosing SBO than CT scan, but this test requires a skilled practitioner to get high-quality results. Treatment of SBO involves IV hydration, surgical consultation for possible operative intervention, pain medications, antiemetics, and electrolyte repletion. Nasogastric tube placement for gastric decompression is helpful in patients who have marked abdominal distension, intractable vomiting, or have risks for aspiration (i.e. altered mental status).

The most common cause of SBO is adhesions (Choice B), not malignancy (Choice A). Diabetic ketoacidosis (Choice C) can present with abdominal pain, nausea, and vomiting. However, DKA becomes more likely when the glucose is elevated over 250mg/dL. The presence of air-fluid levels and dilated small bowel on X-ray imaging also supports SBO over DKA. Delayed gastric emptying (Choice D) is the cause of gastroparesis, a diagnosis that can also present as nausea and vomiting. The other signs, symptoms, and imaging results make SBO a more likely diagnosis than gastroparesis.

References

Cite this article as: Joseph Ciano, USA, "Question Of The Day #35," in International Emergency Medicine Education Project, April 16, 2021, https://iem-student.org/2021/04/16/question-of-the-day-35/, date accessed: December 4, 2021

Question Of The Day #34

question of the day
qod34

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

This patient is pregnant in the first trimester presenting to the Emergency department with right lower quadrant pain. Any first trimester pregnant patient with abdominal pain should be evaluated for ectopic pregnancy. Other causes of this symptom include ovarian torsion, ovarian cyst rupture, pelvic inflammatory disease, tubo-ovarian abscess, urinary tract infection, ureterolithiasis, colitis, or appendicitis. An intra-uterine pregnancy is confirmed on transvaginal ultrasound which excludes ectopic pregnancy from the differential. Ovarian pathologies are also investigated on the ultrasound and are not discovered. 

Another common diagnosis based on the patient’s pain location, young age, and markedly tender abdomen is acute appendicitis. The most common presenting symptom in appendicitis is right lower quadrant pain. Other signs include fever, anorexia, nausea, or vomiting.  Pregnant women may present with back or flank pain, rather than right lower quadrant pain, as the uterus may displace the appendix in the abdomen. There is no single symptom or laboratory test that can reliably exclude the diagnosis of appendicitis. The gold standard test for acute appendicitis diagnosis is a CT scan of the abdomen with IV contrast dye. PO or PR contrast are additionally used in some institutions based on preference and protocols.  In children, appendiceal ultrasound is performed first to avoid excessive radiation exposure and financial cost. CT scanning (Choice A) is similarly avoided in first-trimester pregnancy to diagnose appendicitis, although it is the test of choice in non-pregnant adults. MRI imaging of the abdomen and pelvis (Choice C) is another diagnostic option for pregnant patients, but this is not recommended until an ultrasound is performed. IV antibiotics (Choice D) may be needed to treat appendicitis or other abdominal infections, but this patient lacks a definitive diagnosis or signs of sepsis or shock which would support emergent antibiotics. The best next step to further evaluate the cause of this patient’s symptoms is conducting an appendiceal ultrasound (Choice B). If this study is non-conclusive or is not available, an MRI should be performed. 

Emergency department treatment for acute appendicitis is IV antibiotics, IV hydration, and surgical consultation for appendectomy. Immediate surgery may be avoided in patients who present several days after symptom onset or with a ruptured appendix. These cases are treated with IV antibiotics, IV hydration, bowel rest, and close monitoring.

References

Cite this article as: Joseph Ciano, USA, "Question Of The Day #34," in International Emergency Medicine Education Project, April 9, 2021, https://iem-student.org/2021/04/09/question-of-the-day-34/, date accessed: December 4, 2021

Question Of The Day #33

question of the day
qod33
AAA CT scan possible rupture

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

This elderly male patient presents to the emergency department with abdominal pain. Compared to younger patients, abdominal pain in an elderly patient has a higher likelihood of being due to a surgical emergency or from a diagnosis that carries a higher mortality. Elderly patients may have more nonspecific associated symptoms that may make it difficult to confirm a dangerous diagnosis without advanced imaging. Additionally, elderly patients do not always have a fever or elevated white blood cells during an abdominal infection. The differential diagnosis of abdominal pain in an elderly patient should be broad and encompass conditions related to many body systems.

