D.R.E.S.S. Syndrome  (Drug Reaction with Eosinophilia and Systemic Symptoms)

Condition is a very rare Type IV(b) adverse hypersensitivity reaction  to certain medications, with gradual onset,  on average about 32 days after a new medication. Can occur earlier or later.

Most common medications are anticonvulsants (phenytoin, carbamazepine, phenobarbital, levetiracetam, lamotrigine.  NSAIDS, B-Lactam antibiotics. Vancomycin, Allopurinol, TMP/SMZ.

INCIDENCE: About 1:10,000 of adverse cutaneous drug reactions, with a high mortality rate, if undiagnosed in the range of (3.8%-10%)

The rash is generalized morbilliform, but can be limited to the face, causing facial edema/erythema, mimicking erysipelas/angioedema.

CLINICAL FINDINGS:  Besides the rash, are fever, chills, malaise, pruritus and generalized lymphadenopathy, involving the cervical, axillary and inguinal lymph nodes. Can appear minimally ill or toxic, depending on stage of presentation.

Can cause multi-organ involvement, with liver being the most common target and as well as the kidneys.

Most common cause of death is due to hepatic necrosis with fulminant hepatitis and renal failure.

LABORATORY DATA: Eosinophilia > 6000x10(3)/uL. Thrombocytopenia/Pancytopenia. Leukocytosis Coagulopathy, elevated liver enzymes (ALT x 2 normal). Elevated BUN, proteinuria.

Above laboratory findings are indicators of poor prognosis!

DIAGNOSIS: High clinical suspicion. Should always be on the differential diagnosis of any erythematous rash, in patient on above medications.

DIFFERENTIAL DIAGNOSIS:  Steven-Johnson syndrome. Toxic epidermal necrolysis. Kawasaki disease, Hypereosinophilic syndrome. 

TREATMENT: Discontinue potential causative agent(s). Systemic corticosteroids (Prednisolone IV with gradual tapering. Cyclosporine IV, if no response or steroid contraindicated. Supportive care. Vigilant monitoring for potential multi-organ involvement.

 RS3PE SYNDROME (Remitting Seronegative Symmetrical Synovitis with Pitting Edema).

Clinical syndrome is a rare entity, often mimicking an infectious process.

Patients will present with unilateral or often bilateral abrupt onset of  painful, erythematous swelling 

of upper or lower extremities, associated with palpable pitting edema.

Usually afebrile, but mild temperature elevation can occur (secondary to the inflammatory process).

Generally, recurrent with increasing episodes of flare ups.  Patient often mistakenly treated with

antibiotics, with no significant improvement. Condition, generally abates spontaneously without

any therapy and  next flare up is treated with antibiotics, again. 

Thus, RS3PE can be undiagnosed for many months.

Epidemiology:  More common in patients greater then age 60, male>female, rural setting, rapid onset.

Frequently misdiagnosed as cellulitis, erythrodermatosis, RSD (reflex sympathetic dystrophy)

About 50% likelihood of undiagnosed underlying malignancy (prostate/breast/lung carcinoma).

Laboratory findings:  Elevated inflammatory markers (CRP/Sedimentation rate).

Mild leukocytosis.  Negative RF and Anti-CCP-Ab. 

Treatment: High index of clinical suspicion. 

Hint: Onset of abrupt bilateral cellulitis is extremely unlikely.

Low dose prednisone 10-20 daily, provides rapid improvement.

Remain vigilant for underlying undiagnosed malignancies!

SARS-CoV-2    CLINICAL CLUES...basic findings

Covid-19 related symptoms vary from quite atypical (anecdotal)  to "classic" clinical presentations in the emergency department setting, requiring a high degree of suspicion.

The following are a short list of symptoms--presentations to consider:

Classic presentations are: 1. Dyspnea with hypoxia (pulse oximetry < 92% on room air)

                                             2. Tachypnea-tachycardia

                                             3. Fever, chills, night sweats

                                             4. Cough

                                             5. Myalgias

Atypical presentations:     1. Profound malaise-physical exhaustion

                                             2. Lack of appetite

                                             3. Insomnia

                                             4. Dysgeusia (altered-impaired sense of taste)

                                             5. Anosmia-hyposmia  (altered sense of smell)

                                             6. Nausea-diarrhea

                                             7. Delirium

                                             8. Embolic-thrombotic events in younger pationts

                                             9. Headache-vertigo

Laboratory data:               1. CBC with differential--lymphopenia

                                             2. Elevated ALT/AST

                                             3. Elevated LDH

                                             4. Elevated CRP

                                             5. Elevated serum Ferritin

                                             6. ABG--hypoxemia

Chest x-ray:                        1. Bilateral basilar infiltares to ARDS finding

CT scan chest:                    1, Ground glass appearance

              

"INTERNATIONAL" Infectious diseases....

