Original Article Surgical treatment of large substernal thyroid goiter: analysis of 12 patients
Marisa Glashow, MS IV. 21 y/o Female with PMHx ovarian cysts and hypercholesterolemia Substernal...
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Transcript of Marisa Glashow, MS IV. 21 y/o Female with PMHx ovarian cysts and hypercholesterolemia Substernal...
Marisa Glashow, MS IV
•21 y/o Female with PMHx ovarian cysts and hypercholesterolemia
•Substernal Chest Pain x 10 days
•Pain worsened 3 days ago
•Radiates to left scapula and epigastrum
•Sharp, 10/10, constant pain
•Worse with movement, breathing, and laying supine
•SOB associated with pain
•Dry Cough x 1 week
HPI
HPI•Two days prior to onset of symptoms patient strained back
•One week prior to onset of symptoms patient took two 6 hour car rides
•Intentional 25 lb weight loss over past 18 months
•Mild reflux
•LMP 1 week prior to visit
•Denies:
•Fever/chills • Nausea/Vomiting•Calf Pain
Allergies•NKDA
Medications•Lovaza•OCP
PMHx•Ovarian Cysts, Hypercholesterolemia
PSHx•Tonsillectomy
Social Hx•+ Tobacco 1 ppd x 4 years
Vital Signs
• Temp 97.7 F• HR 111• RR 22• BP 130/66• Sp02 99%, room air
Physical ExamGeneral•No Acute Distress
Respiratory•Rapid, shallow breaths•CTA bilaterally•No wheezes/rales/rhonchi
Cardiac•+S1/S2•Regular rate and rhythm•No murmurs/rubs/gallops
Physical ExamAbdomen•Soft•+ Bowel Sounds•Nondistended•Tender to palpation slightly distal to xiphoid process that extends to right and left anterior axillary lines•Negative Murphy’s Sign
Extremities•No calf tenderness•No edema of lower extremities
Back•Reproducible tenderness over left scapula•Limited ROM of left shoulder
Labs14.0
12.0 222
40.7
142
4.5
104
27.5
12
0.9
88
Total Bili 0.6Alk Phos 95AST 16ALT 11
BHcG (-)U/A (-)
Differential Diagnosis
• Pericarditis• Pneumothorax• PE• Gastritis• Costochondritis• Musculoskeletal• Pneumonia• Cholecystisitis• Splenic Rupture
ED Course• EKG & Troponins
• EKG: Normal Sinus Rhythm• Troponin: 0.00• CK: 42
• Maalox & Zantac• No improvement
• Toradol 30mg IV• No improvement
• CXR• No significant findings
• D-dimer• 0.65
• CT Chest with PE Protocol• Bibasilar consolidation• Discharged with Azithromycin
Atypical Pneumonia
• Most common organism is Mycoplasma pneumoniae• Symptoms:
• Chest Pain Low-Grade Fever• Headache Fatigue• Sore Throat Myalgias• Dry Cough
• Signs:• Pulse-Temperature Dissociation• No Signs of Consolidation
• Diagnostic Studies:• PA & Lateral CXR-diffuse reticulonodular infiltrates with absent or
minimal consolidation
• First-Line Treatment:• Macrolides or Doxycycline
CXR vs. CT• Retrospective study determining the incidence of PNA diagnosis
in the ED using thoracic CT after obtaining a negative or non-diagnostic CXR
• Analyzed charts of 1057 patients diagnosed with PNA• 97 patients had both CXR and CT performed
• 26 (27%) of patients had negative or non-diagnostic CXR, but CT showed infiltrate or consolidation consistent with PNA
• CT has a higher sensitivity than CXR for diagnosing PNA
• Concluded that future studies need to analyze radiographic diagnostic techniques used for PNA
CXR vs. CT
• False Negative CXR more common:• dehydrated patient• immunocompromised patient• portable CXR done at bedside
• Drawbacks to CT:• cost• limited availability• increased radiation exposure
• Consider CT:• empyema or effusion suspected• immunocompromised patient• underlying malignancy suspected• diagnosis is unclear
CXR vs. Ultrasound• Determine whether there is a difference in sensitivity, specificity,
and likelihood ratios in the diagnosis of PNA with lung ultrasound vs. CXR
• Subjects were 120 patients admitted to the hospital with community-acquired pneumonia
• Ultrasound Exam:• Performed by one ED physician who was non-blinded to the
subject’s clinical condition• Longitudinal and oblique views of the inferior and superior
portions of the anterior and lateral chest• Two mid-posterior views
• PA & Lateral CXR read by radiologist who was blinded to the subject’s clinical condition
CXR vs. Ultrasound
CXR vs. Ultrasound
Things to Remember…
• Don’t forget to consider atypical pneumonia
• When ruling out pneumonia, don’t forget that CXR can be falsely negative• Dehydrated patients• Immunocompromised patients
• Ultrasound has a higher sensitivity than CXR for diagnosing pneumonia
• CT continues to be the gold standard for diagnosing pneumonia
BibliographyAgabegi, Steven. Step-Up to Medicine. 2. Philadelphia: Lippincott
Williams & Wilkins, 2008.Cortellaro, F. "Lung ultrasound is an accurate diagnostic tool of
pneumonia in the emergency department." Emergency Medicine Journal. 29. (2012): 19-23.
Goljan, Edward. Rapid Review: Pathology. 3. Philadelphia: Mosby Elsevier, 2010.
Hayden, G. "Chest radiograph vs. computed tomography scan in the evaluation of pneumonia." Journal of Emergency Medicine. 36.3 (2009): 266-270.
Marrie, TJ. "A controlled trial of a critical pathway for treatment of community-acquired pneumonia. CAPITAL Study Investigators. Community-Acquired Pneumonia Intervention Trial Assessing Levofloxacin.." JAMA. 283.6 (2000): 749-755.