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

Presentation Tips!

All of us have been or will be involved in teaching, however, very few physicians are formally trained instructors. Here is the link to a keynote presentation in pdf format about the standard delivery of instruction. 

I hope it helps.

Family Medicine Morning Report Google Group

You can see a fantastic 3min TED Talk at the following link. 

How to tie your shoes!

CATCH Rule in Pediatric Head Trauma

ID: 10y/o boy; referred to EM from a walk-in clinic following a fall while playing with a friend in his PE class. 

HPI: Was dragged from behind while playing, fell on the ground, and  hit his head. 15min witnessed LOC. He remembers being assessed in the office at school. Mom was notified, and took him to a walk in clinic. After vomiting once in the walk-in clinic, was referred to the ER. Was seen in the ER approximately 4h after the incident. Vomited once again in triage. Generalized head ache(HA) which was getting better, no N/V, anterograde amnesia of about 15min. 

PMH: Previously healthy. 

Meds: Non

Allergies: NKDA

E/P: Drowsy, Oriented ✗ 3, Not in acute distress (NAD), 

VSSA

HEENT: 3 ✗ 3cm bruise on the Rt temple. No racoon or Battle's signs, No otorrhea/rhinorrhea/hemotympanum. Palpation of facial bones showed no #.

Neuro:  GCS 15

Pupils symmetric, reactive; No RAPD

CN II-XII normal; Motor/Sensory normal; Gail normal

MSK: Able to move limbs ✗ 4 w/o pain.

I/P: 11y/o boy with a minor head injury, does not meet CATCH criteria for CT head. Admit for a short period of observation. D/C with f/u precautions. F/U with GP in 1wk if residual sx. 

Discussion:

The length of observation in the ER probably depends on the reliability of the caregiver, and distance of their residence from the ER. 

The CT head rule does not apply to children. Instead the CATCH rule can be used for the paediatric population with mild head injury. You can also use PECARN algorithms(3) to decide whether or not a CT head is necessary.

Canadian Assessment of Tomography for Childhood Head injury: the CATCH rule

CT of the head is required only for children with minor head injury* and any one of the following findings(1):

High risk (need for neurologic intervention)

1. Glasgow Coma Scale score < 15 at two hours after injury 

2. Suspected open or depressed skull fracture

3. History of worsening headache

4. Irritability on examination

Medium risk (brain injury on CT scan)

5. Any sign of basal skull fracture(e.g.,hemotympanum, “raccoon” eyes, otorrhea or rhinorrhea of the cerebrospinal fluid, Battle’s sign)

6. Large,boggy hematoma of the scalp

7. Dangerous mechanism of injury(e.g.,motorvehiclecrash,

fall from elevation ≥ 3 ft [≥ 91 cm] or 5 stairs, fall from bicycle with no helmet)

*Minor head injury is defined as injury within the past 24 hours associated with witnessed loss of consciousness, definite amnesia, witnessed disorientation, persistent vomiting (more than one episode) or persistent irritability (in a child under two years of age) in a patient with a Glasgow Coma Scale score of 13–15.

Below is the Canadian CT Head rule for comparison. Keep in mind that CT Head Rule dose not apply in the following situations:

- Non-trauma cases

- GCS < 13

- Age < 16 years

- Coumadin or bleeding disorder

- Obvious open skull fracture

Canadian CT Head Rule(2): 

CT Head Rule: CT Head is only required for patients with minor head injuries

with any one of the following:

High risk (for neurological intervention)

● GCS score <15 at 2 h after injury

● Suspected open or depressed skull fracture

● Any sign of basal skull fracture (haemotympanum, ‘racoon’ eyes,

cerebrospinal fluid otorrhoea/rhinorrhoea, Battle’s sign)

● Vomiting two episodes

● Age 65 years

Medium risk (for brain injury on CT)

● Amnesia before impact >30 min

● Dangerous mechanism (pedestrian struck by motor vehicle,

occupant ejected from motor vehicle, fall from height >3 feet or five stairs)

Minor head injury is defined as witnessed loss of consciousness, definite amnesia, or witnessed disorientation in a patients with a GCS score of 13–15.

References:

1. Osmond, M., for the Pediatric Emergency Research Canada (PERC) Head Injury Study Group, Pediat Emergency Res Canada PERC H, & Pediatric Emergency Research Canada (PERC) Head Injury Study Group. (2010). CATCH: A clinical decision rule for the use of computed tomography in children with minor head injury. Cmaj, 182(4), 341-348. doi:10.1503/cmaj.091421

2. Stiell, I. G., Cass, D., Eisenhauer, M. E., Greenberg, G., Worthington, J., Wells, G. A., . . . CCC Study Grp. (2001). The canadian CT head rule for patients with minor head injury. Lancet, 357(9266), 1391-1396. doi:10.1016/S0140-6736(00)04561-X


3. Kuppermann, N., Borgialli, D. A., Badawy, M. K., Schunk, J. E., Quayle, K. S., Mahajan, P., . . . PECARN. (2009). Identification of children at very low risk of clinically-important brain injuries after head trauma: A prospective cohort study. Lancet, 374(9696), 1160-1170. doi:10.1016/S0140-6736(09)61558-0