In clinical practice and frequently on board exams, it is important to consider infectious diseases
that occur in certain "international", geographic regions, as these subtle hints will help with diagnosis
and in correctly answering the question. Examples:



1.     Patient from Egypt/Northern Africa develops hematuria. What organism is the likely cause?


2.     Patient from Mexico (Central/South America) develops a seizure.
        What is the likely cause?


3.    Patient from Scandinavia, develops B12 deficiency.
       Likely etiology?


4.    Patient returning from a vacation in the Caribbean, develops sudden headache,
       retroorbital pain, myalgias, arthralgias and high fever.
       What is the causative factor?



5.    Patient returning from a wild boar hunting trip develops gradual onset of
       myalgias, ,periorbital edema, persistent fever,malaise and photophobia.
       What organism is responsible?


========================================================================

Answers:

 1.  The diagnosis is SCHISTOSOMIASIS, specifically, S. Haematobium, that is prevalent
      in the fresh waters of African continent, Middle East and India.
      It is a Trematode (Fluke), a flat worms that infect mainly the GU tract, causing bladder
      ulceration, hematuria, that can frequently result in anemia and squamous  cell carcinoma
      of the bladder. Infertility is a frequent consequence.


2.   Diagnosis is NEUROCYSTICERCOSIS. It is a pork tapeworm, Taenia Solium.
      It can only occur from consuming undercooked pork. When the agent invades the
      CNS, the first symptoms is usually a seizure as usually it is asymptomatic.
      However, can have vague headaches, focal neurologic deficits and hydrocephalus.


3.   Diagnosis is DIPHYLLOBOTHRIASIS. The organism is a freshwater fish tapeworm.
      It is prevalent in Northern, cooler climates, worldwide, and especially common in
      Finland, Norway, Sweden.   Consumption of raw fish causes, the D. Latum to invade
      the small intestine, especially the terminal ileum, causing B12 deficiency, from
      continued feeding.



4.    Diagnosis: Acute DENGUE FEVER.  It is a disease transmitted by mosquitos, especially
       common in tropical regions. Caribbean, Puerto Rico, etc.  Caused by a flavivirus.



5.    Diagnosis:  Acute TRICHINOSIS.    This is another infectious disease, common in
       countries that consume pork, wild boar or even bear meat. The classic nematode is
       T. Spiralis. 



Will soon continue.
      

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.

DERMATOLOGY...."Which is which"???

There are good several diseases in dermatology that sound CONFUSINGLY ALIKE.
These will very likely be covered on your examination...so, let's cover them and simplify.


Q:   What is ECHTYMA GANGRENOSUM?


A:   It is an infection of the skin...caused by an undelying  PSEUDOMONAS AUREGINOSA
       systemic infection. Common in the ICU setting.




Q:   What is PYODERMA GANGRENOSUM?


A:   It is an INFLAMMATORY condition...causing necrotizing-bullous eruptions, especially of
       the extremities.  Corticosteroids WILL IMPROVE  and antibitotic (e.g. dapsone) may have added effect.
       There are 3 types...and 70% will be assiciated with a variety of underlying diseases, e.g.
       MULTIPLE MYLOMA, IBD (Crohn's disease/Ulcerative colitis), ARTHRITIS(primarily RA) and DM.



Q:  What is a PYOGENIC GRANULOMA?


A:  It is a HARMLESS skin growth, also called Eruptive Hemangioma, that can occur on any part
      of the body, especially fingers and gingiva.  The name remained...because it was initially thought
     of as being infectious in etiology.



Q:  What is SEBORRHEIC KERATOSIS?


A:  It is a WARTY growth of the skin....predominantly of the elderly....causing a "STUCK-ON"
      appearance, commonly seen on the scalp, face, chest and back.  Can transform into SQUAMUS
      CELL CARCINOMA...in immunocompromised patients.



Q:  What is SEBORRHEIC DERMATITIS?


A:  It is a SCALY eruptive lesion seen commonly in AIDS patient and in  patients suffering
      from PARKINSONISM.  The rash typically affects the face, nose, scalp.
      Causative organism is PITYROSPORUM OVALE.
   



