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:)!
Monday, August 22, 2011
Monday, March 7, 2011
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.
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.
Thursday, December 16, 2010
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.
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.
Saturday, October 30, 2010
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....
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....
Saturday, July 31, 2010
RARE INFECTIOUS DISORDERS...
These disorders may be rare in clinical practice...but are frequently the topic of board
exams...so, it's worth remembering.
Q: What is CREUTZFELD-JACOB DISEASE?
A: It is a rapidly progressive encephalopathy caused by a PRION. It is similar to Mad Cow
Disease....causing ataxia, dementia and myoclonic jerking movements along with visual
defects. CT/MRI Images of the Brain are normal. EEG shows Triphasic Waveforms.
Almost always FATAL.
Q: What is PML (Progressive Multifocal Leukoencephalopathy)?
A: It is...as the name implies a form of encephalopathy....caused by JC-VIRUS ( a papovavirus),
which causes LYSIS of the Oligodentrocytes....leading to a WHITE MATTER disease.
There is no effective therapy.
Q: What is HAM (HTLV-1 Associated Myelopathy)?
A: It is a RETROVIRUS borne disorder, that MIMICS Multiple Sclerosis. In USA can occur
in Southeast Florida. Pathophysiology: It is due to an autoimmune attack by CD8 T Cells
on HTLV-1 infected GLIAL cells. Serologies will confirm diagnosis.
Q: What type of meningitis is associated with GENITAL HERPES HSV-2 ?
A: MOLLARET'S MENINGITIS. It is a cause of BENIGN recurrent lymphocytic meningitis.
An astute practitioner will identify clinical findings in the genitalia (ulcers/lesions).
TX: Self Limited illness....No Acyclovir needed. DX: Confirmed by PCR.
Q: What Infections Disorders are most common and important to consider in TRAVELERS?
A: 1. MALARIA
2. TYPHOID FEVER
3. HEPATITIS (HAV/HBV/HEV/HCV)
4. DENGUE FEVER
5. AMEBIC LIVER ABSCESS
Thanks for your time....be back soon.
exams...so, it's worth remembering.
Q: What is CREUTZFELD-JACOB DISEASE?
A: It is a rapidly progressive encephalopathy caused by a PRION. It is similar to Mad Cow
Disease....causing ataxia, dementia and myoclonic jerking movements along with visual
defects. CT/MRI Images of the Brain are normal. EEG shows Triphasic Waveforms.
Almost always FATAL.
Q: What is PML (Progressive Multifocal Leukoencephalopathy)?
A: It is...as the name implies a form of encephalopathy....caused by JC-VIRUS ( a papovavirus),
which causes LYSIS of the Oligodentrocytes....leading to a WHITE MATTER disease.
There is no effective therapy.
Q: What is HAM (HTLV-1 Associated Myelopathy)?
A: It is a RETROVIRUS borne disorder, that MIMICS Multiple Sclerosis. In USA can occur
in Southeast Florida. Pathophysiology: It is due to an autoimmune attack by CD8 T Cells
on HTLV-1 infected GLIAL cells. Serologies will confirm diagnosis.
Q: What type of meningitis is associated with GENITAL HERPES HSV-2 ?
A: MOLLARET'S MENINGITIS. It is a cause of BENIGN recurrent lymphocytic meningitis.
An astute practitioner will identify clinical findings in the genitalia (ulcers/lesions).
TX: Self Limited illness....No Acyclovir needed. DX: Confirmed by PCR.
Q: What Infections Disorders are most common and important to consider in TRAVELERS?
A: 1. MALARIA
2. TYPHOID FEVER
3. HEPATITIS (HAV/HBV/HEV/HCV)
4. DENGUE FEVER
5. AMEBIC LIVER ABSCESS
Thanks for your time....be back soon.
Saturday, May 15, 2010
CLINICAL ALLERGY-IMMUNOLOGY
This is the perfect season for this topic to be covered....
Pollen, bee stings and lots of outdoor activities.
Of course, as you well know by know...the boards want to know....how much you know.
Q: What is an ANAPHYLACTIC REACTION?
A: It is an immune response... IgE mediated Type I...hypersensitivity reaction.
HINT: Best way to remember...Ig"E" = "E"mergency. This is important on the
boards.
Q: Which laboratory test can be useful in definitely establishing the diagnosis of
Anaphylaxis?
A: SERUM B-TRYPTASE, if drawn within 30 minutes of onset. It will help differentiate
from other similar, but NON-anaphylactic reactions.
Q: Does anaphylaxis have a LATE PHASE?
A: Yes, it tends to be BIPHASIC....thus, it is best to admit the patient to ICU for 24 hours.
As, despite the treatment given in the ER...the patient can experience another bout
of clinical symptoms.
Q: What is the BEST medication to use in patients with anaphylaxis, who are on B-Blockers?
A: GLUCAGON...1 mg...this medication is also useful in REFRACTORY anaphylaxis.
Q: What is an ANAPHYLACTOID REACTION?
A: It is a NON-IgE mediated!!! ...MAST CELL or COMPLEMENT induced reaction.
Clinically indistinquishable from anaphylaxis.
Q: What are most common causes of an ANAPHYLACTOID REACTION?
A: IV CONTRAST or NSAID, ASA administration.
Q: Can a patient who is ASPIRIN sensitive be given NSAIDS?
A: NO....there is a strong degree of CROSS REACTIVITY.
