jmj11 Posted September 11, 2005 Share Posted September 11, 2005 Right! Smart group here. BTW, this condition isn't a "zebra" as I see a case about once every 1-2 months. Most of these have been missed by the referring Dr. In the early stages the headache may only be present with laying down, valsalva, etc. . . . but soon becomes constant. What is the major diagnostic physical finding? The main avenue of treatment IS weight loss (if the patient is obese) but what is the specific drug of choice for treatment, while you are waiting on the weight loss? What's drug of second choice? What are the two surgical treatments? Quote Link to comment Share on other sites More sharing options...
JenGintheED Posted September 11, 2005 Share Posted September 11, 2005 What is the major diagnostic physical finding? The main avenue of treatment IS weight loss (if the patient is obese) but what is the specific drug of choice for treatment, while you are waiting on the weight loss? What's drug of second choice? What are the two surgical treatments? Going off of memory here... let's see how far we go... Major diagnostic physical finding is papillaedema in the absence of CT evidence of increased ICP. Specific drug of choice? Hmmm.. would it be a diuretic? Surgical treatment... serial LPs? VP shunt? Quote Link to comment Share on other sites More sharing options...
Guest WVgirl03 Posted September 11, 2005 Share Posted September 11, 2005 Yes, you are both correct! The most serious thing to not miss is herpes simplex keratitis (which shows up as a dendritic lesion under fluorescein stain - sort of like a little fern leaf), but you can also pick up foreign bodies, corneal ulcers, and conjunctival abrasions. The symptoms of herpes keratitis can present like conjunctivitis, so if you have any suspicion for herpes, you must stain the eye to make the diagnosis. Let's see.... other questions.... How about this: Your patient presents with low back pain. What question must you be sure to ask in order to rule out a rare but serious condition? (I learned this yesterday in the ER too!) You would ask if they could hold their urine and bowel movements as well as ask about saddle paresthesia to rule out cauda equina syndrome. Quote Link to comment Share on other sites More sharing options...
ajnelson Posted September 11, 2005 Share Posted September 11, 2005 BTW, this condition isn't a "zebra" as I see a case about once every 1-2 months. I hadn't realized it was that common...I thought my answer was way off because it was a zebra. Good info to know - something I can keep my eyes open for in patients & hopefully not miss it :) Quote Link to comment Share on other sites More sharing options...
jmj11 Posted September 12, 2005 Share Posted September 12, 2005 Going off of memory here... let's see how far we go... Major diagnostic physical finding is papillaedema in the absence of CT evidence of increased ICP. Specific drug of choice? Hmmm.. would it be a diuretic? Surgical treatment... serial LPs? VP shunt? Partially correct. The pharmacological treatment of choice is acetazolomide (Diamox). This is a carbonic anhydrase inhibitor and has diuretic properties. If the patient can’t take acetazolomide (does have a sulfa molecule that can cause allergies) then furosemide is the drug of second choice. If the visual field begins to decrease, despite pharmacological treatment, then surgery is often required. Although therapeutic LPs have been tried (and some still claim that they can be effective) most have given up on that approach. Shunting had been the treatment of choice up until recently. Now, optic nerve sheave fenestration via laser has now becoming the most common treatment. Okay, one last question on this thought. The preliminary diagnosis is made when the symptoms alert you and you find papillaedma. The final diagnosis is made by opening LP pressures. What is one set that MUST be done between finding the papillaedema and doing the LP? Why is this second step so important? Mike Quote Link to comment Share on other sites More sharing options...
jmj11 Posted September 12, 2005 Share Posted September 12, 2005 I hadn't realized it was that common...I thought my answer was way off because it was a zebra. Good info to know - something I can keep my eyes open for in patients & hopefully not miss it :) Well, it might be a zebra in tha family practice setting, however, I work full time in headache so I see it far more often. Mike Quote Link to comment Share on other sites More sharing options...
ajnelson Posted September 12, 2005 Share Posted September 12, 2005 The preliminary diagnosis is made when the symptoms alert you and you find papillaedma. The final diagnosis is made by opening LP pressures. What is one set that MUST be done between finding the papillaedema and doing the LP? Why is this second step so important? Mike CT? To rule out an actual tumor or any other reason for increased ICP - to prevent uncal herniation. Quote Link to comment Share on other sites More sharing options...
jmj11 Posted September 12, 2005 Share Posted September 12, 2005 CT? To rule out an actual tumor or any other reason for increased ICP - to prevent uncal herniation. Exactly!!!:) Okay, I'm out of here . . . this goup is too smart for me to stump:cool: . Quote Link to comment Share on other sites More sharing options...
pahopeful Posted September 13, 2005 Author Share Posted September 13, 2005 Mike, Don't leave us! We need some more questions to challenge us that will be clinically relevant (like your previous case). pahopeful Quote Link to comment Share on other sites More sharing options...
ajnelson Posted September 13, 2005 Share Posted September 13, 2005 Mike, Don't leave us! We need some more questions to challenge us that will be clinically relevant (like your previous case). pahopeful Definately! Your question definately stumped me for a while, then I just started listing a differential till I found something that fit. It makes me acutally retain all of the things I crammed into my head last year:) Quote Link to comment Share on other sites More sharing options...