The syncopal event and signs of shock should raise concern for a more serious etiology of the patient’s symptoms. The CT image provided shows a dilated aorta filled with contrast dye and a large surrounding intra-luminal thrombus. An infrarenal abdominal aorta measuring over 3cm is considered aneurysmal. This patient’s abdominal aorta measures approximately 7cm from outer wall to outer wall using the scale provided on the right-hand side of the image. The green measurement line in the image below shows the size of the aorta from outer wall to outer wall (includes thrombus).

The diagnosis for this patient is a ruptured abdominal aortic aneurysm (AAA). This condition carries a high mortality and is often lethal without prompt surgical intervention (Choice A). Administration of blood products is helpful if there are signs of hemorrhagic shock as in this patient. Antibiotics, like IV Vancomycin and Piperacillin-Tazobactam (Choice B), are not helpful in the management of this diagnosis. Endotracheal intubation (Choice C) is needed prior to operative intervention, but Emergency department management should focus on volume resuscitation and close communication with the surgical team for operative repair. IV Heparin (Choice D) may be beneficial in acute mesenteric ischemia from an embolic etiology (i.e. Atrial fibrillation), but anticoagulation would worsen this patient’s hemorrhagic shock.

AAAs can present to the Emergency department without any symptoms and be discovered incidentally on imaging or on physical exam as a pulsatile abdominal mass. Other presentations include severe back pain (the abdominal aorta is retroperitoneal) and circulatory shock. Rupture of a AAA can be large and result in rapid decompensation and death, or bleeding can be contained in the retroperitoneal space with transiently stable vital signs. Risk factors for AAA formation are male sex, tobacco use, hypertension, increased patient age, Marfans syndrome, or Ehlers-Danlos syndrome. The diagnosis of AAA is clinical and includes the use of bedside aortic ultrasound or CT aortic angiogram imaging. Treatment for AAA depends on aortic size and patient symptoms. Operative repair is indicated for any AAA over 5.5cm diameter in men, over 5.0cm diameter in women, or any size if there are signs of shock or concern for AAA rupture.

References

Cite this article as: Joseph Ciano, USA, "Question Of The Day #33," in International Emergency Medicine Education Project, April 2, 2021, https://iem-student.org/2021/04/02/question-of-the-day-33/, date accessed: December 4, 2021

Question Of The Day #32

question of the day
qod32

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

This patient has intermittent epigastric abdominal pain with nausea and vomiting that radiates to the back. He has a history of alcohol abuse, but lacks tremors or tongue fasciculations to demonstrate signs of active alcohol withdrawal. Laboratory testing reveals pre-renal acute kidney injury (BUN/Creatinine ratio >20), elevated liver function tests with a hepatocellular pattern (AST>ALT in 2:1 ratio), and a markedly elevated lipase.  This information supports a diagnosis of acute pancreatitis. Administration of IV midazolam, a benzodiazepine, would be an appropriate next step if the patient had signs or symptoms of alcohol withdrawal. Alcohol withdrawal can begin as early as 6 hours after refraining from alcohol intake in a chronic alcohol user.  Information regarding alcohol intake is not provided in the question, but objective clinical signs indicating withdrawal are not present on exam. Ordering a CT scan of the abdomen and pelvis (Choice B) is not required in making the diagnosis of acute pancreatitis.  A CT scan can be helpful if you are considering an alternative diagnosis (i.e. AAA, abdominal abscess, etc) or if there is concern for sepsis or fulminant pancreatitis. 

