IV Notes 💉

A 65-year-old man comes to the emergency department due to substernal chest pain, severe shortness of breath, and diaphoresis that began suddenly 40 minutes ago. The pain radiates to his left arm and does not remit with sublingual nitroglycerin. The patient has vomited twice since the pain started. ECG shows ST elevations in the anterior leads. Temperature is 36.9 C , blood pressure is 110/70 mm Hg, pulse is 60/min, and respirations are 32/min. Oxygen saturation is 90% on 4 L/min oxygen by nasal cannula. Basilar crackles extending halfway up the lung fields bilaterally are noted on auscultation. The patient is given aspirin, clopidogrel, and atorvastatin, and anticoagulation is started.

This patient's postprandial dull and constant abdominal pain in the RUQ, nausea, and vomiting suggest biliary colic. This condition is caused by increased intraluminal gallbladder pressure as a result of gallbladder contraction against an occluded cystic duct, most commonly due to gallstones. Referred pain to the shoulder and interscapular region, as seen here, can also occur secondary to diaphragmatic irritation via the phrenic nerve. Patients with uncomplicated cholelithiasis usually have normal laboratory values, as seen here; fever and leukocytosis should raise concern for acute cholecystitis or acute cholangitis, and jaundice and hyperbilirubinemia suggest choledocholithiasis Stones in CBD means Choledocholithiasis which can manifest with postprandial nausea, vomiting, and RUQ pain that radiates to the back and right shoulder, all of which are seen here. However, choledocholithiasis typically also manifests with findings of cholestasis (e.g., jaundice, hyperbilirubinemia), which are not seen in this patient. Infection in biliary tract means Acute cholangitis which can manifest with RUQ pain, nausea, and vomiting, all of which are seen here. However, other typical findings, such as leukocytosis, hyperbilirubinemia, and jaundice and high fever (together with RUQ pain, these are referred to as the Charcot triad), are not present. Inflammation of gall bladder mucosa means Acute cholecystitis  which manifests with postprandial RUQ pain that radiates to the right shoulder, nausea, vomiting, and normal AST and ALT values, all of which are seen here. However, other typical features of acute cholecystitis, such as fever, leukocytosis, and a positive Murphy sign, are absent in this patient.

A 43-year-old obese woman comes to the emergency department because of a 3-hour history of upper abdominal pain that radiates to her right shoulder and upper back. During this period, she has also had nausea and one episode of nonbloody vomiting. She says the pain is dull and constant. One hour prior to the onset of her current symptoms, she was eating fast food. She has hypertriglyceridemia and hypertension. Her temperature is 36.3°C , pulse is 84/min, respirations are 22/min, and blood pressure is 135/85 mm Hg. The abdomen is soft and there is mild right upper quadrant tenderness to palpation; there is no guarding or rebound. Laboratory studies show a leukocyte count of 9,000/mm3, AST 35 U/L, and ALT 36 U/L; total bilirubin is 0.9 mg/dL.

This patient's persistent cough and substernal chest pain are consistent with gastroesophageal reflux disease (GERD), for which obesity is a risk factor. GERD is a known trigger of asthma and is associated with difficult-to-treat disease. It is thought to worsen asthma as a result of chronic microaspiration of stomach contents into the upper airways. Asthma that worsens when lying down or after meals should raise concern for GERD-induced disease. Since this patient has only had a partial response to her recently initiated asthma medication, a trial of empiric therapy with a proton pump inhibitor is the most appropriate next step in management. systemic steroids are used to treat acute asthma exacerbations or severe, therapy-refractory chronic asthma. This patient does not present with acute dyspnea and wheezing, which makes an acute asthma exacerbation unlikely. Salmeterol is a long-acting beta agonist that is used in the management of moderate chronic asthma. Salmeterol would be a reasonable next step in the escalation of her asthma therapy because this patient currently uses a short-acting beta agonist and a corticosteroid inhaler. However, other comorbidities that potentially worsen asthma should be treated before escalating asthma therapy. An echo may be considered to evaluate underlying cardiac pathologies. This patient's recurring chest pain, exertional dyspnea, and cough exacerbation when lying supine are possible symptoms of heart failure. In some cases, severe mitral valve stenosis may lead to hoarseness due to recurrent laryngeal nerve damage by an enlarged left atrium. However, further signs and symptoms of heart failure such as peripheral pitting edema, increased jugular venous distention would be expected at this point. Moreover, except for obesity, this patient has no risk factors for heart disease (e.g., history of smoking, rheumatic fever, or hypertension), making a different etiology of her symptoms more likely.

A 42-year-old obese woman comes to you for follow-up. Two months ago, she was diagnosed with asthma after a 1-year history of a chronic cough and dyspnea with exertion. Her symptoms have improved since starting inhaled salbutamol and beclomethasone, but she still coughs most nights when she is lying in bed. Over the past 2 weeks, she has also had occasional substernal chest pain. She does not smoke. Vital signs are within normal limits. She has a hoarse voice and frequently clears her throat during the examination. The lungs are clear to auscultation.

