Your Next Patient: A confused 80 year old man

An 80 year old man is brought into your emergency room by his adult son. The son tells you that his Dad seems completely confused. He was up all night looking in all of the rooms of the house, and he seems agitated. He is also a little unsteady on his feet. He was generally well until 10 days ago when he had an exacerbation of his COPD. He was hospitalized for 3 days and went back to his sons house with some puffers and medications. Initially he was improving but the last two days have been ‘terrible’ according to the son.

He is worried that his father has dementia, or has had a stroke. He says that 2 weeks ago his Dad was ‘the kind of guy who still put up the neighbours Christmas lights, but now he is totally out of it.’

The past medical history is notable for COPD, hypertension and restless legs syndrome. He does not drink alcohol, and he is an ex-smoker.

His medications include: Amytryptilline 50mg hs (for restless legs), Nifedipine 30mg BID (for hypertension), Ipratropium MDI (for COPD), Moxifloxacin 400mg OD (for AECOPD), Prednisone 60mg OD (for AECOPD), and Diphendryramine 50mg OD (for nausea associated with moxifloxacin)

EVERY medication on this list is associated with delirium. The BEERS list provides a useful reference for medications that can be problematic for elderly patients.

The diagnostic criteria for delirium in the DSM-IV are:

  1. Disturbance of consciousness with reduced ability to focus change or shift attention.
  2. A change in cognition or perceptual disturbance not better accounted for by pre-existing dementia.
  3. The disturbance develops over a short period of time and tends to fluctuate.
  4. History, physical and ancillary tests indicate the disturbance is caused by a general medical condition.

On examination the patients vital signs are HR95, BP140/85, RR20, Temp 37.7C, O2 97%RA His skin is slightly flushed. Ears, nose and throat exam is normal. The respiratory exam is normal, there is no wheeze and good air entry to all fields. Cardiac exam, abdominal exam and head & neck exam are all normal. There are no focal neurological signs but you note that the patient is unsteady on his feet, and disoriented to time and place.

There remains a broad differential diagnosis for altered mental status in the elderly patient. The mnemonic AEIOU TIPS is often suggested as a memory aid to help sort out the cause.

  • A – Alcohol (intoxication or delirium tremens)
  • E – Epilepsy, Endocrine, Electrolytes, Encephalopathy
  • I – Insulin (hypo or hyperglycemia)
  • O – Oxygen (hypoxia), Opiates, Overdose
  • U – Uremia (encephalopathy)
  • T – Trauma, Toxidromes
  • I – Infection (Sepsis, meningitis, UTI)
  • P – Psychiatry (Depression, Psychosis, Dementia), Porphyria, Pharmacy (medication side effect)
  • S – Stroke, Space occupying lesion, Subarachnoid haemorrhage
This is an excellent mnemonic to remind us to consider  every possible medical condition in the evaluation of the altered elderly patient. Unfortunately it is far too broad to guide a work-up, and at the same time leaves out causes of altered mental status (STEMI/ACS may, for instance, present as confusion or AMS in an elderly patient).
In reality a patient driven work-up is required. When I see an elderly patient with AMS I ask myself; Is this inter-cranial catastrophe? Is this trauma? Is this Infection? Is this encephalopathy or metabolic derangement? Is this a toxidrome or medication side effect? Is this a systemic illness manifesting as AMS? Is this dementia or a psychiatric process?
A careful initial evaluation can guide an initial work-up designed to rule in or out important causes of AMS that threaten life or long term function.

You order some investigations; ECG, CBC, electrolytes, BUN, Creatinine, Lactate, Troponin, Urinalysis, Chest x-ray, and CT head. All of these investigations are within normal limits.

The patient is on 3 medications with significant anti-cholinergic properties; amitryptilline, diphenhydramine and ipratropium.

You decide that the patient is having delirium, likely related to his current medications. You suspect that his anticholinergic medications are the culprit, especially given his slightly elevated temperature and flushed skin. His prednisone, moxifloxacin and nifedipine could also be the culprit, but you consider this less likely. As far as you can tell the patient has recovered from his exacerbation of COPD, and currently has a normal respiratory exam.