Q:  What is ACTINIC KERATOSIS?


A:  It is a PRECANCEROUS condition.....can lead to SQUAMUS CELL CARCINOMA.
      They are "red itchy bumps"...occuring especially on SUN EXPOSED surfaces, such as
      hands, forearms. At times the lesions can BLEED and become painful.



Q:  What is DERMATITIS HERPETIFORMIS?


A:  They are MICROABSCESSES and IgA DEPOSITS on the basement membrane of the skin,
      causing BLISTER like lesions of the elbows, low back, buttocks...likely due to immune mediated
      etiology.   It is commonly assiciated with CELIAC SPRUE...thus, a GLUTEN FREE diet, will
      frequently clear the dermatosis.



Suggest a good memorization of these VERY SIMILAR SOUNDING disorders, as they will be
asked on the examinations. 


  

URINALYSIS.....diagnostic clues.

URINALYSIS can give us instant CLUES to  an underlying pathology...and is also a
frequent topic of the boards.  We'll review some common and (not so common) findings.



1.   CALCIUM OXALATE...usually associated with Ulcerative Colitis or Ethylene Glycol Poisoning.

2.   ERYTHROCYTE CASTS...Pathognomonic for Acute Glomerulonephritis (AGN)

3.   HYALINE CASTS....implies moderate to severe dehydration...eg. Prerenal Azotemia

4.   GRANULAR CASTS...imlplies necrotic insult, such as Acute Tubular Necrosis (ATN)

5.   MUDDY BROWN CASTS....usually due to Acute Tubular Necrosis. (ATN)

6.   EOSINOPHILURIA.....very suggestive of ALLERGIC Interstitial Nephritis.
                                             (Best diagnosed with use of Hansel's stain).

7.   WHITE CELL CASTS...also commonly found in ALLERGIC Interstitial Nephritis.

8.   STERILE PYURIA...is a classic finding in Acute Interstitial Nephritis. (AIN).

9.   TUBULORETIC INCLUSIONS....pathognomonic for renal manifestation of HIV.

10.  URINE OSMOLALITY....reflects the kidneys ability to process water 
                                               An INCREASED osmolality = Concentrated urine (dehydration).
                                               An DECREASED osmolality = DILUTE urine.



Thanks for your time...be back shortly.

QUICK TAKES II

Q:   What is Lateral Epicondylitis?


A: 

QUICK TAKES

We'll review some uncommon clinical scenarios...not so uncommonly covered, by the medical boards.


Q: What does a WIDENED MEDIASTINUM most commonly imply?



A: 1. Dissecting Thoracic Aneurysm
2. Inhalational Anthrax

3. Improper patient positioning during CXR (this is most common).




Q: What does finding of CALCIUM OXALATE in urinalysis imply?


A: 1. Ethylene Glycol Poisoning
2. IBD (Crohn's Disease)




Q: What are BURTON'S LINES?



A: Bluish discoloartion along the gingival margins of teeth...in CHRONIC LEAD POISONING.
Not seen in edentulous persons. It is a highly suggestive sign!






Q: What is a PINGUECULA?



A: It is a harmless, yellow-while collagen (jelly-like) depostion on the corneal surface.
Can be removed for bothersome-cosmetic reasons.




Q: What are MEES' LINES?



A: A whitish transverse discoloration of the fingernails...seen in ARSENIC or LEAD poisoning.






We'll continue soon!

HEMATOLOGICAL EMERGENCIES...

We'll continue with interesting topics in hematology, specifically disorders that need quick diagnosis and management.



1. WHAT IS TTP (Thrombotic Thrombocytopenic Purpura)?


A: TTP is an uncommon but not infrequent blood dyscrasia, that primarily affects
platelets. As the name implies, platelet numbers are very diminished causing
cutaneous purpura. This is primarily a disease of ADULTS.

The PENTAD for diagnosing TTP are:
1. Thrombocytepenia
2. Purpura
3. Confusion (mental status changes)
4. Renal Insufficiency/failure
5. Fever

Usually not all 5 charactersitic findings are present. To make the diagnosis, besides the low
plateletet count and reactive purpura...the presence of an additional finding, will do.





2. WHAT IS THE TREATMENT FOR TTP?


A: Emergent PLASMA EXCHANGE, as well as meticulous supportive care.





