h***y
发帖数: 834 | 1 ☆─────────────────────────────────────☆
Aplusplus (Hakuna Matata) 于 (Sun Mar 27 11:11:49 2011, 美东) 提到:
首先我申明，我放弃我的ignore list， 欢迎所有ID参加。
每个医生护士或者其他相关人员， 无论在中国还是美国， 肯定都有一些case刻骨铭心
。 请大家把你印象最深的一例写出来， 与大家分享。 比方说， 清华男被鉈杀案，
那个中国来的护士就是诊断的关键， 相信本例就是她一辈子也忘不了的诊断。
我觉得这样的讨论有助于大家提高学医热情，丰富医学知识，开拓临床思维， 间接帮
助考版医生复习，准备CS，和 interview. 你要是能从中挑一个case让你PD
impressed，我想我的目的就达到了。
希望所有ID， 包括考生， resident， fellow， attending，PA/NP, nurse 和中国来
的医生不再从事医疗工作的， 都能奉献你的pearl. 英文中文都行。
我先来：
CC: Left leg pain for 5 days.
35 yrs old female woke up with left foot pain. Saw her PCP, had x-rays, and was
given motrin. No improvement but worse with left leg pain as well. See
another PCP again, diagnosis was sciatica. She was given neurontin. No
effect. She came to me on herself. (walk-in)
After my exam, I agreed with her PCP's assessment and management. But before
the patient put on her socks, I noticed the left foot skin color was a
little different from the other side. So I put my hands on both her feet
simutanously: One was warm and the other was "ice" cold.
I ordered a stat vascular U/S.
The patient had an emergent surgery for left leg popliteal artery thrombosis
. She was a heavy smoker.
☆─────────────────────────────────────☆
Aplusplus (Hakuna Matata) 于 (Sun Mar 27 11:17:33 2011, 美东) 提到:
I forgot to attach the picture.
☆─────────────────────────────────────☆
abcd2010 (abc) 于 (Sun Mar 27 11:59:14 2011, 美东) 提到:
您应该也整个专线。
☆─────────────────────────────────────☆
herby (迎春) 于 (Sun Mar 27 12:02:42 2011, 美东) 提到:
Buerger’s Disease?
☆─────────────────────────────────────☆
Aplusplus (Hakuna Matata) 于 (Sun Mar 27 12:19:35 2011, 美东) 提到:
Right，Buerger’s Disease is vasculitis and its symptoms could be close to this case.
I believe she has ischemic PVD due to smoking.
希望case 不单单是最后诊断。
You can present the case as a brief SOAP Note：
1. Subjectives, 病人的症状
2. Objectives， 你的发现， 包括PE， lab， images， etc
3. Assessment， 你的诊断， 为什么。
4. Plan。 治疗意见， 有好的结果最佳！
☆─────────────────────────────────────☆
Aplusplus (Hakuna Matata) 于 (Sun Mar 27 12:31:13 2011, 美东) 提到:
你也来个case吧，不需要很复杂的。
我强调的是过程， 不光是结果。
大家随便说说， 我已经抛砖了。。。
☆─────────────────────────────────────☆
chugol (看风景) 于 (Sun Mar 27 13:34:22 2011, 美东) 提到:
你觉得为什么之前的PCP误诊的原因是什么？
经验不够？还是这个病人的病程决定的？譬如说在这个病人在看你之前她的症状还没有
这么坏，artery thrombosis in its early stage, for instance.
你个人从这个病例中总结出的经验是什么呢？
☆─────────────────────────────────────☆
Aplusplus (Hakuna Matata) 于 (Sun Mar 27 14:00:53 2011, 美东) 提到:
Q: 你觉得为什么之前的PCP误诊的原因是什么？
A: 没有A++的水准？ LOL
Q: 经验不够？还是这个病人的病程决定的？
A: 可能两者皆有。 你其实回答了你自己的问题。
Q：你个人从这个病例中总结出的经验是什么呢？
A: 1. 不要相信Telemedicine. 有诱惑， 曾经想在家工作，后来觉得risk太大。
2. 细节一定不要放过， 我想我的诊断来自观察， 愿意蹲下摸她的“臭脚”，LOL
3. 不要想当然take existing diagnosis.
☆─────────────────────────────────────☆
rainingcats (喵喵) 于 (Sun Mar 27 15:10:51 2011, 美东) 提到:
赞！
不过我没什么经验，围观一下
this case.
☆─────────────────────────────────────☆
cqfly (cq) 于 (Sun Mar 27 15:34:38 2011, 美东) 提到:
同赞,排队围观.
☆─────────────────────────────────────☆
chestnuts (chestnut) 于 (Sun Mar 27 15:43:33 2011, 美东) 提到:
year ago.
did not see the patient. History by pt's daughter, my co-worker
53 years old femal, no medical history, c/o both leg weakness. Pt wen to a
clinic getting some Chinese meds IV drip, no improvment. LOL
no PE
postive family history: brother and sister hypothyrodism
suggestion: CMP and thyroid hormone
Feedback: she was diagnosed as hyperthroidsm
no detail, as I said, not my patient.
I was so proud, because this co-worker treated me totally different after
that.
☆─────────────────────────────────────☆
stardust (水晶) 于 (Sun Mar 27 17:55:28 2011, 美东) 提到:
Firstly, thanks LZ for the great thread. I will follow once I have a good
one.
@chestnuts: You are great! did you make the suggestion by their history or
something else?
☆─────────────────────────────────────☆
abcd2010 (abc) 于 (Sun Mar 27 18:19:04 2011, 美东) 提到:
我有生以来给人最伟大的诊断就是： Alzheimer's disease, 但好像被版主给删了。不支持我的诊断。
☆─────────────────────────────────────☆
Aplusplus (Hakuna Matata) 于 (Sun Mar 27 19:17:05 2011, 美东) 提到:
Interesting.
