Tick bite

ID: 36y/o ♀ otherwise healthy with a suspected tick bite in the ER; 

HPI: was camping in the woods; noticed a mildly painful, small, round, red skin lesion on her thigh; did not see the tick, but is concerned; wants to know if she needs any tests for lyme disease; no fever/chills; ROS non contributory; 

E/O: Looks well; not ill/toxic; VSSA;

A round, well circumscribed, indurated red papule on the Rt medial thigh; mildly tender to touch; no surrounding erythema or bull’s eye appearance; 

A/P: suspected tick bite; daxycyclin 200mg po once; f/u precautions; testing for lyme disease is not recommended; 

Discussion^(1,2): 

Factors affecting disease transmission: 

1. Tick species and stage of development: nymphal stage of deer tick (Ixodes scapulars); 
2. Season: late spring, early summer; 
3. Engorgement: transmission needs >36hr of feeding; tick on the skin needs 24hr before it starts feeding; 

How to remove a tick from skin: 

Grasp the tick with a fine forceps as close to skin as possible; pull straight up; if mouth pieces (does not increase transmission) remain do not try removal (to prevent trauma to skin); do not use other methods such as burning or using chemicals (may irritate the tick ➜ act as a syringe ➜ injects the organism into the host ➜ increases the risk of transmission)

Erythema migrans (EM)⁽³⁾: Characteristic lyme disease rash; bull’s eye appearance; 

Approach to prophylaxis as per Infectious Diseases Society of America (IDSA) guidelines: antibiotic prophylaxis is indicated if the patient meets all the following criteria,

1. Adult or nymphal Ixodes scapularis tick (deer tick).
2. attached for ≥36 hr;
3. Prophylaxis given within the first 72 hours of tick removal.
4. Local rate of infection of ticks with B. burgdorferi is ≥20 percent;
5. No contraindications for Doxycycline (<8 y/o, pregnant, or lactating).

If the patient meets all of these criteria, give doxycycline 200 mg po once (4 mg/kg po once in children >8y/o max dose 200mg). If any contraindications, then no prophylaxis is recommended; 

IgM to B. burgdorferi appears 1-2wk after the signs and sx of lyme disease; IgG appears 2-6wk after the onset of EM; 

  

References: 

1. http://www.cdc.gov/lyme/transmission/blacklegged.html
2. http://www.uptodate.com/contents/evaluation-of-a-tick-bite-for-possible-lyme-disease?source=search_result&search=tick+bite&selectedTitle=1%7E86
3. http://www.bada-uk.org/wp-content/uploads/Erythema_migrans1.jpg

Sudden pop in the Lt ankle while playing soccer

15y/o healthy ♂; was playing soccer; while running backwards, felt a sudden pop a/w immediate onset of severe pain in the left ankle; fell on the ground; wasn’t able to mobilize initially; limping now; no prior similar episodes; no ankle pain prior to this incident; no previous injuries to the Lt ankle; ROS non-contributory; 

PMH: non-contributory; 

E/O: VSSA; 

Lt ankle: mild posterior swelling and ecchymosis; no erythema; no atrophy; tenderness over Achilles tendon with a palpable gap 4cm above its calcaneal insertion; Thompson’s test +ve; 

I/P: Achilles tendon rupture; NSAIDs; RICE; urgent ortho consult; 

Discussion^(1-2):

>75% occur in 30-40 yr olds; Male/Female=10/1; usually happens 30-40min after the start of the activity; Patients feel as if “I was kicked in the back of the leg” a/w a painful snap; 

Total rupture: Thompson’s/Simmonds’ calf squeeze test +ve; “Hatchet strike” defect (palpable, tender defect 3-6cm proximal to the calcaneal insertion) may be present in the immediate post rupture period; not palpable after a few days due to swelling; Only 25% of the tendon fibers are needed for normal Achilles tendon function, hence the difficulty in Dx of partial tears; Weak or absent active dorsiflexion; 

