Saturday, 30 June 2007

Chest Pain, Collapse and Vomiting

A patient to another institutions ER department who presented with:

  • Chest Pain
  • Collapse

The patient had gone to a care centre earlier in the day, and on arriving there, the patient fell to the floor which was witnessed by her carer.

The patient had not lost consciousness but complained of severe chest pain followed by three episodes of vomiting.

The patient was then brought by ambulance to the ER department.

The patient suffered from dementia and was only able to say that there was chest pain. Sometime later, the patient said that there was also upper back pain.

There was no description from the admitting doctor of the quality of the pain or radiation.

The vomitus was of food only and contained no blood.

The previous medical history included dementia and untreated hypertension.

No other history was known.

On initial examination by the ER staff, the patient was afebrile, pulse 90 beats per minute, blood pressure 190/110, respiratory rate 18 per minute with oxygen sats of 90%.

Blood pressure in both arms was said to be the same.

Chest examination revealed bilateral crackles only with normal heart sounds.

Abdominal examination was said to be normal except for some epigastralgia but the chest pain at that time had resolved.

From history and examination differential diagnoses were formulated and included:

  • Dissecting aortic aneurysm
  • Acute myocardial infarction
  • Unstable angina
  • Acute perforation of an abdominal viscus
  • Biliary colic
  • Pancreatitis
  • Oesophageal spasm

The ECG showed an old inferior myocardial infarction but nothing acute. The chest Xray was abnormal with evidence of possible tracheal shift to the right and a right paratracheal mass. The right basal lung appeared to be collapsed and there was an effusion at the left base.

This was an unexpected finding from the history as there was no apparent serious illness with this patient in the past.

The patient appeared confused but in obvious pain from the wincing of the face but pain was denied on several occasions.

Hands were cold and the radial pulse was felt to mildly collapse. There was still a wide pulse pressure in the blood pressure despite intravenous anti-hypertensive therapy in the ER. Quinke Sign, Corrigan Sign and DeMusset Sign of aortic regurgitation were negative.

JVP was not raised. Frank sign of the earlobe was positive suggesting some coronary artery disease.

Trachea was depressed (tracheal tug) and mildly deviated to the right. There were no cervical lymph nodes present.

Heart examination revealed a very subtle murmur of aortic regurgitation with the occasional Austin Flint murmur that was no present on every cardiac cycle.

Lung examination revealed dullness at both bases with right basal crackles. On pressing the sternum, this reproduced some central chest pain but it was uncertain whether this was the same as the presenting chest pain as the patient could not describe the problem.

Abdominal examination revealed no AAA but on auscaultation there was a left renal bruit.

Pulses were equal in the upper limbs and femoral areas. The left dorsalis pedis was weaker than the right.

In summary, this patient had a sudden collapse without loss of consciousness, onset of central chest pain and upper back pain followed by vomiting. The patient had later complained of epigastralgia .

The examination had revealed a collapsing pulse and the murmur of aortic regurgitation, right basal crackles and an left renal bruit with a slight inequality of the dorsalis pedis arteries.

Pulling all the main features together to make one unifying diagnosis, it was considered to be a Proximal to Distal Dissenting Aortic Aneurysm.

CT scan showed some minor right basal lung collapse, no obvious apical problem, but the aorta was slightly abnormal.

The advice was to

  • Obtain expert radiological advice on the CT scan
  • Obtain an urgent cardiac echo to observe the aortic valve and to check for a potential tamponade
  • To obtain a doppler study of the kidneys to assess blood flow to ascertain if there was an obstruction to the arterial orifice from a dissection.

The radiologist had confirmed that the CT findings were consistent with an aortic dissection and the patient was admitted under the appropriate specialty.

DIAGNOSIS: Aortic Dissection

This case markedly shows how a history and detailed examination with the basics of an ECG and chest Xray can lead one to the diagnosis of dissection.

Never rely purely on upper limb pulses being equal; they can be equal and there can still be a dissection.

A chest Xray can aid with the diagnosis if there is a widening of the mediastinum and in some cases there can be a left sided pleural effusion which can be a haemothorax due to the dissection. In this case, there was a left sided pleural effusion, but the effusion was not tested , so it remained unknown as to its origin.

Echocardiography is very important as it can show valvular insufficiency and tamponade.

The abdominal bruit was a gift sign in this case as it signified narrowing of an arterial foramen which suggested abdominal extension of the dissection.

The CT scan here was helpful to give more weight to the diagnosis although it was used to confirm the diagnosis rather than to make a surprise diagnosis.

Tuesday, 26 June 2007

Rectal, Rectal, Rectal !!!!!

Dear Bloggers

This case has been anonymised for patient confidentiality.

