A young female w/ history of Crohn’s in remission presents with fever + RUQ pain found to have transaminitis + neutropenia with an odd-looking “collapsed gallbladder” on imaging. She is being treated broadly for cholecystitis, but the underlying cause of her imaging findings is still unclear; GI and Surgery are involved.
1. Although PSC more commonly occurs in UC patients, it is also (though less) associated with Crohn’s Disease.
2. Acute Liver FAILURE requires the presence of INR > 1.5 and encephalopathy. This patient did NOT have acute liver failure.
3. Neutropenic fever pearls
-As Morgan noted, the diagnosis and management of “neutropenic fever” we often discuss strictly applies to chemotherapy-induced neutropenia. The infectious risk in patients with non-chemotherapy neutropenia of unclear etiology ranges from benign to life-threatening; the infectious risk is highest when neutropenia is related to bone marrow suppression or vasculitis. However, when the risk is unknown it is reasonable to manage ALL people with neutropenic fever with broad-spectrum antibiotics including pseudomonal coverage.
-Infectious risks are highest when ANC < 500 AND duration of neutropenia is >7 days
A middle aged woman w/ obesity who presents with sudden onset profuse diarrhea and SIRS. She was initially sent home after a CT was negative at her first ED visit, but represented two days later with worsening symptoms and temperature to 104. A CT was ultimately repeated with IV and PO contrast, and showed diverticulitis c/b contained perforation.
*The sensitivity and specificity of abdominal CT [with oral AND IV contrast] for the diagnosis of acute diverticulitis are 94 and 99 percent, respectively
*25% of patients with acute diverticulitis have associated complications – complications include bowel obstruction, abscess development, fistula, or a colonic perforation (as seen in this case)
*Indications for urgent surgery: failure of medical treatment, obstruction, abscess failing nonoperative intervention
An elderly male w/ CAD and prior MI, afib, CHB now paced, HTN presents with chest pain “that feels like my last MI”. He had a fairly negative workup and was treated briefly with heparin for MI vs PE, but this was ultimately stopped when LFTs showed transaminitis with a late-peaking bilirubin, most consistent with a passed stone.
How do I interpret signs of ischemia in someone who is ventricular-paced? (Hint – there’s no foolproof way…)
-Compare to prior EKGs and look for changes
-Look for ANY non-paced beats that conduct via the AV node (ie narrow QRS). All of these native beats are still interpretable for ischemia
The definition of hepatojugular reflux:
We discussed this often confusing physical exam maneuver. The most important thing is that you hold pressure for at least 10-20 seconds to see if the rise in JVP sustains – if it sustains that long, then the test is abnormal. Normal subjects will have a JVP that rises initially but returns to normal within seconds.