Clinical Problem Solving Exercise

Clinical Problem-
Solving (CPS) Cases
Gurpreet Dhaliwal, MD
Management of the Hospitalized Patient
2012

“They are presented every conceivable problem
related to their specialty. They solve cases by history
alone. They laugh a lot and clearly enjoy what they
are doing. And not only do they demonstrate superb
diagnostic acumen, but they also model many of the
ACGME Core Competencies.”

Ground Rules for CPS Exercise
• Goop has never heard these cases
– Not a trivial undertaking
• Today: 2 cases, one bread & butter, other
a little harder
• Goal is to make the thought process of a
master clinician transparent
–It’s not magic
– You don’t have to “know everything”
• “Getting it right” is cool, but relatively
unimportant in the grand scheme
• Enjoy – this is the fun part of medicine

Case #1: Clinical History
CC: An 82 year-old woman with thoracic spine
compression fractures presented to the ED with
post-traumatic back pain.
HPI: The patient has a history of osteoporosis
and prior t-spine compression fractures, treated
with kyphoplasty in the past. She developed
severe back pain after being accidentally struck
in the back during happy hour at her
independent living facility. Unable to achieve
relief with Tyco, she presented to the ED a
week later. She noted constipation but no
radiation, focal neurologic sxs, or incontinence.

Scene from Happy Hour

Past History/Meds/Social History
• Osteoporosis with kyphoscoiosis
– On no meds, couldn’t tolerate alendronate
• S/p kyphoplasty x2 (most recent 2011): good relief
• “Irregular heart beat” – exact etiology unclear
• HTN
• Hyperlipidemia
• Symptomatic GERD
• Meds: Metoprolol, pravistatin, omeprazole, Tylenol
#4, occasional vitamin D/calcium
• SH: nonsmoker, occ EtoH, no drug abuse; lives in
independent living facility

Physical Exam
• T 36.6, HR 76, BP 122/85, RR 18, 99% RA, pain
8/10
• General: Mild distress from back pain
• HENNT: NC/AT, EOMI, PERRL, OP clear, neck
supple
• CV: RRR, no m/r/g, no jvd
• Resp: Lungs clear bilaterally
• GI: +BS, soft NT, slightly distended, no masses
• MSK: Severe kyphosis, TTP mid T-spine
• Neuro: A&O x 3, CNs 2-12 intact. 4+/5 strength, nl
sensation, 2+ reflexes throughout

Goop’s Initial Thoughts

\ 12.4 /
6.7 ---- 331
/ 36.8 \
Labs
139| 103 | 11 /
---------------------- 114
3.6 | 27 | 0.61 \
INR: 1.0
Trop:

Admission Chest X-Ray

Admission EKG

CT of Spine

Initial Plan
• Admitted to medicine w/ neurosurg consult
• Consultants recommended spinal fusion
with kyphoplasty under general anesthesia
if pain persists
• Plan: pain control, bowel regimen, PT/OT,
admit to tele, MI ruled out, cont home meds
• Pain control difficult; day 4 patient went to
OR for posterior spinal fusion with
kyphoplasty of acutely compressed
vertebrae

Immediate Post-Op Course
• Lengthy but uneventful OR case, minimal
blood loss
• Within a few minutes of wound closure,
she developed acute hypotension (SBP
60s), HR fell to 40s. Unresponsive to fluids
and phenylephrine
• Sedation held, patient turned supine, given
atropine and started on epi drip

Post-Op Studies
ABG: 7.26/28/216 (100% FiO2), lactate 7.5, Hgb 6.7
4 units PRBC transfused: Hgb 6.7 -> 9.6 -> 13.1
\ 14.7 /
13.9 ---- 113
/ 43.5 \
139| 111 | 7 / iCa: 1.02 INR: 1.6
---------------------- 169 Mg: 1.9 PTT: 40.2
4.5 | 21 | 0.61 \ Phos: 7.2 Trop: 0.15

Post-Op CXR

Post-Op EKG

Admission EKG (for comparison)

Vital signs at ICU admission
• T 37.6, HR 90s, BP 117/80, RR 20, 99% on AC
400 x 10, PEEP 5, FiO2 100%
• Intubated, sedated, not arousable but pupils
equal, + gag, + cough
• CVR: Irregularly irregular, nl s1s2, no m/r/g
appreciated. Distended neck veins present.
• Pulmonary: Lungs clear bilaterally
• MSK: Extremities cool distally
• Exam otherwise unchanged except for surgical
changes

What do you think is going on?
1. Cardiac tamponade
2. Tension pneumothorax
3. Pulmonary embolism
4. RV infarct
5. Septic shock
6. TRALI
7. Thyrotoxic storm

TTE

TTE

What would you do now?
1. Unfractionated heparin
2. One of those new-fangled anticoagulants
3. Stress dose steroids
4. Broad-spectrum antibiotics
5. Aspirin
6. Emergent cardiac catheterization
7. CT angiogram of chest

ICU Management and Course
• Team felt PE vs. RV infarct most likely dx
• Troponins trended, peaked at 1.7
• Anticoagulation considered but held in
light of recent spine surgery
• After transfusions, hemoglobins trended
and remained stable

A diagnostic procedure
was performed

Gurpreet Dhaliwal,
Gurpreet Dhaliwal,
what is your…
final answer?