Thyroid disease presentations are so non-specific that the diagnosis is
somewhat difficult. I remember when I was an medical student in China, one
of my classmates made a diagnosis of Grave's disease at his cardiology rotation
after the patient was misdiagnosed as heart disease by multiple senior
residents and attendings. He ended up being an endocrinologist.
☆─────────────────────────────────────☆
chestnuts (chestnut) 于 (Sun Mar 27 19:23:27 2011, 美东) 提到:
Hyperthyroidism can cause myositis, periodic paralysis, low potassium, etc,
either can lead to weakness.
So far I am still not clear the family trend of thyroid disease, but
periodic paralysis, or periodic hypokelamia has family trait.
Got thoes from my Endo rotation, I had a patient who had myostitis secondary
to hyperthyroidism.
☆─────────────────────────────────────☆
SUMO2009 (（MAP）) 于 (Sun Mar 27 19:29:55 2011, 美东) 提到:
One of the students told me exactly the same story when he did his
rotation in our department.
one
rotation
☆─────────────────────────────────────☆
Aplusplus (Hakuna Matata) 于 (Sun Mar 27 20:30:02 2011, 美东) 提到:
Smart people thinks same, lol.
P.S. Dr.Newbie says: Great minds think alike.
☆─────────────────────────────────────☆
Aplusplus (Hakuna Matata) 于 (Sun Mar 27 20:39:51 2011, 美东) 提到:
Alzheimer's diagnosis = great diagnosis. Are you sure?
I know Ronald Reagan started to have symptoms 13 years prior to the
diagnosis. If you were able to call him "an idiot" during his presidency,
which I bet he had been called multiple times, you were probably great. But
that kind of call does not take a doctor's degree to make, lol.
Bring it up, let us enjoy...
不支持我的诊断。
☆─────────────────────────────────────☆
Aplusplus (Hakuna Matata) 于 (Sun Mar 27 20:48:49 2011, 美东) 提到:
That's why we always check TSH for chronic fatigue syndrome.
,
secondary
☆─────────────────────────────────────☆
Aplusplus (Hakuna Matata) 于 (Sun Mar 27 21:01:08 2011, 美东) 提到:
We are waiting...
I know everyone has at least one great case, how about our BZ/BFs?
☆─────────────────────────────────────☆
skyscorpio (天之蝎子) 于 (Sun Mar 27 22:28:04 2011, 美东) 提到:
赞一个！
贵在坚持哈 ：）
☆─────────────────────────────────────☆
Aplusplus (Hakuna Matata) 于 (Sun Mar 27 22:32:36 2011, 美东) 提到:
你来一个case？
☆─────────────────────────────────────☆
skyscorpio (天之蝎子) 于 (Sun Mar 27 22:38:00 2011, 美东) 提到:
掩面疾走
☆─────────────────────────────────────☆
Aplusplus (Hakuna Matata) 于 (Sun Mar 27 23:39:15 2011, 美东) 提到:
C'mon， don't go away.
Ok, since you do not want to contribute, please read this:
When your program director interviews you and asks you：“I noticed on your
CV your nickname at mitbbs is Scorpion, would you mind telling me why
chinese people eats Scorpion? "(see picture)
Your answer?
☆─────────────────────────────────────☆
abcd2010 (abc) 于 (Mon Mar 28 00:24:24 2011, 美东) 提到:
照片上的吃客不一定是Chinese。
☆─────────────────────────────────────☆
skyscorpio (天之蝎子) 于 (Mon Mar 28 10:21:23 2011, 美东) 提到:
uPig?
LOL
your
☆─────────────────────────────────────☆
Aplusplus (Hakuna Matata) 于 (Mon Mar 28 12:28:33 2011, 美东) 提到:
Actually the answer is for pain.
Where is Dr.Lexian?
iPig
☆─────────────────────────────────────☆
Lexian (蒙古大夫) 于 (Mon Mar 28 15:10:16 2011, 美东) 提到:
oh yeah? u sure? i thought ppl eat it because it tastes like shrimp. lol
scorpion poison might have some anesthetic effect, but not a bbq one like in
your picture though. hehe
☆─────────────────────────────────────☆
pineyan3 (pineyan3) 于 (Mon Mar 28 15:55:35 2011, 美东) 提到:
I have a sad case.
I was rotating at a US #1/2 cancer center.
A 40 Yr old man came in due to HA. He was diagnosed with Burket's lymphoma
and had chemotherapy several weeks ago. his labs shows leukopenia that is
likely from the chemo. He had CT, MRI that are showed white matter changes
and some sinus wall thickening. I did an LP which showed several lymphocytes
. I asked the neurosurgery to perform a biopsy but they refused. My top 1
differential was Mucor. since i was only a starting second year resident, no
one wants to listen to me, including my attending (who was a good
oncologist), ID atttending. They all think it is lymphoma involvement of the
brain. anyways, the patient lost his left eye sight on the second day of
admission, his right eye sight on thirdday, then paralysed on one side the
fourth day. he died in 1 week. an autopsy showed mucomycosis.
it is one of the reasons that I did not choose oncology as my subspecialty.
I just can't forget the many patients who died during my two months of
oncology rotation. it just makes me sad.
☆─────────────────────────────────────☆
chestnuts (chestnut) 于 (Mon Mar 28 16:12:01 2011, 美东) 提到:
interesting, lyphoma, chemo, lyphoma involvment vs mucor infection, sinus
wall thickening.
just wonder is there other way to test the spinal fluid for mucor infection
, or biopsy is the only way.
lymphocytes
no
the
☆─────────────────────────────────────☆
Aplusplus (Hakuna Matata) 于 (Mon Mar 28 19:40:53 2011, 美东) 提到:
Great case. Pearls in this case include:
1. Immunosuppressed patients are vulnerable to fungus infection. When
headache is present, CNS infection should be considered, besides the
leptomeningeal carcinomatosis.
2. CSF neg does not necessorily R/O CNS infection.
3. CNS Mucor most likely comes from invasion of sinus mucor infection
directly. If that was the case, you might consult ENT instead of NSG. If
sinus mucor can be comfirmed, treat the sinusitis aggressively instead of
encephalitis.