Elderly patients with delirium require supervision at a level that is rarely possible in the home environment and often require hospitalization. These patients are at risk for falls and wandering.

Any underlying precipitant of the delirium should be treated, and in the case of medication side effect the offending agent(s) should be weaned or removed. Severe agitation may require treatment (ie. with low doses of haloperidol) but excessive sedation should be avoided. Verbal calming and reorientation is a key part of treatment.

The patient was admitted to the hospital and all of his medications were discontinued. Initially he required constant bedside supervision and haloperidol 1mg po qhs for night-time agitation. His delirium settled over 1 week, and eventually he was discharged into his son’s care.

Delirium in elderly patients is associated with poor prognosis. In the year following an episode of delirium 20% of patients will be admitted to long term residential care (nursing homes), and 10% will die. Delirium is also associated with cognitive injury and many patients never regain their pre-morbid cognitive state.

It is unclear to what extent these outcomes are the result of delirium versus delirium being a marker of poor physiological reserve.

 

Your Next Patient: A 62 Year Old Man With Advanced Lung Cancer

It’s 9PM in your busy emergency department when an ambulance arrives with a 62 year old man who appears to be very short of breath. His wife explains that he has advanced metastatic lung cancer and has been waiting for a bed at a local hospice, but none have been available. They have been trying to manage at home but he has been getting worse rapidly today. Tonight he is struggling to breathe and in pain. He has been unable to take his medications because of breathlessness so they called the ambulance.

You review the patients records and find that he is a long-time smoker and has COPD. About one year ago he developed lung cancer. It was metastatic at the time of discovery and unresponsive to chemotherapy. Currently the cancer is widely metastatic in both lungs with invasion into the left chest wall causing severe pain. The patient has been followed by palliative care and has a do not resuscitate order in place.

On examination the patient is a cachetic man in overt respiratory distress and moaning in pain. His vital signs are: HR 120, RR 30 (shallow/laboured), BP 100/60, O2 80% on room air. Examination reveals the following positive findings: bilateral firm fixed supraclavicular adenopathy, no audible air entry on the left lung field with dull percussion tone, poor air entry on the right lung field, with a palpable right lateral chest wall mass. Heart sounds are noted to be tachycardic and diminished and jugular venous distension is present. Abdominal examination reveals an enlarged hard liver edge, suspicious for metastatic disease.

The patient has respiratory distress, diminished heart sounds and JVD. This raises a number of diagnostic possibilities familiar to most emergency physicians. In our patient, with advanced cancer, there are some additional important considerations.

  • Pericardial tamponade
  • Tension pneumothorax
  • Massive pulmonary embolism
  • Superior vena cava syndrome
  • Tension hydrothorax
  • Lobar collapse/lobar atelectasis
  • A complex combination of more than one of these possibilities

This is a complex question. A do not resuscitate order in it’s most basic form is only useful when the patient arrests and it does not provide any other guidance for the patients medical care. The presence of a do not resuscitate order may allow the physician to focus on treatment goals that have short term positive benefits.

Some patients may have detailed advanced directives that spell out the patients wishes in specific circumstances but this is rare. In the case of our patient he has a signed and witnessed document that states ‘In the event of death please do not resuscitate, please allow a natural death.’

It is also important to note that a DNR order can be revoked or changed at any time by the patient.

Like all other care decisions the physician must discuss options with the patient. In this case the patient is experiencing an uncomfortable natural death and available options aimed at relieving that suffering should be offered.

Our patient has severe dyspnea and pain due to tumor invasion of the chest wall. He has been unable to take his medications due to breathlessness.

The cornerstone of initial management is parentral opioids. In this case an opioid medication will provide both pain relief and relief of dyspnea. Either intravenous or subcutaneous medication is acceptable and medication should be titrated to symptom relief. Medications with a long interval to onset of action, such as transdermal fentanyl patches, should be avoided for acute symptom management.