3. WHAT IS ITP (Idiopathic Thrombocytopenic Purpura)?


A: ITP predominately affects CHILDREN in about 90% of cases, due to immune phenomenon.
Generally occurs as after a recent VIRAL EXANTHEM, UPPER RESPIRATORY
INFECTION, INFECTIOUS MONONUCLEOSIS,etc. Clinically, similar to TTP above.



4. WHAT IS THE TREATMENT OF ITP?


A: Medical treatment for ACUTE TTP, with active bleeding consist of GLUCOCORTICOIDS.
If steroids are unhelpful...IVIG (Intravenous Immunoglobulin) infusion is recommended.
Emergency SPLENECTOMY is reserved for severe ITP.




5. WHAT IS POST (PLATELET) TRANSFUSION PURPURA?


A: Occurence of LOW PLATELET COUNT 7-10 DAYS, after platelet transfusion.
Patients usually present with bleeding from gums, purpura and severe thrombocytopenia.
It is due to presence of an ANTIGEN called...HPA-/a.

6. WHAT IS THE TREATMENT?


A: IVIG or PLASMAPHERESIS.



Thanks for your time!

INTERESTING CASES....

Just the other day I've seen a few real interesting cases in the emergency department.
In fact, interesting because they are quite rare even by ER standards....and to have
seen it all on one 12 hour shift is even more unique.


1. RELAPSING POLYCHONDRITIS

An elderly woman presented with a painful and swollen, beet red right ear.
She tought it was an insect bite...but does not recall being bitten.
Upon further questioning, she states to have similar occurence in the left ear
two months ago, which resolved with NSAID's...and reddeneded ears about
one year prior. Fortunately for her, no tracheal symptoms were present.




2. ACUTE PERICARDITIS

Yes, it is more common then the above...bit still only see few clinical cases per year.
This 30 year old woman presented with 2 weeks history of recurrent sharp anterior
chest pains and symptoms of dyspnea.
EKG revealed classis ST elevations in inferior leads with CONCAVE downsloping.
Another give away was the pathgnomonic KNUCKLE sign in AVR.
Upon seeing it....it was reassuring to await the enzymes. She was admitted for observation
and a 2D-Echo.




3. ACUTE VIRAL HEPATITIS

A 22 year old male presented with 8 days history of recurrent vomiting and not feeling
well. Also complained of fatigue and darker urine.
What was unusual is the lenght of vomiting. Normally with gastroenteritis symtoms,
vomiting last 3-4 days.
Upon receiving the lab tests, all liver enzymes were modereately elevated.
A hepatitis panel was ordered and on re-exam a faint scleral icterus was noted, not
picked up on the initial exam
The patient probably experienced the prodromal phase of Acute Hepatitis A (HAV)
infection with his lingering constitutional symptoms.




All on one shift:)!

ENDOCRINOLOGY...Part I

It has been a bit of a hiatus since the last posting...but we'll just continue on the path of learning
new and exciting material....in Endocrinology.


Q: What is SHEEHAN'S SYNDROME?


A: It affects affects only WOMEN in the immediate POST PARTUM time period.
Due to sudden hypovolemia or shock, therefore decreased blood flow to the
PITUITARY GLAND....causes silent infarction of the gland. Subsequently,
patients experience LACK of normal LACTATION, AMENORRHEA and FATIGUE.



Q: What is GALACTORRHEA?


A: It is an abnormal and inapproproate release of MILK (lactation) in both men and women.

The primary cause is usually due to a PROLACTIN releasing PITUITARY ADENOMA.
It can also be caused by various medications e.g. OPIOIDS, PHENOTHIAZINES, and
METHYLDOPA. Diagnosis is usually made by an elevated SERUM PROLACTIN levels.
An MRI of the Pituitary gland is the radiologic diagnosis of choice in identifying the
adenomas, being either a microadenoma (<10mm)>10mm) in size.



Q: What is DIABETES INSIPIDUS (DI)?


A: It is a either a DEFICIENCY of VASOPRESSIN (ADH) due to a hypopthalamic-pituitary
disorder....called CENTRAL DIABETES INSIPIDUS (CDI)...Hint: CNS!!!

....or from RESISTANCE of the KIDNEYS to VASOPRESSION (ADH)....this is called.
NEPHROGENIC DIABETES INSIPIDUS (NDI).

The main symptoms are due to enormous amount of fluids being consumed by the
patient...thus, THIRST, POLYDIPSIA, POLYURIA ...and very commonly, NOCTURIA.


Q: Which THYROID CANCER type is MOST COMMON?