4. Avoid brain biopsy as much as possible if you suspect an infection.
Do you remember how many cells(mono, not lymph in CSF)exactly? What was
protein/glucose? What was india ink? what about fungal culture?
At any rate, given the CNS fungal infection, chance to survive is almost nil
.
lymphocytes
no
the
☆─────────────────────────────────────☆
Aplusplus (Hakuna Matata) 于 (Mon Mar 28 19:53:07 2011, 美东) 提到:
I believe you can do Mucor PCR.
infection
☆─────────────────────────────────────☆
Aplusplus (Hakuna Matata) 于 (Mon Mar 28 20:13:57 2011, 美东) 提到:
I think Scorpion may be good for Rheumatoid Arthritis(RA) which causes
chronic pain. So it is deemed as analgesics.
If Scorpion has ture analgesic effect, the patient may just have a breakfast
of scorpion prior to surgery. No more needs for Dr.Lexian. And you just
need to set up a farm for raising scorpion instead. lol.
I don't think anyone eats scorpion. Just for medical use. Someone exaggerates it.
in
☆─────────────────────────────────────☆
NPtobe (tiantian) 于 (Tue Mar 29 02:29:37 2011, 美东) 提到:
Also make sure check B12 level on old people who coming in with MS changes
or psychosis.
☆─────────────────────────────────────☆
NPtobe (tiantian) 于 (Tue Mar 29 02:30:22 2011, 美东) 提到:
Also make sure check B12 level on old people who coming in with MS changes
or psychosis.
☆─────────────────────────────────────☆
NPtobe (tiantian) 于 (Tue Mar 29 02:49:52 2011, 美东) 提到:
38yr, female, present with diarrhea for 4 days, initially loose watery
diarrhea, 3-4 times/days, now every hour, and blood mixed with the stool,
medium volume, non-foul smelling, with mild crampy abd pain. Had a course of
antibiotics (Keflex) 2 weeks ago
Labs:
LFTs/Amylase/Lipase: WNL
Chemo: Na 137 K 3.4 Cl 108 CO2 23 BUN 6 Cr 0.6 Glu
127
CBC: WBC 13.6 Hgb 12.4 HCT 37.9 Plt 264
Coag: PT 12.2 INR 1.1 PTT 29
Hospital Course:
1. IVF, po hydration
2. Stool Cultures, Stool O&P *3, Stool C.diff *3
3. Abx: Flagyl 500mg po Q8hrs + Levaquin 750mg IV qd
4. CT A/P with contrast was performed, which showed sigmoid colon mild to
moderate wall thickening, possibly representing colitis of infectious
etiology, with inflammatory bowel disease not excluded.
5. GI consulted, for Flex Sigmoidoscopy
☆─────────────────────────────────────☆
Aplusplus (Hakuna Matata) 于 (Tue Mar 29 17:42:28 2011, 美东) 提到:
Would you please finish your case? Please also tell us why this case is so
imressive to you.
Thanks.
of
☆─────────────────────────────────────☆
Mindset (Tough) 于 (Wed Mar 30 00:18:55 2011, 美东) 提到:
House is one of my favorite shows. In one episode, House started one treatment
plan cause all other possibilities are fatal. Was it why other attendings did
take mucor seriously?
My best diagnosis: Lupus.
☆─────────────────────────────────────☆
Aplusplus (Hakuna Matata) 于 (Wed Mar 30 12:49:11 2011, 美东) 提到:
Would you present the case of lupus? I can not wait.....
treatment
attendings did
☆─────────────────────────────────────☆
Aplusplus (Hakuna Matata) 于 (Fri Apr 1 21:26:42 2011, 美东) 提到:
Weekend case:
52 yrs old male, single, lives along, was sent to ER by the girlfriend for
new onset confusion. He was initially hallucinating and become drowsy and
progressively worse over 2-3 days. He just saw his neurologist a day before
and was sent to home, but no details available. He was directly admitted to
ICU.
PMH: ETOH abuse with pancreatitis. But he quits ETOH for 15 years. He has been seeing his neurologist for chronic pancreatits per his girlfriend.
Social: No current smoking or ETOH abuse. Used cocaine 1 month ago, but this
time all drug screen is neg.
PE: T: 100.4 F, BP 140/90, HR: 100, Stuporous,combative, sweating,
periodic myoclonus of all extremities. No focal weakness. Neg Babinski.
CT of Brain is neg. CBC, CMP and NH3 is normal. Drug screen is neg.
LP is neg.
He got Ativan 6 mg total and Haldol 5 mg, no changes.
A dose of Drug A dramatically reversed his symptoms.
BZ for first right answer. BZ/BFs, how much are you going to sponsor? I'll
match...
☆─────────────────────────────────────☆
skyscorpio (天之蝎子) 于 (Fri Apr 1 22:19:53 2011, 美东) 提到:
您老是前辈，您说奖励多少包子我们版务就奖励多少，呵呵
看着不像很难的样子，虽然我自己不知道答案 ：）
before
to
this
☆─────────────────────────────────────☆
nanajj (Bumblebee Doc) 于 (Fri Apr 1 22:20:58 2011, 美东) 提到:
Serotonin syndrome - cyproheptadine
before
to
this
☆─────────────────────────────────────☆
Aplusplus (Hakuna Matata) 于 (Fri Apr 1 22:24:46 2011, 美东) 提到:
Haha, 10 wb if within 10 answers.
Why don't you try it? I give u 50 if u hit it.
☆─────────────────────────────────────☆
Aplusplus (Hakuna Matata) 于 (Fri Apr 1 22:27:30 2011, 美东) 提到:
Good thought, but there is no history supporting serotonin syndrome.
This is a real case I managed in ICU.
I just added an additional clue: I called his girlfriend and she claimed he had been seeing his neurologist for chronic pancreatitis, believe or not.
