Dx of CHF in Dyspneic Pt: Need Echo?

53M PMH unknown 30 pack-year smoker presents with dyspnea to the ED. It's 2AM Saturday morning. The ED is PACKED with traumas, boarders, psychos… not to mention med students, residents & nurses strung out on caffeine or their stimulant of choice. Pt is desat'ing. Need to decide quick: Diuresis vs. Nebs? Diuresis won't help a dried out COPDer, and adrenergic nebs won't help a drowning CHFer. Echo Tech unavailable (this county hospital makes strategic budget cuts). 

How do you proceed?

NB: The H&P is very useful! Take the time to interview & examine the patient. Tell the med students & nurses to QUIET DOWN so you can hear that S3!

PV CHF LRs Collection:
Rivas CHF Dx Stats Collection:

NB2: Keep in mind that in CHF most findings are not conditionally independent  so usually cannot combine LRs for post-multiple-tests probabilities. Instead, rely on the most powerful finding you discover in that case (e.g. S3 to confirm dx or BNP less than 100 to exclude dx of CHF in dyspneic pt). Awesome free online course on Medical Decision Making btw. 

ROC Curves [BNP outperforms Echo EF%]



NB3: Here's the that shiny pearl you were waiting for…

CHF Dx Algorithm

NB4: This algorithm makes it look like H&P is useless. It's EXTREMELY useful (see LR tables above)! If you still can't make the diagnosis, obtain ECG & CXR. It should be the rare case when H&P+EKG+CXR is insufficient to make the diagnosis. In those scenarios, order BNP. Then, if BNP is indeterminate, perform bedside echo for Doppler MV Analysis for low Early/late (E/A) velocity ratio or short MV flow velocity Deceleration Time (DT) to cinch the diagnosis. Refer back to Rivas CHF Dx Stats. 

Explanation of MV E/A Ratio from Echo Doppler:

How to perform bedside Echo doppler MV assessment?
- Liz Turner from UC Irvine on FATE Exam: http://www.youtube.com/watch?v=9ybQ10m3uEY
- - That didn't quite answer my question, but came close. #FOAMed US gurus out there, help us out! Teach US!

Sources:
See losrivas EN Note. 

Ultrasound before MCTPA for PE dx

57M PMH COPD on home O2, smoker, CHF (baseline EF 30%), HTN, DM, obese (BMI 35), CKD (baseline Cr 1.6) presents to the ED with acute onset sharp, pleuritic chest pain at the right anterior chest radiating to the right axilla. Sinus tach on EKG with LVH & TWI that were present on prior EKGs. Tachypnea, O2 sat 90% on 4L NC. Afebrile. BP 127/89. A rhonchi & rales bilaterally. 3/6 holosystolic murmur throughout precordium. Obese abdomen. Bilateral LE edema pitting to the knees. Cr 2.2. WBC 12. CXR poor inspiration, bibasilar interstitial congestion, cardiomegaly, no pneumothorax, no fractures. It's a saturday night (skeleton crew - U/S tech isn't in, radiologist is tele-radiology, only one CT-tech in house with multiple emergent CTs in que). Pt has had multiple chest CTs in the past.

What's the risk of PE? Do you order a D-dimer? If you have a moderate to high suspicion for PE, do you go straight to CTPE? What about the likely delay in CT & the pt's acute on chronic renal failure? Another CT - are you worried about radiation exposure? Is there a way to spare this pt the CT?

A new study provides insight on a new diagnostic algorithm to to reduce the burden of CT for PE in the ED - if you've got the docs with the right skills! And again ALiEM provides PV Cards for easy access to relevant diagnostic & treatment rules and MDCalc helps too!

Dx of Meningitis - CT before LP

25M college student p/w worst headache of his life, fevers, chills, painful & stiff neck. PMH epilepsy. Off meds. Hasn't had a seizure in 10 years. No other significant past medical. Tachy, febrile, tachypnic, normal O2 sat. Positive nuchal rigidity on exam. Oriented, follows commands, no motor or gaze palsy. WBCs 14. Does he need a head CT before LP?

Click here for a JAMA Rational Clinical Exam piece on bedside dx of acute meningitis (can you trust Kernig and Brudzinski?), the study that established the CT before LP rules, and some useful cards from ALiEM's PV series to enhance your bedside recall of these rules.

tPA for the Management of Acute Ischemic Stroke - FreeOAM vs. {industry funded} Guidelines

In noon conference today, the presenting resident reviewed the AHA/ASA March 2013 guidelines on management of acute ischemic stroke. It was a good overview of the guidelines, but there wasn't a lot of room for debate on the evidence for and against tPA in this scenario. Luckily I've been privy to the tPA in acute stroke debate in the #FOAMed community.

