Case 3 – A 28-year-old pregnant woman with postpartum bleeding

A 28-year-old G1P1 woman at 39 weeks’ gestation presents to the emergency department complaining of severe, regular uterine contractions. On cervical examination she is 5 cm dilated and is promptly admitted to the labor and delivery unit. The patient reports no complications with her pregnancy and has no medical problems. After almost 22 hours of active laboring, the patient delivers a 3.6-kg (8-lb) healthy baby girl. The placenta is delivered without difficulty, but the patient continues to bleed postpartum. Vaginal examination reveals the patient has extensive perineal lacerations.

How is this condition classified?

First-degree perineal laceration due to birth trauma are a common obstetric complication caused by stretching of the birth canal by the infant. First-degree lacerations are limited to the vaginal mucosa, skin, and superficial subcutaneous and submucosal tissues. Perineal lacerations due to birth trauma are categorized into four groups. First-degree lacerations are explained above. Second-degree lacerations penetrate into the superficial fascia and transverse perineal musculature, while third-degree lacerations extend further, tearing the anal sphincter. Fourth-degree lacerations extend beyond the anal sphincter and into the rectal lumen.

What are the risk factors for this condition?

Risk factors associated with lower genital tract trauma in the obstetric setting include nulliparity, a large infant, precipitous birth, operative delivery, and/or episiotomy.

What is the most appropriate management for this patient?

First-degree lacerations of the perineum or vagina not involving underlying tissues rarely require repair, as they tend to heal quickly and neatly. Sutures are needed only for such injuries in the event of active bleeding. Second-, third-, and fourth-degree lacerations, however, always require surgical repair. In these lacerations the tissues may be frayed and in some cases macerated, making identification of the tissue ends and suture lines more difficult. In the event of a fourth-degree laceration, the torn rectal mucosa must be repaired separately from the rest of the tissue and with specific attention and care to avoid fistula formation.

By Hindi Stohl Posy, MD, Resident in Obstetrics and Gynecology, Johns Hopkins University; in association with Le TT, Schabelman E, Shivaram A, and Klein J, eds: First Aid Cases for the USMLE Step 2 CK. New York: McGraw-Hill, 2007.

Case 2 — A 43-year-old woman with malaise and myalgia

A 43-year-old woman presents to her primary care physician complaining of general malaise and widespread myalgia. She has not had a good night’s sleep for years and always wakes up exhausted. The fatigue that she feels in the mornings lasts all day, which she says is greatly affecting her ability to work. She used to be active but now even her 5-block walk to work leaves her tired and short of breath. On the weekends, she spends all day in bed because she is unable to motivate herself to do anything but rest. In addition to her lack of energy, the patient also is suffering from muscle and joint pain, which is particularly bad in the mornings. The pain is mostly concentrated around her neck, shoulders, and back. The pain is sometimes so bad that even her clothing causes extreme discomfort. On examination has no inflammation or swelling of any joints but is tender to palpation over her shoulders bilaterally and her neck. Other than this, the patient’s entire neuromuscular examination is unremarkable. An extensive laboratory work-up, including red blood cell count, white blood cell count, erythrocyte sedimentation rate, antinuclear antibody, thyroid function testing, and muscle enzymes, is negative.

What conditions should be included in the differential diagnosis?

Numerous conditions are associated with chronic pain and fatigue:

1. Ankylosing spondylitis
2. Fibromyalgia
3. Hypothyroidism
4. Inflammatory myositis and metabolic myopathies
5. Myofascial pain syndromes
6. Polymyalgia rheumatica
7. Psychiatric disorders, sleep disturbances, and migraine
8. Systemic and rheumatic diseases (rheumatoid arthritis, Sjögren’s syndrome, systemic lupus eruthematosus)

What is the most likely diagnosis?

Fibromyalgia. While considered a diagnosis of exclusion, fibromyalgia should be diagnosed in patients who present with chronic myalgias and arthralgias but who have no evidence of joint or muscle inflammation on physical exam or laboratory testing. Fibromyalgia is ten times more common in women than in men, and it most often presents in people 30-50 years old. It is associated with depression, anxiety, sleep disorders, and irritable bowel syndrome (IBS).