☆─────────────────────────────────────☆
chipmunk (花栗鼠) 于 (Fri Apr 1 22:47:05 2011, 美东) 提到:
From hx and available w/u, delirium tremens, intoxications, infx dz like
encephalitis, meningitis are less likely. Pt saw neurologist and might start
a neuroleptic medication. Therefore, NMS - dopamine agonist?
Thank u!
he had been seeing his neurologist for chronic pancreatitis, believe or not.
☆─────────────────────────────────────☆
Aplusplus (Hakuna Matata) 于 (Fri Apr 1 22:55:08 2011, 美东) 提到:
Sorry, he was not on any neuroleptics.
You may use D2 agonist for NMS, but more useful drug is benzo.
start
not.
☆─────────────────────────────────────☆
lll00000 (00000) 于 (Fri Apr 1 22:59:09 2011, 美东) 提到:
spontaneous bacterial peritonitis?
for
☆─────────────────────────────────────☆
Aplusplus (Hakuna Matata) 于 (Fri Apr 1 23:01:22 2011, 美东) 提到:
May I ask you why? There was no sign of sepsis.
☆─────────────────────────────────────☆
lll00000 (00000) 于 (Fri Apr 1 23:19:57 2011, 美东) 提到:
oops,no PE,no sepsis.
alcohol withdrawal? drug A is benzodiazepine?
☆─────────────────────────────────────☆
Aplusplus (Hakuna Matata) 于 (Fri Apr 1 23:23:51 2011, 美东) 提到:
Nope.
☆─────────────────────────────────────☆
skyscorpio (天之蝎子) 于 (Fri Apr 1 23:25:17 2011, 美东) 提到:
慢性胰腺炎去看神经科，有意思
☆─────────────────────────────────────☆
Aplusplus (Hakuna Matata) 于 (Fri Apr 1 23:32:28 2011, 美东) 提到:
haha, you almost get it!
☆─────────────────────────────────────☆
Jolie2010 (dreamseeker) 于 (Fri Apr 1 23:49:49 2011, 美东) 提到:
what the blood sugar level?
☆─────────────────────────────────────☆
herby (迎春) 于 (Sat Apr 2 00:10:43 2011, 美东) 提到:
偶去google了一下，瞎说几句： 慢性胰腺炎的神经痛？然后用了opioid，然后出现了
withdrawal syndrome?
☆─────────────────────────────────────☆
carrie66 (麦地听风) 于 (Sat Apr 2 00:16:50 2011, 美东) 提到:
Morphine to control Chronic Pancreatitis Neuropathic Pain--Naloxone
for
and
before
admitted to
has been seeing his neurologist for chronic pancreatits per his
girlfriend.
but this
☆─────────────────────────────────────☆
Aplusplus (Hakuna Matata) 于 (Sat Apr 2 08:29:52 2011, 美东) 提到:
Bingo!
This guy has been seeing his neurologist for chronic pain. He got his
narcotics prescription that day but did not get refill right away. Then he
developped withdrawal syndrome and became confused.
A dose of Morphine reversed his symptoms in 5 min. I started him on oral
opioids and he was discharged in 2 days.
I have to go now and great job for Herby.
☆─────────────────────────────────────☆
Aplusplus (Hakuna Matata) 于 (Sat Apr 2 08:32:55 2011, 美东) 提到:
U are very close.....
☆─────────────────────────────────────☆
herby (迎春) 于 (Sat Apr 2 10:59:29 2011, 美东) 提到:
多谢前辈，很有意思的一个case :)
he
☆─────────────────────────────────────☆
skyscorpio (天之蝎子) 于 (Sat Apr 2 11:51:17 2011, 美东) 提到:
这个例子不错！结论就是要珍惜生命，远离烟酒 ：）
我转了100伪币请您代发吧
he
☆─────────────────────────────────────☆
Lexian (蒙古大夫) 于 (Sat Apr 2 14:34:40 2011, 美东) 提到:
good case. how u suggest to manage him after this fiasco?
☆─────────────────────────────────────☆
Aplusplus (Hakuna Matata) 于 (Sun Apr 3 00:05:54 2011, 美东) 提到:
Thanks.
I think the key for this case is getting a good history. If you get a good
history, you make a good diagnosis.
I posted this case 2 yrs ago in a physician web site. Nobody got right
answer: Call the girlfriend for more history.
Well, Kudos to Herby BF. Good job. That is why I always think, CMGs can do
as well as AMGs, if not even better.
蝎子BZ was right in the front of door, but he seemed to be too shy to knock
it, didn't he? lol.
I'll use up this 100 wb, many thanks to BZ.
☆─────────────────────────────────────☆
Aplusplus (Hakuna Matata) 于 (Sun Apr 3 00:06:56 2011, 美东) 提到:
I sent him to Dr.Lexian for pain management.
☆─────────────────────────────────────☆
NPtobe (tiantian) 于 (Sun Apr 3 00:24:42 2011, 美东) 提到:
38yr, female, present to PAH on 4/4/10 with diarrhea for 4 days, initially
loose watery diarrhea, 3-4 times/days, now worse and loose watery stool
every hour, and blood mixed with the stool, medium volume, non-foul smelling
, with mild crampy abd pain. Have had 5 BMs since yesterday, and the last
one almost all blood. (+) subjective fever, no chills, no cough/SOB. Had a
course of antibiotics (Keflex) 2 weeks ago (3/9/10- 3/14/10).
