Question: A 59-year-old man presents to the emergency department after a sudden onset of slurred speech and right upper extremity weakness. His symptoms lasted 20 minutes but by the time he arrived at the emergency department he was symptom-free. The patient denies any preceding symptoms. He has a history of diabetes, obesity, and hypertension but does not see a physician for his underlying conditions. His temperature is 99.2°F (37.3°C), blood pressure is 140/85 mmHg, pulse is 82/min, respirations are 16/min, and oxygen saturation is 100% on room air. Physical exam reveals normal vision, strength, and sensation with a stable gait. Finger-nose testing and tandem gait are unremarkable. A CT scan of the head is performed and is unremarkable. Which of the following is the most appropriate next step in management?

Answer: Aspirin

Explanation:
This patient is presenting with a transient episode of neurologic dysfunction (slurred speech and right upper extremity weakness) that has completely resolved, which is concerning for a transient ischemic attack. In the setting of his normal head CT, aspirin should be administered next.

A transient ischemic attack (TIA) is a brief episode of focal neurologic dysfunction that completely resolves without any residual deficits. Patients with a TIA are at high risk for future TIAs and stroke. For this reason, management is immediately centered on a thorough neurological exam followed by a CT scan of the head to rule out a hemorrhage. Subsequently, aspirin should immediately be administered which reduces the incidence of future stroke. Patients will subsequently be discharged on aspirin in addition to other morbidity-lowering agents including a statin and tight blood pressure and glycemic control as well as a second antiplatelet agent in appropriate patients. Further workup for a TIA may include a CTA head/neck, an MRI brain, and an echocardiogram. Modification of risk factors is also critical in these patients including weight loss, smoking cessation, exercise, glycemic control, and blood pressure control.

Clissold et al. review transient ischemic attacks. They note that transient ischemic attacks (TIA), if untreated, carry a high risk of early subsequent stroke. They recommend, after appropriate diagnostic workup, early administration of an antiplatelet agent.

Incorrect Answers:
Answer B: Atorvastatin is an important initial intervention in the management of patients who have TIA/stroke. However, this intervention takes weeks of consistent therapy in order to have a significant effect on morbidity, thus it would not be the most important next step in management when compared to aspirin, which is more important in reducing acute stroke risk. Further, a lipid panel is generally performed first to determine if a statin is needed.

Answer C: CTA head/neck is a part of the workup of a TIA to rule out carotid stenosis/dissection/atherosclerosis as the cause of the patient's symptoms. It is more important to give aspirin early in TIA/stroke prior to obtaining further imaging (though this study would still be performed).

Answer D: Labetalol and other blood pressure medications are important in risk factor modification to prevent future strokes/TIAs. Patients with diabetic nephropathy should be on an ACE inhibitor or angiotensin-receptor blocker which are nephroprotective. Of note, his blood pressure currently is not very elevated nor is it causing end-organ dysfunction.

Answer E: MRI brain should be performed to further characterize whether there was any ischemic injury to the brain; however, this usually will occur after a CTA head/neck and certainly after the patient receives an aspirin. It can more accurately characterize if a stroke occurred, and the extent of the injury.

Bullet Summary:
The workup of a transient ischemic attack should be centered on a thorough neurological exam, a non-contrast CT scan of the head, and administration of aspirin assuming there is no intracranial bleed.


Question: A 67-year-old woman presents from a nursing home with altered mental status. She was last known to be normal the night before. The patient has dementia at baseline and is minimally interactive. This morning, she was found to be obtunded. No further history was provided from the nursing home, and the patient is unable to provide any history. Her temperature is 95.0°F (35.0°C), blood pressure is 84/54 mmHg, pulse is 50/min, respirations are 9/min, and oxygen saturation is 98% on room air. Physical exam reveals an obtunded woman who only withdraws her extremities to pain. Her skin is cool and pale, and her hair is thin. There are no signs of trauma noted on exam. Laboratory values are notable for a whole blood sodium of 120 mEq/L. The patient is given several intravenous boluses of fluids and her blood pressure improves to 100/60 mmHg. Which of the following is most likely to confirm the underlying cause of this patient's symptoms?

Answer: Check serum TSH and free T4 levels

Explanation:
This patient is presenting with obtundation, bradycardia, hypotension, hypothermia, thinning of her hair, and hyponatremia, which are concerning for myxedema coma. A serum TSH and free T4 would be most informative in confirming this diagnosis.

Myxedema coma (decompensated hypothyroidism) is the most life-threatening manifestation of hypothyroidism. Key clinical features include hypothermia (often the temperature is <95.9°F (35.5°C)), bradycardia, hypotension, bradypnea (causing a respiratory acidosis), hypoxia, and obtundation. Immediate management is centered on warming the patient, warmed IV fluids, and protecting the patient's airway, if needed. If there is high clinical suspicion for myxedema coma, then IV levothyroxine can be given empirically. Otherwise, the TSH and free T4 should be checked, which will reveal an elevated TSH and a low free T4. Patients are often critically ill and require active rewarming and close monitoring in an ICU setting.

Wall reviews myxedema coma. Wall notes that myxedema coma is a life-threatening manifestation of hypothyroidism. She recommends that generally IV T4 (levothyroxine) is preferred over IV T3 in initial management.

Incorrect Answers:
Answer A: Administering glucagon would be appropriate in a beta-blocker overdose, which presents with bradycardia, hypotension, and altered mental status. There is no indication that this patient intentionally overdosed, and her hyponatremia and thinning hair supports a diagnosis of hypothyroidism. Other treatments that can be given in a beta-blocker overdose including epinephrine, calcium, insulin, dextrose, and lipid emulsion therapy.

