Dr CT LuiTMH A&EAug 2012

Case 1: complete hydatidiform mole Case 2: UGIB Case 3: PJP pneumonia Case 4: addisonian

crisis/hypothermia/hyperK Case 5: SAH

A 38-year-old lady, attended for vaginal bleeding with lower abdominal discomfort. On and off vomiting for recent 2-3 weeks

BP 130/85. P100. Temp 37oC Urine Preg test +ve

State 3 most common differential diagnoses Miscarriage

(threatened/inevitable/incomplete/missed) Ectopic pregnancy Molar pregnancy

What’s the single most useful investigation in ED? Ultrasound pelvis

(transvaginal/transabdominal)

Transabdominal USG pelvisLongitudinal view

• What’s the sonographic feature?– heterogeneous mass with numerous discrete anechoic spaces showing

“snowstorm pattern”– ± theca lutein cyst may be found in USG

• What’s the diagnosis?• Molar pregnancy, likely complete hydatidiform mole

• What are the associated clinical features/complications for the above named condition?

– Thyrotoxicosis– Larger than date uterus– Hyperemesis gravidarum– Early onset preeclampsia– Theca lutein cyst and cyst complications

• Label 2 important risk factors for the above condition– AMA (Advanced maternal age)– Previous GTD

• What’s the definitive management?– Suction currettage of uterus

• What need to be monitored after treatment and how?

– ß-hCG– Weekly until 3 consecutive normal

• If the monitoring showed plateau / risk in the marker, what’s the diganosis?

– Persistent trophoblastic disease• What’s the malignant form of the above

named condition and what’s the first line of treatment?

– Choriocarcinoma– Chemotherapy (e.g. methotrexate)

• A 50-year-old gentleman attended for vomiting with blood stained vomitus

• What relevant points in history taking?– Recent use of aspirin / NSAID– History of hepatic disease / portal

hypertension / known variceal diseases– Vomiting / alcohol binge– History of peptic ulcer diseases

• Do you know of any validated scoring system for risk stratification for the above condition?

Glasgow-Blatchford Bleeding Score (GBS) Low risk = Score of 0 Any score higher than

0 is "high risk" for needing a medical intervention of transfusion, endoscopy, or surgery.

Blood Urea

≥ 6·5 <8·0 2

≥ 8·0 <10·0 3

≥ 10·0 <25·0 4

≥ 25 6

Hemoglobin (g/L) for men

≥ 12.0 <13.0 1

≥ 10.0 <12.0 3

<10.0 6

Hemoglobin (g/L) for women

≥ 10.0 <12.0 1

<10.0 6

Systolic blood pressure (mm Hg)

100–109 1

90–99 2

<90 3

Pulse ≥100 (per min) 1

Presentation with melaena

1

Presentation with syncope

2

Hepatic disease 2

Cardiac failure 2

• The patient had history of alcoholic cirrhosis with previous endoscopic treatment for UGIB. What’s the most likely cause for the bleeding?– Variceal bleeding from esophageal varices

• What are the ED management?– NPO– IV fluid resuscitation– Blood taking for crossmatch– Consult surgeon for endoscopy

If you are in a rural hospital and the shortest time to the definitive treatment is 2 hours. Patient become hypotensive with BP 70/40, P130 despite supportive treatment. State 2 ED management. Insertion of sengstaken-blakemore

tube / Minnesota tube Octreotide / Terlipressin infusion

• List 3 treatment options for the above condition– Endoscopic banding or sclerotherapy– PTE (Percutaneous transhepatic

embolization) or Transjugular intrahepatic portosystemic shunt (TIPS)

– Surgery• Portosystemic shunt• Esophageal devascularization• Liver transplantation

• A 34 year old gentleman presented with fever, dyspnea and productive cough for 5 days. Progressive dyspnea in recent 1 day.

• BP 100/70, P120, temp 39.1C, RR30, SpO2 85% on RA

• State 3 important points in history taking– Past medical history / immunosuppression– TOCC (Travel history, occupation, cluster, contact)– Drug allergy

• What special aspect during resuscitation?– Infection control (negative pressure resuscitation

room, Personal protective equipment) and staff protection.

The patient had history of HIV infection on treatment.

CXR was taken

What’s the CXR finding? What’s the diagnosis? State 2 validated guidelines / scores for managing patients

with the above diagnosis for risk stratification. Is this typical or atypical type for this patient with the above

diagnosis? List 3 common corresponding microbes for both. What’s the most important microbe to be considered in this

patient? What’s the diagnostic modality for definitive diagnosis?

What’s the treatment? If the patient become abruptly dyspneic, list one possible

complication associated with the above diagnosis.