Severe dyspnea can cause anxiety in many patients. In some patients anxiety resolves as the symptoms are controlled, while others require specific treatment with benzodiazipines.

Our patient receives hydromorphone 0.5mg IV q5minutes x 3 doses (1.5mg total) and has good relief of both his pain and dyspnea. His anxiety is also greatly reduced and he is offered lorazepam 0.5mg sublingual but he declines.

The doctrine of double effect (DDE) is a philosophical principle (probably first discussed by Thomas Aquinas). The principle is that harms are sometimes a side effect of actions intended to bring about a good result, and that these unintentional harms are ethically permissable.

In our case the doctrine of double effect is important. Some physicians are reluctant to treat palliative patients with opioids or benzodiazipines for fear they will hasten their death. This doctrine permits the treatment of palliative patients pain and suffering, even if that same treatment also hastens their death.

(In fact proper pain treatment has never been shown to hasten death, but this myth persists and is worth addressing.)

Our patient initially decides he might consider interventions that would improve his symptoms and some investigations are undertaken. A bedside ultrasound shows a moderate sized pericardial effusion. A CT scan shows diffuse metastatic lung cancer with a high disease burden, there is a massive left effusion with some mediastinal compression and diffuse liver metastases are now apparent. The patient is anemic with a hemoglobin of 71, and has metabolic derangement with a creatinine of 425, BUN 25 and K 6.0.

You discuss the results with the patient and offer interventions likely to improve symptoms, in particular left thoracocentesis. You discuss the difficulty of managing severe anemia and hyperkalemia in the face of renal failure. The patient decides that he does not wish to have any interventions except medications for pain control as he has had good results with the IV hydromorphone. You admit him to the hospital to wait for a bed in hospice but the hospital is over full so he remains in your emergency department.

Four hours later you are approached by the patients wife. She tells you that the patient is deeply sleeping with shallow and slow respirations. She is concerned because he has a loud gurgle in his throat and wonders if there is anything that can be done about this?

  • Glycopyrolate 0.1-0.2mg SC q2-4h
  • Scopolamine 0.3-0.6mg SC q3-6h
  • Atropine 0.1-0.4mg SC q2-4h

The patient is treated with glycopyrolate with good result. He dies 2 hours later still in our emergency department having never been admitted to a hospital bed or hospice due to overcrowding.

Palliative care seems on face as far out of the realm of emergency medicine as can be. However, with chronic overcrowding, hospital and hospice congestion and boarded patients a fact of life in most emergency departments, means that the provision of palliative care is becoming an important consideration for many of us.

Your Next Patient: A 35 year old with disproportionate pain

A 35 year old, somewhat rough looking, man arrives in your emergency room around midnight under his own power. He is complaining of 10/10 severe left arm pain. He says the pain started 5 hours earlier and has gotten worse every hour. The pain is mainly about the elbow and forearm. There pain began around 19:00 while he was watching TV. There is no history of trauma or injury. The pain does not radiate. there is no chest pain or shortness of breath. The patient is right handed.

The patient has no past medical history. He works as a roofer, and he drinks 6 beers per day and smokes a pack a day, he denies drug use.

On exam the patient is screaming and rolling around the stretcher, examination is difficult because every time you touch his arm he begins screaming and swearing. His arms are both heavily muscled, and his left forearm is slightly larger in girth than the right. The patient refuses to move the wrist. The pulses are present at the wrist, and sensation over the hand is intact.

The patient receives 10mg of IV morphine but his pain is unchanged. After a further 10 mg of morphine the patient is somewhat sleepy but says his pain is unchanged.

The nurse taking care of the patient asks you ‘Come on, are you buying this?’ and rolls her eyes.

The primary job of the emergency doctor is to consider the possibility of serious and dangerous diagnoses. Judging patients who present with disproportionate pain to be symptom magnifiers, malingerers, or drug seekers is a pitfall to be avoided.

