Typo

You are cross-covering 80 floor patients overnight and a nurse calls you for one of them because her monitor keeps having the finding shown above. You look at the sign-out given and it's a 40 year old woman admitted for abdominal pain. The last set of labs were:
WBC 11, Hgb 11, Hct 31, Plts 210
Na 134, K 4.1, Cl 101, HCO3 22, BUN 12, Cr 0.9, Glucose 220, Ca 10, Mg 1.7, Phos 4
b-HCG negative
UA with 1+ leukocyte esterase and 5-10 WBC.

You stop by her floor and jot a quick order in the chart on your way to the call room. An hour later, you hear a rapid response being called for this patient. When you run to the bedside, you hear the nurse saying, "She isn't responsive. Her vitals are HR 62, BP 102/68, RR 6, O2 sat 94% on room air."

Challenge: This illustrates a JCAHO (Joint Commission on Accreditation of Healthcare Organizations) violation...what happened?

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No Case Today

Hi Everyone,

I rarely take a break, but I got behind so there's no case today. I'll find a good one for Thursday, so check back then. If you have any good ideas, feel free to post them in reply - I will see them and comments aren't automatically public, so it's a good way of sharing that factoid you just learned or case you just saw.

Craig

Anti-Fruitarian

You are in General Surgery Clinic and you see a woman who has allergies to kiwi, banana, peach, avocado, chestnut, fig, bell pepper, tomato, and white potatoes. You roll your eyes. You ask what happens, and she says her throat swells up, she feels lightheaded, and she breaks out into generalized hives. She pulls two Epi-Pens from her pocket. She is scheduled for a laparoscopic hernia repair.

You present this case to your attending who, prior to being a surgeon, completed a medicine residency and an allergy and immunology fellowship. "Ah," she says, "11% of these patients will be sensitive to something in the operating room. And conversely, 35% of people who have that sensitivity show one of those food allergies." She draws the diagram shown above.

Challenge: When you call the operating room to schedule this case, you make sure they know she could have a reaction to...what?

P.S. Despite being Californian, your attending does not use organic locally harvested sustainable eco-friendly kiwi-skin meshes for her hernia repairs.

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Chole

A patient underwent the procedure shown above four days ago but returns with fever and abdominal pain. Labs show a leukocytosis and elevated bilirubin, alkaline phosphatase, and gamma-glutamyl transferase. A trans-abdominal ultrasound shows a contained collection of fluid in the gallbladder fossa.

Challenge: What went wrong?

Image shown under GNU Free Documentation License, from Wikipedia.

Free Living

A young adult is rushed into the emergency department with acute onset headache, fever, neck stiffness, nausea, and vomiting. She notes that things taste and smell funny as well. Labs show a leukocytosis with elevated PMNs. A lumbar puncture has elevated opening pressure, PMN pleocytosis, increased protein, decreased glucose. She's started on appropriate antibiotics for bacterial meningitis, but she suffers progressive deterioration with seizures, ataxia, cranial nerve palsies, and confusion. Imaging shows cerebral edema, leptomeningeal enhancement, and areas of hemorrhage and necrosis. Finally, she falls into a coma and then dies. Lifecycle stages of the organisms recovered are shown above.

Challenge: How is this disease acquired?

Image is in the public domain.

Inconsistent

A 60 year old man with hypertension, untreated colon cancer, and a history of NSTEMI presents to the emergency department with immediate onset dyspnea two hours ago. He is short of breath at rest. He has a cough with streaky bloody sputum and associated chest pain while coughing or taking a deep breath. He has two pillow orthopnea. He says he has been taking all his prescribed medications but forgot to bring in a list. His social history is significant for being mostly bedbound due to obesity and living alone.

On exam, vital signs are heart rate 70, blood pressure 110/70, respiratory rate 26, and oxygen saturation 90%. You hear a regular rate and rhythm. He has rales and decreased breath sounds. He has some jugular venous distension. His ABG is 7.50/30/68. His CXR is unremarkable. His EKG is normal sinus rhythm with several old Q waves.

Challenge: When you present your most likely diagnosis to your attending, he says that the heart rate isn't consistent. How do you explain the patient's heart rate?

Thrower

This five year old child appeared normal at birth, but started having problems in the third month of life. At that time, she had developmental delay and recurrent respiratory infections with chronic nasal discharge. Although her growth was fine for the first year, this slowed by the second and third year to minimal. Her developmental milestones peaked at multiword sentences and walking at age 3, but has started to regress. Parents are concerned that her trouble walking is because of joint stiffness and contractures. Past medical history is significant for frequent ear, sinus, and pulmonary infections with thick secretions.

On exam, you palpate both the liver and the spleen as well as an inguinal hernia. The eye exam is noted below, and indeed, her vision and hearing has declined. While she is in the waiting room, she falls asleep and you note some sleep apnea.

Challenge: Unfortunately, the average life expectancy is 5 years and nearly all patients die before 10 years if they have what disease?

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Blue Man Group

Challenge: What's this patient's past medical history?

(Ooh! Isn't this a good case?)

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