NSAIDs prn; RICE; ortho consult; surgical vs conservative management; needs careful patient selection; recent trend toward conservative Rx with early ROM (cast for 2wk then functional brace); conservative Rx earlier return to function; surgery less re-rupture at 1-4% (conservative at 10-30%), but ↑complications (infection, DVT & PE, adhesions); 

References: 

1. https://itunes.apple.com/ca/app/5-minute-sports-medicine-consult/id445352494?mt=8

2. Brukner, P., Brukner, P., D.R.C.O.G, & Khan, K. (2009). Clinical sports medicine. North Ryde, N.S.W: McGraw-Hill.

Refractory Hypotension

ID: 51 y/o ♀; new immigrant; found unconscious in her apartment by her daughter, and was brought in by EMS.

HPI: Daughter went to visit her; found her on the floor, non-responsive, but breathing; called 911; no suicide note; no empty pill containers around; as per daughter long-standing depression, worse after immigration; regained consciousness in the ER, and denied suicidal attempt or intentional overdose; ⊘ trauma; ⊘ hemoptysis; ⊘ hematuria; ⊘ hematemesis; ⊘ melena/hematochezia; 

⊘ incontinence. 

PMH: Depression, HTN, DM-II; no prior suicide attempts;

Meds: Atenolol; nifedipine; metformin; atorvastatin; citalopram; ⊘ anticoagulants/antiplatelets; 

All: NKDA 

SH: New immigrant; language barrier; lives alone; ⊘ drugs; ⊘ ETOH;

E/O: responsive to voice; NAD; ⊘ ill/toxic; ⊘ obvious bleeding;

BP: 56/p  P: 45  R: 11  Sat: 94% RA  Temp: 36.4 ℃

CBG: 6.1

ABCDE: 100% O₂ by mask; 2 large bore IVs; NS 2L IV bolus; CBCD, Rapid Metabolic Panel (RMP), Lactate, ETOH level; acetaminophen and salicylate levels; Venous Blood Gas (VBG); ECG; continuous cardiac monitoring; respiratory therapist and ICU were paged; no signs of trauma in the rapid primary survey (RPS).

HEENT: ⊘ tongue biting. 

CVS: Bradycardia; otherwise unremarkable. 

Resp: AE=AE; bilat. clear fields. 

Abdo: protuberant; BS active; soft; ⊘ peritoneal.

Neuo: Pupils 3mm, symmetric, reactive, ⊘ RAPD; 

moves limbs ✗ 4; ⊘ focal.

Skin: cold extremities; not diaphoretic. 

BP refractory to NS 2 Lit IV bolus; lab results normal; 

ECG: sinus brady @45 with 1st º AV block. 

I/P: beta blocker overdose was suspected; BP responded to glucagon 3mg IV bolus then 3mg/h IV infusion,and D50W 50ml bolus + insulin 60U IV push; insulin infusion 0.5U/kg/h + dextrose 1g/kg/h as D10W were started; CBG repeated q15min; electrolytes repeated q30min; was admited to ICU after initial resuscitation;  

Discussion⁽¹⁾: 

The “toxidrome-oriented” physical examination: 

1. vital signs
2. LOC
3. pupil size and position
4. mucous membranes
5. skin temperature and moisture
6. bowel sounds
7. assessment of motor tone

DDx of hypotension + bradycardia cased by overdose:

1. Beta-blockers (associated w HYPOglycaemia)
2. CCBs (associated w HYPERglycaemia)
3. Digoxin (GI Sx, ECG ▵s)
4. clonidine
5. cholinergics

The empiric use of the so-called “coma cocktail” (dextrose, oxygen, naloxone, and thiamine) is no longer recommended in pt presenting with non-traumatic ↓LOC.

Reference: 

1. http://www.uptodate.com/contents/initial-management-of-the-critically-ill-adult-with-an-unknown-overdose?source=search_result&search=betablocker+poisoning&selectedTitle=2%7E9

Wrist Pain in a Construction Worker

ID: 38 y/o ♂ otherwise healthy, came in with Rt wrist pain.

