WHAT YOU EAT.......IS WHAT YOU GET.

When patients present to the emergency department with GI symptoms, vague muscle aches/pains and malaise, with or without fever, it is good to consider the FOOD(S) they have consumed, as the
cause of their symptoms.

Often, we "diagnose" them with "viral gastroenteritis", etc. but the medical literature is replete with
conditions associated with a non-viral agents.  The boards also favor these topics!

These following list of associations is partial but may help with your next diagnosis!


CONSUMPTION:                                                   AGENT/ILLNESS:



  1.  RAW MILK ...................................................Campylobacter Jejuni


  2.  SALMON/SQUID.........................................  Anisakiasis


  3.  PORK (undercooked)......................................Trichinosis
                                                                                Neurocysticercosis


  4.  TUNA/MACKAREL/MAHI-MAHI...............Scombroid



  5.  RAW EGGS/CHICKEN..................................Salmonella



  6.  GROUPER/SNAPPER....................................Ciguatera



  7.  RAW OYSTER................................................Vibrio Vulnificus



  8.  BEEF (undercooked)........................................E.Coli (O:157:H7)



  9,  SHELLFISH.....................................................Vibrio Parahemolyticus



10.  WATER (unsanitary)........................................Giardia Lamblia



11.  RASPERRIES...................................................Cyclospora



12. FRIED RICE......................................................Bacillus Cereus




Thanks for viewing. We'll continue soon.


 
                                                                         

UNCOMMON CAUSES OF CHEST PAIN....

In the daily practice of emergency medicine, we all come across the common causes of chest pain, such as Angina, Acute MI, pericarditis, Pleurisy, PE and an occasional Thoracic Dissection.

But often, even after extensive work-up, the diagnosis remains elusive...thus, making the diagnosis of ATYPICAL CHEST PAIN or UNDETERMINED CHEST PAIN common.


The list below is partial, but including them in your differentials, will certainly help close the gap!


UNCOMMON CAUSES OF CHEST PAIN:


   1. DRESSLER'S SYNDROME
      
       CLUES: Recent myocardial infarction. Normal cardiac enzymes. Fever. Elevated ESR.
                      Benign of pericarditis like findings on EKG.

 
   2. ACUTE PNEUMOMEDIASTINUM

       CLUES: Main symptom is severe chest pain, due to rupture of alveolar blebs with air
                      escaping into the mediastinum. Can palpate subcutaneous crepitations,
                      especially at the suprasternal notch/anterior neck. No dyspnea as opposed to
                      an acute pneumothorax.


   3. BOERHAAVE'S SYNDROME

       CLUES: Repeated emesis with sudden onset of intense chest pain, causing the tear in
                      the esophageal wall. CXR will show pneumonia-like findings. An increases
                      serum amylase and WBC is also key.  Condition can be especially common
                      in post head/neck radiation patient, esophageal cancer patient or in  patients
                      with previous damage of esophagus due to corrosive ingestion.


  4. ACUTE VARICELLA ZOSTER

      CLUES: Generally elderly patient presenting to ED with sharp stabbing pain, without
                     an obvious cause, involving the specific dermatome.  Can be challenging to
                     diagnose, as pain always occurs 2-3 days before the rash.


  5. CORKSCREW/NUTRCRACKER ESOPHAGUS

      CLUES: Due to an esophageal motility disorder, causing severe intense episodic chest
                     pains, especially after consuming carbonated beverages. The esophagus is
                     spasmodic and hypercontracting. Difficult to diagnose, as patients repeatedly
                     present to ED's with chest pain. Diagnosis: Barium swallow and best confirmation
                     study is Manometric Study of Esophagus.


 6. ACUTE CHEST SYNDROME

     CLUES: This is a complication of Sickle Cell Anemia affecting a subset of patients.
                    Carries a high mortality, if not treated early. Pathophysiology involves occlusion
                    of pulmonary microvasculature by deformed (sickled) RBC.'s causing infarction.


 7. KAWASAKI DISEASE

     CLUES: It is a form of vasculitis involving small-medium coronary arteries, causing blood
                    vessel aneurysms, that lead rupture, causing myocardial infarction.
                   This is the most common acquired coronary vascular disorder in children
                   Death can be sudden an unpredictable.





Thanks for your time. Will continue soon.
                  

COMMON TICK BORNE ILLNESSES....Differential diagnosis.

Tick borne illnesses are commonly seen in emergency departments.
As we all know, many times the patient has no awareness of being bitten by a tick and can present
with multiple vague complaints, which we'll present on the next posting.

However, most importantly it is always good practice to keep a list of alternate diagnosis
besides LYME'S, when considering this illness in the first place. Most  have very similar presentations and ALL have one thing in common....TICKS.


ALTERNATES TO CONSIDER:



1. BABESIOSIS (due to Babesia Microti).

2. ROCKY MOUNTAIN SPOTTED FEVER (due to Rickettsia Ricketti).

3. Q FEVER (due to Coxiella Burnetti).

4. TULAREMIA (due to Francisella Tularensis)

5. EHRLICHIOSIS  2 TYPES:
              
            * HUMAN MONOCYTOTROPIC EHRLICHIOSIS (HME)
               ( due to Ehrlichia chaffeensis)

            * HUMAN GRANULOCYTOTROPIC ANAPLASMOSIS (HGA)
               ( due to Anaplasma phagocytophilum)

CLINICAL SCENARIO.......Answers.

CORRECT ANSWERS to the posted questions are as follows:


1.    The answers is INFECTIOUS MONONUCLESOSIS.

       Best CLUES to the diagnosis are:

               *** Protracted duration of the illness.
               *** Kehr's Sign. left shoulder pain.
                      (due to splenomegaly).
               *** Early Satiety (due to splenomegaly).