PMHx: Kidney stones, Seizure disorders, Vit D deficiency
PSHx: Sinus Surgery 3/10/10 for deviated nasal septum
FHx: NC
SHx: (-) smoking/ ETOH/IVDA, mental health worker
Allergies: Codeine
ROS: all negative, except as noted in HPI
PE:
Appearance: NAD
HEENT: no sclera icterus, PERRLA
PULM: B/L lungs CTAs,
CV: (+) S1, (+)S2, RRR, (-) murmurs
GI: Abd soft, mild tenderness, nondistended, (+) BS in 4 quadrant
NEURO: AAO*3
Labs:
LFTs/Amylase/Lipase: WNL
Chemo: Na 137 K 3.4 Cl 108 CO2 23 BUN 6 Cr 0.6 Glu
127
CBC: WBC 13.6 Hgb 12.4 HCT 37.9 Plt 264
Coag: PT 12.2 INR 1.1 PTT 29
Hospital Course:
Pt was admitted on 4/4/10
1. IVF, po hydration
2. Stool Cultures, Stool O&P *3, Stool C.diff *3
3. Abx: Flagyl 500mg po Q8hrs + Levaquin 750mg IV qd
4. CT A/P with contrast was performed, which showed sigmoid colon mild to
moderate wall thickening, possibly representing colitis of infectious
etiology, with inflammatory bowel disease not excluded.
5. GI consulted, for Flex Sigmoidoscopy on 4/5/10
4/5/10 AM:
Stool cultures: (-) Salmonella/Shigella/Campylobacter/Giardia/Crytosporidium
Antigen isolated in 24 hours
Flex Sigmoidoscopy: Diffuse moderate inflammation characterized by erosion,
erythema, friability, and shallow ulcerations was found in the sigmoid colon
and in the descending colon with rectal sparing, likely secondary to Crohn
’s disease. Biospies was taken with cold forceps for histology.
Dx: Crohn’s disease
Recommendations: Prednisone 40mg po QD
Outpt GI F/U in 10-14 days
4/6/10:
C.diff (-) *1
Tolerated clear liquid diet, started on low residue diet
Biopsy: mild acute colitis with crypt abscesses, no granulomata are seen, no
chronic architectural changes identified
Pt D/C’ed on prednisone 40mg po QD, F/U with GI as outpt in 10-14 days,
will consider immunomodulator or biologic agent as outpt
4/7/10:
Lab called stool culture came back: (+) shigella
Called patient at home, told her to taper steroid, and start cipro 500mg po
bid*5 days, pt is thrilled.
Requestion the patient about sick contact:
Pt is Jewish, and during Passover, had dinner with family members from upper
New York, some of them was sick.
Lesson:
Always make sure for negative stool studies before start steroid.
☆─────────────────────────────────────☆
Aplusplus (Hakuna Matata) 于 (Sun Apr 3 00:51:25 2011, 美东) 提到:
Good case.
I think the management is reasonable.
First, based on initial neg culture and positive biopsy, steroids is the
right treatment.
3 days later, shigella became positive, I wonder why not just stop steroids?
I believe in this case a tapering dose of steroids is still the right
treatment. Just like we commonly use medrol dosepack.
Again, the diagnosis would be simple if the intern got more history from the
family, LOL.
smelling
a
☆─────────────────────────────────────☆
chestnuts (chestnut) 于 (Sun Apr 3 10:26:03 2011, 美东) 提到:
I would like to present another case that is not diagnosed by me.
I took care of this 17 years old girl 2 days ago, who came to surgical floor
for VP shunt replacement for her pseudo cerebri disease. Primarily she
presented to neurologist for her 7 years history of headache, which is
constant, both sides, 4-5/10 in intensity, vague trigger factor, acerbating
two times every month,lasting one week, at the point, pain would reach 8-9/
10 in intensity.
FH: her older sister has psychiatry diagnosis. Parents are healthy, some
secondary realtives postive with autoimmunive disease.
PE: develop well, slightly malnourished .negative for other signs.
lab: Brain ct,MRI, EEG negative. Anti ssa ssb positive (for which she is
following the rheumatologist)
LP tap three times , open pressure as 20, 24. 40
pseudo cerebri is diagnosed , pt strongly requests VP shunt surgery,
immediately after surgery , the headache is gone.
The patient has been seeking for the dx and treatment for sever years, she
was diagnosed as migraine, seizure, etc.Finally they came to this
neurologist who specializes in headache.
I myself had bad headache yesterday for the whole day, I am sincerely glad
for this girl.
☆─────────────────────────────────────☆
Aplusplus (Hakuna Matata) 于 (Sun Apr 3 12:00:57 2011, 美东) 提到:
Is this girl obese?
Young female, over weight, with chronic daily headache, should be considered as
pseudotumor cerebri. On exam, you may find papillary edema. Treatment
includes diamox and LP. VP shunt is the final step. It is a brain surgery.
floor
acerbating
☆─────────────────────────────────────☆
chestnuts (chestnut) 于 (Sun Apr 3 18:06:14 2011, 美东) 提到:
She is very very slim, onset age is 10 years old. Not quite typical though.
considered as
surgery.
☆─────────────────────────────────────☆
Aplusplus (Hakuna Matata) 于 (Wed Apr 13 20:22:42 2011, 美东) 提到:
Just see it.
This reminds me a similar case: A very slim girl about 12 yrs old has
pseudotumor.
☆─────────────────────────────────────☆
Aplusplus (Hakuna Matata) 于 (Wed Apr 13 20:51:25 2011, 美东) 提到:
This case is tough. 20 WB for the first. (from BZ)
A 35 yrs old WF, was sent to ER by her husband in AM since he could not wake
her up.
The patient was entirely normal before last dinner. They planned to have
BBQ, but after she drank a can of beer and 3 cans of soda, she felt sick. So
she went to bed directly.
At ER, she was stuporous, a drug screen was neg. CT of brain, EKG, CXR were
all normal. LP is neg. UA(-), Blood culture was sent. All lab was normal
except Glucose was 60. So she was given D5 1/2NS and tranferred to ICU.
When she arrived ICU, she was comatose and subsequetly she was intubated.
PMH. Healthy except Gastric bypass surgery 6 month ago.
Social: No Cig/ETOH abuse, no drug abuse.
FMH: CAD, HTN.
ROS: N/A
PE: BP: 90/60, P: 45-55, Temp: 93.5 F
Gen： Comatose, on vent.
HEENT: Normal.