 

Diagnosis of pancreatitis is made clinically based on the history and physical exam, risk factors for the disease, and laboratory testing.  Pancreatitis typically presents as upper abdominal pain that radiates to the flanks and back.  Nausea and vomiting are frequent accompanying symptoms. The disease can range from mild symptoms to severe symptoms with pancreatic necrosis, multi-organ failure, shock, and Acute Respiratory Distress Syndrome (ARDS). Serum lipase testing is more specific than amylase for pancreatitis. Lipase is elevated in pancreatitis.  Risk factors for the disease include gallstones, alcohol use, abdominal trauma, recent ERCP, hypertriglyceridemia, pancreatic ischemia, scorpion envenomation, certain viral infections (Mumps, CMV), hypercalcemia, and certain medications (sulfonamides, azathioprine, valproic acid, etc).  The most common cause of first-time pancreatitis is gallstones. A gallbladder ultrasound should always be performed in patients with a gallbladder who present with pancreatitis. A surgical consultation (Choice C) for gallbladder removal would be warranted if this patient had gallstone pancreatitis, but the patient has a history of a cholecystectomy. The likely cause of this patient’s pancreatitis is his alcohol abuse which causes direct pancreatic injury and inflammation. Treatment of pancreatitis includes IV hydration (Choice D), analgesia, antiemetics, and monitoring for electrolyte abnormalities. Avoiding food or liquid intake (NPO) for “pancreatic rest” has been recommended historically for all cases of pancreatitis, however there is not robust evidence to support this practice.  Routine antibiotics are not recommended for acute pancreatitis, unless there are signs of sepsis.

References

Cite this article as: Joseph Ciano, USA, "Question Of The Day #32," in International Emergency Medicine Education Project, March 26, 2021, https://iem-student.org/2021/03/26/question-of-the-day-32/, date accessed: December 4, 2021

Question Of The Day #31

question of the day
qod31
CT bowel wall thickness - m

Which of the following is the most likely diagnosis causing this patient’s symptoms?

This elderly female patient presents to the emergency department with acute onset of severe abdominal pain, vomiting, and diarrhea. Compared to younger patients, abdominal pain in an elderly patient has a higher likelihood of being due to a surgical emergency or from a diagnosis that carries a higher mortality. Elderly patients may have more nonspecific associated symptoms that may make it difficult to confirm a dangerous diagnosis without advanced imaging.  Additionally, elderly patients do not always have a fever or elevated white blood cells during an abdominal infection.  The differential diagnosis of abdominal pain in an elderly patient should be broad and encompass conditions related to many body systems.

The patient in this question has pain that is reported as being significantly high in relation to the minimal amount of abdominal tenderness provoked by the physical exam. This finding, known as “pain out of proportion” should raise concern for an ischemic etiology of the patient’s pain.  Ruptured appendicitis (Choice A) is less likely as the patient lacks clinical signs of peritonitis (i.e. diffuse tenderness with guarding, fever, hypotension, signs of shock).  Appendicitis, although not impossible in an elderly individual, is a diagnosis that occurs more often in younger patients. Ruptured abdominal aortic aneurysm (Choice B) typically results in death rapidly from hemorrhagic shock. This patient lacks signs of shock (hypotension, tachycardia, altered mental status), and her aorta on CT scan is not enlarged or aneurysmal (see image below).  Ureterolithiasis (Choice D), or a stone in the ureter, typically manifests as unilateral intermittent flank pain with hematuria. The question stem does not report a history of prior stones, and a first-time stone at an elderly age is not likely. 

Given the patent’s advanced age, her “pain out of proportion”, acute onset, risk factors for thromboembolic disease (Atrial fibrillation), the most likely diagnosis is acute mesenteric ischemia (Choice C). X-ray imaging can be used prior to CT angiogram imaging, but CT imaging is more specific and sensitive in making the diagnosis.  X-ray imaging may show bowel dilation, ileus, or pneumatosis intestinalis (air in bowel wall) in severe cases.  Lactate and D-Dimer testing can be used in the evaluation of these patients, but neither test is specific for mesenteric ischemia and reliable enough to rule out the disease. CT angiogram imaging of the abdomen and pelvis is the gold-standard diagnostic test for mesenteric ischemia.  Early CT findings include bowel wall thickening (seen on this patient’s imaging), dilated bowel, mesenteric edema, or ascites. Late CT findings include pneumoperitoneum, portal venous gas, and pneumatosis intestinalis.  Treatment of acute mesenteric ischemia is fluid resuscitation, broad spectrum antibiotics, surgical consultation, and consideration for anticoagulation.