Severe pain in the absence of compelling physical findings has a number of serious life and limb threatening causes. Premature closure, or mislabelling of the patient in these cases can have dire consequences. When confronted with disproportionate pain in a limb I like to consider if the patient could have:

  1. Vascular catastrophe
  2. Compartment syndrome
  3. Necrotizing soft tissue infection

With the patient now in a near somnolent state you re-examine the arm. The area of maximal tenderness seems to be the proximal volar forearm, and there are perhaps some subtle parasthesias over the palm. The patient wakes with agonized screams with passive ranging of the wrist or elbow.

The real answer is no, this patient has a surgical forearm (in the same way a patient with a rigid abdomen has a surgical belly). The patient requires immediate surgical consultation.

Getting a surgeon to attend the patient without ancillary testing is another matter…

If you have the equipment available a measured compartment pressure is the best test in this case to help differentiate among possible causes. An excellent review of the use of the Stryker pressure monitor can be found at emedicine.com

Blood tests are unlikely to be useful in this case. The white blood cell count will likely be elevated regardless of cause, the CK may be elevated in either necrotizing myofasciitis or compartment syndrome. Serum lactate may be elevated but is non-specific.

A CT scan of the arm may be useful. Contrast enhanced images including aortic imaging should be obtained if vascular catastrophe is suspected. An edematous compartment may be visible, and signs of necrotizing infection may be apparent.

A pressure of > 30 mmHg is considered diagnostic of compartment syndrome. However, it is probably more useful to consider the issue of compartment perfusion pressure (in the same way we think about cerebral perfusion pressure). Patients with low perfusion states, such as the trauma patient with hypovolemic shock, are at risk of compartment syndrome at lower absolute  compartment pressures.

In this case a Stryker monitor was not available. The patient’s bloodwork was notable for an elevated CK at 13,000, and a WBC of 18 (worthless) and a lactate was normal. A CT scan showed edema of the volar compartment of the forearm.

The patient was taken to the OR for fasciotomy of the volar forearm, and made a good recovery. In retrospect the patient had been using a heavy impact drill in the left hand the previous day and this was thought to have precipitated the compartment syndrome.

  • Pain out of proportion to physical findings should make the emergency physician very wary.
  • Be reluctant to define a patient as a symptom magnifier, malingerer or a drug seeker.
  • Vascular catastrophe, compartment syndrome and necrotizing skin infection can all present with disproportionate pain and subtle or no physical findings.
  • A swollen painful limb with any neurovascular findings represents a surgical emergency.

Your Next Patient: A 76 year old man with abdominal pain

The following case is meant to simulate an oral examination question. Information will be presented, and the candidate asked to discuss the situation or answer specific questions. The information will be presented sequentially. This is not intended to be a comprehensive topic review, rather it is meant to examine specific candidate competencies. If you are preparing for an oral exam consider having a friend give you this question.

You are the emergency physician in a large urban hospital. Your next patient is a 76 year old man with abdominal pain. He says that the pain began 4 hours ago and is severe and generalized over his entire abdomen. He tells you that the pain is probably due to a ‘bad sandwich’ he ate at lunch about an hour prior to onset. The onset of pain was sudden and he had one episode of diarrhea 20 minutes after the pain began, and he was also nauseous but vomited 3 times. Currently he says the pain is unbearable, and that he continues to be nauseous and dizzy, he is rolling around the stretcher and it is difficult to get him to answer questions. He denies chest pain or shortness of breath.

His wife tells you that his past medical history includes a stroke with no residual deficit, hypertension, hyperlipidemia and a remote appendectomy. His medications include hydrochlorothiazide, digoxin, simvastatin, and ASA.

The candidate may continue to try to take history but nothing further will be forthcoming. The patient will emphasize the severity of his pain in response to any questions.

Physical examination reveals the following: An obese man who appears his stated age. HR 105, BP 100/60, RR 20, O2 98% room air, temperature 37C. HEENT, , skin, neurological and respiratory exams are normal if asked for. Cardiovascular exam reveals an irregularly irregular rhythm and is otherwise normal. Abdominal exam reveals diffuse tenderness with no guarding, no rebound, and bowel sounds are inaudible. There are no palpable masses. Pulses are present and symmetrical in 4 limbs if asked for.

