MSO case discussion!

Discussion in 'Case Discussions' started by frootloop, Feb 15, 2017.

  1. frootloop

    frootloop Six years down, two to go Moderator

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    Ok, so I've got med school finals at the end of the year, so I need a semk-legitimate excuse for the amount of time I spend on here :p

    So, come up with clinical vignettes, and then ask everyone questions based on them.

    A few quick rules:

    - Don't post actual cases. But if you remove all identifiable information and modify enough aspects of the case that, it should be fine to loosely base scenarios on things you've actually seen.

    - For each scenario, make sure you post a question or two for preclinical students to answer as well. Just so we can get as many people as we can in on the discussion, and it can help the preclins tie what they're learning into clinical stuff.

    - Write your own cases. Don't just copy-paste out of textbooks or stuff your med school has given you or any other copyrighted material.

    - Underneath each of your questions, post your own replies in an offtopic box.

    - Try not to just google the answers. It's far more useful if we try and reason stuff out ourselves and then discuss it.

    - Finally, and this is aimed mostly at the schoolkids out there, I'll delete any trolling and s**tposts on this thread.

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  2. frootloop

    frootloop Six years down, two to go Moderator

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    I'm on orthopaedics at the moment, so we'll start with a straightforward one:

    (Nb, if anyone wants to critique how I write this up, please feel free. After a year out I've gotten a touch rusty in pretty much every area)

    A 68-year-old Caucasian female presents to the ED with severe (9/10) left ankle pain. She stood up from a seated position, and her foot slid out from underneath her, resulting in an audible 'crack' from her ankle. She has been brought in in a wheelchair, as she is unable to weight-bear on the left side.

    On inspection, the ankle and the dorsal aspect of the foot are severely swollen, but the foot is not grossly displaced. There are no lacerations or abrasions, and the colour and temperature of the left foot and ankle are normal. She has bimalleolar tenderness, but her foot and lower leg are non-tender. She is unable to actively perform any ankle or foot movements on the left side, and has lost sensation over the dorsum of the foot. She sustained no other injuries during her fall. She is otherwise well, and reported no abnormal symptoms prior to her fall. Her only significant history is of a radial fracture after a FOOSH 7/12 ago.

    X-rays reveal a trimalleolar fracture.

    1) List the bones and major ligaments involved in the ankle joint

    2) What are some possible complications to watch for following this type of injury, and how would you monitor these?

    3) What other injuries commonly co-occur with ankle injuries caused by rotational forces?

    4) Management plan and rationale. Go. Include in your answer why surgery is/isn't likely to be required for this type of injury.

    5) This is her second fracture in the past year. What are her risk factors for osteoporosis, and how (if at all) would you test her for it?

    6) Both of her recent fractures occured following falls. List 5 possible factors which may have contributed to these falls, keeping in mind her demographic factors and the mechanism of the fall given in the vignette. Outline how you would go about determining which (if any) may have been responsible, and how these could be managed going forward.

    I'm on my phone, so I can't be bothered typing out my answers. I'll edit them in later.
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  3. Benjamin

    Benjamin Intern (JCU MBBS) Administrator

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    Just quickly - instead of using my offtopic box I made (which has currently broken!) use the insert spoiler button. It's on the top of the text editor as what looks like a newspaper article (3 right from the smiley face button). Alternatively you can use the following BB code
    [SPOILER] Your hidden text here [/SPOILER]
    Here's a case from me, discuss at will/ask any question you want and I'll try get you an answer. My cases will all be aimed at ED presentations from initial work-up to referral/discharge because that's where I'm at currently.

    75+ year old male with sudden onset of continuous vertigo, nausea & diaphoresis at 0500hrs this AM which he still has when you see him in the ED at 0900hrs but resolves by 0930hrs. He describes his vertigo as being "unable to walk properly, like I had to hold onto things so I wouldn't fall over" but denies any weakness, sensation changes or speech disturbances. He has a significant past medical history of coronary artery bypass grafting (CABG) in 2012 & a transient ischaemic attack 6 months prior.

    He has had no chest pain or abdominal pain & is unable to give you a list of his regular medications other than to say he takes "one for fat in my blood, one for my blood pressure and one to keep my blood thin"

    His observations are as follows: HR 85 regular / BP 180/105 / RR 14 / SpO2 98% on RA / Afebrile

    What are your main differentials for this patient/what do you need to exclude?
    For most cases of vertigo & nausea the main differentials depend on whether the cause is peripheral or central - i.e. in the brain or outside the CNS.

    1. Posterior circulation cerebrovascular event given continuous nature of vertigo + past history of TIA 6/12 ago. A full cerebellar examination is vital in this case of vertigo.
    2. Myocardial ischaemia/infarct. Sudden onset of his symptoms + PMHx + diaphoresis make this potentially a silent MI with cerebral ischaemia. Excluded with investigations.
    4. Electrolyte or metabolic abnormalities - i.e. hypoglycaemia etc.
    5. Acute vestibular syndromes - vestibular neuritis, labyrinthitis etc. causing the vertigo would be peripheral causes. These would typically have a more gradual onset and be found on a HiNTs examination with abnormal head impulse/loss of vestibular-ocular reflex +/- horizontal nystagmus beating in one direction + no eye skew.
    6. Benign paroxysmal positional vertigo - only if the vertigo is intermittent and positional!
    What are you going to look for on examination or what other history would you like to exclude/include these differentials?
    There is a lot of history missing from this case but by far the most important is whether the vertigo is continuous or intermittent. A diagnosis of benign positional paroxysmal vertigo (BPPV) should NEVER be given to a patient that has vertigo persisting when their head is still or not worsened by changing position. BPPV is vertigo that worsens with head movement but settles when the head is not moving & eyes are closed. If the vertigo is continuous and not relieved by sitting still then a posterior CVA/stroke should be excluded. Thankfully this can be done with the HiNTS exam which is explained succintly by Scott Weingat here (originally from this paper) and a great review article on the topic is here. It wasn't until I actually read that paper that I realised you want an ABNORMAL head impulse test to exclude a posterior circulation stroke - i.e. an ABNORMAL head impulse test indicates the issue is within the vestibular nerve and not central in origin.