HPI: pain started gradually yesterday a few hr after moving heavy timber, no restricted ROM yesterday; woke up this am with significant Rt wrist pain; unable to move Rt wrist due to significant pain; no recent trauma; reports weak grip; no fever/chills; no previous Rt upper extremity injuries; mild swelling; no bruising or colour changes; no deformity; no numbness/tingling. 

PMH: ⊘

All: NKDA

E/O: A+O ✗ 3 - NAD - ⊘ ill/toxic

VSSA

Rt upper extremity: shoulder, elbow, MCP, and PIP joints are unremarkable. 

Wrist mildly edematous; ⊘ color/temp ▵s; significantly reduced active/passive ROM due to pain; no anatomical snuff box tenderness; severe tenderness on the ulnar aspect of the wrist; weak grip; neuro-vascular exam Ⓝ; 

X ray wrist ➜ ⊘ #

U/S wrist jont ➜ ⊘ effusion, possible TFCC tear.

I/P: 38 y/o ♂ with acute Rt wrist pain most likely caused by TFCC (Triangular Fibro-Cartilage Complex) tear.

RICE (Rest, Ice, Compression, Elevation), NSAIDs, protective bracing, physiotherapy; discharge home w F/U precautions; 

Discussion⁽¹⁾: 

TFCC consists of, triangular fibrocartilage, ulnar meniscus homolog, ulnar collateral ligament, carpal ligaments, extensor carpi ulnaris tendon sheath

Mechanism of injury: compressive loads to the wrist esp. if accompanied by ulnar deviation; can also be injured in distal radial/ulnar #s or disruption of the distal radio-ulnar joint; arthroscopy can be done for Dx or Rx purposes. 

Tenderness on the dorsal ulnar aspect of the wrist; pain on resisted dorsiflexion and ulnar deviation; Press test +ve;   

Reference: 

1. Brukner, P., Brukner, P., D.R.C.O.G, & Khan, K. (2009). Clinical sports medicine. North Ryde, N.S.W: McGraw-Hill. 

Superficial Venous Thrombosis

ID: 36y/o healthy female, came in with Lt leg pain. 

HPI: Sudden onset of pain, Lt leg 5/7, constant, stabbing, no swelling; no SOB; no cough/hemoptysis; no CP; no fever/chills; does not interfere with mobilization; no recent trauma/surgery; no IVDU; 

PMH: Endometriosis on Cyclomen (danazol) ✗ 2yr; no Hx of DVT, PE, clotting disorders; 

FH: noncontributory.

E/O: A+O ✗ 3 - NAD - ⊘ill/toxic

BP: 118/76 P: 86  R: 18  SAT: 98% RA  T: 36.7 ℃

Significant localized tenderness on the upper anteromedial aspect of the Lt leg; equal leg circumference on both sides;  no colour changes, Lt leg not warmer than the contralateral side; no calf tenderness; dorsalis pedis/pos. tibial pulses symmetrical; capillary refill normal.

CVS, Resp, Abdo exams unremarkable.

CBCD, Rapid Metabolic Panel (RMP), INR, all Ⓝ

U/S ➜ 2cm clot in the saphenous vein; no DVT; 

I/P: 36 y/o healthy ♀ with superficial venous thrombosis (SVT) precipitated by danazol. 

Stop danazol; pain management (warm/cold compress, elevation, compression stockings, NSAIDs); discuss pros and cons of NSAIDs alone vs full anticoagulation ✗ 4wk; F/U with GP in 7-10 days; discharge home with F/U precautions;   

Discussion ⁽¹⁾: 

Increased risk of thromboembolism if, ≤5cm from the saphenofemoral/saphenopopliteal junction (deep venous system), thrombus ≥5cm in length, +ve medical risk factors for DVT; These patients may benefit from anticoagulation (Rx decision should be individualized); otherwise Rx with NSAIDs, pressure stockings, elevation, warm/cold compress.

Optimum agent,dose, duration unclear; fondaparinux, UFH, LMWH, and warfarin all effective and can be used.