Answer C: Obtaining blood cultures and a serum lactate is the appropriate management of sepsis/septic shock. Generally, patients with septic shock present with hypotension (refractory to fluid resuscitation), tachycardia, and fever or hypothermia. Though myocardial depression may happen in critically ill patients who are about to undergo cardiac arrest, hypothyroidism better explains this patient's constellation of symptoms. It would be appropriate to obtain cultures and a serum lactate in this patient while the differential is being narrowed.

Answer D: Performing a CT scan of the head would be indicated at some point in the workup of patients with altered mental status if there was a suspected central nervous system etiology such as a subdural hematoma. However, hemodynamically unstable patients should never be sent to the CT scanner prior to stabilization and resuscitation. A subdural hematoma is more common in older patients and patients with alcohol use disorder who experience head trauma as the atrophy of their brain makes the bridging veins more vulnerable.

Answer E: Performing an echocardiogram may show reduced cardiac function; however, it is unlikely to reveal the underlying cause of this patient's hypotension and bradycardia other than showing poor cardiac function.

Bullet Summary:
Myxedema coma presents as a critically ill, obtunded patient who is hypothermic, bradycardic, and hypotensive, and the diagnosis can be supported with a high TSH and a low free T4.


Question: A 55-year-old man presents to the emergency department with epistaxis for the past hour. He has never had epistaxis before and has been unable to control it with pressure, head elevation, and ice. The patient has a past medical history of atrial fibrillation and is currently taking metoprolol and warfarin. His temperature is 98.5°F (36.9°C), blood pressure is 123/81 mmHg, pulse is 90/min, respirations are 13/min, and oxygen saturation is 97% on room air. Physical exam reveals a comfortable man in no distress. Inspection reveals active bleeding in the anterior nares. There is not a clear, single bleeding vessel. Which of the following is the most appropriate initial step in management?

Answer: Topical oxymetazoline

Explanation:
This patient on warfarin is presenting with epistaxis from the anterior nares (and is currently hemodynamically stable) suggesting anterior epistaxis. Prior to more invasive measures, topical therapy with oxymetazoline should be tried as it is very successful in reducing or resolving epistaxis.

Epistaxis can be a benign or life-threatening presentation. For anterior epistaxis, the management is centered on compression of the anterior nares as most cases are caused by bleeding from Kiesselbach plexus. If this fails, the next step in management is having the patient blow their nose to remove any clots, followed by vigorous application of topical oxymetazoline which vasoconstricts the vessels in the nares and is highly effective in treating epistaxis. If this fails, other topical agents include topical tranexamic acid, and thrombogenic foams. If pressure and topical therapy fail to resolve epistaxis, then anterior nasal packing (such as nasal tampons) may be used.

Kucik and Clenney review treatments for epistaxis. They note that the first-line treatment of anterior epistaxis is compression of the anterior nares. If this fails, they recommend other measures such as topical vasoconstrictors, cautery, and packing.

Incorrect Answers:
Answer A: Cauterization with silver nitrate is appropriate for anterior epistaxis, but generally should be reserved for patients who have failed initial medical therapy with topical agents. It may also be appropriate first-line therapy in patients with recurrent epistaxis from a clear, single bleeding vessel (which is not present in this patient).

Answer B: Fresh frozen plasma and intravenous phytonadione is the appropriate reversal agent for warfarin. While this may stop the patient's epistaxis, he is hemodynamically stable and the bleeding is not life-threatening; thus, the risk of thrombus from atrial fibrillation is likely greater than the risk of bleeding in this case of epistaxis. Less invasive medical therapy should be started/tried first.

Answer C: Intravenous tranexamic acid would be appropriate in an acutely hemorrhaging patient to reduce bleeding in the setting of hemorrhagic shock. Topical (not intravenous) tranexamic acid may be an appropriate first-line agent for anterior epistaxis.

Answer D: Placement of posterior nasal packing would be indicated if there was persistent bleeding in the setting of posterior epistaxis (often from bleeding from the sphenopalatine artery), which presents with more profuse bleeding that may threaten the airway. This patient's bleeding is clearly anterior as it can easily be visualized in the anterior nares; thus, this intervention is not needed.

Bullet Summary:
Topical oxymetazoline and other topical agents such as tranexamic acid are appropriate first-line agents in the management of epistaxis if pressure alone fails to resolve symptoms.


Question: A 67-year-old man presents with a recurrent episode of syncope. He states that this has happened to him multiple times, particularly when he changes body position from sitting to standing, exerts himself, or turns his head quickly. He says that he notes numbness, vertigo, and sometimes even trouble with speaking immediately prior to fainting. The episodes usually last 1-5 minutes. When he wakes up, he is mildly confused but typically returns to baseline within a minute. The patient has a past medical history of diabetes, dyslipidemia, and hypertension. His temperature is 98.5°F (36.9°C), blood pressure is 153/89 mmHg, pulse is 90/min, respirations are 11/min, and oxygen saturation is 97% on room air. The patient's neurological exam is unremarkable. However, when he is asked to stand up and start walking, he experiences the same numbness and tingling and feels like he may faint. Which of the following is the most likely diagnosis?

Answer: Blood vessel narrowing

Explanation:
This elderly patient with risk factors for vascular disease (diabetes, dyslipidemia, hypertension) is presenting with episodes of dizziness, vertigo, numbness/tingling, dysarthria, and syncope, which seem to be provoked by standing rapidly and changing head position. This is concerning for vertebrobasilar syndrome, caused by blood vessel narrowing.