Final Diagnosis
• Cement pulmonary embolism
– Extending from main pulmonary artery trunk
to RUL PAs; other fragments in paravertebral
and azygos vein

Management and Course
• After discussion with IR, pulm and cards, decision
made not to try to remove cement
• Anticoagulation discussed (cement is often
thrombogenic) but withheld due to recent surgery
• Right heart failure managed with dobutamine,
levophed, diuretics, amiodarone, inhaled NO
• Improved and extubated day 5, weaned off
pressors
• Complex hospital course (UTI, ileus, delirium) but
improved. Repeat TTE: RV smaller, better EF
• Discharged to SNF – no SOB, back pain

Now at the Independent Living
Center…

Take Home Points
• Kyphoplasty: used for
pain control of
osteoporotic
compression fxs
– Surgeon enters weak part
of bone, dilates space
with balloon, injects
methymethacrylate
cement, which hardens
– Usually closed or
minimally invasive surgery

Take Home Points
• About 20% of patients have some cement
leakage outside spine
– Usually asymptomatic or nerve root
compression
• ~ 300 cases in literature of symptomatic PE;
probably about 1-3% incidence (asx higher)
– No consensus on management
• ? Heparin – probably yes ? Surgical removal – if dire
• Treat right heart failure if present
• Prevention: use “toothpaste” consistency
cement, slow injection, stop if extravasation
Krueger. Management of pulmonary cement embolism…: a systematic review of
the literature. Eur Spine J 2009.

CASE #2

HPI
� 37 year-old man with no significant PMH
presents with 4 days of chills, sweats,
diarrhea, N/V, generalized weakness, and
severe fatigue.
� On presentation to the ER, he was febrile
to 39 with a HR of 148, BP 136/84, RR 30,
and O2 sat of 98% on NRB. His CXR
showed a multi-lobar infiltrate and he was
intubated for respiratory distress.

Goop’s Initial Thoughts

6 wks PTA
Oral surgery c/b infection
Takes ABx, resolves
5 wks PTA
Visits ex-fiancee in Rhode Isl.
Feeling well
No significant exposures
More HPI…
3 wks PTA
Goes to Sonoma with friends for a week
Returns to SF feeling well
1 wk PTA
Goes to Pittsburgh for a funeral
Starts feeling ill: diaphoretic, chills, fatigue
Skips the funeral, returns to SF
Develops diarrhea, epistaxis, confusion
Brought to the ER

A bit more about Sonoma…
• A group of friends stayed at a house in Sonoma
• Copious quantities of food and wine consumed
• Spent lots of time in a hot tub
• One of the other guests had flown in from India
and had flu-like symptoms and “a stiff neck”
• Many of the other guests developed flu-like sx
while they were there (our patient did not)
• The house in Sonoma said to have once had a
“rodent problem,” but this was thought to be
under control

More History
•PMH: none
• Meds: none
• SH/Exposures:
– Lives in the Mission District of SF, works
downtown as a computer analyst
– No tobacco, occasional EtOH
– H/o remote Ecstasy use, none currently and
no h/o IVDU
– No pets
– Sexual history unclear
•FH:none

The most salient clue here is…
1. Hot tub
2. Rodents
3. Wine
4. Pittsburgh
5. Ecstasy use
6. Computer analyst
7. Flu in friends
8. Diarrhea

Physical Exam
• VS: Temp 39.0, BP 136/84, HR 148, RR
30, O2 98% on 100% NRB � intubated
• General: Sedated
• HEENT: PERRL, OP clear
• Lungs: Bilateral rhonchi
• CV: Tachy, no MRG
• Abd: Soft, NT
• Extremities: No edema
• Meuro: Alert and oriented x 4, non-focal.
Neck supple

15
42
126
Diff: 98% PMNs
133
2.7
97
19
Data
54
142
3.6
1.1
385 76
55
coags nl
lipase 85
CK 16,000

CXR

Chest CT

I think this is most likely to be…
1. Wegener’s granulomatosis
(or whatever they’re calling it these days)
2. Influenza pneumonia
3. Coccidiomycosis
4. Pneumocystis pneumonia
5. Tularemia
6. Tuberculosis
7. Legionella pneumonia
8. Endocarditis
9. Hantavirus

Microbiology
• HIV Ab and VL: negative
• Blood Cultures x 4: negative
• Influenza A and B: negative
• Trach aspirate x 2: oral flora
• Sputum AFB x 3: negative

Hospital Course
• The patient was started on ceftriaxone and
azithromycin
• He remained febrile and his WBC
remained at 15
• CVVH begun for rhabdo/ARF
• On HD#3, ABx were changed to
vanc/cefepime/azithro
• ID was consulted on HD#6 given lack of
improvement

A diagnostic procedure was
performed

Gurpreet Dhaliwal,
Gurpreet Dhaliwal,
what is your…
final answer?