References

Cite this article as: Joseph Ciano, USA, "Question Of The Day #31," in International Emergency Medicine Education Project, March 19, 2021, https://iem-student.org/2021/03/19/question-of-the-day-31/, date accessed: December 4, 2021

The Importance of Wellness in Medicine – My Story and Introduction to a Series of Blog Posts

wellness in medicine

Either be the light in the room or the mirror that reflects it

I always believe that going to work means putting personal issues aside. As physicians, we have a role to make every patient feel welcome, cared for, and heard. However, being in the ER can be stressful. Not only can stress impact our job performance, but it can increase the burnout rate. So begs the questions; how you handle stress, why is it important and what happens when you lose your main source of stress reduction, is there a back-up plan. For my wellness series, I hope to discuss my own experience of losing my main outlet for stress so you know who I am and why I am writing about this topic, the importance of physical fitness, effective quick workouts for a busy ED lifestyle, and a favorite topic of mine, imposter syndrome. As medical students, aspiring ED physicians or an ED physician, I believe we have a role to protect our own health, so that we may best support our patients. 

As medical students, aspiring ED physicians or an ED physician, I believe we have a role to protect our own health, so that we may best support our patients.

brenda - who I am

My name is Brenda-Maricela and I have just finished my first year of medical school at Central Michigan University as an international student, having done all prior education in Canada. While, academically, I had performed well in medical school, mentally, I was burnt out. It is not that I was not used to difficult schoolwork, I had graduated from the University of Toronto, where I was quite accustomed to immense workloads, working part-time jobs and juggling extra-curriculars. It was the fact that I had no outlet for my stress.

You see, prior to medical school, my outlet would be running. I was a modern-day Forest Gump. I craved the long runs that would allow me to shake off any stress I was holding onto. The longer the run the better. I was addicted. During my MSc, I was training with the University of Toronto Triathlon club, running road races and trying to win my age group and felt I could face any challenge that crossed my path. However, I would never have anticipated that I would not be able to run for 2 years. 

In the summer of 2018, I recall the moment where I was getting off of a chair at a conference. I felt a twinge in my right knee but thought nothing of it. I had a minor limp, but nothing too severe. A week later the pain grew, and before I knew it, I was in the ER. “I believe you have Patellar Femoral Pain Syndrome,” the doctor told me while reviewing my X-Rays. Patellar Femoral Pain Syndrome (PFPS) is a clinical term to define anterior knee pain, which often shows no structural damage in imaging.

brenda ER

It is most common in female athletes, and given the multifactorial nature, there is no single treatment. However, it often resolves with physical therapy and reducing activity. Reading about PFPS is one thing, experiencing it is a nightmare.

What would I do without running? The most common advice that I had received was to switch to biking and swimming, something which was a lower impact. These strategies worked, but as time had waned on, my knees became worse and soon, even the pool became a source of pain. I was in a rut. I would do anything to get the endorphins, but nothing would suffice. I would do anything to run again, let alone kneel in a yoga class. I saw multiple doctors, physical therapists, chiropractors and each time, I got the same diagnosis and was told it would resolve on its own.

Spring 2019, I got the phone call informing me of my acceptance to medical school. It was something I had dreamed of since I was a little girl. On one hand, I was ecstatic, but on the other hand, I was drained, depressed and couldn’t look at a jogger on the roads without feeling a sinking feeling in my stomach. How on earth was I going to get through medical school? During my undergraduate degree, I had exercising to sharpen my mind and combat stress. I knew medical school would be intense. How would I deal with the stress? What if my knee got worse? I would be in a new country, without friends and family. Would I draw too much attention if I limped, sat all the time, didn’t participate with social outings? I almost wanted to defer a year. However, my father and biggest mentor reminded me that I had managed to get through the application process without my exercises, perhaps studying would be a good distraction.