Vertebrobasilar syndrome is caused by narrowing (via causes such as atherosclerosis, dissection, or congenital narrowing among others) of the vertebrobasilar vascular system. It is a common cause of syncope that may be worsened by changes in head position or standing rapidly. Other unique features include numbness/tingling, a sensation of vertigo, nausea, vomiting, dysphagia, and dysarthria. Note the episodes of syncope in this condition are intermittent and specifically provoked and do not have lasting/permanent neurological deficits in contrast to a stroke. Management is first centered on vascular imaging which may include a CTA head/neck or an MRA head/neck. Further care depends on the symptoms present but typically involves smoking cessation, glycemic control, blood pressure control, aspirin, and a statin.

Xuan-Ting et al. review posterior circulation strokes which occur more frequently in patients with atherosclerosis of the vertebrobasilar system. They note that MRI is one of the most accurate tests for assessing posterior circulation strokes which may present with dizziness and syncope. It is far superior to CT imaging. For this reason, they recommend that CT imaging alone cannot definitively rule out a posterior circulation stroke.

Incorrect Answers:
Answer B: Cardiac dysrhythmias such as ventricular tachycardia can cause sudden onset and offset syncope without prodromal symptoms. The differentiating feature of this form of syncope is the rapid onset and offset in a high-risk patient. The diagnosis can be confirmed with an ECG; however, many patients will require prolonged observation on telemetry.

Answer C: Seizure presents with impaired consciousness, tonic-clonic activity, and a post-ictal state which gradually improves over hours. The lactate may be elevated after a seizure, and the prolactin level is a more specific indicator of a seizure. However, the diagnosis is most appropriately made based on history, exam, and EEG.

Answer D: Stroke involving the vertebrobasilar system may cause syncope in addition to ongoing dizziness and vertigo with ataxia. However, this patient's symptoms seem to be positional and have entirely resolved; thus, a stroke is unlikely. He is at higher risk of stroke given his vertebrobasilar insufficiency and an MRI should still be performed in this patient.

Answer E: Vagal event presents with a warm prodrome with palpitations, flushing, and syncope. Muscle twitching (but no tonic-clonic activity) may be seen. Patients may wake up slightly confused but return to baseline within seconds.

Bullet Summary:
Vertebrobasilar insufficiency may present with positional episodes of syncope caused by insufficient blood flow through the vertebrobasilar blood vessels.


Question: A 65-year-old man presents to the emergency department with sudden-onset altered mental status. He was last seen normal 1 hour ago. His wife noticed that he was confused, slurring his speech, and had notable weakness that caused him to drop his cup of coffee. The patient is confused and not able to answer any questions. Facial drooping of the left lower face is noted, and the patient cannot follow any commands. He has a past medical history of diabetes and atrial fibrillation and is currently taking warfarin. His other medications are not known. His temperature is 98.0°F (36.7°C), blood pressure is 150/90 mmHg, pulse is 115/min, and respirations are 17/min. The patient is not able to follow any commands for further neurologic evaluation but does not appear to be moving his right upper extremity. In addition to further physical exam, which of the following is the most appropriate next step in management?

Answer: Fingerstick blood glucose

Explanation:
This patient is presenting with sudden onset confusion, slurred speech, asymmetric smile, and weakness in the setting of risk factors for stroke (atrial fibrillation, diabetes, and hypertension). The most important initial step in management in a patient with altered mental status and neurological deficits is to obtain a fingerstick blood glucose.

The workup of stroke is first centered on a thorough history and physical and immediately calculating an NIH stroke scale (11-domain assessment of stroke severity involving patient consciousness level, orientation, ability to follow commands, degree of gaze palsy, degree of vision loss, ataxia, motor drift, sensation, inattention, language/speech) as well as ascertaining when the patient was last known to be neurologically normal. While performing the exam and NIH stroke scale, a fingerstick blood glucose should be performed in all patients as hypoglycemia may present identically to a stroke. Severe hypoglycemia may present with lethargy, confusion, focal or global weakness, nausea, vomiting, agitation, and even seizures. If the patient is hypoglycemic, dextrose can be given which will rapidly correct the patient's underlying deficits.

Ohshita et al. review other possible causes of stroke-like symptoms. They note that hypoglycemia may mimic stroke and cause focal neurological signs with common findings being unilateral motor weakness with mild or moderate alteration of consciousness. They noted that all patients improved within 1 hour of glucose injection in this study, thus the recommendation to check a fingerstick blood glucose in all stroke patients.

Incorrect Answers:
Answer A: Alteplase would be indicated if a patient presented with disabling neurologic deficits from an ischemic stroke within 4.5 hours of symptom onset only after a CT scan of the head has ruled out an intracranial bleed. The patient must have no other contraindications to thrombolytics including but not limited to recent trauma, known intracranial hemorrhage, rapidly improving neurologic deficits (spontaneously), and no other clear reversible cause (among many other contraindications).

Answer B: CT head is the most appropriate initial step in the management of an acute stroke; however, a rapid fingerstick blood glucose takes precedence as hypoglycemia can mimic a stroke and be immediately addressed thus removing the need for further workup if there is a complete resolution of symptoms with normoglycemia. While an exam is ongoing, a fingerstick blood glucose is being obtained, and neuroimaging is also often ordered to be performed immediately after.

Answer D: Fresh frozen plasma and vitamin K would be indicated in this patient if he had a hemorrhagic stroke (a CT of the head would need to confirm this) to reverse his anticoagulation with warfarin. Factor concentrate can also be used to rapidly reverse anticoagulation with warfarin.

Answer E: MRI brain would be indicated in the workup of a stroke or transient ischemic attack after all emergency interventions and labs including CT head, serum chemistries, CBC, and ECG. It delineates the extent of the stroke and gives useful prognostic and diagnostic information. It also may elucidate strokes missed on other forms of neuroimaging such as CT perfusion.