Repeat U/S may be necessary based on physical exam and physician’s discretion.

Remember DVT can occur in the ipsi- or contralateral lower limb in patients with SVT. 

Reference: 

1. http://www.uptodate.com/contents/superficial-thrombophlebitis-of-the-lower-extremity?source=preview&anchor=H20&selectedTitle=1~54#H20

Polyarticular arthritis

ID: 67y/o ♀, multiple medical comorbidities, brought in by EMS due to inability to walk due to joint pain. 

HPI: Hx of a mechanical fall one week ago; no ↓LOC; no head trauma; gradual onset of pain, erythema, warmth, and swelling in multiple large joints (Rt elbow and knee, Lt wrist) past 2/7. Lost ROM in the involved joints due to sever pain; unable to mobilize; no fever/chills; ROS otherwise noncontributory. 

PMH: gouty arthritis 1-2 attacks/yr on allopurinol; always Lt 1st MTP joint; last episode 2mo ago; CKD eGFR=35; stable angina on medical Rx; controlled HTN; 

E/O: A+O ✗ 3 - NAD - ⊘ill/toxic

VSSA

HEENT: no oral mucosal ulcerations; pupils 3mm symmetric, reactive, ⊘RAPD

MSK: Rt elbow, Rt knee, Lt wrist: erythematous, swollen, warm, extremely tender to touch; no active/passive ROM due to severe pain; 

The rest of the exam noncontributory. 

I/P: 67 y/o ♀ with gouty arthritis involving multiple joints precipitated by recent blunt trauma.

CBC, rapid metabolic panel (RMP), INR, serum uric acid (sUA), ESR; X ray involved joints; medicine/rheumatology consult regarding admission;  Rx as acute gouty arthritis with prednisone 50mg PO daily taper to a total course of 7d;

Discussion; 

Acute gouty arthritis can be precipitated by trauma, fatty foods, beer and spirits (NOT wine), dehydration, starvation, low-dose aspirin.

Always consider the possibility of septic arthritis, even in pt with long-standing Hx of gout. Septic and gouty arthritis can occur simultaneously in a joint.  

Release of cytokines may cause lower sUA during an attack. For most accurate sUA measurements, wait at least 2wk after complete resolution of Sx⁽¹⁾. 

Reference: 

http://www.uptodate.com/contents/clinical-manifestations-and-diagnosis-of-gout?source=preview&anchor=H7&selectedTitle=1~150#H7

Jones fracture

ID: 43 y/o ♀ previously healthy came in due to Rt foot pain and swelling. 

HPI: Pain started suddenly 2wk ago in her dancing class. The pain came on suddenly with a direction change while practicing her steps. Thought it was a sprain, and did not seek medical attention. Pain and swelling did not resolve; pain is worse, does not radiate; constantly present but worse with weight bearing; interferes with walking, and work; causes limping; OTC NSAIDs help; ⊘ ankle pain; 

Very active lifestyle;    

PMH: Noncontrubutory

Meds: ⊘

All: NKDA

E/O: A + O ✗ 3; NAD; ⊘ ill/toxic

VSSA

Rt foot: Swollen compare to the Lt side; mild bruising mid foot region; 5th metatarsal (MT) base tender to touch; MTP and ankle joints Ⓝ painless ROM; 

Neurovascular Ⓝ; ⊘ deformity;  

Gait: antalgic; 

Foot XR: proximal 5th MT # (Jones #)

Fig1⁽¹⁾

I/P: A 43 y/o lady in good health, and active lifestyle with Jones#. 

Pain management; non-weight bearing cast for 6-8wk. Outpatient F/U Ortho, next week. 

Discussion: 

Jones # is the fracture of the proximal 5th MT at the metaphyseal-diaphyseal junction(1.5cm distal to the tuberosity). Involves the 4th-5th MT joint. 

Fig.2⁽²⁾

Should not be confused with the avulsion # of the 5th MT styloid which is more common (90% of the cases). Other DDx include, stress #, and os peroneum. If acute (≺3mo)+minimal displacement conservative Rx. 