حد سألني بما إن هنا حصل Mechanical bowel obstruction بال stone اللي موجودة طيب ليه المشكلة دي اسمها gallstone ileus برغم إنك بتقول في الفويس إن فيه فرق واضح ما بين ال Mechanical obstruction & ileus ده فيه حاجة سادة ال intestine وبيبقى presented في الأول ب hyperactive bowel sound عكس ال ileus اللي بتكون functional problem وبتيجي من الأول ب silent bowel الإجابة إن الإسم ده " gallstone ileus " إسم غلط أصلا 😄 بس هما زمان سموه كدة ومعرفناش نغيره لدلوقتي وده بقى الإسم المتعارف عليه ولكن لو كنا بنحاول نوصفها علميا فده مش ileus الحقيقة لأن فيه mechanical obstruction

Cholecystoenteric fistula is an abnormal connection between the gallbladder lumen and the adjacent bowel (usually duodenum). The fistula allow passage of gallstones from the gallbladder into the bowel and for air from the bowel into the biliary system (pneumobilia) Large gallstones can become lodged in the distal ileum (most commonly the ileocecal valve), causing gallstone ileus.

This patient has risk factors for gallstone disease (e.g., obesity, age > 40, female gender). In a patient with signs of intestinal obstruction (e.g., vomiting, abdominal pain, abdominal distension, hyperactive bowel sounds), the presence of pneumobilia is highly suggestive of gallstone ileus. superior mesenteric artery syndrome (obstructed duodenum) would not explain this patient's pneumobilia. jejunal obstruction is typically caused by bowel adhesions or intussusception, not gallstones. This patient's history does not include risk factors for adhesions (e.g., prior abdominal surgery), and she is outside of the typical age range for intussusception (children) hepatic duct obstruction typically manifests with jaundice, which is not seen in this patient. Moreover, signs of intestinal obstruction would not be expected. Pancreatic duct obstruction by a gallstone can cause acute pancreatitis with abdominal pain, nausea, vomiting, and fever, which are symptoms seen in this patient. However, symptoms of small bowel obstruction (e.g., hyperactive bowel sounds) would not be expected. In addition, pancreatitis would not cause pneumobilia , also biliary pancreatitis expected to be associated with jaundice.

بأكد تاني الإجابات مجهولة حاول تجتهد في الإجابة على ما تقدر ومتقلقش محدش هيعرف اخترت ايه ومحدش يكتب اجابته في كومنت عشان يدي فرصة للكل انه يفكر هنزل ال explanation عشرة مساءا ان شاء الله

A 67-year-old obese woman comes to you because of a 5-day history of episodic abdominal pain, nausea, and vomiting. She has coronary artery disease and type 2 diabetes mellitus. She takes aspirin, metoprolol, and metformin. Her temperature is 38.1°C. Physical examination shows dry mucous membranes, abdominal distension, and hyperactive bowel sounds. Ultrasonography of the abdomen shows air in the biliary tract.

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Dull pain that gradually worsens and eventually localizes to the right abdomen is characteristic of acute appendicitis. Although appendicitis pain classically localizes to the RLQ (McBurney point), in pregnant patients the gravid uterus can displace the appendix towards the right upper quadrant or the flank. Sterile pyuria is a common finding in appendicitis and can occur if part of the urinary tract (usually the right ureter) is within close proximity of the inflamed appendix, causing ureteric irritation and/or inflammation. abdominal ultrasound is the best initial imaging modality for suspected appendicitis in pregnancy. Acute cholangitis can manifest with fever, RUQ pain, and leukocytosis. Pregnant women are at an increased risk of cholelithiasis, which in turn is the most important risk factor for cholangitis. However, acute cholangitis does not lead to pyuria, and the absence of signs of cholestasis (e.g., jaundice, hyperbilirubinemia, increased alkaline phosphatase) makes this diagnosis unlikely. Pyelonephritis can manifest with fever, leukocytosis, and pyuria. However, the pain in pyelonephritis is most commonly localized to the flank. In addition, patients typically present with costovertebral angle tenderness, rather than RUQ tenderness. Cystitis can manifest with pyuria. However, RUQ pain and vomiting are not consistent with cystitis. Most patients with cystitis present with dysuria, urinary frequency/urgency, and suprapubic pain. HELLP syndrome is a life-threatening complication of pregnancy that can manifest with vomiting, abdominal pain, and RUQ tenderness. By definition, HELLP syndrome is also associated with hypertension, proteinuria, and signs of hemolysis (e.g., decreased hemoglobin, increased indirect bilirubin), none of which are seen here. Renal stone classically presents with flank pain that radiates to the groin. This patient has upper abdominal pain and RUQ tenderness, which is atypical for renal stones. In addition, most patients have evidence of hematuria on urinalysis rather than pyuria. Pelvic inflammatory disease typically presents with acute lower abdominal or pelvic pain, fever, and cervical or vaginal discharge. This patient's pain is more localized to the upper abdomen. PID is almost never seen in pregnant patients because hormonal changes in pregnancy lead to altered cervical mucus that protects the uterus from ascending infection.