Bullet Summary:
A fingerstick blood glucose should be obtained immediately in all patients with stroke-like symptoms or altered mental status.


Question: A 66-year-old man presents to the clinic with a 6-week history of bloody stools. He describes the blood as bright red wisps that float on the surface of the stool. He has no pain with bowel movements but notes on occasion he may strain. He does not endorse fatigue, fever, constipation, diarrhea, nausea, vomiting, abdominal pain, weight loss, or dyspnea. His last colonoscopy was 3 years prior to presentation and was benign. He has a medical history significant for hypertension that is well-controlled with lisinopril. He had an uncomplicated appendectomy when he was 23 years old. He has no family history of gastrointestinal malignancy. His temperature is 98.6°F (37.0°C), blood pressure is 140/90 mmHg, pulse is 76/min, and respirations are 16/min. On physical exam, the patient's abdomen is soft, non-distended, and non-tender with normal bowel sounds and without organomegaly or masses. The anus is patent without fissures, hemorrhoids, or skin tags. Which of the following is the most appropriate next step in management?

Answer: Colonoscopy

Explanation:
This patient is presenting with painless bright red blood per rectum. Because he is over 50 years old and having rectal bleeding, he should be evaluated for malignancy with a colonoscopy.

Bright red blood per rectum has a broad differential diagnosis including anal fissures, hemorrhoids, angiodysplasia, inflammatory bowel disease, diverticular bleed, infection, polyps, and colon cancer. However, as patients age, their risk for malignancy increases significantly. Therefore, stable patients older than 50 years of age with rectal bleeding, regardless of their symptoms or family history, should receive a colonoscopy to rule out malignancy. Patients younger than 50 with warning signs of colon cancer (abnormal bowel habits, weight loss, family history of colon cancer, iron deficiency anemia) should also be evaluated with a colonoscopy. Often, colonoscopy is performed routinely at the age of 50 or 10 years prior to the age of presentation for malignancy in family members (whichever is sooner). Of note, even if there is an apparent cause for a lower GI bleed in patients 50 or older (such as hemorrhoids) colonoscopy is still indicated to rule out malignancy.

Barry et al. note the guidelines for colon cancer screening. They note the different age cutoffs. The USPSTF recommends screening for colorectal cancer in all adults aged 50-75 years.

Incorrect Answers:
Answer B: Computerized tomography scan of the abdomen and pelvis is incorrect because colonoscopy is the gold standard for diagnosis of suspected colon cancer. A CT scan may detect larger masses and a CTA may be performed if there is active bleeding and concern for an arterial source of bleeding that can be intervened upon.

Answer C: Increasing fiber in the diet may help patients with constipation or hemorrhoidal bleeding. Constipation presents with straining to have bowel movements and hard stools. However, because of this patient's age, he needs a colonoscopy to rule out malignancy.

Answer D: Observation is not appropriate at this patient's age. Patients greater than 50 years old with bright red blood per rectum should receive a colonoscopy to rule out malignancy despite any recent negative colonoscopy results.

Answer E: Sigmoidoscopy is less preferred to colonoscopy, as a smaller portion of the colon would be visualized, and colonic polyps or malignancies may be missed. For this reason, it is not the preferred study in this patient.

Bullet Summary:
Patients with bright red bleeding per rectum over 50 years old or with warning signs of colonic malignancy (weight loss, abnormal bowel habits, positive family history, or anemia) should receive a colonoscopy.


Question: A 55-year-old man presents to the emergency department with chest pressure and diaphoresis. His symptoms started at work when he was lifting boxes. He states that he currently feels crushing pressure over his chest. He is given aspirin and an ECG is performed in triage, as seen in Figure A. His past medical history is notable for diabetes and obesity. He has smoked 1 pack of cigarettes per day for the past 30 years. His temperature is 97.9°F (36.6°C), blood pressure is 155/99 mmHg, pulse is 110/min, respirations are 22/min, and oxygen saturation is 98% on room air. Physical exam reveals an uncomfortable, diaphoretic man. His heart and breath sounds are unremarkable. A repeat ECG in the emergency department is performed, also seen in Figure A. The patient’s chest pain is worse when the ECG in the emergency department is taken, compared to the one taken in triage. He is given nitroglycerin, with minimal improvement in his symptoms. A troponin level is drawn. Which of the following is the most appropriate next step in management?

Answer: Repeat ECG in 10 minutes

Explanation:
This patient is presenting with a pattern of chest pain (pressure and diaphoresis) that is highly concerning for an acute myocardial infarction. This patient initially has ST depressions (in triage) followed by ST segment normalization and possibly hyperacute T waves which raises concern for an acute ST elevation myocardial infarction (STEMI) requiring frequent ECGs to determine if a STEMI evolves.

A STEMI presents with crushing substernal chest pain, diaphoresis, chest pressure, nausea, vomiting, and abdominal pain among many other possible presentations. When a patient presents with symptoms concerning for a STEMI, aspirin should be administered and an ECG should be performed. Early in a myocardial infarction, ST depressions with hyperacute T waves may be present. As the infarction evolves, the T waves may become more acute and the ST segment will begin to elevate. There may be a brief period of pseudonormalization where the ST segment appears to be normal. If the patient appears better, this can be reassuring. However, ongoing chest pain in the setting of these findings raises concern for pseudonormalization of the ST segment (an ST segment that is going to continue to rise). Nitroglycerin can be administered to see if the patient can become chest pain-free, and serial ECGs should be performed to determine if a STEMI is present. If symptoms resolve and the ECG is stable, this is reassuring and medical optimization and an elective catheterization may be performed. If the ECG evolves into a STEMI, then cardiac catheterization is indicated emergently.