• What’s the CXR finding?– Bilateral lung field patchy infiltrate

• What’s the diagnosis?– Bilateral bronchopneumonia

• Do you know of any validated guidelines / scores for managing patients with the above diagnosis who could be managed outpatient?– CURB-65– Pneumonia Severity Index (PSI)

• Is this typical or atypical type for this patient with the above diagnosis?

– Atypical pneumonia– Typical: strep pneumoniae, haemophilus

influenzae , moraxella catarrhalis.– Atypical: legionella pneumophila,

mycoplasma pneumoniae, M TB, chlamydia pneumoniae, chlamydia psittaci

• What’s the most likely microbe to be considered in this patient?

– pneumocystis jiroveci

What’s the diagnostic modality for definitive diagnosis? What’s the treatment? Bronchoalveolar lavage (BAL) for PCP Septrin

If the patient become abruptly dyspneic, list one possible complication associated with the above diagnosis. Pneumothoraces (can be bilateral)

Symptom Points

Confusion 1

Urea>7mmol/l 1

Respiratory rate>30 1

SBP<90mmHg, DBP<60mmHg

1

Age>=65 1

The risk of death at 30 days increases as the score increases:0—0.6%1—3.2%2—13.0%3—17.0%4—41.5%5—57.0%

0-1 treat as an outpatient 2 consider a short stay in hospital or watch very closely as an outpatient 3-5 requires hospitalization

Step 1: Stratify to Risk Class I vs. Risk Classes II-VPresence of:

Over 50 years of age Yes/No

Altered mental status Yes/NoPulse ≥125/minute Yes/No

Respiratory rate >30/minute Yes/No

Systolic blood pressure <90 mm Hg Yes/No

Temperature <35°C or ≥40°C Yes/No

History of:

Neoplastic disease Yes/NoCongestive heart failure Yes/NoCerebrovascular disease Yes/No

Renal disease Yes/NoLiver disease Yes/No

If any "Yes", then proceed to Step 2

If all "No" then assign to Risk Class I

Step 2: Stratify to Risk Class II vs III vs IV vs V

Demographics Points AssignedIf Male +Age (yr)

If Female +Age (yr) - 10

Nursing home resident +10Comorbidity

Neoplastic disease +30Liver disease +20

Congestive heart failure +10

Cerebrovascular disease +10

Renal disease +10Physical Exam Findings

Altered mental status +20

Pulse ≥125/minute +20

Respiratory rate >30/minute +20

Systolic blood pressure <90 mm Hg +15

Temperature <35°C or ≥40°C +10Lab and Radiographic Findings

Arterial pH <7.35 +30

Blood urea nitrogen ≥30 mg/dl (9 mmol/liter) +20

Sodium <130 mmol/liter +20Glucose ≥250 mg/dl (14 mmol/liter) +10

Hematocrit <30% +10

Partial pressure of arterial O2 <60mmHg +10

Pleural effusion +10

∑ <70 = Risk Class II∑ 71-90 = Risk Class III∑ 91-130 = Risk Class IV∑ >130 = Risk Class V

Comparison of Typical and Interstitial (Atypical) Pneumonias

Feature Typical Pneumonia Interstitial (Atypical) Pneumonia

Onset Sudden Gradual Rigors Single chill “Chilliness” Facies “Toxic” Well

Cough Productive Nonproductive: paroxysmal

Sputum Purulent (bloody) Mucoid Temperature 103–104°F < 103°F Pleurisy Frequent Rare Consolidation Frequent Rare

Gram stain (sputum) Neutrophils Mononuclear cells

White blood cell count and differential count

> 15,000/mm3 with left shift > 15,000/mm3

Chest radiograph Defined density, lobar

pneumonia Nondefined infiltrate or interstitial

pneumonia

Most common cause Streptococcus pneumoniae Mycoplasma pneumoniae

Opportunistic pneumonia in HIV/AIDS or immunocompromised

Dx by induced sputum / BAL for immunofluorescent stain

PCP prophylaxis by septrin in susceptible host Tx

Septrin Pentamidine Trimethoprim-dapsone Clindamycin-primaquine

A 70-year-old gentleman was brought in by ambulance for “decreased general condition” for 2 days and noted hypothermia

BP 70/40. P45. Rectal temp 32C. RR 14. SpO2 96% on O2.

On examination, patient was cachexic, bradycardic and drowsy.

