Educational Objective:

Screen for ovarian cancer.

Key Point:

There is not currently a viable screening test for ovarian cancer, and it is unfortunately usually detected on the basis of nonspecific symptoms such as pelvic fullness or vague gastrointestinal complaints.

Explanation:

Ovarian cancer is diagnosed in late stages in nearly all cases because of its insidious onset and vague symptoms. Most ovarian neoplasms grow quickly and painlessly, causing symptoms that may be found in any number of nonmalignant conditions. Much effort is concentrated on finding an effective screening tool because diagnosis during early stages would make the disease more curable and, thus, improve our ability to prevent deaths from ovarian cancer. However, no tool has yet been found that is helpful in the general population. CA-125 is elevated in nearly all cases of ovarian cancer, but it is also elevated in many nonmalignant conditions as well. In addition, performing this costly test on everyone to detect the small percentage of women with ovarian cancer is not cost effective.

Two studies looking at the value of screening ultrasonography showed that 5 cancers were found out of 5000 studies, and 6 cancers were found out of 6470 studies. These numbers are not cost-effective, and, furthermore, they resulted in unnecessary surgeries for many women in whom abnormalities were found that were not dangerous or malignant.

Yearly pelvic examinations may be helpful, but a study showed that 10,000 examinations must be performed to find 1 ovarian cancer. Sedimentation rates are nonspecific and not an effective screening tool for anything. The best chance found for early diagnosis of ovarian cancer is for healthcare professionals to have a high index of suspicion in any patient with persistent, vague gastrointestinal complaints that remain undiagnosed, as these may be initial symptoms of ovarian cancer.

Reference:

Eisenhauer EL, et al. Epithelial ovarian cancer. In: Di Saia PJ, Creasman WT. Clinical Gynecologic Oncology. 8th ed., 2012:285-328.

Educational Objective:

Recognize the risk factors for recurrent bleeding from peptic ulcer disease.

Key Point:

Endoscopic findings during the treatment of peptic ulcer disease can predict the risk of recurrent or persistent bleeding. Of the possible findings, active bleeding is most strongly associated with recurrent bleeding and a high rate of mortality.

Explanation:

The details of this patient’s endoscopic treatment may predict whether or not her hematemesis represents rebleeding of her ulcer or bleeding from a new or overlooked source.

According to the Forrest classification of upper gastrointestinal bleeding, which stratifies the re-bleeding risk based on endoscopic findings, active (spurting) bleeding on endoscopy confers the highest risk of recurrent bleeding, with a 55% incidence of rebleeding from the same site as well as a mortality rate of 11%.

A nonbleeding, visible vessel is the next worst prognostic factor, with a 43% risk of recurrent bleeding and an 11% mortality rate (lower rebleeding risk but same mortality rate as active a bleeding vessel).

Clean-based ulcers and flat, pigmented spots confer less than a 10% risk of recurrent bleeding.

Forrest classification

Acute hemorrhage

• Forrest I a (Spurting hemorrhage)
• Forrest I b (Oozing hemorrhage)

Signs of recent hemorrhage

• Forrest II a (Non bleeding Visible vessel)
• Forrest II b (Adherent clot)
• Forrest II c (Flat pigmented haematin (coffee ground base) on ulcer base)

Lesions without active bleeding

• Forrest III (Lesions without signs of recent hemorrhage or fibrin-covered clean ulcer base)

Follow this link to the online calculator.

Note: various authors list slightly varying re-bleeding risk, based also on statistics before or after endoscopy.

References:

Kovacs TO, Jensen DM. Gastrointestinal hemorrhage. In: Goldman L, Schafer AI. Goldman-Cecil Medicine. 2016: 879-884.e2.

Forrest Classification of Upper GI Bleeding

"Stomach: Forrest classification in Atlas of Gastroenterological Endoscopy by A. Freytag, T. Deist". 

Lee AW, Hess JM. Esophagus, Stomach, and Duodenum. (Chapter 79) In: Walls R, et al. Rosen’s Emergency Medicine: Concepts and Clinical Practice. 9th ed., 2018: 1067-1082.e2

Educational Objective:

Discuss treatment of endophthalmitis.

Key Point:

Endophthalmitis is a medical emergency that should be treated with intravitreal antibiotics and vitrectomy.

Explanation:

The patient has acute postcataract endophthalmitis, a common cause of endophthalmitis usually presenting in the first postoperative weeks. The presentation is with blurry vision and ocular pain. Physical findings include conjunctival chemosis, a decrease of visual acuity, and hypopyon. The diagnosis is confirmed with aspiration of aqueous or vitreous fluid. The condition is a medical emergency and should be treated with empirical intravitreal antibiotics such as vancomycin and amikacin. Debridement of the inflamed vitreous, also called vitrectomy, is the surgical treatment of choice.