Daga et al. discuss STEMI and its workup. They note the ECG manifestations, and the pathophysiology in addition to the appropriate workup of acute coronary syndrome. They recommend aspirin and catheterization in an acute STEMI.

Figure/Illustration A demonstrates an initial ECG with ST depression (blue arrows) followed by pseudonormalization of the ST segment (green arrows) and possibly hyperacute T waves (black arrows), which are concerning for ischemia.

Incorrect Answers:
Answer A: Cardiac catheterization may be required in this patient; however, if the patient’s chest pain improves or if the troponin is negative, it is unlikely he is having an acute myocardial infarction requiring immediate catheterization. Repeating the ECG will allow for triaging of the patient and will aid in determining if emergency cardiac catheterization is needed.

Answer B: Chest radiography is appropriate in the workup of chest pain as it can rule out diagnoses such as pneumothorax or may suggest diagnoses such as an aortic dissection (type A) if there is a widened mediastinum. In this patient, the ST segment changes and characteristic history make acute coronary syndrome a more likely diagnosis, and while a chest radiograph should be performed at some point, repeating the ECG is a more dire initial step in management.

Answer C: CK-MB level could be helpful in determining if a myocardial infarction has occurred as it elevates rapidly and also decreases fairly rapidly. This makes it useful when diagnosing a new myocardial infarction after a recent infarction as the troponin may still be elevated from the previous infarction. This patient has no history of recent myocardial infarction, and a repeat ECG is more dire to determine if this patient needs emergent intervention. Of note, the decision for emergent catheterization should not wait on cardiac biomarkers.

Answer D: Heparin should not be given empirically to patients in chest pain. It does not necessarily decrease mortality but does increase the risk of bleeding. It is often given to patients with an NSTEMI.

Bullet Summary:
Pseudonormalization occurs when an ST depression begins to elevate and appears normal in the setting of a myocardial infarction, requiring close monitoring and serial ECGs to ensure that a ST elevation myocardial infarction does not occur.


Question:
A 72-year-old man presents to his primary care physician for a general checkup. He states that he has been a bit more fatigued lately but believes it is secondary to poor sleep at his new house. The patient is otherwise healthy and takes no medications. His temperature is 98.0°F (36.7°C), blood pressure is 141/90 mmHg, pulse is 82/min, respirations are 16/min, and oxygen saturation is 98% on room air. Physical exam is notable only for minor pallor but is otherwise unremarkable. Basic laboratory studies are ordered as seen below.

Hemoglobin: 10 g/dL
Hematocrit: 30%
Leukocyte count: 67,500/mm^3
Platelet count: 119,000/mm^3

Serum:
Na: 141 mEq/L
Cl: 103 mEq/L
K: 4.0 Eq/L
HCO3-: 24 mEq/L
BUN: 22 mg/dL
Glucose: 109 mg/dL
Creatinine: 1.2 mg/dL
Ca: 10.0 mg/dL

Which of the following is the most likely diagnosis?

Answer: Chronic lymphocytic leukemia

Explanation:
This elderly patient is presenting with minor fatigue, anemia, thrombocytopenia, and a leukocyte count >50,000/mm^3, which is most likely caused by chronic lymphocytic leukemia (CLL).

CLL is a monoclonal proliferation of incompetent mature B-cells. It is common in elderly men and is the most common form of leukemia in the United States. Patients are often asymptomatic when the diagnosis is made or may present with vague constitutional symptoms including fatigue, malaise, and weight loss. It is important to note that symptoms may be subtle or absent. Other findings include non-tender lymphadenopathy and splenomegaly. The diagnosis is supported when the white blood cell count is >50,000/mm^3 and can be supported with a peripheral smear which will show smudge cells. The cells in CLL may be CD5, CD20, and CD23 positive. The most common cause of death in this population is infection given the lack of competent B-cells.

Hallek reviews CLL. They discuss updated guidelines on the diagnosis and management of CLL. They recommend the use of targeted agents in initial therapy and acknowledge the need for further clinical trials to guide therapy.

Incorrect Answers:
Answer A: Acute lymphoblastic leukemia (ALL) is a common malignancy seen in children and presents with pancytopenia, anemia, fatigue, leukopenia (leading to recurrent infections), and thrombocytopenia (leading to bleeding). Other findings may include fever, bone pain, lymphadenopathy, splenomegaly, and hepatomegaly. Translocations in ALL include: t(12:21) which is the most common and denotes a favorable prognosis and t(9:22) (the Philadelphia chromosome) which is less common and denotes a poor prognosis

Answer B: Acute myelogenous leukemia occurs secondary to the proliferation of myeloblasts and presents in older patients. Patients will present with fatigue, malaise, weight loss, anorexia, fever, leukocytosis, anemia, thrombocytopenia, and neutropenia. Auer rods are frequently present on a blood smear.

Answer D: Chronic myelogenous leukemia is a neoplastic proliferation of myeloid stem cells and presents with a leukocyte count often >50,000/mm3. The increased myeloid lines include red blood cells, granulocytes, monocytes, and platelets. Many patients present in the chronic phase with minimal symptoms; however, the blast phase can lead to a hematologic emergency termed a blast crisis which may cause a hyperviscosity syndrome. This condition is more symptomatic and less common than CLL.

Answer E: Hairy cell leukemia occurs when there is a neoplastic proliferation of mature B cells with abundant cytoplasm with “hairy” cytoplasmic processes. The cells are tartrate-resistant acid phosphatase positive. Patients will present with splenomegaly, pancytopenia, weakness, and fatigue. This is a more rare diagnosis when compared to CLL.

