Quick Case: Pleuritic Chest Pain

Image from: Maeng, C. H., Chin, S. O., Yang, B. H., Kim, S.-Y., Youn, H.-J., Cho, K. S., Baek, S. K., et al. (2007). A case of organizing pneumonia associated with rituximab. Cancer research and treatment : official journal of Korean Cancer Association, 39(2), 88–91. doi:10.4143/crt.2007.39.2.88

30yo male presenting with forearm cellulitis, also complaining of right-sided sharp chest pain worse with deep inspiration and some movements of the ipsilateral shoulder. Found to have multiple pulmonary nodules (suggestive of metastasis) with the largest being a subpleural nodule in the superior/anterior portion of the RUL (roughly the location of the patient’s pain).

 

Differential Diagnosis of Pleuritic Chest Pain

Causes of Pleuritic CP

Location of Referred Pain

Referred Pain

 

Pediatric Fever

CXR with infiltrates

ID:

5yo girl brought to the pediatric emergency department by her mother due to 3 days of fever.

HPI:

The patient’s fever was first noted 3 days ago, measured at home to 103°F. It is associated with a moist cough, vomiting, and decreased PO intake. Her mother reports that she appears lethargic and has been urinating less frequently. The patient denies headache, changes in vision, burning with urination, or ear pain. No known sick contacts, attends day care.

PMH (Birth History):

No significant medical/surgical history. Ex-term born NSVD with no complications.

PE:

  • VS: 95/65mmHg, 100bpm, 102.6°, 22/min
  • General: Well-appearing, mildly irritated but consolable
  • HEENT: NC/AT, PERRL, oropharynx without erythema, no cervical LAD
  • CV: RRR, no M/G/R
  • Lungs: No evidence of respiratory distress (retractions, flaring), faint crackles over right inferior lung fields
  • Abd: +BS, soft, non-distended, TTP RLQ > LLQ, no rebound/guarding
  • Back: No CVAT

Labs/Imaging:

  • CXR PA/Lateral: RML/RLL infiltrate

Assessment:

5yo with 3 days persistent high fever and cough. These symptoms along with examination findings of crackles warranted further imaging (CXR) which revealed infiltrate in the right inferior lung field. The patient appeared clinically stable and was tolerating PO intake in the ED and was discharged home with azithromycin 5mg/kg/dose (with loading dose), clinic follow-up and strict return precautions.

Evaluation and Management of Pediatric Fever

Algorithm for the Evaluation of Pediatric Fever

A System for Pediatric Fever:

Pathophysiology:

Pathophysiology

Diagnosis:

  • <3mo: 38.0°C, 100.4°F
  • 3-36mo: 39.0°C, 102.2°F
  • Rectal > oral > axillary

Differential Diagnosis of Pediatric Fever:

Causes Of Fever

Serious Bacterial Illness (SBI):

1) UTI and pyelonephritis

  • Most common cause of SBI
  • Accounts for 3-8% of uncharacterized fevers
  • Female > male, uncircumcised > circumcised
  • Consider BCx, CSF evaluation as 5-10% bacteremic at presentation
  • Urinalysis: LE 75% specificity, Nitrites 97% specificity

2) Pneumonia and sinusitis

  • Sinusitis uncommon <3yo (sinuses unformed)
  • PNA diagnosed with CXR, obtain if findings of respiratory distress (grunting, tachypnea, hypoxemia) or rales on exam

3) Meningitis

  • Diagnose with LP
  • Meningitis suggested if:
    • ANC > 1,000
    • Protein > 80
    • Seizure (particularly complex febrile seizure)

Diagnosis by Age Group:

<3mo

  • Physical exam findings:
    • Tachypnea, hypoxemia → LRT infection
    • Irritability, inconsolability, bulging anterior fontanelle → meningitis
    • Vomiting/diarrhea → non-specific, GE, AOM, UTI, meningitis
  • History
    • Recent immunization: increased risk of SBI (usually UTI) 24-72h after immunization
    • Confirmed bronchiolitis (viral): enterovirus/parainfluenza associated with SBI

3-36mo

  • Physical exam findings:
    • Viral (URTI, GE) → vomiting, diarrhea, rhinorrhea, cough, rash; still playful and responsive
    • UTI → fever, foul-smelling urine, crying when urinating
    • Meningitis → irritability with handling, vomiting, bulging anterior fontanelle, complex febrile seizures

>36mo

  • Physical exam findings: presentation more adult-like
  • Watch for:
    • Group A Streptococcal pharyngitis
    • Infectious mononulceosis
    • Kawasaki: high fever (>5d), strawberry tongue, conjunctivitis, desquamating rash on palms/soles

External Links

Syncope

ID:

A 50 year-old male with a reported two-year history of infrequent spells, presenting with two spells in the past two days.