Mini FOAMed Lit Review on the use of tPA for the management of acute ischemic stroke:

1. Emergency Med Lit of Note were out of the gate quick early this year to question the integrity of the ACEP guidelines on this topic.
2. theNNT convinced me with their thorough evidence based review. Their "red light" made it clear to me what the answer is on this topic. 
3. Recently LiTFL posted a two part series on this topic by Michelle Johnston. She left the final decision on the validity of tPA use for this indication to the reader, but her analysis is thorough and presents a strong case to exercise caution when considering tPA. 
4. Just this morning ALiEM's Todd Seigel posted a review focused primarily on the NINDS study, AHA, & ACEP guidelines. His post stands in contrast to the other FOAM contributions to this debate, and Graham Walker of theNNT & MDCalc was quick to point out this contrast. 

But can FOAMed stand up to 3 major organizations (AHA, ASA & ACEP) all arguing strongly for use of tPA in select patient groups?

Thankfully, there's at least one organization that has stood strong & reasonable. The AAEM have put out statements, commentaries, educational material, & letters all asking for an injection of evidence-based, calmly considered, carefully weighed thought, skepticism, debate, and further investigation on this topic. 

Despite some guidelines, it can at least be said, tPA for the management of acute ischemic stroke is not the standard of care.

Bad Belly

57 year old male with a long history of heavy alcohol consumption presents with complaints of severe abdominal pain and nausea. On exam he's mildly agitated and disoriented to time. Mildly febrile, tachycardic, tachypnic, blood pressure 90s/50s, normal O2 saturation. Jaundiced, numerous spider angiomata including telangiectasias on his face, arms, and chest. Abdomen is grossly distended, obvious fluid wave, and diffusely tender, no guarding but tenderness is elicited on abdominal percussion and rebound.

What acute illness to you most suspect? How will you confirm the diagnosis? How will you perform the diagnostic test? What results do you suspect? If results confirm your suspicion, how will you manage the patient?

Click here for checklists, videos, and guides on this diagnostic question.

Alkaline Phosphatase and Shortness of Breath

A twenty year-old black female presents to the emergency department complaining of gradually worsening shortness of breath, very gradually worsening over 3 months. She tried her friend's inhaler but it provided no relief. Her only other complaint elicited on review of systems is a new bothersome rash on her shins.

On exam she is a slender woman. Vitals are normal. She has trace wheezes in the mid to upper lung fields bilaterally. Her breaths are somewhat shallow even when asked to "take a deep breath". She has about a dozen slightly raised, tender, mildly erythematous round lesions approximately 1cm in diameter on her pre-tibial legs bilaterally.

Labs are notable for an alkaline phosphatase of 156. Her calcium was elevated at 10.8. Other labs were unremarkable.

What diagnosis do you suspect? What is the next test you would order? What are the results you expect?

Click here to find out.

How do you remember the MEN syndromes?

Have a good mnemonic for remembering the MEN syndromes? If so, post it in the comments.

Check out this link for a great mnemonic for this!

Headache & Weakness

Case (What's the diagnosis, how do you know, and what is your management strategy?):

A 25-year-old female presented to the emergency department complaining of flashing lights in her right eye that started one hour earlier while watching a home movie. The patient reported that while trying to read, she was unable to discern the words but could understand words spoken to her. She also felt disoriented and thought that she was slurring her words. Following the onset of numbness in her lips, she noted weakness in her right leg. A bilateral parietal headache occurred shortly after the symptoms began. She denied any history of headaches and had no other medical problems. She was not pregnant and was not taking any medications. She denied use of illicit drugs or alcohol. Her family medical history was negative for migraine headaches. She was afebrile, with blood pressure 152/76, heart rate 96, respiratory rate 24, and oxygen saturation 100%. On physical examination, she had ptosis of her right eye and decreased sensation around the right side of her mouth. A right homonymous hemianopsia was present. Her right lower extremity muscle strength was 4/5 compared to 5/5 on left lower extremity. She ambulated well but had difficulty turning around to return to bed, stating she felt disoriented. Her headache was persistent during the examination but she had no photophobia. Complete blood count and electrolytes were within normal limits. Her urine drug screen was negative. There were no acute findings on head CT without contrast. Within 2 hours, her symptoms and headache completely resolved. In a young female with no prior medical history, what could this be?


Click here for the source of this case, the answers to the case, and a good review on management of this illness.

Alkaline Phosphatase: Sources

What are the sources of Alkaline Phosphatase?
What's a good Mnemonic to remember this differential Diagnosis? See link for answers.

Post in comments other mnemonics, memory tools, or trivia on this topic.