Bullet Summary:
Chronic lymphocytic leukemia (CLL) presents in elderly patients with malaise, fatigue, and other nonspecific signs (but can also be asymptomatic), with anemia, thrombocytopenia, and a white blood cell count often >50,000/mm^3.


Question:
A 75-year-old man presents to the emergency department with fatigue. He has had severe nausea, vomiting, and diarrhea for the past 3 days. Today, his wife noticed that he was confused. The patient has a history of coronary artery disease with a drug-eluting stent placed 1 year ago, obesity, hypertension, and dyslipidemia. He denies chest pain or dyspnea, but complains of diffuse abdominal pain. His temperature is 99.0°F (37.2°C), blood pressure is 100/60 mmHg, pulse is 105/min, and respirations are 22/min. Physical exam reveals a confused man with dry mucous membranes. His abdomen is diffusely tender to palpation. Laboratory studies are ordered and notable for the following:

Serum:
Na+: 147 mEq/L
Cl-: 112 mEq/L
K+: 3.5 mEq/L
HCO3-: 14 mEq/L
BUN: 80 mg/dL
Glucose: 100 mg/dL
Creatinine: 2.1 mg/dL
Troponin: 0.10 mcg/L (normal < 0.01 mcg/L)

An ECG is ordered and is pending. Which of the following is the most appropriate management of this patient's elevated troponin?

Obtain a urinalysis and creatine phosphokinase level

Answer: Ringer lactate bolus

Explanation:
This patient with likely gastroenteritis (given his nausea, vomiting, and diarrhea) is dehydrated, as indicated by his low blood pressure, tachycardia, dry mucous membranes, and prerenal kidney injury (elevated BUN and creatinine with BUN:creatinine ratio > 20:1) in the setting of an anion gap (anion gap = [Na+] - [Cl-] - [HCO3-] = 147 - 112 - 14 = 21). His elevated troponin is likely secondary to poor renal clearance and dehydration, which is most appropriately addressed with IV fluids such as Ringer lactate.

Troponin is a lab marker classically thought to be elevated when there is an injury to the heart causing leakage of this enzyme from the cardiac myocyte. However, there are many possible causes of an elevated troponin that may not be directly cardiac in nature or related to myocardial ischemia. Acute kidney injury is a common cause of an elevated troponin. For this reason, patients with an elevated troponin with kidney dysfunction without any cardiac symptoms or ECG changes should have their renal etiology addressed, and this will often clear the troponin. In the setting of a prerenal injury (dehydration causing poor kidney perfusion and a BUN:creatinine ratio > 20:1), IV fluids will restore perfusion and treat the underlying cause. Patients with chronic kidney disease or kidney failure should have an ECG obtained and their current troponin should be compared to previous troponin levels to ensure it is not higher than their baseline. If there is uncertainty regarding a troponin level, it can be trended to see if it is rising, falling, or staying the same. Correlation with clinical symptoms is important when evaluating an elevated troponin level.

Masri et al. review the causes of an elevated troponin. They note that a troponin elevation can be seen in myopericarditis, renal failure, heart failure, pulmonary embolism, septic shock, rhabdomyolysis, stroke, and many other possible causes that are not related to myocardial infarction. They recommend keeping a broad differential and correlating the troponin with the patient's clinical presentation.

Incorrect Answers:
Answer A: Aspirin would be appropriate management of an elevated troponin secondary to acute coronary syndrome as its antiplatelet activity reduces mortality. It should be administered prior to performing an ECG in patients with chest pain thought to be from a cardiac etiology.

Answer B: Aspirin, heparin, clopidogrel, and cardiac catheterization is appropriate management of a ST elevation myocardial infarction, which presents with chest pain, diaphoresis, dyspnea, and ST elevation within a vascular distribution with reciprocal changes on ECG. This patient has no cardiac symptoms and has a better alternative explanation for their troponin elevation.

Answer C: Metoprolol and aspirin may be indicated in acute coronary syndrome, and metoprolol would reduce this patient's heart rate. However, note that this patient's tachycardia is secondary to volume depletion; thus, beta-blockade for sinus tachycardia is inappropriate and may make the patient hemodynamically unstable.

Answer D: Obtaining a urinalysis and creatine phosphokinase level may be performed in rhabdomyolysis which presents in the setting of seizures, electrical shock, heatstroke, or with vigorous exertion. Patients will complain of muscle pain, oliguria, and dark urine. Management is centered on the administration of large volumes of fluid to protect the kidney and clear the toxic myoglobin. Note that rhabdomyolysis may elevate the troponin; however, there is nothing in this patient's history that suggests rhabdomyolysis.

Bullet Summary:
Prerenal injury causing an acute kidney injury may elevate the troponin due to decreased renal clearance and should be addressed with the administration of fluids.


Question: A 24-year-old woman presents to clinic for a routine annual exam. She has generally been feeling well, but notes feeling intermittent palpitations over the past few months. Her past medical history is unremarkable and she is not currently taking any medications. She denies drinking alcohol, smoking cigarettes, or using recreational drugs. She attributes her palpitations to recently drinking more caffeine, but would like to obtain an electrocardiogram since her symptoms are worrisome and affecting her ability to concentrate on her career as a fitness instructor. Her temperature is 36.9°C (98.4°F), blood pressure is 116/76 mmHg, pulse is 55/min, respirations are 12/min, and oxygen saturation is 98% on room air. Her electrocardiogram is shown in Figure A. Which of the following is the most likely diagnosis?

