Case -- Riddle

[jmj11]

jmj: good case.  I will admit I am not very good at fundoscopic exams.  I'm betting at the ER it wasn't done. I will take this case to heart and  work at doing better fundoscopic exams.  I honestly don't know why I find them hard to do....I also have had difficulty looking at things under a microscope.  Too much stuff floating around, but it could be my eyes and the posterior vitreous detachments that I get...IDK. 

 

Does anyone have any tips?

A Panoptic will double what you can see in the un-dilated eye.  Just my opinion.  I couldn't see crap in an old (person's) undilated eye, that required a lot of correction with my old W.A. scope. I can at least see the optic nerve in everyone now.

[Boatswain2PA]

I can't tell you the last time I tried looking at a fundus.  Perhaps if/when anywhere I work gets a panoptic than I will start looking again, but until then a fundoscopic exam in the ED just exposes me to their bad breath and influenza.

Asymptomatic (no HA/dizziness/vision/urinary/CP/cough/breathing/etc) elevated HTN in the ED = f/u with PCM asap.  Since where I work my patients typically have very good follow up, I MIGHT start them on HCTZ (or, more commonly, re-start them).

Any symptoms, as in this case a HA, they get a full HTN workup in the ED.  CMP, trops, EKG, CXR.  That would've found the renal failure and connected the dots. 

How quickly should you drop the BP in someone like this?  Stick with the 25% reduction in 2-4 hours?  Could that impair renal flow and worsen the renal failure??

[Guest Paula]

Whew, I feel better it's not just me.  We have the regular ophthalmoscope that hangs on the wall in most rooms.  One of the rooms has a panoptic that was never used because the bulb was burned out and the doc did not use it.  It was in the  room he typically sees his patients.  Last fall a rep from the panoptic company came (i was not informed about it) and he did a whole inservice on it's use and the doc got to practice with a few of the nurses as patients).  I came out of one of my exam rooms to meet the panoptic rep as he was leaving.  He introduces himself and said he just trained the doc.  I asked to have the training (jeez...15 more minutes of his time) and he had to leave.  By this time doc was in on the conversation and he says to me ' Oh, I forgot about you, Paula, I should have had you in on this, I'll show you how to use it".  I was so mad and of course he never showed me.  I have experimented on my own now.  It is one of the little things in my practice that drove me to the edge and I start my new job in 6 weeks in IM in my home state where I live.  Bye-bye tribe.  I suffer from PTSD (post Tribal stress disorder).  Never again will i work at a tribe. 

 

Rant over.  Sorry.  I just feel better now. 

[Guest Paula]

Back to the topic now!  I was wondering what one would do when someone comes in with hypertensive crisis and you work at a tribe.  It is snowing and the state patrol just closed the 2 main highways that intersect the town.  No one can get in  or out.  The clinic can get an EKG, CXR, some basic labs, UA/CR, pregnancy test, test for cocaine use, put in an IV for fluids (but no IV drugs available), has a pharmacy on site with only oral drugs.  

 

What would I do?  P.S. I'm working alone and it's a Friday. Staff consists of lab tech, 2 RN's, 2 LPNs and pharmacist, xray tech and me.  

 

I would first call the closest ER and get an ER doc on the phone to walk me through such a crisis, attempt to get EMS here, and call the SP who is probably at home having a drink sitting in front of the fireplace sharpening his arrows for a deer hunt. 

 

I woke up thinking about this scenario so it must've been a bad dream.  6 more weeks to go!

[primadonna22274]

Paula, what PO drugs do you have?

We typically do IV labetalol and/or hydralazine for true hypertensive crisis. Cardene drip in ICU sometimes.

However, many many drugs PO you could use:

Clonidine of course (we never use), labetalol (200-400mg PO vs 10-20 IV) and hydralazine PO (50-100 mg similar to IV dose). I particularly like amlodipine 10mg PO because it is well-tolerated, modestly effective and safe. Remember TRUE hypertensive crisis is defined by end-organ damage. You can help with IV fluids to give the kidneys a break. Someone else mentioned a couple posts back that it's not safe to drop the BP too quickly--I think the 20-25% recommended is the most I would try to do per 12 hr. The RAAS needs time to adjust as does cardiac output and tissue perfusion. Hydration (with a loop diuretic chaser if necessary for diuresis) can buy time and improve patient's status to a more acceptable BP.

Here in the south we rarely blink at a DBP<140. It's so common. 160 makes me nervous though ????

I think the highest I've seen was 289/168 in a tiny little slip of a woman with CKD, poor compliance and a love of cocaine. She only showed minor left heart strain on EKG and bumped her troponins slightly. No real change in her baseline poor renal function.

[primadonna22274]

Ugh I hate when part of my post gets lost.

...rarely blink if DBP<140. I think the highest I've seen is 289/168 in a tiny slip of a woman with CKD, chronic pancreatitis, epic noncompliance and a love of cocaine. She barely showed left heart strain on EKG and bumped her troponins a little bit. Admitted for chest pain r/o, for probably the tenth time that year, and what may have been a mild HTN crisis for her but she lived at 220/130 chronically.

Another neat trick is an inch of nitro paste, but be careful as they can drop really fast and really you haven't accomplished any meaningful change if they rebound as soon as it's worn or rubbed off.