Bedside ultrasound is unreadable due to bowel gas if asked for.

The candidate should recognize that the patient has unstable vital signs and a potentially serious medical condition and commence intervention concurrently with further work-up. Appropriate initial steps include intravenous access, O2, monitors, airway equipment to the bedside. A fluid bolus/challenge is appropriate. Pain medication in titrated aliquots is appropriate. Additional investigations will be ordered by the candidate.

The patients nurse obtains an ECG for the patient and hands it to you.

The candidate should demonstrate competence in reading the ECG. The ECG shown demonstrates atrial fibrillation with rapid ventricular response. The rate varies between 100 and 150 bpm. There are no ischemic changes.

You reassess the patient following a 1 litre fluid bolus and intravenous narcotic pain medication. His vitals are now HR 110, BP 95/60, RR 22, O2 98% 5lpm O2, temp 37C. The physical examination is unchanged. The patient tells you his pain is unchanged.

The following labs return: WBC 18,000, Hb 125, Plt 450. AST 20, ALT, 20, Lipase 20 (normal), Bili 25 (mild elevation), lactate 2.8. Electrolytes, glucose, BUN, Creatinine and coagulation studies are all normal. An abdominal plain film is unremarkable.

The candidate should provide a differential diagnosis with a focus on high risk conditions; mesenteric ischemia/infarction, cholangitis, cholecystitis, perforated viscous, appendicitis, aortic aneurysm/dissection and other vascular catastrophe (eg. other arterial aneurysms).

The candidate should recognize that the patient is unstable and deteriorating. Additional imaging should be discussed, abdominal CT scan, CT-angiography, or percutaneous angiography. The candidate should request a surgical consultation.

  • Arterial embolism: 1/3 of cases, embolism is usually from a cardiac source, and usually affects SMA (superior mesenteric artery).
  • Arterial thrombosis: 1/3 of cases, atherosclerotic disease of mesenteric arteries with acute plaque rupture, may be preceded by symptoms of intestinal angina.
  • Non-occlusive mesenteric ischemia (NOMI): 1/3 of cases, due to prolonged vasoconstriction or low output states (e.g. severe CHF). Dialysis, CHF, digoxin, cocaine, sepsis and shock states are risk factors.
  • Venous thrombosis: Rare, usually seen in hyper coagulable states.

  • Atrial fibrillation
  • Previous arterial-occlusive event
  • Age >60
  • Coronary artery disease
  • Valvular heart disease
  • CHF
  • Hyper-coagulable state
  • Renal Failure
  • Dialysis
  • Shock states
  • Digoxin
  • Cocaine
  • Vaso-pressors/Vaso-active medications

This case presents an unstable elderly patient with mesenteric ischemia. The candidate must recognize abdominal pain in an elderly patient as a high risk diagnosis. The candidate must recognize that the patient is unstable based on vital signs.

The candidate should identify multiple risk factors for mesenteric ischemia including; age, previous arterial occlusion (CVA), atrial fibrillation, and digoxin use. The history, physical, progression of disease and laboratory findings are all consistent with mesenteric ischemia. The candidate should recognize that an elderly patient with severe abdominal pain and unstable vital signs represents a surgical emergency, and should ask for consultation prior to definitive diagnostic testing.

In order to pass this station the candidate must recognize mesenteric ischemia as a diagnostic possibility, arrange surgical consultation and appropriate definitive diagnostic testing.

This case is of moderate difficulty, mainly because the presentation is purposefully vague.

Your Next Patient #2: A peanut, a rash and a wheeze

The following case is meant to simulate an oral examination question. Information will be presented, and the candidate asked to discuss the situation or answer specific questions. The information will be presented sequentially. This is not intended to be a comprehensive topic review, rather it is meant to examine specific candidate competencies. If you are preparing for an oral exam consider having a friend give you this question.