Second degree atrioventricular block, Mobitz type II

Answer: Second degree atrioventricular block, Mobitz type I

Explanation:
This patient's progressively increasing PR intervals until a P wave is not followed by a QRS complex on ECG is consistent with second degree atrioventricular (AV) block, Mobitz type I, also referred to as Wenckebach phenomenon.

Second degree AV block, Mobitz type I can occur in a variety of settings, such as in the context of digoxin, beta blockers, calcium channel blockers, or increased vagal tone. On ECG, there is progressive lengthening of the PR intervals until a P wave is not followed by a QRS complex (a dropped beat); then, the PR interval resets. Patients are typically asymptomatic, but should undergo evaluation for an underlying etiology of the dysrhythmia, such as electrolyte imbalances, medication side effect, or structural heart disease, as well as a follow-up ECG to evaluate for any progression. If the dysrhythmia is caused by medication, the offending agent should be discontinued, but otherwise there are no specific treatments necessary for asymptomatic patients. Patients who are symptomatic and hemodynamically stable can undergo telemetry monitoring and receive atropine with limited efficacy. Patients who are hemodynamically unstable and not responsive to atropine may need cardiac pacing. Generally, there is a low risk of progression to third degree AV block, and a pacemaker is rarely required (in contrast to second degree heart block type II).

Barold and Hayes review second-degree heart block. They note the changes in AV node conduction time on ECG in this condition. They recommend using the correct definition of the different heart blocks for the correct underlying treatment.

Figure/Illustration A is an ECG showing PR intervals that gradually prolong until a P wave is seen not followed by a QRS complex (note the blue bars that show the progressive lengthening of the PR intervals until the dropped beat).

Incorrect Answers:
Answer A: First degree AV block is seen on ECG with prolonged PR intervals greater than 0.2 sec, but a consistent 1:1 ratio of P waves to QRS complexes. This finding is typically found in younger patients with increased vagal tone or in athletes, and does not require treatment.

Answer C: Second degree AV block, Mobitz type II is seen with fixed PR intervals and occasional dropped QRS complexes. Patients with Mobitz II sometimes present with syncope and frequently progress to third degree AV block. This finding may be associated with fibrotic changes to the conduction system or from acute, subacute, or prior myocardial infarction, and should be treated with placement of a pacemaker in most cases.

Answer D: Sinus bradycardia findings on ECG include normal sinus rhythm with a ventricular rate of less than 60 beats per minute. Patients with sinus bradycardia may be asymptomatic, but may also present with syncope, lightheadedness, chest pain, or hypotension. No treatment is required if the patient is asymptomatic, but atropine may be given to increase the heart rate in symptomatic cases. Pacemaker placement is required for patients with chronic symptoms.

Answer E: Third-degree AV block occurs when the atria and ventricles depolarize independently on ECG. There is no relationship between P waves and QRS complexes. Patients may present with syncope, dizziness, acute heart failure, or hypotension. The treatment is pacemaker placement.

Bullet Summary:
Second degree atrioventricular block, Mobitz type I, is characterized by progressively lengthening PR intervals until a P wave is not followed by a QRS complex.


Question: A 52-year-old man presents to the emergency department by ambulance for evaluation of hematemesis. His wife states that he began vomiting bright red blood this evening while eating dinner, and has produced about 5 cups total. He has a history of alcohol use disorder and has vomited small streaks of blood in the past, but has never undergone formal medical workup for it. On exam, he has bright red blood in his mouth and pharynx, and also displays a distended abdomen with a fluid wave, jaundice, scattered spider angiomas, and multiple ecchymoses. His temperature is 98.4°F (36.9°C), blood pressure is 98/68 mmHg, pulse is 125/min, and respirations are 22/min. A rapid point-of-care hemoglobin and platelet count is 8.8 g/dL and 80,000/mm^3, respectively. The patient is given 1L of normal saline. Which of the following is the most appropriate initial step in management?

Answer: Octreotide

Explanation:
This patient with a history of alcohol use disorder and signs of liver failure (jaundice, ascites, spider angiomas, and ecchymoses) presents with acute hematemesis and hypovolemic shock (hypotension, tachycardia, tachypnea) most concerning for a variceal hemorrhage. The first step in the resuscitation of patients with variceal hemorrhage is rapid administration of intravenous (IV) fluids and octreotide.

Esophageal and gastric varices, most commonly seen in patients with cirrhosis, are abnormally distended veins that are a product of venous congestion from portal hypertension. As these varices can project into the gastrointestinal lumen, they are subject to rupture either spontaneously or by mechanical disruption (e.g., tearing by food particles). Variceal hemorrhage is a life-threatening complication of cirrhosis as it can quickly progress to hemorrhagic shock or airway loss (if profuse vomiting is present). Patients should immediately receive 2 large-bore peripheral IVs (or central IV access) with which to administer IV fluid boluses to increase circulating volume. Blood should be transfused as needed, and a massive transfusion protocol may be needed. Patients should also be given octreotide, a splanchnic vasoconstrictor, in an effort to divert blood away from the hemorrhaging varices. Other treatments that should be given include ceftriaxone (to reduce bacteremia and mortality), proton pump inhibitors, and possibly interventions such as tranexamic acid. Upper GI endoscopy and banding are the definitive therapy.

Stanley et al review the management of acute upper gastrointestinal bleeding with initial IV fluid resuscitation as the first measure to achieve hemodynamic stability. They also report that for patients with cirrhosis, vasoactive drugs such as octreotide should be started as soon as variceal hemorrhage is suspected. Red blood cell transfusion is indicated at a hemoglobin transfusion of 7.0-8.0 g/dL. Definitive therapy is endoscopy with variceal ligation.

