Comparing accuracy of bedside ultrasound examination with physical examination for detection of pleural effusion.

BACKGROUND: In detecting pleural effusion, bedside ultrasound (US) has been shown to be more accurate than auscultation. However, US has not been previously compared to the comprehensive physical examination. This study seeks to compare the accuracy of physical examination with bedside US in detecting pleural effusion. METHODS: This study included a convenience sample of 34 medical inpatients from Calgary, Canada and Spokane, USA, with chest imaging performed within 24 h of recruitment. Imaging results served as the reference standard for pleural effusion. All patients underwent a comprehensive lung physical examination and a bedside US examination by two researchers blinded to the imaging results. RESULTS: Physical examination was less accurate than US (sensitivity of 44.0% [95% confidence interval (CI) 30.0-58.8%], specificity 88.9% (95% CI 65.3-98.6%), positive likelihood (LR) 3.96 (95% CI 1.03-15.18), negative LR 0.63 (95% CI 0.47-0.85) for physical examination; sensitivity 98% (95% CI 89.4-100%), specificity 94.4% (95% CI 72.7-99.9%), positive LR 17.6 (95% CI 2.6-118.6), negative LR 0.02 (95% CI 0.00-0.15) for US). The percentage of examinations rated with a confidence level of 4 or higher (out of 5) was higher for US (85% of the seated US examination and 94% of the supine US examination, compared to 35% of the PE, P < 0.001), and took less time to perform (P < 0.0001). CONCLUSIONS: US examination for pleural effusion was more accurate than the physical examination, conferred higher confidence, and required less time to complete.

Symptoms of Pleurisy as the Initial Presentation of COVID-19.

BACKGROUND Severe acute respiratory syndrome coronavirus 2, the virus responsible for Coronavirus Disease 2019 (COVID-19), has infected more than 8 million people worldwide and placed massive strains on healthcare systems around the world. Although classically causing cough, fever, and shortness of breath, increasing evidence suggests that manifestations of COVID-19 can be more subtle or masquerade as other clinical entities. CASE REPORT A 48-year-old man with hypertension and type 2 diabetes mellitus presented to the Emergency Department with acute-onset pleuritic chest pain that had developed 1 day earlier and was found to be hypoxemic, requiring supplemental oxygen. He was admitted under the internal medicine service and underwent an extensive workup for his chest pain and hypoxemia, including a negative computed tomography scan with pulmonary embolism protocol, negative nuclear medicine ventilation/perfusion scan, normal electrocardiogram, and normal echocardiography. In the end, he was diagnosed with viral pleuritis as the diagnosis of exclusion. Our patient subsequently developed a fever and shortness of breath and his nasopharyngeal swab performed on admission to hospital returned positive for COVID-19. The patient's pleuritic pain and oxygen requirements improved with supportive management over the next several days. CONCLUSIONS I report a patient who experienced pleuritic chest pain from viral pleurisy that was the initial manifestation of COVID-19 which, to the best of my knowledge, has not yet been reported in the literature. This case report further emphasizes that COVID-19 may present with atypical symptoms. It is crucial to be aware of these atypical presentations of COVID-19 so that patients are appropriately identified, isolated, and treated, while protecting health care workers from exposure.

Recurrent episodes of hypercapnic respiratory failure triggered by panic attacks in a patient with chronic obstructive pulmonary disease.

A 67-year old female with moderate chronic obstructive pulmonary disease (COPD) and generalized anxiety disorder presents with three episodes of severe hypercapnic respiratory failure over the previous three months without a clear precipitant that were treated with invasive and non-invasive ventilation. These episodes were labelled as acute exacerbations of COPD, however she lacked any typical features or triggers and responded faster than expected to treatment and she underwent extensive investigations to identify an alternative etiology. While admitted and under observation, she became extremely anxious, began to hyperventilate and went into hypercapnic respiratory failure, which was successfully aborted with sublingual lorazepam causing resolution of tachypnea. It became clear that the patient was suffering from panic attacks as the precipitant for her respiratory failure and she was successfully treated with psychiatric medication and breakthrough anxiolytics. Anxiety and panic disorders are more prevalent in patients with COPD than the general population and effective management is important as patient's with anxiety and COPD have worse clinical outcomes than with COPD alone. Additionally, panic attacks should be considered as an etiology for hypercapnic respiratory failure in patients with COPD and anxiety when the clinical presentation is atypical.

Epidemiology and patient predictors of infection and sepsis in the prehospital setting.

PURPOSE: Paramedics are often the first healthcare contact for patients with infection and sepsis and may identify them earlier with improved knowledge of the clinical signs and symptoms that identify patients at higher risk. METHODS: A 1-year (April 2015 and March 2016) cohort of all adult patients transported by EMS in the province of Alberta, Canada, was linked to hospital administrative databases. The main outcomes were infection, or sepsis diagnosis among patients with infection, in the Emergency Department. We estimated the probability of these outcomes, conditional on signs and symptoms that are commonly available to paramedics. RESULTS: Among 131,745 patients transported by EMS, the prevalence of infection was 9.7% and sepsis was 2.1%. The in-hospital mortality rate for patients with sepsis was 28%. The majority (62%) of patients with infections were classified by one of three dispatch categories ("breathing problems," "sick patient," or "inter-facility transfer"), and the probability of infection diagnosis was 17-20% for patients within these categories. Patients with elevated temperature measurements had the highest probability for infection diagnosis, but altered Glasgow Coma Scale (GCS), low blood pressure, or abnormal respiratory rate had the highest probability for sepsis diagnosis. CONCLUSION: Dispatch categories and elevated temperature identify patients with higher probability of infection, but abnormal GCS, low blood pressure, and abnormal respiratory rate identify patients with infection who have a higher probability of sepsis. These characteristics may be considered by paramedics to identify higher-risk patients prior to arrival at the hospital.

Correction to: Epidemiology and patient predictors of infection and sepsis in the prehospital setting.

The original version of this article unfortunately contained a mistake.

Diffuse Deep T-Wave Inversions Following a Generalized Seizure.

BACKGROUND Stress cardiomyopathy (SCM) is a transient dysfunction of the left ventricle due to physical or emotional triggers that produces a range of electrocardiogram (ECG) changes. While ST-segment elevation or depression often leads to more urgent investigation and diagnosis, T-wave inversions can result in delayed diagnosis. CASE REPORT A 44-year-old woman with a prior left middle cerebral artery septic embolic stroke from endocarditis resulting in residual dense right sided hemiparesis and aphasia was admitted to the hospital for treatment of Staphylococcus aureus bacteremia. While hospitalized, she experienced a generalized seizure that was aborted with lorazepam and then loaded with phenytoin. Her ECG following the seizure showed a prolonged QT interval, for which her methadone that she was stabilized on during hospitalization was held. Her ECG to follow-up on her QT interval 25 h following the seizure showed new diffuse symmetric deep T-wave inversions. While initially believed to be due to the either the discontinuation of methadone or initiation of phenytoin, retrospective analysis revealed that these changes were more suggestive of a missed SCM. CONCLUSIONS We report a patient who experienced a generalized seizure resulting in diffuse, symmetric, deep T-wave inversions that were incorrectly attributed to medication effects before identifying the likely diagnosis of SCM. Fortunately for this patient, there were no consequences of the delayed diagnosis, but this case emphasises the importance of considering SCM following a generalized seizure in any patient with ECG abnormalities.