My father was right about studying being a distractor. At times, I would be so focused on learning the content, that I forgot about the pain. Other times, my brain would be so fried that I needed a distraction. But what could I do? Sitting for so long, my body craved movement, but my knees would be hesitant. During this time, I did educate myself on other exercise styles such as High-Intensity Interval Training (HIIT), or As Many Reps as Possible Workouts (AMRAP), both with weights, and both focusing on the upper body and core. I will discuss the concept of AMRAP and HIIT in my second article, where I talk about quick and effective workouts. I believe that a sound body and mind are critical to perform well and avoid burn out in, school, the ED and beyond. However, the busy lifestyle as a medical student or a physician may make the time a limiting factor. Therefore, short effective workouts may be of use, and I hope to share my research and experiences.

So, while AMRAP and HIIT didn’t replace running, it would provide some mental soundness on days when I felt particularly on edge. Over time my knees improved, and I owe thanks to some wonderful healthcare providers in Michigan. Unfortunately, while volunteering with Special Olympics in November 2019, I got a hockey-related injury to my knees, setting my progress back a few weeks. I was devastated. Mentally, I was fried, emotionally I was drained. However, the schoolwork was still there, and I had to study. So, what did I learn from November 2019 to present? I learned how important mental health and physical wellness is. This has been a topic among peers who lost their gyms due to COVID-19, thus experiencing a loss of an outlet for stress. Personally, I saw the difference that stress made in my productivity, wellbeing and ability to retain information. So, I started exploring different outlets, many of which will be discussed in upcoming articles.

Exercise is still my favorite outlet, and I think it should be a part of a daily regimen. So, for my next two articles, I will discuss different styles of exercises and free resources I discovered on the web, such as timers, YouTube Channels and websites. Following my articles on exercise and fitness, I would like to dive into the science of yoga. I remember being told about traditional meditation, however, I found that my mind was too busy, and ironically, meditation caused me stress. Many of my ED-oriented friends similarly need to keep mentally busy, and one had recommended yoga as an active meditation. This being said, traditional mediation is effective, and my ED mentor loves it. Therefore, meditation will be discussed, most likely through research and interviews with those who have benefited from it. Finally, I intend to write about imposter syndrome. A lack of self-love can be a mental stressor. If we can learn to love and appreciate all that we have accomplished, I believe that the stress will go down. To show some self-love sounds simple but is often something that so many medical students struggle with. I know I question my own acceptance into medical school, being my own worst critic.

To conclude this article, I want to say I am passionate about medicine, and in seeing my colleagues succeed. Given my enthusiasm for exercise, and having done some personal training in the past, I am eager to share all I know. Maybe I’ll be running when I write my next article. If not, I know there are alternatives, and I hope what I share can be of use to my colleagues around the world. As I tell my friends, even if life clips your wings, just know you have all it takes to fly.

References and Further Reading

LaDonna KA, Ginsburg S, Watling C. “Rising to the Level of Your Incompetence”: What Physicians’ Self-Assessment of Their Performance Reveals About the Imposter Syndrome in Medicine. Acad Med. 2018;93(5):763-768. doi:10.1097/ACM.0000000000002046

Moukarzel A, Michelet P, Durand AC, et al. Burnout Syndrome among Emergency Department Staff: Prevalence and Associated Factors. Biomed Res Int. 2019;2019:6462472. Published 2019 Jan 21. doi:10.1155/2019/6462472

Petersen W, Ellermann A, Gösele-Koppenburg A, et al. Patellofemoral pain syndrome. Knee Surg Sports Traumatol Arthrosc. 2014;22(10):2264-2274. doi:10.1007/s00167-013-2759-6

 

Cite this article as: Brenda Varriano, Canada, "The Importance of Wellness in Medicine – My Story and Introduction to a Series of Blog Posts," in International Emergency Medicine Education Project, August 17, 2020, https://iem-student.org/2020/08/17/the-importance-of-wellness-in-medicine/, date accessed: December 4, 2021

Triads in Medicine – Rapid Review for Medical Students

triads in medicine

One of the most convenient ways of learning and remembering the main components of disease and identifying a medical condition on an exam are Triads, and medical students/interns/residents swear by them.