Incorrect Answers:
Answer A: Balloon tamponade is often performed in the emergency department or intensive care unit as a temporizing measure to achieve hemostasis for patients with severe and persistent variceal hemorrhage. The balloon is inserted into the esophagus or stomach and inflated to apply direct pressure to the bleeding varices; this buys valuable time in the transition to definitive endoscopic management.

Answer B: Ceftriaxone is administered to patients with cirrhosis who present with an upper gastrointestinal bleed as a prophylactic measure against spontaneous bacterial peritonitis. This patient is hemodynamically unstable, and antibiotics should not delay initial intravenous fluid resuscitation as well as other measures to reduce and/or stop the bleeding. While this patient should receive ceftriaxone, it is more dire to first give fluids, blood, and octreotide.

Answer C: Nadolol or other nonselective beta-blocker therapy is indicated as secondary prophylaxis to prevent future bleeding episodes for patients with a history of variceal hemorrhage. Non-selective beta blockers such as nadolol decrease portal pressure, but are contraindicated in the acute setting as they could exacerbate hypovolemic shock by reducing cardiac output.

Answer D: Platelet transfusion is required for patients with variceal hemorrhage with an initial platelet count < 50,000/mm^3, and for those who receive a significant amount of blood products during their resuscitation (significant dilutional thrombocytopenia can occur after 10-12 units of transfused red blood cells). This patient's platelet count is above 50,000/mm^3, and he has not yet received blood products.

Bullet Summary:
The most appropriate initial step in the management of a cirrhosis patient with acute variceal hemorrhage is the rapid administration of intravenous fluids and octreotide, a splanchnic vasoconstrictor.


Question: A 77-year-old man presents to the emergency department with a complaint of sudden onset weakness in his right upper extremity. At home, the patient thought he was simply dehydrated, but he rapidly began to have trouble speaking. When his wife noted this she brought him into the hospital. On arrival to the emergency department, the patient is not responding to verbal stimuli and only withdraws his left upper extremity and lower extremity to pain. His past medical history is notable for hypertension and atrial fibrillation treated with metoprolol, apixaban, and lisinopril. His temperature is 99.0°F (37.2°C), blood pressure is 170/100 mmHg, pulse is 95/min, and respirations are 16/min. The patient has a seizure and subsequently demonstrates agonal breathing. He no longer responds to painful stimuli. A fingerstick blood glucose is 122 mg/dL. Which of the following is the most likely etiology of this patient's symptoms?

Answer: Intracerebral hemorrhage

Explanation:
This patient with a medical history of hypertension on blood thinners (apixaban) is presenting with rapidly progressive neurologic symptoms. Initially, his symptoms are in his right upper extremity, which then progresses to affect his speech and cause altered mental status, obtundation, and seizures, which is suggestive of a left-sided intraparenchymal hemorrhage.

Intraparenchymal (IPH) cerebral hemorrhages often present with sudden-onset focal neurologic deficits. A unique feature is that IPHs tend to present with progressive/worsening symptoms in contrast to ischemic strokes which often demonstrate stable or improving symptoms. It is not uncommon for a patient to present with focal neurologic deficits, which then progress to seizures and obtundation. Risk factors include older age, hypertension, and blood thinners. The prognosis is poor in intraparenchymal hemorrhages, and outcomes are dependent on the size and location of the bleed. Initial workup should be centered on obtaining a fingerstick blood glucose, securing the airway, and obtaining CNS imaging (often with a non-contrast CT scan). Further management is centered on elevating the head of the bed, reversing the patient's anticoagulation status, and possible neurosurgical intervention (though prognosis is very poor in general).

Gross et al. review IPH. They note that IPH has very high morbidity and mortality even when treated. There is ongoing research into minimally invasive approaches for evacuation of primary IPH to optimize and improve outcomes, although immediate medical therapy is needed to reduce mortality which is recommended.

Incorrect Answers:
Answer A: Epidural hematomas present after trauma with the "talk and die" syndrome beginning with a period of unconsciousness, a lucid interval, and then progressive obtundation. A CT of the head would demonstrate a lens-shaped lesion, and a burr hole to drain the collection of blood is the treatment of choice. Acute epidural hematomas do not typically begin spontaneously.

Answer C: Ischemic strokes present with sudden onset, focal neurologic deficits. Generally, after the initial ischemic event, patients will be stable or even note an improvement in their symptoms. It is less likely that this patient's progressive symptoms and seizures are caused by an ischemic stroke when compared to a hemorrhagic stroke or intraparenchymal hemorrhage. This diagnosis is certainly possible, and further workup with CT imaging and possibly MRI is needed to clarify the diagnosis and direct further care.

Answer D: Subarachnoid hemorrhages generally present with a "thunderclap" headache with meningeal signs. It is possible that patients may present with obtundation and confusion with severe subarachnoid hemorrhages. Seizures are uncommon in subarachnoid hemorrhages and generally do not present with such focal neurologic deficits. CT will show blood in the subarachnoid space. The diagnosis can be supported with CTA or a lumbar puncture. Further management may involve nimodipine, neurosurgical intervention, and observation if the bleed is small and has stopped on its own.

Answer E: Subdural hematomas are more common in the elderly patients and patients with alcohol use disorder and present after trauma with a gradual progression of altered mental status to obtundation. Note that large subdural hematomas may present with a rapid progression of symptoms. CT of the head will demonstrate a crescent-shaped lesion that crosses suture lines. Management may involve neurosurgical evacuation with large subdural hematomas causing mass effect.

Bullet Summary:
Intraparenchymal hemorrhages may occur spontaneously in the setting of hypertension and blood thinners and present with progressive neurologic deficits that get worse over time with possible seizures.