Neck: supple.
Chest/CVS: Normal except bradycardia.
Abdomen: Normal.
GU: Normal
Skin: No bruises/ Rash.
Neuro: PERRL. (+)Doll's eye.
(+)pain withdrawal bilaterally. Low muscle tone. No jerking.
(-)Babinski.
Workup in ER please refer to history.
A treatment rapidly reversed her sysptoms.
What is your assessment and plan?
☆─────────────────────────────────────☆
yuzaiusa (Expecto Patronum!) 于 (Wed Apr 13 22:05:54 2011, 美东) 提到:
alcohol intoxication?
treated with HD?
☆─────────────────────────────────────☆
Aplusplus (Hakuna Matata) 于 (Wed Apr 13 22:17:04 2011, 美东) 提到:
No, please read the info carefully:
1. She is not alcoholic.
2. Drug screen is negative.
☆─────────────────────────────────────☆
Lexian (蒙古大夫) 于 (Wed Apr 13 22:20:16 2011, 美东) 提到:
Dumping?
☆─────────────────────────────────────☆
daisyy (Daisy) 于 (Wed Apr 13 22:21:50 2011, 美东) 提到:
except Glucose was 60.
Healthy except Gastric bypass surgery 6 month ago.
恩？这病人在减肥？
Chest/CVS: Normal except bradycardia.
难道是beta blocker过量？
Glucagon
☆─────────────────────────────────────☆
snowfox01 (雪山飞狐) 于 (Wed Apr 13 22:27:49 2011, 美东) 提到:
Let me guess,
Dr. Lexian(前辈) almost get the reason. patient who had gastric bypass surgery
will get dumping symptoms, that is why she went to bed within 30~40 min
after take the alcohol. Also after bypass surgery, patient will absorb
alcohol quickly and excrete slowly.
☆─────────────────────────────────────☆
Aplusplus (Hakuna Matata) 于 (Wed Apr 13 22:35:07 2011, 美东) 提到:
You caught a clue.
☆─────────────────────────────────────☆
Aplusplus (Hakuna Matata) 于 (Wed Apr 13 22:36:03 2011, 美东) 提到:
Glucose 60 is borderline.
She is not on any drugs.
☆─────────────────────────────────────☆
snowfox01 (雪山飞狐) 于 (Wed Apr 13 22:37:26 2011, 美东) 提到:
I will go with Yuzaiusa, My guess is: alcohol intoxication and hypoglycemic
shock.
Don't know how to treat the patient.
☆─────────────────────────────────────☆
Aplusplus (Hakuna Matata) 于 (Wed Apr 13 22:39:49 2011, 美东) 提到:
Why hypothermia?
Why Bradycardia?
☆─────────────────────────────────────☆
Aplusplus (Hakuna Matata) 于 (Wed Apr 13 22:41:25 2011, 美东) 提到:
The fact was that she got worse after she received D5 1/2NS.
And I repeat: Drug screen is neg for ETOH. So no intoxication.
hypoglycemic
☆─────────────────────────────────────☆
yuzaiusa (Expecto Patronum!) 于 (Wed Apr 13 22:43:21 2011, 美东) 提到:
What was her ABG?
★ Sent from iPhone App: iReader Mitbbs 6.88 - iPad Lite
☆─────────────────────────────────────☆
Aplusplus (Hakuna Matata) 于 (Wed Apr 13 22:49:56 2011, 美东) 提到:
Normal.
☆─────────────────────────────────────☆
snowfox01 (雪山飞狐) 于 (Wed Apr 13 23:00:01 2011, 美东) 提到:
It must have something to do with the bypass surgery. I know post bypass
surgery can cause B12 deficiency and iron deficiency, not sure about B1
deficiency. May be caused by B1 deficiency and D5 can worsen the symptoms.
☆─────────────────────────────────────☆
daisyy (Daisy) 于 (Wed Apr 13 23:05:03 2011, 美东) 提到:
恩。这个beta blocker虽然使心率减慢，但是降低insulin的释放，是会使血糖升高的
，所以也不合
理。
☆─────────────────────────────────────☆
daisyy (Daisy) 于 (Wed Apr 13 23:09:46 2011, 美东) 提到:
dumping syndrome 糖类进入肠道过快，引起insulin释放过多。 补糖水的话insulin就
继续增
高？
octreotide 可以降低insulin的释放？
☆─────────────────────────────────────☆
Aplusplus (Hakuna Matata) 于 (Wed Apr 13 23:10:38 2011, 美东) 提到:
Why hypothermia？You never think about sepsis?
☆─────────────────────────────────────☆
Lexian (蒙古大夫) 于 (Wed Apr 13 23:12:54 2011, 美东) 提到:
快抢碘盐。
☆─────────────────────────────────────☆
Aplusplus (Hakuna Matata) 于 (Wed Apr 13 23:14:12 2011, 美东) 提到:
Her Glucose had been normal since D5 was given.
☆─────────────────────────────────────☆
Aplusplus (Hakuna Matata) 于 (Wed Apr 13 23:14:52 2011, 美东) 提到:
LOL!
☆─────────────────────────────────────☆
snowfox01 (雪山飞狐) 于 (Wed Apr 13 23:15:08 2011, 美东) 提到:
Blind loop syndrome?
☆─────────────────────────────────────☆
Aplusplus (Hakuna Matata) 于 (Wed Apr 13 23:16:13 2011, 美东) 提到:
Good thought, but why?
Can you explain why bradycardia?
☆─────────────────────────────────────☆
snowfox01 (雪山飞狐) 于 (Wed Apr 13 23:26:26 2011, 美东) 提到:
Since you mentioned sepsis, blind loop syndrome can cause bacteria over grow.
But I still vote for my B1 deficiency caused by post bypass and alcohol and
D5 consumption.