[primadonna22274]

Sorry I give up

[ventana]

Don't see many cases that are "ER-interesting" in the headache clinic but here is one.

 

My "riddles" are a quick and cheap case presentations. I will give some hints. You are allowed to ask yes or no questions and I will answer them truthfully and see who is the first one to figure this out.

 

Christmas Eve I saw a 33 yo female with a long history of migraine but not too severe and a few times a month. In the past six weeks headaches became worse and finally daily. No other major complaints except for typical migraine (photo phobia, nausea).

 

I was ready to call this typical status migraine until I examined her. She had two positive signs, one neurological and one not. After my exam I had a differential of two things. I guessed the more common one . . . however it turned out to be the other. I wish I had sent her directly to the ER but I started the work up for # 1 first. She ended up in the ER in 48 hours. It is NOT an infectious process.

 

So, each person is allowed two Y/N questions and then a guess. The winner gets all the oxygen they can breath for free for one year.

posting before I read any more of this thread..... nph or some pressure thing.... comes to mind, or some bleed with irritation?

[Guest Paula]

We have nearly  all oral b/p meds available, so looks like we would have options.  We do not have an IV infusion pump so fluid would be given by the old fashioned hung up bag of NS.  

 

We have one patient similar to primadonna's with chronically elevated b/p >200/120 or so, on dialysis and non-compliant to taking most of her meds.  She still makes me nervous when she comes in though.  She loves marijuana instead of cocaine and is usually quite stoned when she comes in and difficult to get a straight answer from any questions I might have.  Skips dialysis too at times. 

[MedicinePower]

I found this podcast to be rather enlightening.

 

http://embasic.org/asymptomatic-hypertension/

 

"The patient’s blood pressure is 190/80 but they feel fine…how do we treat these patients in the ED?  Labs?  EKG? BP meds?  Admission???…but they are here for an ankle sprain!  Asymptomatic hypertension is a challenging complaint to deal with in the ED because of so many conflicting opinions and worries but it doesn’t have to be difficult.  In this episode, we’ll discuss a systematic and rational way to evaluate patients with asymptomatic HTN, do limited and targeting testing, and get them the right followup while calming the patient’s fears and avoiding harm."

 

In this case the PT is sympomatic, tho is a very unusual sort of way. Dr Carroll indicates how severe HTN doesn't usually require ED workup and treatment.

[jmj11]

I will add that with this patient I was focusing on her papilledema and in the context of the headache clinic ICH is the most common reason by far with actual space occupying lesion (actual tumor vs pseudotumor) as the second reason.  I had a brain MRI and ophthalmologist appointment for her in 48 hours. However, I didn't ignore her significant hypertension.  The difficulty was that she was dismissive saying she had been in the ER twice in the previous two weeks and they had noticed elevated HTN and would always "settle down" after her migraine was treated and would be back to normal.  However with a systolic over 200 that is not typical for even severe pain and I was very concerned.  I did start her immediately on nadolol 40 MG with an increase the following morning of 80 MG.  I had her check her B/P at home (she did have access to a cuff) every couple of waking hours and I told her if it had not normalized, as she claimed it did, to go back to the ER. Apparently she did after 48 hours. But I do wish I had sent her directly to the ER again and maybe this time they would have caught her proteinuria and gone down the acute renal failure rabbit hole.

 

The PanOptic is easy to use, but it does cost a grand. One simple view of this video and a little practice is all it takes.  I have a IPhone app for taking photos however, I need a lot more practice with that.  I tried to take photos of this patient's fundi.  The adapter and app takes a string of about 20 photos as you try to position the PanOptic. Then you choose the best one.  My mistake (otherwise I would have some good photos to show you here) is that it only saved the last photo of each eye, both not positioned correctly.

[jmj11]

So, I just got off the phone with this patient, as I called her to follow up.  She was actually in dialysis as I spoke to her.  The final dx was a zebra (http://www.nejm.org/doi/full/10.1056/NEJMra0902814) atypical hemolytic-uremic syndrome.  Which in turn created hypertension, which in turn created papilledema and worsened her pre-existing menstrually related migraine disorder . . . which brought her to me.

 

I asked her about urinary symptoms and she had none during this whole course, including (subjective) normal urinary out-put.  I asked her about her papilledema if it was resolving now that she is on dialysis and her B/P has stablized. She said that I'm the only person (despite all her three ER visits, 4 days in ICU and 10 days on the floor) who has ever looked in her eyes. She is going to keep her ophthalmology visit to have them look.

[jdenning]

Wow. Everyone took the hypertension and ran with it and NO one thought of HOW she got to admission. Curious if she had any brain imaging as an inpatient? Wondering if there are WM ischemic changes from the hypertension. Also curious whether she complained of headache while she was an inpatient

 

Good follow up on her.

[ventana]

eyes are fascinating, but darn they are hard to see.......

 

 

i am toying with doing dilated exams - anyone have any thoughts on this, besides the obvious - they can't drive and need darkness after. 

 

Thinking a pan-optic and dilation.....

[jmj11]

eyes are fascinating, but darn they are hard to see.......

 

 

i am toying with doing dilated exams - anyone have any thoughts on this, besides the obvious - they can't drive and need darkness after. 

 

Thinking a pan-optic and dilation.....

I'm really only interested in the optic nerve and SVP.  A Pan-optic is needed for 90%+ of patients. If you need to see more then dilation might be reasonable.