A canaloplasty is used for the treatment of glaucoma and is not recommended in cases of bacterial endophthalmitis. IV antibiotics do not penetrate appropriately in the eye and likely do not offer an additional advantage over intravitreal antibiotics. Injection of ranibizumab is indicated in patients with macular degeneration.

References:

Chen YH, Chen JT, Tai MC, Chou YC, Chen CL. Acute postcataract endophthalmitis at a referral center in northern Taiwan: Causative organisms, clinical features, and visual acuity outcomes after treatment: A retrospective cohort study. Medicine (Baltimore). 2017 Dec;96(49):e8941.

Taban M, Behrens A, Newcomb RL, Nobe MY, Saedi G, Sweet PM, McDonnell PJ.Acute endophthalmitis following cataract surgery: a systematic review of the literature. Arch Ophthalmol. 2005 May;123(5):613-20.

Most patients with PID are treated in an outpatient setting. Patients should be re-examined within 72 hours after initiation of therapy and should demonstrate substantial clinical improvement (i.e., defervescence; reduction in rebound or direct abdominal tenderness; reduction in uterine, adnexal, and cervical motion tenderness). Patients who do not improve usually require hospitalization, additional diagnostic tests, and possible surgical intervention.

According to the Centers for Disease Control and Prevention, criteria for hospitalization of women with PID include (2014 guidelines):

1. Inability to exclude surgical emergencies (e.g., appendicitis, ectopic pregnancy)
2. Pregnancy
3. Tubo-ovarian abscess
4. Severe illness
5. Nausea and vomiting
6. High fever
7. Non-response to oral therapy. This is defined as failure to respond clinically to outpatient antimicrobial therapy within 48-72 hours, or the inability to tolerate an outpatient oral regimen.

References:

2015 Sexually Transmitted Diseases Treatment Guidelines. CDC Website. Accessed January 30, 2019

Brunham RC, Gottlieb SL, Paavonen J. Pelvic inflammatory disease. N Engl J Med 2015 May;372(21):2039-48.

Bleeding, bruising, thrombotic episodes, cerebrovascular accidents, myocardial infarction, or deep venous thrombosis are the most common manifestations of primary polycythemia.

Janz Glen et al. Anemia, Polycythemia, and White Blood Cell Disorders. In: Marx JA, et al, eds. Rosen's Emergency Medicine: Concepts and Clinical Practice. 7th ed., 2009

Educational Objective:

List the signs of globe penetration in ocular trauma.

Key Point:

With a high-speed and relatively heavy object hitting the eye, lack of visualization of a foreign body should prompt a search for globe penetration.

Explanation:

Although this could be a "burn and bounce" injury from hot steel, this would only be a diagnosis of exclusion. Globe penetration is a real risk in this patient, and further examination and referral are indicated. Thus, the next most appropriate course of action would be to examine the fundus for a foreign body in the vitreous. Eye pressure should NOT be checked in a suspected open globe injury. Anterior chamber cell and flare would not be present 30 minutes after an injury and is also not the most important concern at this point.

Globe Perforation, Old, with Lens Opacification

Though the corneal laceration is not easily identified, note the peripheral tear in the iris at three o'clock. The foreign body penetrated the cornea (which self-sealed), the iris, and then the lens (now with secondary opacification).

Reference:

Guluma K, Lee J. Ophthalmology (chapter 61). In: Walls R, et al. Rosen’s Emergency Medicine: Concepts and Clinical Practice. 9th ed., 2018:790-819.

Injury to the meniscus of the right knee

Individuals who experience a meniscus tear usually experience pain and swelling as their primary symptoms. Another common complaint is joint locking, or the inability to completely straighten the joint. This is due to a piece of the torn cartilage physically impinging the joint mechanism of the knee. The best imaging test for meniscus injury is the MRI.

Minor surgery in a walk-in surgical center Medicare Part A will pay for medically necessary inpatient care and supplies.

Therefore, any type of surgery that is done in outpatient settings, such as a walk-in surgical center, will not be reimbursed. If plastic surgery is medically necessary (e.g., plastic surgery to repair facial damage from a burn), then it will be reimbursed. Costs for organ transplantation, such as kidney transplants, are reimbursed.

Mitral stenosis

The most common complication of mitral valve prolapse (MVP) is mitral valve regurgitation (mitral insufficiency). An abnormal mitral valve increases the chance of developing endocarditis from bacteria, which can further damage the mitral valve. Doctors used to recommend that people with MVP take antibiotics before certain dental or medical procedures to prevent endocarditis (not a current practice). Stroke is a very rare complication of MVP.