An elderly female patient with a two month history of watery diarrhoea was admitted to another hospital. The diarrhoea had started gradually and built up to a peak which had plateaued at 15x per day!! The diarrhoea was described as painful and in the lower abdomen. There was no blood and no mucus in the stool.

The patient described loss of appetite, weight loss of 7 kg and night sweats for the preceding 1 month prior to admission.

On further questioning, the stool was described as looking like 'paper' as it was thin when she produced it, just like paper.

However, the patient had been seen at another hospital where she was told that the problem was irritable bowel syndrome.

Having asked the patient if any doctor had in the last 2 months performed a rectal examination, the answer was NO.

The patient presented to hospital because of the development of urinary frequency, stool-coloured urine and production of gas per urethra at the end of micturition (pneumaturia). The patient also had a feeling of always needing to go to do stool which is known as Tenesmus which is usually an ominous symptom of cancer.

There was no previous medical history and the patient was taking no medications.

There was no relevant family history whatsoever.

Review of systems: No joint pain, no eye discomfort, no myalgias, no bone pain, no chest complaints.

Physical examination revealed a fever of 37.9 degrees C, normal vitals otherwise.

Cardiovascular and Respiratory examinations were unremarkable.

Abdominal examination revealed tenderness in the suprapubic and both iliac fossae. There was no costovertebral angle tenderness. There was no rebound tenderness and no guarding. An indiscrete mass could be palpated.

Bloods revealed a neutrophil leucocytosis, raised CRP and LDH. All other bloods were normal.

CXR was normal.

Differential Diagnosis

From the history of weight loss, appetite loss, night sweats, increasing diarrhoea without blood/mucus and new onset symptoms of UTI are consistent with an advanced colonic tumour NOT irritable bowel syndrome.

Other differential diagnoses should include inflammatory bowel disease but this is somewhat unusual in the absence of bloody diarrhoea. Also, patients will sometimes develop extraintestinal manifestations affecting the eyes (iritis), joints (arthritis), skin (erythema nodosum) etc, which this patient did not have.

Diverticulitis should also be considered, as post-inflammatory masses can occur which cause stricture and can invade the bladder.

CT scan of this patient revealed a colonic mass attaching to the bladder and with air seen inside the bladder which was unsurprising.

Two mistakes were made in the management of this patient.

Firstly, no Rectal Examination was ever done. 45% of all colonic malignancies present in the rectum and are therefore detectable with the tip of the finger! If performed two months ago, this could have perhaps been picked up at a stage when it could have been more amenable to surgical therapy.

Secondly, this patient had a fever and urinary signs of infection including faeces in the urine, white cells >100/hpf , 2+ bacteria and blood. However, the fatal mistake was to rely on urine culture which was negative. Hence, no antibiotic therapy was given on admission. This was clearly wrong as the patient has symptoms and signs of a UTI. Moreover, only 50% of urine cultures prove positive despite a UTI being present. Therefore, giving antibiotics such as a fluoroquinolone antibiotic would be advisable e.g. levofloxacin, as the patient was not being sick, the fluoroquinolones are rapidly absorbed and are effective against gram negative bacteria.

However, the diagnosis could have soon been established by performing a rigid sigmoidoscopy o admission to hospital as again another 25% of colonic cancers can be picked up where they occur in the sigmoid area. [please note 5% occur in the descending colon, 10% in the transverse colon and 15% in the ascending colon].

Thus, 70% of colonic tumour can be potentially picked up with the aid of a finger tip and a rigid signmoidoscope. Simple but rapid and effective in establishing a cause.

The Lessons to be Learnt here include:

  • In patient with any lower GI symptoms ALWAYS DO A RECTAL EXAMINATION. It is negligent to avoid doing one, and relying on CT to make a diagnosis in this circumstance is incorrect. CT is a guide only.

  • The patient had symptoms of OVERFLOW DIARRHOEA. This occurs when there is a blockage in the colon either by a internal occlusion [for example constipation, tumour] or external compression [e.g. invading non-colonic tumour]. Hard stool is unable to pass through the small hole produced by the compression. The liquid stool within the right colon migrates over the obstructed harder stool and through the stenosis of the colon to produce tape-like stool or diarrhoea, just as in the case of this patient. Thus, taking a decent history about the consistency of the stool should have set of warning alarms to do a rectal examination and rigid sigmoidoscopy at the bedside.

  • The patient clearly had developed a fistula from bowel to bladder with subsequent infection. Relying on culture alone is not correct. Look at the history, physical, vital signs [such as fever] and other laboratory data and they ALL point to a UTI. Hence, patient should have been treated on suspicion of infection which might otherwise progress to a complicated UTI.
Please consider..............