You are the emergency physician on shift in a large urban hospital. Your next patient is an 8 year old boy who arrives by ambulance with wheeze and rash. He was at school and during lunch he developed a rash and then became wheezy. His teacher called 911. The paramedics felt he was having an allergic reaction and gave him diphenhydramine 25mg IM, they tell you his rash is looking much better now. The teacher is with the child and tells you that as far as she knows he has no medical problems. The parents are on the way and will arrive in 15 minutes.

The candidate should elicit history directly from the child, including history of allergy asthma and atopy, details of the events, and the possibility of aspiration. The candidate should ask for vital signs, and do a physical examination. The candidate should recognize allergy/anaphylaxis as a possible diagnosis and as for IV, O2, monitoring and advanced airway equipment to the bedside.

The patient tells you he ate half of a friends peanut butter sandwich. He has no medical history that he knows of, but he volunteers that his brother has both peanut allergy and asthma. He denies choking on anything. He tells you he feels nauseous, dizzy and unwell, and he vomits once while you are questioning him.

His vital signs are: HR 130 BP 80/50 RR 28, SaO2 93% Temperature 37.5C

Physical exam reveals a patient who is awake and alert and appears anxious. There is a mild generalized urticarial rash, peripheral pulses are diminished but palpable, and capillary refill time is 5 seconds at the fingers. The oropharynx is normal and there is no stridor. There is tachycardia but no murmur. The chest has bilateral wheeze. The remainder of the exam is normal.

The candidate will recognize that the patient is tachycardic and hypotensive. The diagnosis of probable anaphylaxis will be made based on the history and physical. In particular the involvement of multiple systems and hemodynamic instability will be noted.

The candidate will treat the patient emergently without waiting for parents to arriver for additional labs or investigations. Diphenhydramine will be recognized as an inadequate treatment for anaphylaxis. The candidate will treat the patient with epinephrine and know the dose and route (0.01mg/kg IM in the thigh). Additional medications to be given include IV fluids, steroids, H1 and H2 blockers and salbutamol. The candidate may discuss considering early intubation.

The patient is treated with the following medications: Epinepherine 0.01mg/kg IM, normal saline 20ml/kg IV, ranitidine 1mg/kg IV, diphenhydramine 1mg/kg IV, hydrocortisone 5mg/kg IV and salbutamol 4 puffs with aerochamber. You repeat his physical exam. His blood pressure is now 95/70, HR 120, RR 15. His rash is gone and he is feeling much better.

15 minutes later his parents arrive. They confirm that he, like his brother, does in fact have a peanut allergy. He did not tell you because he was worried he might get in trouble. The parents wonder if they can take him home now since he is looking better?

This patient presents with anaphylaxis and hemodynamic instability. He requires a minimum of 6-8 hours in a monitored setting. The candidate should mention the possibility of a biphasic reaction, and explain the reason for the prolonged observation to the parents.

The patient is observed for 8 hours and has no recurrence of symptoms.

The candidate should recognize that hemodynamic collapse in anaphylaxis is due to distributive shock. The candidate should recognize the need for escalation of therapy including intubation and additional medications.
The candidate should discuss the importance of repeated doses of epinephrine and IV epinephrine infusion in cases of hemodynamic collapse. Large volume crystalloid resuscitation should be discussed, in response to distributive shock.
In the case of complete hemodynamic collapse or cardiac arrest the candidate should discuss this as a case where prolonged CPR may be of benefit.

Avoidance of peanut containing foods should be emphasized.
A prescription for an epipen should be given and it’s use discussed.
The candidate may mention a medic-alert bracelet for peanut allergy.
The signs of allergy/anaphylaxis should be reviewed and cues to return to the hospital reviewed.

This case tests basic competency in a core emergency medicine problem; anaphylaxis. The candidate is required to make a clinical diagnosis without relying on labs or tests. The candidate is expected to have detailed knowledge of the management of anaphylaxis including the dose and route of medications. The candidate is expected to recognize this as a life threatening emergency and treat the patient without waiting for the parents to arrive and provide consent to treatment.
This case is designed to be a straight-forward and basic oral exam question.