How is this condition classified?

As defined by the American College of Rheumatologists, patients diagnosed with fibromyalgia will exhibit:

1. Excess tenderness in at least 11 of 18 predefined (bilateral) anatomic sites:
   1. Occiput, at the suboccipital muscle insertion
   2. Low cervical, at the anterior aspects of the intertransverse spaces (C5-7)
   3. Lateral epicondyle, 2 cm distal to the epicondyles
   4. Knee, at the medial fat pad proximal to the joint line
   5. Second rib, at the second costochondral junction
   6. Trapezius, at the midpoint of the upper border of the muscle
   7. Supraspinatus, above the spine of the scapula near the medial border
   8. Gluteus, in the upper outer quadrants of the buttocks in the anterior fold of muscle
   9. Greater trochanter, posterior to the trochanteric prominence
2. Widespread musculoskeletal pain for ?3 months

Fulfillment of both criteria is 80% sensitive for the diagnosis of fibromyalgia.

What is the most appropriate management for this patient?

Treatment focuses on utilizing multiple modalities to alleviate a patient’s symptoms. Analgesics such as tramadol are often effective in providing pain relief. Because inflammation is not a major part of this disorder, anti-inflammatory medications such as ibuprofen or glucocorticoids are not effective. Antidepressant medications are often used as initial treatment.

By Daniel Osei, MD, Resident in Orthopedic Surgery, Hospital for Special Surgery; in association with Le TT, Schabelman E, Shivaram A, and Klein J, eds: First Aid Cases for the USMLE Step 2 CK. New York: McGraw-Hill, 2007.

This month’s issue from the Journal of the American Medical Association (JAMA) is dedicated to Medical Education and includes a review of the First Aid for the USMLE Step 1 2007 Edition. A summary of their main points:

1. Our “Guide to Efficient Exam Preparation” and “Top-Rated Review Resources” are particular strengths.
2. The diagrams and mechanistic pathways in each section are superb.
3. The Cardiology and Gastrointestinal Tract sections are particularly strong.

The review also listed areas where we can improve.

1. The clinical vignettes that begin each section could be better developed.
2. The Microbiology section’s organization and detail could use revision.
3. The Index should be expanded to allow easier topic reference.

Thanks to all the students that provided feedback this year, many of these points were heard by the First Aid Team and are being addressed in the 2008 Edition. We appreciate the author’s final thought that the “First Aid for the USMLE Step 1 has solidified its role in yearly examination preparation.”

Case 1 – A 70-year-old man with increasing shortness of breath

A 70-year-old man presents to the emergency department complaining of increased shortness of breath with minimal exercise, cough, and fatigue. These symptoms began 2 weeks ago and have progressed gradually. He reports he used to feel this way “all the time” years ago, but that this has not happened much since he began using his inhalers and his “water pill.” He also has a history of chronic obstructive pulmonary disease (COPD), congestive heart failure (CHF), coronary artery disease (CAD), diabetes mellitus, hypertension, and 30-pack-years of smoking. He denies swelling of the extremities, fever or chills, productive cough, chest pain, or palpitations. He cannot remember the names of his medications, but says he has not missed any doses. When asked about his diet, he says he has been eating more hot soup since the weather has gotten colder. His temperature is 37.5°C (99.5°F), blood pressure is 135/90 mm Hg, heart rate is 90/min, respiratory rate is 18/min, and oxygen saturation is 94% on room air. Examination of the neck reveals mild jugular venous distension. Examination of the lungs reveals loud crackles throughout the lung fields bilaterally. Examination of the heart reveals a laterally displaced point of maximum impulse with no murmurs, rubs, or gallops. There is mild clubbing of the extremities, as well as pitting edema of the lower extremities to the knee, bilaterally. His plasma brain natriuretic peptide level on rapid bedside assay is 500 pg/mL, and an x-ray of the chest reveals perivascular haziness, interstitial edema, and an enlarged cardiac silhouette.

