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History: A 60 yr male k/c/o of HTN, Type2DM, and hyperlipidemia presents to the ER with the first episode of rapid palpitations, sob, and chest discomfort. Physical exam shows an irregularly irregular radial pulse at a rate 130 bpm, BP 110/70 mmHg, and RR 20 bpm. Heart sounds are irregular, but no third or fourth heart sound gallop or murmurs are audible. What’s the diagnosis?

Answer: Acute atrial fibrillation (AF) is a episode of a chaotic and irregular atrial arrhythmia. Prevalence increases progressively with age. AF causes significant morbidity and mortality including palpitations, dyspnea, angina, dizziness or syncope, and features of congestive heart failure, tachycardia-induced cardiomyopathy, stroke, and death. ECG shows absent P waves, presence of fibrillatory waves, and irregularly irregular QRS complexes. Treatment in hemodynamically unstable patient is DC cardioversion. In stable patient do rate control with beta-blocker and/or calcium-channel blocker +/- anticoagulation +/- electrical cardioversion or chemical cardioversion with drugs. If the precise timing of the onset of AF is unclear, a transesophageal echocardiogram must be performed to exclude left atrial clots before cardioversion.

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Question: Which of the following tests can be used to make the definitive diagnosis of this disease?

1.  Biopsy showing Donovan bodies
2.  Giemsa stain showing intracytoplasmic inclusion bodies
3. Potassium hydroxide preparation (KOH prep)
4.  Serology
5. Tzanck smear

Answer: This picture shows lesions of Molluscum contagiosum. These lesions may occur in single or multiple lesions. It is spread skin-to-skin contact and is most common in infants, sexually active adults, and immunocompromised individuals. A Giemsa stain of the keratotic core will show intracytoplasmic inclusion bodies or “molluscum bodies.” These lesions usually resolve in 6–24 months without specific treatment. Tape may be applied after showers to prevent friction and spread of the lesions. Other treatments that could be prescribed by a dermatologist include topical cantharidin (blister beetle fluid) applied in the office or imiquimod (Aldara) every day three to five times per week at home to speed the resolution of the lesions. Donovan bodies are seen with granuloma inguinale. KOH prep is used to help visualize the hyphae seen in fungal etiologies of skin lesions. Serology is used for syphilis diagnosis. Tzanck smear is used to help diagnose herpes lesions.

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History: A 19-year-old male presents with a rapid onset of shortness of breath. There is no history of trauma or chronic medical disease. The patient has no risk factors for thromboembolic disease. The following x-ray is consistent with which of the following conditions?

1. Atypical pneumonia
2. Spontaneous pneumothorax
3. Metabolic bone disease
4. Hampton hump

Anwer: The x-ray demonstrates a spontaneous pneumothorax on the right with a small hemothorax in an otherwise healthy young individual. Management of primary pneumothorax includes aspiration of pleural air either by needle thoracostomy or small catheter with or without Heimlich valve. A Hampton hump is a classic sign of pulmonary embolism with pulmonary infarction that is described as a pleural-based triangular wedge with base along the pleural surface and the top of the triangle pointing toward hilum. This is opposed to Westermark sign that is a sign of vascular oligemia distal to the location of a pulmonary embolism and is described as dilation of proximal pulmonary arteries and collapse of distal vessels. An atypical pneumonia would have a different radiographic appearance including patchy or subsegmental infiltrate. There is no evidence of cortical irregularities or displaced rib fractures on this chest radiograph and there is no history of trauma. Metabolic bone disease would likely manifest with some bony lesion either as lytic lesions or osteopenia.

Clinical Rounds by ClinicHours

History: A 65 yr old diabetic woman complains of 1 week of lower anterior molar pain and now with 24 hours of sore throat, difficulty swallowing, and sweats. On physical exam, she is anxious and having difficulty breathing. She has significant trismus and so the pharynx is not visualized. Her tongue appears elevated and she is unable to protrude it beyond her teeth, and the sublingual space is indurated and elevated. What is the next best course of action?

1.  Administer broad-spectrum antibiotics and drain the submandibular abscess.
2. Perform a cricothyroidotomy, administer intravenous fluoroquinolone, order a CT scan, and emergent head and neck surgery consultation.
3. Perform rapid sequence endotracheal intubation, administer intravenous ampicillin–sulbactam, order a CT scan, and emergent head and neck surgery consultation.
4. Perform rapid sequence endotracheal intubation, administer intravenous fluoroquinolone, order a CT scan, and emergent head and neck surgery consultation.
5. Perform awake fiberoptic endotracheal intubation, administer intravenous ampicillin–sulbactam, order a CT scan, and emergent head and neck surgery consultation.

Answer: This patient presents with classic sublingual, submandibular space infection known as Ludwig angina. The tongue can be rapidly displaced posteriorly occluding the airway. The airway of choice is awake fiberoptic endotracheal intubation or awake tracheotomy. A CT of neck and intravenous antibiotics (penicillin, ampicillin–sulbactam and clindamycin) are the preferred choice, and incision and drainage by head and neck surgeon is the appropriate treatment.

Clinical Rounds by ClinicHours

History: A 40 year-old man presents with right neck pain that started while he was wrestling with his friend 2 days ago. Today he also has a right-sided frontotemporal headache and complains that he can hear his heartbeat ringing in his right ear. Vital signs are normal. There is no evidence of head or neck trauma. Neurologic exam shows the abnormalities of the right eye seen. What is the most likely diagnosis?

1. Carotid artery dissection
2. Right third cranial nerve palsy
3. Severe neck strain
4. Temporal arteritis
5.  Vertebral artery dissection

Answer: 1. Carotid artery dissection is uncommon but is a significant
cause of stroke in the young. It usually occurs after major or minor neck trauma. The most common symptom is headache, which is usually frontotemporal, followed by neck pain; pulsatile tinnitus occurs occasionally. Neurologic abnormalities, classically a partial ipsilateral Horner syndrome (no anhydrosis), often occur days after the onset of pain and can be quite subtle. In this case the patient’s right eye miosis is obvious, but the ptosis is very mild.

Neck strain would be a diagnosis of exclusion and is less likely here given the classic presentation of carotid dissection.

Third cranial nerve palsy produces severe ptosis, pupillary dilation, and ophthalmoplegia.

Temporal arteritis occurs almost exclusively in those older than 50 years and is not associated with trauma.

Vertebral artery dissection also occurs after neck trauma but usually causes occipital and nuchal pain and brainstem deficits such as vertigo and ataxia.

Clinical Rounds by ClinicHours