Recently more tendency in favour of early surgical management (earlier return to full weight bearing(wb) in 2-4wk)⁽³⁾. Non union is potential concern in conservative Rx. 

Stress # usually caused by overuse; more gradual onset of pain; may have Sx before +ve XR; distal to 4th-5th MT joint; more prone to nonunion. 

References: 

1. http://radiopaedia.org/cases/jones-fracture

2. http://radiopaedia.org/images/141041

3. Brukner, P., Brukner, P., D.R.C.O.G, & Khan, K. (2009). Clinical sports medicine. North Ryde, N.S.W: McGraw-Hill.

ABCD2 Score in TIA

ID: 83 y/o ♀, w/o significant medical comorbidities,  came in to the ER after experiencing an episode of double vision and imbalance. 

HPI: Sx started suddenly about 2hr ago while sitting. Double vision in all directions of gaze; imbalance associated with spinning sensation; able to walk without assistance but had imbalance; Sx lasted about 20-25min and gradually disappeared on the way to the ER. BP=202mmHg during that episode even though no Hx of HTN before. No subjective Sx in the ER. The episode was NOT associated with LOC, HA, N/V, slurred speech, unilateral weakness, facial asymmetry. 

PMH: MI 10y ago, no cardiac Sx now.

Meds: ASA 81mg/d, Atorvastatin 20mg/d

All: NKDA

E/O: A+O ✗ 3; NAD; ⊘ ill/toxic

BP Both arms(triage)=193/85

BP Both arms(now)=192/81

VS otherwise unremarkable. 

Neuro: 

Pupils 3mm symmetric; reactive; ⊘ RAPD;

CN II-XII normal;

Sensory/Motor normal; ⊘ pronator drift;

Cerebellar tests normal; Gait normal; Romberg -ve;

VA: 20/40 bilat; ⊘ ▵ compared to before the episode; Fundoscopy normal;

CVS, Resp, Abdo exams unremarkable. 

CBC, rapid metabolic panel, INR, were normal; 

ECG sinus @71 with normal axis and intervals, ⊘ ST-T ▵s;

Head CT nil acute. 

I/P: An 83y/o lady with a brief episode of diplopia and imbalance most probably caused by TIA with an ABCD2 Score of 3. BP 2hr after triage 135/73 w/o anti hypertensive meds. Low risk of progression to stroke in the next 48h. Reassurance; D/C home; F/U with neurology next day; F/U precautions.

Discussion: 


TIA ➜ 10-17% risk of stroke in the next 90d; 50% in the next 2/7; if survive this primary high risk period ➜ 43% 10yr risk of MI, stroke, or vascular death; 

We can use ABCD2 Score to estimate the risk of progression to stoke in patients presenting with TIA.

ABCD2 Score(1): 

A Age: 1=age >60 years,

B Blood pressure: 1=hypertension at the acute evaluation; either sBP>140 OR dBP>90 mmHg)

C Clinical features: 2=unilateral weakness, 1=speech disturbance without weakness

D Duration of symptom: 1=10–59 min, 2=>60 min

D Diabetes: 1=present

INTERPRETATION:

LOW RISK (scores 0–3)=risk of stroke 1.0% at 2

days. Does not need hospital admission, unless other indications, e.g. new onset aFib. 

MODERATE RISK (scores 4–5)=risk of stroke 4.1% at 2 days. Hospital observation justified in most situations.

HIGH RISK (scores 6–7)=risk of stroke 8.1% at 2 days. Hospital observation recommended.

Instead you can use the online free medical calculator, MD-Calc. You can find the link to its website on the “Useful Links” page of the blog. 

Reference: 

1. Hui, D., Leung, A. K. C., & Padwal, R. (2011). Approach to internal medicine: A resource book for clinical practice. New York: Springer. doi:10.1007/978-1-4419-6505-9
Kiefer, M., Chong, C., Pocket Primary Care, 2014