HPI:

The patient’s spells began two years ago, he recounts that he was watching television when he lost consciousness and a friend noted he started shaking; he does not recall the event, and awoke in the hospital. The next spell occurred one year later, though the patient is unable to recall much about this episode. The patient remained spell-free until yesterday when he was on a bus, lost consciousness and awoke in a hospital. He notes that he had bit his tongue and lost control of his bladder. He was discharged hours later with a prescription for an AED which he was unable to fill. This morning, the patient had another spell while in the bathroom. His roommate heard him fall, found him on the ground, and noted that his mouth was moving but did not see any other movements.

The patient’s episodes are all associated with loss of consciousness and are followed by 5-10 minutes of disorientation after which he recovers fully. The episodes are sometimes preceded by a feeling of “euphoria”, though this feeling sometimes occurs without subsequent LOC.

The patient denies any associated palpitations, dizziness/LH, chest pain or muscle pain.  He has not had any recent fevers/chills, dysuria, cough, headache, changes in vision, numbness/tingling, weakness, difficulty speaking or swallowing or weight loss. He also denies any history of head trauma.

Physical Examination:

  • VS: Stable and WNL
  • General: Well-appearing, pleasant, and in NAD.
  • HEENT: NC/AT. MMM. Small lesion on tongue.
  • Lungs: CTAB.
  • CV: RRR with occasional ectopic beats, no M/R/G.
  • Abdomen: S/NT/ND. Bowel sounds present.
  • Neurological exam: AAOx4, CN II-XII intact, motor/sensation/reflexes/coordination/gait WNL

Imaging/Studies:

  • EKG: Occasional PAC/PVC
  • CT Brain: Unremarkable except for mild age-related cerebral atrophy

Assessment & Plan:

50 year-old male with a history of HTN and a reported two-year history of infrequent spells presenting with two spells in the past two days. The description of the patient’s episodes could be consistent with seizures. Aspects supporting this notion include loss of consciousness and period of confusion following each episode. One of the recent episodes was also associated with tongue-biting and loss of bladder control. Additionally, some episodes are associated with a sensation of euphoria rising from the abdomen to the head which could be indicative of an aura. Characteristics that suggest other causes include the absence of noted convulsions and non-stereotyped nature of each episode which could be due to the patient’s poor recollection of these events and absence of reliable witnesses. In the case of true seizures, the possible etiologies in this patient include a mass, metabolic abnormalities, substance use, or concomitant infection exacerbating an existing propensity for seizure activity. Other, non-seizure causes warranting evaluation include cardiogenic syncope particularly given the evidence of ectopic beats on examination and electrocardiogram.

Differential Diagnosis of Syncope

First, is it syncope? History is very important for distinguishing syncope from other causes (seizure, dizziness, vertigo, presyncope). Ask about precipitating events, prodromal symptoms, post-ictal confusion. Common causes of syncope and their associated symptoms are detailed in the figure below.

References:

  1. Kapoor, W. N. (2000). Syncope. The New England journal of medicine, 343(25), 1856–1862. doi:10.1056/NEJM200012213432507

Delirium

ID:

A 70 year-old female with a PMH of HTN, DM, hyperlipidemia and stage I breast cancer s/p lumpectomy with sentinel LN biopsy several years ago presented for elective surgery complicated by post-operative bleeding. She is now 4 days post-op and was found to be confused, somnolent and occasionally agitated.

HPI:

The patient could not be interviewed.

PE:

  • VS: Stable and within normal limits
  • General: unremarkable except for crackles in bilateral lung bases
  • MSE: only arouses to sternal rub and becomes agitated, moving all four extremities spontaneously and symmetrically.
  • Reflexes: corneal and gag reflexes present, suppresses eye movements with head turn, deep tendon reflexes 3+ throughout UE/LE bilaterally.

Assessment:

70 year-old woman with a history of HTN, DM, hyperlipidemia and breast cancer presents with worsening confusion, somnolence and occasional agitation four days after surgery. The combination of significantly altered consciousness and absence of focal neurological findings, all in the setting of a complicated surgical course suggest delirium.

Differential Diagnosis of Altered Mental Status:

Levels of consciousness

There are different levels of consciousness, they are named in the diagram below but are better described by the characteristics observed.

Initial assessment

Differential Diagnosis for Altered Mental Status

References:

  1. Inouye, S. K. (2006). Delirium in Older Persons. The New England journal of medicine, 354(11), 1157–1165. doi:10.1056/NEJMra052321
  2. Blueprints neurology. Philadelphia: Wolters Kluwer Health/Lippincott William & Wilkins, 2009.
  3. Tindall SC. Level of Consciousness. In: Walker HK, Hall WD, Hurst JW, editors. Clinical Methods: The History, Physical, and Laboratory Examinations. 3rd edition. Boston: Butterworths; 1990. Chapter 57. Available from: http://www.ncbi.nlm.nih.gov/books/NBK380/