Dyspnea and Hemoptysis after a Rigorous, Open-Water Swim

The case illustrates the diagnosis and treatment of a patient with swimming-induced pulmonary edema (SIPE), an uncommon cause of pulmonary edema in triathletes and military recruits. The pathophysiology is not completely understood but is thought to relate to the effects caused by immersion in conjunction with vigorous exertion. Diagnosis is by history and physical, with the prototypical SIPE patient being a previously healthy athlete exhibiting acute onset edema while exercising in the water. Typical symptoms and signs include shortness of breath, hypoxia, rales, and cough, which may or may not be productive with pink, frothy sputum. Radiographs may be obtained but are mainly obtained to rule out other diagnoses including pneumonia and pneumothorax. Treatment is supportive, although some evidence is mounting that shows decreasing rates of SIPE with prophylactic sildenafil.

Heat Stroke

This case illustrates heat stroke presenting as altered mental status in a young healthy person. The differential diagnosis of altered mental status with hyperthermia is broad so a high clinical suspicion is needed to make the diagnosis of heat stroke. Infectious causes should always be ruled out. Once the diagnosis is made, treatment is aimed at actively cooling the patient, lowering temperature to a targeted goal of 102.2°F. Close attention should also be given to airway protection, correction of metabolic abnormalities, evaluation for rhabdomyolysis, and monitoring for cardiac dysrhythmias. All heat stroke patients should be admitted to the hospital for monitoring even after cooling goals are achieved.

Abdominal Pain

This case demonstrates a common presentation of appendicitis including frequent signs and symptoms and classic examination findings. Options for diagnostic imaging are reviewed. Clinical decision scores may assist in risk stratification, which may be particularly useful in austere or low-resource settings. The discussion introduces the concept of “antibiotics first” treatment for appendicitis including a discussion of patients who are poor candidates for such treatment, risks for need of future operative management, and proposed treatment protocols. While surgical management remains the standard of care in the United States, this case discusses potential utility for an “antibiotics first” protocol when definitive surgical treatment is not readily available.

Abdominal Pain

This chapter is a review of the approach to pediatric abdominal pain, specifically the recognition, diagnosis, and management of appendicitis. Topics covered include red flag symptoms for abdominal pain in the pediatric patient, classic and nonclassic appendicitis presentations, and physical exam techniques that can help in the diagnosis of appendicitis. Also discussed is the Pediatric Appendicitis Score, which rates risk based on anorexia; nausea/emesis; migration of pain; fever (>38°C); pain with cough, percussion, or hopping; right lower quadrant tenderness; white blood cell count; and absolute band count. Middle risk assessment may require further imaging whereas high risk assessment can proceed immediately to surgery. The chapter also compares imaging modalities and reviews the literature for medical versus surgical management of appendicitis.

Fever

This case illustrates one of the most common healthcare-associated infections (HAI) in a patient who is admitted to hospital. Catheter-associated urinary tract infections (CAUTI) can be prevented by eliminating unnecessary urinary catheter use. Furthermore, non-specific symptoms are frequently erroneously attributed to a presumed urinary tract infection (UTI) upon isolating bacteria from a urine sample. Except for a few specific circumstances, asymptomatic bacteriuria should not be treated with antibiotics. Without symptoms consistent with UTI, growth of bacteria from urine does not constitute an infection. Culturing urine without UTI symptoms can lead to misuse of antibiotics, which can increase adverse events and drive antimicrobial resistance. This case reviews common causes of UTIs and criteria for diagnosis.

No Urine Output

The chapter describes a case of acute urinary retention to illustrate the clinical approach to anuria. It reviews the differential diagnosis and initial work up for anuria considering prerenal, renal, and postrenal etiologies. This work up includes serum chemistry, urinalysis, urine culture, urine electrolytes, urine creatinine, urine osmolality, and bedside bladder ultrasound. It discusses the causes of acute urinary retention including neurologic, obstructive, infectious, inflammatory, medication induced, or traumatic causes, and also illustrates the management of acute urinary retention..Urethral catheterization to decompress the bladder is the first-line treatment for acute urinary retention, which is followed by treatment of the underlying cause or causes.

Hypoxia

The case illustrates the approach to an intubated patient on mechanical ventilation with desaturation and clinical deterioration. Included is a list of potential etiologies, including airway obstruction, pneumothorax, mucus plug/atelectasis, aspiration or infection, and pulmonary embolus as well as a description of how to systematically evaluate these patients. Various imaging modalities are reviewed, including the findings of a chest X-ray and results of a limited bedside ultrasound. The case highlights the potential development of a delayed pneumothorax or hemothorax, despite an initially normal chest radiograph, particularly with the addition of positive pressure ventilation. The case highlights the importance of the focused assessment with sonography for trauma (FAST) exam.

Hypotension

Sepsis is a complex and potentially life-threatening sequela of infection that commonly occurs and can be difficult to identify. If unrecognized or undertreated, sepsis can progress to severe sepsis, septic shock, characterized by hypotension and multisystem organ failure, and ultimately death. This case illustrates classic signs and symptoms of sepsis and septic shock in a postoperative patient. Recognizing these symptoms, rapidly initiating resuscitation with intravenous fluids and broad-spectrum antibiotics and aggressive management of these patients is imperative to prevent further decompensation. In 2017, the Surviving Sepsis campaign published new guidelines to assist with the management of patients with sepsis and septic shock. Key points from these guidelines will be highlighted within this case.

Overdose

Salicylate intoxication can be fatal if not recognized and treated in a timely fashion. Presentation may be subtle, and complaints of tinnitus or observation of Kussmaul respirations (rapid, deep breathing secondary to acidosis) may be the clinician’s leading cues. Other signs may include hyperthermia, nausea, vomiting, shortness of breath, confusion, diaphoresis, cardiovascular instability, and/or anion gap acidosis. Salicylate intoxication may be mistaken for sepsis, pneumonia, or ketoacidosis. Exposure may be chronic or acute - either can be deadly. Understanding the mechanisms of salicylate toxicity will guide diagnosis and treatment. Deciding whether or not to intubate and /or dialyze the patient are often critical determinanants of outcome. This chapter reviews recognition and management of this rare but potentially life-threatening toxicity.

Extremity Swelling

The case illustrates the classic clinical features and emergent management of rhabdomyolysis. The pathophysiology results from the breakdown of muscle from intense exercise, drug or alcohol use, seizure activity, trauma, heat illness, or muscle disorders. The clinical history is of a severe muscle pain, sometimes focused on a single muscle group or extremity but often diffuse. Rhabdomyolysis should be suspected in a patient with vague complaints of muscle pain, and an elevation in creatine kinase is diagnostic in this clinical picture. Patients who have been diagnosed with rhabdomyolysis must also be carefully evaluated for compartment syndrome. The mainstay of treatment is aggressive intravenous fluid administration. Serial creatine kinase values as well as the patient’s evolving clinical status should guide further management.