• State 3 relevant investigations in ED– Bedside glucose– ECG– CXR– POCT blood gas

• Bedside glucose was 2.5 mmol/l.• State 3 important aspects of treatment

at this moment– Fluid resuscitation for hypotension / shock– Glucose / dextrose replacement for

hypoglycemia– Rewarming for hypothermia

• What are the ECG findings?– Regular bradycardia– Wide complex– Tall T wave– No J wave

• What was the likely ECG diagnosis? What further investigation to confirm your diagnosis?– Hyperkalemia– POCT for blood gas and Na/K

If the investigation confirmed your ECG diagnosis, state 5 treatments.

Calcium gluconate Dextrose-insulin infusion NaHCO3 Nebulised ventolin K resins Dialysis

If the patient developed respiratory distress and he need to be intubated. What’s the major precaution?

Avoid succinylcholine/suxamethonium (contraindicated in hyperkalemia)

• What’s the methods of rewarming? State one example for each method– Passive

• Blanket– Active external – rewarming shock and

afterdrop• bair hugger (active rewarming blanket)

– Active internal• Warm saline infusion• Bladder lavage with warm saline• Esophageal, pleural, peritoneal

With the whole clinical picture, what is the provisional diagnosis? What investigation could be done to confirm the diagnosis? Addisonian crisis Spot corticol (Critical sample under

stress)

A 50 year old gentlemen presented for headache for 2 hours after coitus, with neck pain and vomiting for 5 times. Now become confused and drowsy.

BP 170/100. P60. Temp 37oC GCS E3V4M5 On neurological examination, noted

left lower limb paresis

What are the CT findings? Hyperdensity at bilateral sylvian fissure Hyperdensity at interhemispheric fissure Hyperdensity at bilateral cerebral sulci No dilated temporal horn / significant

hydrocephalus / IVH What’s the diagnosis?

Subarachnoid hemorrhage

If the initial CT was negative, state one investigation that can assist for diagnosis Lumbar puncture for CSF xanthochromia by

spectrophotometry Name 2 possible specific physical

examination findings Meningismus Retinal subhyaloid hemorrhage on

fundoscopy

State 3 common underlying cause for the above condition. What further investigation could delineate the etiology?

Ruptured saccular aneurysm of cerebral arteries Ruptured arteriovenous malformation of cerebral

vessels Perimesencephalic non-aneurysmal hemorrhage Others: traumatic, intracranial arterial dissection,

cocaine abuse, cerebral venous thrombosis, bleeding tendency/coagulopathy

Digital subtraction angiography (DSA) / CTA / MRA for the cerebral arteries

Name a clinical severity grading for the above diagnosis. What’s the implication with high clinical grading? What’s the grading for this patient?

Hunt and Hess grading (3) World Federation of Neurological Surgeons (WFNS) Grading

(4) Clinical outcome

Name a CT grading for the above diagnosis. What’s the implication with high CT grading? What’s the grading for this patient?

Fisher Scale (3) Claassen grading system (4) Symptomatic cerebral vasospasm

Grade Neurologic status

1Asymptomatic or mild headache and slight nuchal rigidity

2Severe headache, stiff neck, no neurologic deficit except cranial nerve palsy

3Drowsy or confused, mild focal neurologic deficit

4Stuporous, moderate or severe hemiparesis

5 Coma, decerebrate posturing

Hunt and Hess grading of SAH

The grade is advanced one level for the presence of serious systemic disease (hypertension, diabetes, severe arteriosclerosis, chronic pulmonary disease) or vasospasm on angiography

Grade GCS score Motor deficit

1 15 Absent

2 13 to 14 Absent

3 13 to 14 Present

4 7 to 12Present or absent

5 3 to 6Present or absent

World Federation of Neurological Surgeons (WFNS) Grading of SAH

Group

Appearance of blood on head CT scan

1 No blood detected

2 Diffuse deposition or thin layer with all vertical layers (in interhemispheric fissure, insular cistern, ambient cistern) less than 1 mm thick

3 Localized clot and/or vertical layers 1 mm or more in thickness

4 Intracerebral or intraventricular clot with diffuse or no subarachnoid blood

The Fisher Scale

Grade

Head CT criteria

1 No SAH or IVH

2 Minimal SAH and no IVH

3 Minimal SAH with bilateral IVH

4 Thick SAH (completely filling one or more cistern or fissure) without bilateral IVH

5 Thick SAH (completely filling one or more cistern or fissure) with bilateral IVH

Claassen grading system

What specific treatment could be considered for this patient with evidence of improved outcome? Nimodipine 60mg q4h PO/NG

State 5 possible acute complications Vasospasm and cerebral ischemia Rebleeding Obstructive hydrocephalus and increased

intracranial pressure Seizures Non-cardiogenic pulmonary edema Hyponatremia – hypothalamic injury: SIADH

and cerebral salt wasting Myocardial injuries