M&M - Dr. Kiefer

Case 1:  Missed appendicitis

• Abdominal pain is most sensitive finding (sn 80-85%) for children newborn – 16 yo
• Fever (sn 40-70%) and leukocytosis (sn 65%) are not a reliable findings
• Perforation is common in children <6 years old due to difficult history and exam.  Have a high level of suspicion, especially on repeat evaluations for abdominal pain!
• Additional features: low volume diarrhea is common (~32%) of leading to misdiagnosis of gastroenteritis, vomiting is more common (60-70%) and vomiting PRECEDED by pain should absolutely raise the suspicion for appendicitis.
•  Even in adults, 15% of patients had isolated RLQ rebound tenderness, but were afebrile and had normal laboratory studies.

1. Appendicitis in children less than 3 years of age: a 28-year review.  Pediatr Surg Int. 2004 Jan;19(12):777-9. Epub 2004 Jan 16.
2. Acute appendicitis in children under 3 years of age. Diagnostic and therapeutic problems. Med Wieku Rozwoj. 2012 Apr-Jun;16(2):154-61.
3. The presentation of appendicitis in preadolescent children. Pediatr Emerg Care. 2007 Dec;23(12):849-55.
4.  Pain as the only consistent sign of acute appendicitis: lack of inflammatory signs does not exclude the diagnosis. World J Surg. 2010 Feb;34(2):210-5. doi: 10.1007/s00268-009-0349-z.


Case 2: Tako-Tsubo Cardiomyopathy and Hypertensive Emergency

• Global deep wide symmetric T wave inversions with associated QT prolongation is often read by EKG software as concerning for ischemia, but these features actually far more typical of acute CNS event (ex. SAH) or acute adrenergic surge (ex. Emotional, Cocaine, Pulmonary Edema, Hypertensive Emergency, etc.)
•  Inverted T waves from myocardial ischemia are typically characterized by a sharp symmetric T waves with quick downstroke

Case 3: Incidentalomas

• It is our duty to the patient to ensure they understand incidental findings (laboratory, radiological, physical exam, etc.) and to ensure they understand follow up and have a means to obtain it.  
• One effective method is to print out the report and give it to the patient at time of discharge.
• This is a huge area of medico-legal risk.  Ensure adequate documentation in the chart to protect yourself.

Case 4: Sporotrichosis

• Consider in patient with hard, red, nodules that are progressing up arm.  Class is patient involved in rose gardening or in situation with cuts to hands while working in soil.
•  Treated with antifungals (Itraconazole) till 2-4 weeks AFTER lesions resolve.  Usually 3-6 months.

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