Be it a question during rounds, a multiple-choice exam question to be solved, or even in medical practice, the famous triads help physicians recall important characteristics and clinical features of a disease or treatment in an instant.

Since exam season is here, this could serve as a rapid review to recall the most common medical conditions.

While there are a vast number of triads/pentads available online, I have listed the most important (high-yy) ones that every student would be asked about at least once in the duration of their course.

1) Lethal Triad also known as The Trauma Triad of Death
Hypothermia + Coagulopathy + Metabolic Acidosis

2) Beck’s Triad of Cardiac Tamponade
Muffled heart sounds + Distended neck veins + Hypotension

3) Virchow’s Triad – Venous Thrombosis
Hypercoagulability + stasis + endothelial damage

4) Charcot’s Triad – Ascending Cholangitis
Fever with rigors + Right upper quadrant pain + Jaundice

5) Cushing’s Triad – Raised Intracranial Pressure
Bradycardia + Irregular respiration + Hypertension

6) Triad of Ruptured Abdominal Aortic Aneurysm
Severe Abdominal/Back Pain + Hypotension + Pulsatile Abdominal mass

7) Reactive Arthritis
Can’t See (Conjunctivitis) + Can’t Pee (Urethritis) + Can’t Climb a Tree (Arthritis)

8) Triad of Opioid Overdose
Pinpoint pupils + Respiratory Depression + CNS Depression

9) Hakims Triad – Normal Pressure Hydrocephalus
Gait Disturbance + Dementia + Urinary Incontinence

10) Horner’s Syndrome Triad
Ptosis + Miosis + Anydrosis

11) Mackler’s Triad – Oesophageal Perforation (Boerhaave Syndrome)
Vomiting + Lower Thoracic Pain + Subcutaneous Emphysema

12) Pheochromocytoma
Palpitations + Headache + Perspiration (Diaphoresis)

13) Leriche Syndrome
Buttock claudication + Impotence + Symmetrical Atrophy of bilateral lower extremities

14) Rigler’s Triad – Gallstone ileus
Gallstones + Pneumobilia + Small bowel obstruction

15) Whipple’s Triad – Insulinoma
Hypoglycemic attack + Low glucose + Resolving of the attack on glucose administration

16) Meniere’s Disease
Tinnitus + Vertigo + Hearing loss

17) Wernicke’s Encephalopathy- Thiamine Deficiency
Confusion + Ophthalmoplegia + Ataxia

18) Unhappy Triad – Knee Injury
Injury to Anterior Cruciate Ligament + Medial collateral ligament + Medial or Lateral Meniscus

19) Henoch Schonlein Purpura
Purpura + Abdominal pain + Joint pain

20) Meigs Syndrome
Benign ovarian tumor + pleural effusion + ascites

21) Felty’s Syndrome
Rheumatoid Arthritis + Splenomegaly + Neutropenia

22) Cauda Equina Syndrome
Low back pain + Bowel/Bladder Dysfunction + Saddle Anesthesia

23) Meningitis
Fever + Headache + Neck Stiffness

24) Wolf Parkinson White Syndrome
Delta Waves + Short PR Interval + Wide QRS Complex

25) Neurogenic Shock
Bradycardia + Hypotension + Hypothermia

Further Reading

Cite this article as: Sumaiya Hafiz, UAE, "Triads in Medicine – Rapid Review for Medical Students," in International Emergency Medicine Education Project, June 12, 2020, https://iem-student.org/2020/06/12/triads-in-medicine/, date accessed: December 4, 2021