What conditions should be included in the differential diagnosis?

In a patient with a history of CAD, COPD, and CHF who presents with dyspnea on exertion and fatigue, the current condition is likely due to an exacerbation of one of those three underlying diseases. It is of primary importance to distinguish between them when evaluating the presenting symptoms. Shortness of breath as an anginal equivalent can be ruled out by ECG and response to nitrates. However, the causes of COPD and CHF exacerbations are many, and may overlap such that teasing apart the symptomatology proves difficult. Etiologies that, by themselves, can cause gradually worsening shortness of breath and fatigue can include both cardiac and pulmonary diseases, including:

1. Anemia
2. Heart failure secondary to ischemia/infarction, dysrhythmia, valvular dysfunction, infection, or volume overload
3. Lung infections (pneumonia, bronchitis, bronchiectasis)
4. Mechanical impairment of ventilation
5. Pulmonary edema
6. Pulmonary embolism
7. Sepsis

In addition, these conditions can “tip” patients with underlying COPD or CHF “over the edge.”

What is the most likely diagnosis?

CHF exacerbation leading to pulmonary edema. This patient’s dyspnea, jugular venous distension, and tachypnea in the presence of crackles, pulmonary edema, an elevated brain natriuretic peptide (BNP) level, and cardiomegaly suggest an acute exacerbation of CHF. An exacerbation of COPD is unlikely given that this patient does not have fever, productive cough, or wheezing. Additionally, the patient reported increasing intake of soup, a particularly salty food, which can significantly increase water retention, thereby worsening CHF. A mnemonic for the causes of recurrent CHF is FAILURE:

1. Forgot medication
2. Arrhythmia/anemia
3. Ischemia/infarct/infection
4. Lifestyle (increased sodium intake, decreased exercise); most common cause
5. Upregulation (increased cardiac output due to pregnancy, hyperthyroidism, etc)
6. Renal failure
7. Embolus (pulmonary)

How is this condition classified?

The American College of Cardiologists and American Heart Association developed guidelines in 2001 for the classification and treatment of CHF:

What are the typical laboratory/imaging findings in this condition?

In addition to an x-ray of the chest that may show pulmonary edema, patients with CHF exacerbations may have:

1. Decreased hematocrit (anemia may exacerbate CHF)
2. Increased potassium, creatinine, and blood urea nitrogen levels (renal failure may exacerbate CHF)
3. Increased plasma BNP level, which is usually elevated in CHF exacerbations
4. A chest radiograph showing cardiomegaly, cephalization of pulmonary vessels, and/or pleural effusion
5. ECG changes showing left ventricular hypertrophy, arrhythmias, or ischemia or low-voltage or old infarcts (in fact, a normal ECG makes systolic dysfunction highly unlikely)
6. ECG showing abnormal ventricular size (dilated, hypertrophic, or restrictive cardiomyopathy) or function (systolic or diastolic)

What is the most appropriate management for this patient?

This patient appears to have stage C heart failure as defined by the table above. His physical exam and x-ray of the chest show evidence of myocardial hypertrophy, and he is having current symptoms (recurrent). He should probably be admitted to the hospital for a trial of intravenous diuresis (which often succeeds when oral diuretics fail). Upon clinical improvement and discharge, he should be prescribed an ACE inhibitor (given his atherosclerosis, hypertension, and diabetes mellitus), a diuretic (given his evidence of fluid retention), and digitalis (for symptomatic control). He should also recieve frequent blood pressure monitoring, exercise counseling, possibly spironolactone, and/or an angiotensin receptor blocker. In addition, he should take aspirin and a statin for his CAD, and should have an echocardiogram done to evaluate his ejection fraction and any structural heart disease, namely valvular abnormalities.

By Brian Ash, MD, Resident in Anesthesia and Perioperative Care, University of California, San Francisco Medical Center; in association with Le TT, Schabelman E, Shivaram A, and Klein J, eds: First Aid Cases for the USMLE Step 2 CK. New York: McGraw-Hill, 2007.

Next Week: A 43-year-old woman with malaise and myalgia…