    In this case the patient had unrelenting vertigo even when laying still with their eyes closed. They also had a normal head impulse but direction changing nystagmus.

    This patient should have at least a full cardiac, abdominal & neurological examination + an ear examination. A summary of pertinent examination findings are below:

    HR 85 regular / BP 180/105 / RR 14 / SpO2 98% on RA / Afebrile

    Alert + oriented x 3, GCS 15.
    Laying comfortably in bed at 45 degrees, no obvious respiratory distress.
    No obvious pain or discomfort.

    Radial pulses regular + strong bilaterally. Capillary refill time <3 seconds
    No radial-radial, radial-femoral delay.
    BP 180/105 in both arms.

    Heart sounds S1 + S2, nil added.
    JVP not elevated

    Vesicular breath sounds throughout chest posteriorly. Percussion resonant throughout.
    Air entry R = L
    Chest expansion R = L

    Abdomen soft & non-tender throughout.
    No percussion or rebound tenderness.
    No palpable hepatosplenomegaly or masses.

    GCS 15, no gross neurological deficit.
    Cranial nerves II-XII intact. Visual acuity not formally assessed.
    Pupils equal & reactive to light & accomodation

    Tone normal & R = L
    Reflexes 1+, R = L & UL = LL
    Babinski normal. No clonus.
    Motor 5/5 in all movements
    Sensation grossly intact (formal sharp + light touch not conducted prior to imaging)

    Dysdiadokinesis evident with hand-to-hand.
    Heel-shin test normal. No ataxia, past pointing or intention tremor with finger-nose
    Rhombergs -ve. Gait normal.
    Head impulse normal. Direction changing nystagmus to both R & L. Eye skew normal.

    Tympanic membranes clear bilaterally, nil effusion or inflammation.
    Please interpret his ECG (attached at bottom). It is unchanged from a previous ECG in 2016.
    Bens case 1 ECG.jpg

    Use the following format:
    Axis: 1 +ve, AVF -ve: Left axis deviation
    Rate: ~85bpm
    Rhythm: 1st degree heart block
    P waves: normal p waves
    PR segment: prolonged (>0.2s/5 small squares)
    QRS waves: wide QRS waves (<0.12s/3 small squares) evident of left bundle branch block + ?RBBB given prolonged PR segment
    ST segment: difficult to interpret in view of heart block, correlate with previous ECG or use Modified Sgarbossa criteria
    T waves: nil significant abnormalities
    Other: nil
    Summary: LBBB with first degree heart block, though it could also be an incomplete trifasicular block (left anterior + left posterior + right bundle) given prolonged PR segment may represent a RBBB abnormality associated with the + LBBB pattern

    What other investigations would you like to order?

    Full blood count //
    Hb 97 w/ MCV 78
    WCC 8.2
    Plt 377

    CHEM20 //
    Electrolytes: Na 136 / K 4.8 / Cl 105 / Ca 2.10 (corr) / Mg 0.9 / BSL 6.2
    Renal: eGFR 47 w/ creat 110 & urea 10.8. Similar to previous Ix
    LFT's: All within normal limits
    Other: All within normal limits

    Initial Cardiac Troponin I (4hrs post onset of symptoms) //
    0.032 (ref: <0.04)

    Troponin in 2hrs time //
    0.036 (ref: <0.04)

    CHEST X RAY //

    CT Head non-contrast
    Please interpret the above ordered investigations.
    FBC - microcytic anaemia

    CHEM20 - Chronic kidney disease w/ eGFR ~50 on previous studies.

    Troponins - below the cut-off limit for normal (0.04), no evidence of acute myocardial injury.

    CT HEAD:
    No midline shift. No intracranial haemorrhages or masses.
    Periventricular ischaemia with deep white matter hypoattenuation/bilateral white matter hypodensity surrounding the ventricles.
    Correlated with previous films which appeared unchanged.
    Please summarise the case so far
    75+ year old male with vertigo, nausea & diaphoresis OBO CABG 2012 + TIA in 2016 + LBBB with 1st degree heart block. Significant neurological findings of dysdiadokinesia, normal head impulse & direction changing nystagmus suggesting possible posterior circulation ischaemia. Given the symptoms have currently resolved + appear central in origin this is considered a transient ischaemic attack and thus the ABCD2 score can be used to calculate their risk of a future CVA.

    The score can be calculated here, with this patient having a score of 4 for:
    • Age: >60 years old - 1
    • Blood pressure: >140/80 - 1
    • Clinical features other than speech disturbance or weakness - 0
    • Duration >60 minutes - 2
    This gives them a moderate risk of a CVA occurring in the next 2, 7 & 90 days with respective risks of 4.1, 5.9 & 9.8%. They should be referred to the neurology/medical team depending on how your hospital runs potential stroke referrals.


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    Last edited: Feb 16, 2017
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