Thanks for your time...we'll continue soon
Pollen, bee stings and lots of outdoor activities.
Of course, as you well know by know...the boards want to know....how much you know.
Q: What is an ANAPHYLACTIC REACTION?
A: It is an immune response... IgE mediated Type I...hypersensitivity reaction.
HINT: Best way to remember...Ig"E" = "E"mergency. This is important on the
boards.
Q: Which laboratory test can be useful in definitely establishing the diagnosis of
Anaphylaxis?
A: SERUM B-TRYPTASE, if drawn within 30 minutes of onset. It will help differentiate
from other similar, but NON-anaphylactic reactions.
Q: Does anaphylaxis have a LATE PHASE?
A: Yes, it tends to be BIPHASIC....thus, it is best to admit the patient to ICU for 24 hours.
As, despite the treatment given in the ER...the patient can experience another bout
of clinical symptoms.
Q: What is the BEST medication to use in patients with anaphylaxis, who are on B-Blockers?
A: GLUCAGON...1 mg...this medication is also useful in REFRACTORY anaphylaxis.
Q: What is an ANAPHYLACTOID REACTION?
A: It is a NON-IgE mediated!!! ...MAST CELL or COMPLEMENT induced reaction.
Clinically indistinquishable from anaphylaxis.
Q: What are most common causes of an ANAPHYLACTOID REACTION?
A: IV CONTRAST or NSAID, ASA administration.
Q: Can a patient who is ASPIRIN sensitive be given NSAIDS?
A: NO....there is a strong degree of CROSS REACTIVITY.
Thanks for your time...we'll continue soon
Saturday, April 24, 2010
SUCCESS TIPS.....
It has been a bit of a time lapse from the last posting...so thanks for your patience. Now I
have some very good news to share with you.........
I've had great feedback from people taking the PA exam. All have achieved good
results. One emergency medicine PA -C in particular scored outstanding...on the re-certifying
examination....in the top 5%!!!! Congratulations to her and all of you on your hard work.
Today, riding on the wave of recent successes I"d like to expand on the subject of itself.
The ideas are not mine...but universal for ages past. Nonetheless, they become very helpful
if practiced daily. These simple "recipes" will aid you on achieving positive results, whether
at home, the work environment, in preparation for your exam.....or just with life itself.
So, here are tips for YOUR success, as I see them:
1. Demand the BEST of yourself. Don't settle for average. You didn't get to where you
are in your present life and profession, by being just so....!!!
2. Take PRIDE in your work.....it's the only one you have. You can "shine" anywhere you
work, by making it a choice...so, take charge of your perspective, today.
3. Be INQUISITIVE....attempt to carve out 15 minutes a day...to read about a topic, which
you "never have the time" to learn about.
4. Be CARING....do something every day, for someone other then yourself. Do it with genuine
want....and it will become part of you, before you know it.
5. Be HONEST.....first and foremost with yourself, your immediate loved ones and your
co-workers......the rewards are self explanatory.
6. Set HIGH STANDARDS....in all aspects of your life. Being mediocre will lead to, just
that.....mediocre. So, take an honest inventory of yourself to see where you stand.
7. Be of GOOD SPIRITS....it always helps being on the lighter side.
8. Be THANKFUL....appreciate everything you have, as you could just as well have been
on the other side of the fence, in life...."looking in thru the outdoor" !!!
9. Have COMPASSION....with patients and people....life for any of us, could change in a single
instant......So, be happy to be giving care, instead of receiving one.
10. ......lastly PRAY DAILY, to being the fortunate one, to practice all the above!!!!
Thanks for your time...be back real soon.
have some very good news to share with you.........
I've had great feedback from people taking the PA exam. All have achieved good
results. One emergency medicine PA -C in particular scored outstanding...on the re-certifying
examination....in the top 5%!!!! Congratulations to her and all of you on your hard work.
Today, riding on the wave of recent successes I"d like to expand on the subject of itself.
The ideas are not mine...but universal for ages past. Nonetheless, they become very helpful
if practiced daily. These simple "recipes" will aid you on achieving positive results, whether
at home, the work environment, in preparation for your exam.....or just with life itself.
So, here are tips for YOUR success, as I see them:
1. Demand the BEST of yourself. Don't settle for average. You didn't get to where you
are in your present life and profession, by being just so....!!!
2. Take PRIDE in your work.....it's the only one you have. You can "shine" anywhere you
work, by making it a choice...so, take charge of your perspective, today.
3. Be INQUISITIVE....attempt to carve out 15 minutes a day...to read about a topic, which
you "never have the time" to learn about.
4. Be CARING....do something every day, for someone other then yourself. Do it with genuine
want....and it will become part of you, before you know it.
5. Be HONEST.....first and foremost with yourself, your immediate loved ones and your
co-workers......the rewards are self explanatory.
6. Set HIGH STANDARDS....in all aspects of your life. Being mediocre will lead to, just
that.....mediocre. So, take an honest inventory of yourself to see where you stand.
7. Be of GOOD SPIRITS....it always helps being on the lighter side.
8. Be THANKFUL....appreciate everything you have, as you could just as well have been
on the other side of the fence, in life...."looking in thru the outdoor" !!!
9. Have COMPASSION....with patients and people....life for any of us, could change in a single
instant......So, be happy to be giving care, instead of receiving one.
10. ......lastly PRAY DAILY, to being the fortunate one, to practice all the above!!!!
Thanks for your time...be back real soon.
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