☆─────────────────────────────────────☆
Aplusplus (Hakuna Matata) 于 (Wed Apr 13 23:31:07 2011, 美东) 提到:
So what do you call this disease? And what do you do?
grow.
and
☆─────────────────────────────────────☆
daisyy (Daisy) 于 (Wed Apr 13 23:32:44 2011, 美东) 提到:
如果是sepsis的话那不是要用antibiotics?
☆─────────────────────────────────────☆
Aplusplus (Hakuna Matata) 于 (Wed Apr 13 23:36:10 2011, 美东) 提到:
You are right. She was treated with antibiotics. Sepsis can present as
hypothermia.
☆─────────────────────────────────────☆
snowfox01 (雪山飞狐) 于 (Wed Apr 13 23:41:02 2011, 美东) 提到:
Thanks for the case.
☆─────────────────────────────────────☆
daisyy (Daisy) 于 (Wed Apr 13 23:48:00 2011, 美东) 提到:
她这是很严重的sepsis了。都快septic shock了吧。 hypotention（borderline
though), hypothermia,
bradycardia, 再不及时可能DIC都出来了。
请教前辈象她这种开始没有发热进展迅速的sepsis多见吗？ 有个问题，给糖盐水应该
也没有加重她的
病情，只是病情没有得到控制发展的吧？
☆─────────────────────────────────────☆
daisyy (Daisy) 于 (Wed Apr 13 23:52:39 2011, 美东) 提到:
A very good case. Thanks so much!
☆─────────────────────────────────────☆
Aplusplus (Hakuna Matata) 于 (Wed Apr 13 23:55:25 2011, 美东) 提到:
You give up?
The final diagnosis is : Wernicke's Encephalopathy.
Treatment: Thiamine 100 mg iv stat.
Patient dramatically improved after the injection. Her Vitamin B1 level
came back 1 wk later and proved the diagnosis.
Why bradycardia and hypotension, hypothermia? Hypothalamas involvement. But
you need to memorize mammillary body first.
Risk factors? Gastric bypass, poor nutrition, Beer consumption, and giving
D5 without thiamine!
This is not sepsis. Blood culture was negative.
I think Snowfox01 deserves the prize.
Good night.
☆─────────────────────────────────────☆
skyscorpio (天之蝎子) 于 (Wed Apr 13 23:58:39 2011, 美东) 提到:
谢谢！
我其实一眼就想到了 LOL 包子很快发出
But
giving
☆─────────────────────────────────────☆
daisyy (Daisy) 于 (Thu Apr 14 00:01:50 2011, 美东) 提到:
Haha. This makes sense.
I was fooled by your comments.
But
giving
☆─────────────────────────────────────☆
snowfox01 (雪山飞狐) 于 (Thu Apr 14 00:02:32 2011, 美东) 提到:
谢，前辈。
哎，我总赶不上最后一步。“当机遇像雨点般向我洒来,我都镇定自若的一一闪过”
But
giving
☆─────────────────────────────────────☆
snowfox01 (雪山飞狐) 于 (Thu Apr 14 00:03:49 2011, 美东) 提到:
谢， 包子。
☆─────────────────────────────────────☆
Aplusplus (Hakuna Matata) 于 (Thu Apr 14 00:11:35 2011, 美东) 提到:
我早就看出来了， 知道答案的都潜水！
BZ我发。
☆─────────────────────────────────────☆
Aplusplus (Hakuna Matata) 于 (Thu Apr 14 00:13:50 2011, 美东) 提到:
你跟蝎子一样， 美女半夜敲门，你们在门后加锁。
☆─────────────────────────────────────☆
skyscorpio (天之蝎子) 于 (Thu Apr 14 00:14:09 2011, 美东) 提到:
呵呵，您有时间再出一个吧，下回我跳出来献献丑。
☆─────────────────────────────────────☆
Aplusplus (Hakuna Matata) 于 (Thu Apr 14 00:15:02 2011, 美东) 提到:
跟着感觉走。
☆─────────────────────────────────────☆
daisyy (Daisy) 于 (Thu Apr 14 10:32:14 2011, 美东) 提到:
From Wiki:
Thiamine is released by the action of phosphatase and pyrophosphatase in
the upper small intestine. At low concentrations, the process is carrier
mediated and at higher concentrations, absorption occurs via passive
diffusion. Active transport is greatest in the jejunum and ileum (it is
inhibited by alcohol consumption and by folic deficiency).
symptoms.
☆─────────────────────────────────────☆
susufairy (susufairy) 于 (Thu Apr 14 17:16:19 2011, 美东) 提到:
来说个比较特别的例子，谁都没诊断出来而且病人死了。当时在国内一医院当实习医生
见到的，所以不好用英文，一孕39周产妇入院，入院时已开4指，并伴有宫缩疼（注意
，很可能不一定是宫缩疼，我后面会说），入院后生命体征一切正常除了腹疼，偶伴有
恶心，未吐。所有人都认为是宫缩疼，因为开指非常缓慢，记不清多长时间，最终产妇
于第二天行C-SECTION，手术也还顺利，只是手术过程中发现病人血液呈紫色，腹腔中
有小量血性积液。术后两天病人仍腹痛，且有低热，当时考虑是可能术后感染和术后疼，因为是实习医生，再后来做了什么检查就不记得了，后病人诊断为妊辰合并急性坏死性胰腺炎
，病人于C-SECTION后5天死亡，可怜那只有几天的宝宝就这样失去了妈妈。
☆─────────────────────────────────────☆
Aplusplus (Hakuna Matata) 于 (Thu Apr 14 17:41:06 2011, 美东) 提到:
Sad story.
That's why physician should never be dogmatic. Pelvic pain and abdominal
pain are different but if a physician never had the idea that acute
pancreatitis can be a complication of pregancy, he/she just would be
clueless like the case.