A positive RST is considered a reliable indication that group A betahemolytic streptococcus (GABHS) is present in the oropharynx.

The RST has a 90% to 95% sensitivity for detecting GABHS (much lower if antibiotics were already taken), though a positive antistreptolysin O blood test is still the only valid method for confirming a GABHS infection. A negative RST is less useful; the patient might still have undiagnosed GABHS and remain at risk for developing rheumatic fever.

Most cases of pharyngitis/tonsillitis are due to viral agents and follow a benign, self-limiting course. Overall, the presence of viral symptoms such as cough, coryza, and rhinorrhea and the absence of cervical adenopathy make GABHS (or any other bacterial pharyngitis/tonsillitis) less likely, whereas high fevers, marked cervical adenopathy, a sandpaper rash (scarlet fever) and the absence of cough, coryza, and rhinorrhea makes a diagnosis of GABHS more likely. But this distinction is only moderately reliable and the positive diagnosis of "strep pharyngitis" can only be made in the context of bacterial confirmation with a test. Unfortunately, it is clinically impossible to reliably distinguish bacterial from viral pharyngitis.

Bacterial pharyngitis due to GABHS peaks in the 5 to 15 year old group, but can occur at any age. In children within this age range, GABHS is the number one cause of bacterial phayrngitis. In adults, acute bacterial pharyngitis is typically caused by all groups (not just group A) of betahemolytic streptococci (23%), Mycoplasma pneumoniae (9%) or Chlamydia pneumoniae (8%).

GABHS must be treated within 9 days to prevent rheumatic fever - a complication that occurs in 0.3 % of patients. Another complication - poststreptococcal glomerunephritis - is not affected by antibiotics.

Exudate does NOT necessarily point to a bacterial infection. Adenovirus is common and can present with an especially severe pharyngitis/tonsillitis with a large amount of white exudates.

Pearl: Influenza (scratchy throat) and syphilis (painless lesions) are two infections of the pharynx that are less commonly associated with exudates. See the second reference for good pictures of pharyngitis from various causes.

References:

Lean, Wei Ling, et al. "Rapid diagnostic tests for group A streptococcal pharyngitis: a meta-analysis." Pediatrics 134.4 (2014): 771-781.

Subashini, Beula, Shalini Anandan, and Veeraraghavan Balaji. "Evaluation of a rapid antigen detection test for the diagnosis of group-A beta-hemolytic Streptococcus in pharyngotonsillitis." Journal of global infectious diseases 7.2 (2015): 91.

Educational Objective:

State the complications a mother who smokes during pregnancy may have with pregnancy or with her neonate.

Key Point:

A pregnant woman who smokes tobacco is more likely to have an ectopic pregnancy, placenta previa, placental abruption, and premature rupture of membranes. Her neonate is more likely to have a low birth weight, fetal growth restriction, cleft lip, and cleft palate.

Explanation:

A woman who smokes tobacco before pregnancy is more likely to become infertile; have an ectopic pregnancy, placental previa, or an abruption; or experience premature rupture of membranes.

She is also more likely to deliver prematurely and deliver a neonate with a low birth weight, fetal growth restriction, or a cleft lip or cleft palate. Her baby is also more likely to die of sudden infant death syndrome.

References:

Centers for Disease Control and Prevention. Tobacco use and pregnancy. Revised September 29, 2017. Accessed March 1, 2019.

Little leaguer's elbow refers to a constellation of findings in the adolescent as a result of damage to the immature epiphyses within the elbow joint from repetitive throwing. The injuries can include avulsion fracture of the medial epicondyle (most common) or compression fractures of the subchondral bone of the lateral epicondyle or radial head. Adolescent athletes with this condition should be forced to rest the elbow and referred (orthopedics or sports medicine) for follow-up. Epicondylitis is thought to result from activities that require repetitive pronation and supination of the forearm. Symptoms include pain over the lateral epicondyle or radiohumeral joint, and radiographs are usually normal. Olecranon bursitis presents with pain, tenderness, and swelling over the olecranon, and is usually the result of repetitive minor trauma (e.g., leaning on the elbow while working on the floor). The most important aspect of the evaluation of an olecranon bursitis is to separate a benign inflammatory process from the more malignant septic entity. Aspiration of the bursa is both therapeutic and diagnostic.

Reference:
Behrman RE, Kliegman RM, Jenson HB (eds): Nelson Textbook of Pediatrics, 17th ed. WB Saunders Company, Philadelphia, 2004