     
       Viral Pharyngitis....,,,,,, does not present with above symptoms/signs.
   
       Exudative Tonsillitis....is very unlikely due to lack of exudates.
                                             Also does not produce splenomegaly.

       Vincent's Angina..........is a necrotizing ulcerative gingivitis,
                                             (Trench Mouth), which this pt. does not have.

       Acute Herpangina........is a group A coxsackie viral infection.
                                             Findings of many palate ulcerations.





2.   The answer is PSITTACOSIS.


       Best CLUES to the diagnosis are:

               ***Household  pet bird.
               ***Abrupt onset with high fevers.


      Chlamydia Pneumonia.....typically is preceeded by a recent sore throat
                                                or upper respiratory infection.

     Mycoplasma Pneumonia...typically occurs in younger patients.
                                                Such are college dormitory or military
                                                barrack residents.

     Legionnaire's Disease........Pt. must  have had history of exposure to
                                                water vapors/condensation. Such as air-
                                                coditioning, humidifiers, etc.

    Lofren's Syndrome..............Is triad of:  * Hilar adenopathy
                                                                   * Erythema Nodosum
                                                                   * Arthritis

                                                 It is also called Sarcoid Arthritis.
              



Vincent's Angina was named after a French physician:
                JEAN HYACYNTHE VINCENT.

Lofren's Syndrome was named after a Swedish clinician:
                SVEN HALVAR LOFGREN.
              



      
                                                               

BOARD QUESTIONS.....

The BOARD QUESTIONS herein, are examples of real cases enountered in clinical practice.
All of the questions are materially simulated by the author.



Q   1.   Patient is a 21 y/o white male  presents to the ED with 10 days
            hx. of malaise,low grade fever and sore throat. Appetite is poor.
            Also noted that minimal amount of eating gives him a sense
            of fullness with a mild LUQ discomfort. C/o aching in left shoulder.
            He is a college student. No recent travels or pet ownership noted.
            Past medical/surgical histories are negative.
.
            On exam, appears prostrated, but non toxic.  Vitals normal, except for
            oral temp. of 100.7 F.   ENT exam shows redness & exudate of the pharynx.
            Mild submandibular adenopathy and LUQ fullness is noted on palpation.

            Based on the  history alone, what is the LIKELY diagnosis?

           A.  Acute Viral Pharyngitis
           B.  Acute Exudative Tonsillitis
           C.  Vincent's Angina
           D.  Acute Herpangina
           E.  Acute Infectious Mononucleosis


Q   2.  Patient is a 33 y/o white female presented to her PCP with 3 -4 day history
           of high fevers, cough, malaise and  myalgias. Has been taking OTC
           antipyretics and antitussives. Today noted pleuritic pain  with deep
           breaths.  Pt. is a librarian by profession. Owns a recently purchased
           parakeet. Pt. was well prior to onset of illness. Lives alone.
           No recent travels. Past medical/surgical histories are negative

           On exam  appears ill, with paroxysms of deep cough. Oral temp. 103.2 F.
           EENT=unremarkable.  LUNGS=Scattred ronchi bilaterally.
           Rest  of the physical exam is normal. No rash of synovitis are noted.

           Based on the above H&P, what is the likely diagnosis?

           A.  Acute Chlamydia Pneumonia
           B.  Acute Mycoplasma Pneumonia
           C.  Acute Legionnaire's Pneumonia
           D.  Acute Psittacosis
           E.  Lofgren's Syndrome
           


 Feel free to select the ONE correct choice.  The next POSTING will have the answers.

MEDICAL NOMENCLATURE II.....

Continuing with selected medical terminologies:




1.    Double vision.............................DIPLOPIA


2.    Ringing in the ears.....................TINNITUS


3.    Coughing of thick phlegm..........BRONCHORRHEA


4.    Coughing of  blood.....................HEMOPTYSIS


5.    Vomiting of blood.......................HEMATEMESIS


6.     Brigh red bloody stool................HEMATOCHEZIA


7.    Tarry black/maroon stool.............MELENA


8.    Enlarged tongue..........................MACROGLOSSIA


9.   Decreased urination......................OLIGURIA


10. No urination(output).....................ANURIA



We'll continue soon.
Thanks for your time!

MEDICAL NOMENCLATURE....Revived.

It has been my observation, that our professional nomeclature is fast being "watered down" over the
years.  Here are some of the very common examples one can find of such, in daily use.

Proper wording is not only better charting....but more professional, as well.  Have fun!




1.    HICCUPS.................................................SINGULTUS

2.    HEARTBURN..........................................PYROSIS

3.    ITCHING..................................................PRURITUS

4.    NASAL CONGESTION (cold)................CORYZA

5.    HEADACHES...........................................CEPHALGIA

6.     EARACHE................................................OTALGIA

7.    BODY ACHES...........................................MYALGIA

8.    GENERALIZED WEAKNESS..................ASTHENIA. MALAISE

9.    BEE STING................................................HYMENOPTERA STING

10.  HIVES.........................................................URTICARIA

11.  FEVER........................................................HYPERPYREXIA

12.  PAINFUL SWALLOWING......................  ODYNOPHAGIA

13.  DRY SKIN...................................................XERODERMA

14.  DRY EYES...................................................XEROPTHALMIA

15.  LIMPING WALK.........................................ANTALGIC GAIT




Just a reminder, there can be alternative words for the above examples, but every attempt was
made to use, the most common medical terminology.


Will return soon.