A: PAPILLARY CARCINOMA....tumor usually occurs on patients ages 30-60.
Female to male ratio, usually 3:1.



Q: Which Thyroid Cancer is MOST COMMON among the ELDERLY?


A: FOLLICULAR CARCINOMA



Q: Which Thyroid Cancer produces CALCITONIN?


A: MEDULLARY CARCINOMA...the hormone is produced by the parafollicular cells,
called, C-CELLS. Thus, the best test is a SERUM CALCITONIN level, which is
significanlty elevated.



Thanks for your time, we'll return shortly.

Men's Health.....Part II.

We'll continue with health issues specifically affecting men, that you are very likely to
encounter on your board examination and in the clinical setting.


Q: Why is TESTICULAR TORSION an urologic emergency?


A: As in any condition with arterial circulatory compromise...time is golden.
Testicular salvage is 80-100% at within 8 hours and ZERO percent at 12 HOURS.




Q: What is the BEST immediate procedure of choice for treatment of torsion?



A: MANUAL DETORSION... by rotating the testis outward offers a 30-70% chance of
restoring arterial blood flow,,, with immediate PAIN RELIEF being the best guide.




Q: What is the MOST COMMON AGE GROUP for occurence of torsion?


A: The AGES of 12-18 YEARS. It is uncommon after age 30.




Q: What is ORCHITIS?



A: It is an INFECTION of the testes....usually under the age of 10. The MOST COMMON
cause is VIRAL....typically MUMPS.




Q: What is PRIAPISM?



A: It is a painful, continued ERECTION lasting greater then 4 hours.



Q: What is the MOST COMMON CAUSE?



A: Today....DRUG THERAPY for erectile dysfunction is the primary cause. In the past
ischemic (venoocclusive) was the most common cause...due to decrease or absence
of cavernous blood flow. E.g. Sickle Cell Crisis or pelvic vascular thrombosis.




Q: What is the BEST MEDICAL THERAPY?



A: Immediate application of ICE PACKS....then ORAL TERBUTALINE 5mg.
If this fails....an alpha AGONIST like PHENYLEPHRINE is injected.




Q: What is EPIDIDIMYTIS?



A: It is an infectious process (usually bacterial) involving the epididymis.
It is IMPORTANT to REMEMBER that on the boards...AGE is the main CLUE
as to the cause.
Thus, UNDER AGE 35...the likely causative agents are STD's...primarily
Chlamydia Trachomatis and Nisseria Gonorrheae

OVER AGE 35...Gram Negative bacteria, such as E.COLI is the likely cause.




Thanks again for your time...we'll continue soon.

Men's Health....TESTICULAR TUMORS.

It has been a while since the last posting...but we'll make up for it in the months ahead.

Today's topic is a suggestion of a students rotating through the ED. She has lamented, that on prepation for the boards, the subject of men's health specifically, is lacking. With this in mind we'll cover some important disorders...with due credit to Shara.


TESTICULAR CANCERS:


Q: What is the MOST COMMON cell type...causing testicular cancer?


A: GERM CELL tumors cause approximately 95%.



Q: What classification are they divided into?


A: SEMINOMAS....account for about 60% and NON-SEMINOMAS...@ 40%.





Q: What cell type causes the remaining 5% of testicular cancer?


A: STROMAL CELL tumors....namely LEYDIG CELL CA or SERTOLI CELL CA.



Q: How to definitely DIAGNOSE testicular cancer?


A: NEVER BIOSPY!!!!....an INGUINAL ORCHIECTOMY is the procedure of choice.



Q: What are the RISK FACTORS for development of testicular cancer?


A: 1. Undescended Testicle (Abdominal Cryptorchidism).
2. Prior History of Testicular Cancer
3. Kleinfelter's Syndrome
4. Positive Family History
5. Testicular Feminization Syndromes



Q: What are the GENERAL CURE RATES?


A: They are HIGHLY CURABLE!!!

NON-METASTATIC DISEASE....100% cure rate.
METASTATIC DISEASE................70% cure rate.



Q: What are the common AGE GROUPS affected by testicular cancer?



A: It tends to be BIMODAL. Most common in young men, ages 15-35....and another peak
occuring in at age > 60.




Q: What is the HALF LIFE of serum B-HCG and AFP.. and why are they important?


A: The half life of B-HCG is ONE DAY.......and that of AFP is ONE WEEK!

They are important post surgically....because if either one is elevated beyond the
expected half life.....RESIDUAL DISEASE EXISTS.




We'll continue with more of Men's Health soon....