CME4Life Top 10 Case Studies - Can you solve them all?

Solution

A. Endocarditis

When looking at the patient with the lesions and fever the answer is endocarditis.

Duke’s criteria includes having two major symptoms, or one major and three minor symptoms or just five minor symptoms.

Major criteria can be the following; 2 positive blood cultures from 2 different sites or same site drawn 12 hours apart, endocardial involvement on echocardiogram, and/or new regurgitant murmur.

Minor criteria included predisposing heart condition or IV drug use, fever > 38°C (100.4°F), vascular phenomena (i.e.. cutaneous hemorrhages, aneurysm, systemic emboli, pulmonary infarction); immunologic phenomena (i.e. glomerulonephritis, Oslernodes, Roth spots, rheumatoid factor); positive blood culture or echocardiogram findings that do not meet major criteria. In this case, the patient has one major criteria (regurgitant murmur), and three minor criteria (fever, splinter hemorrhages, and Janeway lesions).

Solution

Great work on the 24 y.o.m with chest pain case! He was indeed a taller gentleman with a tension pneumothorax! As Mike Sharma PA-C (CME4Life Speaker) has pointed out, shock is the key difference between a simple pneumothorax and a tension pneumothorax. This patient needs a needle thoracostomy, followed by a chest tube.

So with this, let's talk about the procedures. What size and type of needle would you use and what would be the best place for the needle for decompression?

Then what is the procedure for placing the chest tube?

Mike Sharma PA-C: "He needs a big scary needle. 14g, 3.25" long. Primary site is the 2nd intercostal space (ICS) along the mid-clavicular line... draw an imaginary line down from the mid-point of the patient's collar bone down to the space between the 2nd and 3rd rib. Insert it perpendicular to the chest wall just superior to the rib to avoid neurovascular bundles that run along the inferior aspect of the rib. Things to consider: if the patient is very muscular or fluffy, you may need an even longer needle or you should consider an alternative insertion site in the 4th or 5th ICS along the the mid-axillary line... draw an imaginary line down from the mid-point of the patient's armpit down to the space between either the 4th and 5th rib or the 5th and 6th rib. This will buy the patient time until you can get a chest tube in. If there is a prolonged transport time or other prolonged time to chest tube, the patient may need the procedure repeated, as the hole often seals up even if you leave the angiocatheter in the chest wall. When we evacuated patients that we had decompressed, we would tape a couple of these needles to the patient's chest and tell the flight medic that if he starts decompensating in flight to consider decompressing him again. You can go right back into the same hole you made the first time."

Solution

This is a great place to use the "Who's Your PAPPA" pneumonic when thinking about his differentials to avoid missing the high risk causes of chest pain:

P - Pericarditis
A - ACS
P - PE
P - Pneumothorax
A - Aortic aneurysm

This is where history comes in. He states he has "a stent" and "heart disease". (Could be ACS) His chest pain "just bothers him" and it is localized to his right side. He denies falls or trauma, no cough, dyspnea or fever. (Could be Pneumothorax) He also has multiple sclerosis that is flaring up and he has been sitting more than normal. He is in fact he is now wheelchair bound for the past two weeks. His vital signs were all normal, including a oxygen saturation.

During his admission, he said, "Oh by the way, my leg hurts." And guess what he had? A DVT. But why did he have a DVT? Turns out he was newly immobilized due to his depression and his MS flare, which led to his DVT and his PE. Oh, and his D-Dimer was NEGATIVE. This case illustrates a few good points:

1. D - Dimers can be negative and patient can still have a PE/DVT.

2. When you find one abnormality, keep looking for more. You have heard the saying "What is the most commonly missed fracture? The second one, because after the first we stop looking. If you find a clot in the lung, look at the legs.

3. The s1q3t3 pattern can be a helpful tool if it is present. About 10% of patients will have it, and the lack of it will not mean they do not have a PE, but it can give you ammo to pull the trigger on the CT to look for it.