Dr. Weber presents a middle-aged female who presents to the ER with a fall in the midst of a 3 week history of "flu-like" symptoms.
1. How do we approach a concern as general as..."I fell"?
Important components of the history include:
Activity of the faller at the time of the incident
Prodromal symptoms - try to be as specific as possible. Lightheaded? vertigo? Imbalance?
Where did the fall occur?
Did you lose consciousness? This is associated with injurious falls and should raise concern for orthostatic hypotension, cardiac or neurologic disease
What medications are you taking and when did you take them? Particularly psychotropic medications, sedative hypnotics, antidepressants, antihypertensive medications
Other social risk factors - alcohol use?
Environmental risk factors - lighting, floor covering, dogs, door threshold, railings, and furniture
Evidence based clinical exam:
Neurologic exam - looking for focal weakness, and then focusing particularly on lower-extremity strength, gait, postural stability
Postural vital signs should always be obtained - remember this requires measurement of blood pressure and heart rate in the supine position and then after one and three minutes of standing
Visual acuity
Extremities - deformities of the feet that may contribute to risk of falling
"Get up and Go test" - individual rises from a standard arm chair, walks a fixed distance across the room, turns around and walks back to the chair and sits back down. May help you look at strength, balance, vestibular dysfunction and gait. This is timed and compared to mean time of adults in their age group
Diagnostic evaluation - there is no standard evaluation!
Glucose
CBC to evaluate for anemia
BMP to look for dehydration
Serum 25-hydroxyvitamin D, as studies have shown some benefit to supplementation
EKG in the immediate workup, studies have shown no proven value of routinely performing holter monitoring, echo, brain imaging or radiographic studies (unless symptomatology tells you otherwise!)
2. How do we define "fever of unknown origin"?
Fever higher than 38.3 on several occasions
Duration of fever for at least three weeks
Uncertain diagnosis after one week of study in the hospital
So, our patient doesn't fit this criteria....so what next?
It's helpful to think of prolonged illness and fever as something that can likely fall into one of three categories - infections, malignancies, and systemic rheumatic diseases.
Infection: think about etiologies that may be hiding, or gradually worsening. For example, abscesses, infective endocarditis (don't forget the organisms that are difficult to culture such as bartonella), fungal infections, HIV. History and physical exam will be helpful - travel history? focal pain or localizing symptoms? animal exposure?
Malignancy: Anything causing neutropenia OR leukocytosis can result in fever. Solid tumors can result in fevers on their own OR can cause syndromes like post-obstructive pneumonia, intra-abdominal infection, etc.
Rheum: Particular consideration of vasculitis or rheumatoid arthritis, but your differential should be dependent on your age range and symptomatology
Diagnostic evaluation - it may be helpful to start with the following:
Markers of inflammation
Serum LDH
TB test, depending on your clinical suspicion
HIV if high risk
Three routine blood cultures from different sites over a period of at least several hours without administering antibiotics
RF
CPK
Heterophile antibody test (if they are the right age group)
ANA
SPEP
CXR if the history points you in this direction
CT abdomen or CT chest - depending on localizing symptoms
3. AML teaching points:
Can present non-specifically: anemia, bleeding, bruising, infection, headache
Blasts comprise at least 20% of the bone marrow biopsy sample or the peripheral white blood cell count w/ evidence that blasts are of myeloid lineage
Leukostasis (WBC >100K or symptoms of tissue hypoxia) occurs in 10-20% of new AML diagnoses and is an emergency situation (carries a hig mortality rate). This can present as dyspnea, hypoxia, headache, visual changes, mental status changes, fevers, MI, AKI, bowel or limb ischemia
Tumor lysis syndrome is another emergency caused by tumor cell lysis - damage of kidneys and rapid release of K, phos, and nucleic acids
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