Legionella testing returns
• Legionella urine antigen positive
• Legionella culture was negative (sent 7
days into therapy)
• Legionella Ab (against L pneumophila
serogroup 1):
– IgM 1:64 (normal is

Case Follow-up
• He was treated with azithromycin 500mg
IV daily for 2 weeks
• He was extubated after 2 weeks and
was weaned off hemodialysis
• He was discharged ~3 weeks after
admission in good condition

Legionella: History
• American Legion convention,
July 1976 at the Bellevue-
Stratford Hotel in Philadelphia
• 221 cases, 34 were fatal
• An EIS led investigation
eventually identified Legionella
pneumophila
• Use of an antibody test led to
the discovery that several prior
unsolved PNA outbreaks (as
far back as 1947) had been
due to Legionella Bellevue-Stratford Hotel, Philadephia
(closed 1976-79 but then re-opened)
Fraser, 2005. The challenges were legion. Lancet ID 2005.

College Students Self-Medicating

Microbiology/Ecology
• Natural habitats:
– Aquatic environments (streams, ponds, thermal pools)
– Moist soil, mud, potting soil
– Optimal growth temperature of 35°C
• All outbreaks associated w/ man-made aquatic
habitats:
– Human-made water sources with warm water:
• Air-conditioning towers, hot water systems, shower heads,
whirlpool spas, respiratory ventilators, fountains, ice machines
• Construction can lead to alterations in plumbing
– Often form biofilms in water systems, and thus can
survive chlorination or biocides
• Transmission: inhalation by aerosol
Diederen. Legionella spp and Legionairres’ Disease. J Infection 2008.
Fields et al. Legionella and Legionnaires’ Disease. Clin Micro Rev 2002.

Host Risk Factors
• Increased age (peak in the 60s-70s)
• Males>females
• Impaired respiratory or cardiac function
• Alcoholism
• Tobacco use
• Immunocompromise (cancer, AIDS, ESRD)
• Diabetes mellitus
• Travel (hotel, campsites, cruise ship) in
25%

• Legionella
accounts for 2-
15% of CAP in
various studies
• Considered one
of the main
causes severe
CAP
Legionella and CAP
Falco et al. Legionella pneumophila: A cause of severe CAP. Chest 1991.

Legionella: Clinical Findings
• Incubation 2-10 days
• Clinical features:
– Fever, myalgias, headache, anorexia common (may be
prodrome)
– Non-productive cough, dyspnea
– Diarrhea
– Neuro symptoms: especially AMS
• Labs:
– Elevated CK, hyponatremia, abnormal LFTs
– Pancreatitis (rare)
• Mortality rate
– 10% (down from 26% in 1970s)
Diederen. Legionella spp and Legionairres’ Disease. J Infection 2008.

Legionella vs Strep Pneumo
• Less likely pleuritic,
purulent; more likely
GI, neuro sxs
• No difference in initial
CXR
– But Legionella often
progressed to
multilobar
involvement
• Labs:
– No difference in
hyponatremia
– Legionella more likely
to have elevated
AST/ALT, alk phos,
creatinine
Falco et al. Legionella pneumophila: A cause of severe CAP. Chest 1991.

Infectious Causes of Rhabdo
Viral Infections
• Due to direct viral
invasion of muscle
• 34% had ARF, 8% died
• Etiology (# cases):
– Influenza A and B (25)
– HIV (8)
– Coxsackie (8)
– EBV (5)
– Echovirus (4)
– CMV, adenovirus (2)
– HSV, parainfluenza, VZV
(1)
Bacterial Infections
• Due to toxin generation and
direct muscle invasion
• 57% had ARF, 38% died
• Etiology (# cases)
– Legionella (14)
– Francisella tularensis (9)
– Strep pneumo (8)
– Salmonella (6)
– Staph aureus (5)
– GAS, GBS, Listeria, Vibrio (2)
Singh and Scheld. Infectious causes of rhabdomyolysis. CID 1996.

Take Home Points
• Clues to diagnosis of Legionella pneumonia:
– Water exposure (hot tub, spa, plumbing work)
– Recent travel (within 2 weeks)
– Elevated CK, transaminases
– Negative cultures
– Severe PNA requiring ICU care
• Diagnosis best made by combination of urine Ag (best
sensitivity and specificity) with sputum culture (for
detection of other subtypes, serogroups, species)
• Treat with levofloxacin or azithromycin

• Seth Cohen
• Kara Bischoff
• Jenn Babik
Thank You

Helen Keller on Exposures
“Avoiding danger is no
safer in the long run than
outright exposure. The
fearful are caught as often
as the bold.”