Thanks, susufairy, for your contribution. BZ for you. (contributed by bZ
and Snowfox)
Reasons for Acute Pancreatitis and Pregnancy
Most cases of acute pancreatitis in pregnancy are caused by gallstone
disease. It is thought with the weight and hormonal changes induced by
pregnancy, gallstones are more likely to form and thus travel down the
common bile duct to obstruct the pancreas duct outflow. Another proposed
mechanism for acute pancreatitis in pregnancy is high fat levels in the
blood called triglycerides. Again, the hormonal changes of pregnancy can
predispose certain women to developing this condition. When the
triglyceride levels become too high, oxygen cannot adequately travel to the
pancreas via the bloodstream, and pancreatitis can ensue. Of course, all of
the other reasons for developing acute pancreatitis – alcohol use,
reaction to certain medications, trauma to the pancreatic duct – can also
lead to acute pancreatitis in pregnancy
疼，因为是实习医生，再后来做了什么检查就不记得了，后病人诊断为妊辰合并急性坏
死性胰腺炎
☆─────────────────────────────────────☆
yuzaiusa (Expecto Patronum!) 于 (Thu Apr 14 18:56:47 2011, 美东) 提到:
interesting case. I thought EtOH intoxication can suppress the resp. center
, cause hypoxia, then bradycardia. metabolic acidosis can cause bradycardia
and hypotension too. Never thought about vitamin deficiency. Thanks.
But
giving
☆─────────────────────────────────────☆
Aplusplus (Hakuna Matata) 于 (Thu Apr 14 20:06:43 2011, 美东) 提到:
This tough case was mishandled at multiple steps.
At ER, she was found to be hypoglycemic which is very common to cause MS
changes, so she got the D5 without thiamine which made her worse.
Second, she developped hypothermia which led to a diagnosis of Sepsis.
Bradycardia and hypotension were thought to be septic shock.
Fortunately, I took over the case and made the diagnosis after I had a long
talk with her husband.
She hardly had any residual symptoms at the discharge. But if untreated, she
would end up with Korsakoff's syndrome if she survives.
center
bradycardia
☆─────────────────────────────────────☆
Lexian (蒙古大夫) 于 (Thu Apr 14 21:08:05 2011, 美东) 提到:
A big thank you, A , i think everyone joined this discussion wont forget
Wernicke's encephalopathy from now on.
had u seen one in training before this case? I only read about in textbook,
always thought it's a chronic presentation.
This tough case was mishandled at multiple steps.At ER, she was found to be
hypoglycemic........
★ Sent from iPhone App: iReader Mitbbs 6.88 - iPhone Lite
☆─────────────────────────────────────☆
Aplusplus (Hakuna Matata) 于 (Thu Apr 14 21:18:42 2011, 美东) 提到:
Be honest with you, I did not.
But I know, chances favor prepared mind, lol.
,
be
☆─────────────────────────────────────☆
Lexian (蒙古大夫) 于 (Thu Apr 14 21:25:54 2011, 美东) 提到:
I'm sure your internal reward from this case far outweight your 1500 bill,
lol. Hats off to u.
Be honest with you, I did not. But I know, chances favor prepared mind, lol.
★ Sent from iPhone App: iReader Mitbbs 6.88 - iPhone Lite
☆─────────────────────────────────────☆
Aplusplus (Hakuna Matata) 于 (Thu Apr 14 22:25:24 2011, 美东) 提到:
你来个麻醉case？ 讲讲张春桥妹妹被laughing gas谋杀之事？
lol.
☆─────────────────────────────────────☆
Lexian (蒙古大夫) 于 (Thu Apr 14 23:28:14 2011, 美东) 提到:
我做的主要是操作， 诊断大多很简单， 就是要on alert, 出状况时反应要快， 处理
要及时。
几年前在一个inner city的trauma center值班，急诊来了个举枪自杀的小伙子， 据说
为情所困， 大概太激愤了的缘故，开枪时头后仰的厉害。 子弹从下巴射入， 居然从
右眼出来。 大脑没事。 送来时半边脸肿成猪头， 嘴里从咽喉以上一片血糊。 ems插
管插不进去。 我操了根纤维镜顺着有气泡的方向往里送， 居然找到气管里。 管插好
了， 其它很快就稳定下来了。 这大概是internal reward最大的case了。呵呵。
☆─────────────────────────────────────☆
Aplusplus (Hakuna Matata) 于 (Thu Apr 14 23:43:31 2011, 美东) 提到:
我最最佩服的是你们插管和腰穿的技巧。仰视。。。
☆─────────────────────────────────────☆
blulue (小黑) 于 (Fri Apr 15 02:16:32 2011, 美东) 提到:
But
giving
相当好的帖子阿,一直跟着看,学到很多东西!!
看了解释,我有几个没想明白的点,自己搜了搜答案,还是有些地方不太明白,想向
Aplusplus前辈请教:
"Wernicke-Korsakoff syndrome results from severe acute deficiency
superimposed on chronic deficiency."
1,Wernicke的表现?考试时候背的classic triad of oculomotor abnormalities,
ataxia, and confusion?
原来经典三联征齐全的,只有20%的病人.这个病人影响到hypothalamas,低压低温.
还有病人影响到thalamas,progressing hearing loss.
2,Chronic deficiency何来?gastric bypass surgery 6 months ago.
B/C Bypass partial small intestine--defect absorption. In early post op
period,difficult to eat enough for enough VitB1.
Google到两个bypass sugery以后VitB1缺乏致病的,一个术后5个月,一个术后4个月.
3,severe acute deficiency 何来?
是beer consumption吗?她没饮酒史,alcoholism造成chronic deficiency算不上.还是
ER补糖不补B1?感觉更像后者...那beer在这起来神马作用呢?
抱歉写得罗里罗嗦,先谢谢前辈!
☆─────────────────────────────────────☆
Aplusplus (Hakuna Matata) 于 (Fri Apr 15 10:36:03 2011, 美东) 提到:
1,Wernicke的表现?考试时候背的classic triad of oculomotor abnormalities,
ataxia, and confusion?
原来经典三联征齐全的,只有20%的病人.这个病人影响到hypothalamas,低压低温.
还有病人影响到thalamas,progressing hearing loss. |
|