JenGintheED Posted September 13, 2005 Share Posted September 13, 2005 More, more, more!!! Quote Link to comment Share on other sites More sharing options...
jmj11 Posted September 13, 2005 Share Posted September 13, 2005 Okay, I'll throw out one more. It is based on a personal experience with a patient this summer. A 68 year old man is sent to you for evaluation by the courts after being arrested for indecent conduct and molestation. This gentleman is a retired mechanical engineer and has never been in trouble with the law before. He was arrested after walking up to a group of middle school kids sitting on a picnic table, in broad daylight. He grabbed one of the girls in the crotch. :eek: The kids scream and reported him. He is deeply troubled about this whole experience and is almost suicidal over the embarrassment.:o :o His name is in the paper for the crime and he has never done anything like this before. His exam was normal and he scored 28/30 on a mini mental status exam and slightly abnormal on a mild cognitive impairment exam.:confused: His wife is brought back and interviewed. She says he has been normal, emotionally prior to this happening. This was completely out of character for him, because he is a very modest man. She said three months earlier he had made sexual comments to one of his nieces, which was very embarrassing for the patient afterwards.:o His wife has also noticed that occasionally he will forget appointments and ask his wife questions that she had previously answered. What is one name for this type of behavior and what is one potential (organic) cause? What is the only objective test (although this it is usually not paid for by insruances) to prove what he has . . . which I did do and was able to get all charges dropped because of it's findings? ;) So, you think this is a form of dementia, then why didn't he score worse on the mini mental status exam? Mike Quote Link to comment Share on other sites More sharing options...
Guest pac4hire Posted September 13, 2005 Share Posted September 13, 2005 is it korsikovs synfrome???? i know ppl with it can have dishibition(sp)....very interesting case. Quote Link to comment Share on other sites More sharing options...
jmj11 Posted September 13, 2005 Share Posted September 13, 2005 is it korsikovs synfrome???? i know ppl with it can have dishibition(sp)....very interesting case. I think that the primary presenting symptom with Korsakov's syndrome is a proflound antegrade and retrograde memory impairment. I believe it too is usually associated with alcoholism, poor nutrition. This patient scored relatively well on his mini mental status exam, (better than I do on Monday mornings . . . or when the answering service calls me at 3 AM). His memory is only starting to deterioate. I will give the additional information that the patient has never been a drinker and he lives with his wife who keeps him well-fed with wonderful home cooking. You are right, social disinhibition is the presenting sign. I must also add that this patient shows more concern about his behavior than most patients with this disorder (maybe he didn't care about his behavior until he was arrested). Quote Link to comment Share on other sites More sharing options...
Moderator EMEDPA Posted September 13, 2005 Moderator Share Posted September 13, 2005 does he have a form of temporal lobe epilepsy? I know some of these folks can go off and do some pretty weird stuff but at times appear normal..... Quote Link to comment Share on other sites More sharing options...
jmj11 Posted September 13, 2005 Share Posted September 13, 2005 does he have a form of temporal lobe epilepsy? I know some of these folks can go off and do some pretty weird stuff but at times appear normal..... That could be in the differential. I have the luxuary of knowing the patient and the details . . . you guys only know a little of the story. But his story (part that I have not shared) made it clear to me that this disinhibition didn't come in spells but in the background. Anyway, it was not temproal lobe epilepsy. I didn't mean to mis-lead anyone by my previous statement that this (disinhibition) without much memory loss didn't sound like the usual dementia. I will say, this man's problem IS a dementia. Okay, I've almost given it away. The question is, what type of dementia is it and what is the objective finding that I used to confirm the diagnosis and have the charges dropped? Quote Link to comment Share on other sites More sharing options...
ddoorn_04 Posted September 14, 2005 Share Posted September 14, 2005 1st year PA-S here, I'll give it my best shot! Could it be Huntington's Disease? I didn't see any mention of choreiform movements and he seems a little old for an early onset for this. If this isn't the case I would think it's definitely a subcortical dementia because of the personality change and decreased inhibitions. As for the test, I know there can be DNA analysis done to identify the genetic marker. A CT scan showing a loss of matter in the caudate nucleus would suggest HD also I believe. This is my best guess for now. Excellent case! Quote Link to comment Share on other sites More sharing options...
merseur Posted September 14, 2005 Share Posted September 14, 2005 maybe an early sign of alzheimers. Atypical presentation. Quote Link to comment Share on other sites More sharing options...
amanquee Posted September 15, 2005 Share Posted September 15, 2005 I remember learning about this in a sensation/perception psych class and it's killing me that I can't remember the name of it!! Quote Link to comment Share on other sites More sharing options...
Marlene G Posted September 15, 2005 Share Posted September 15, 2005 I will take a stab at Pick's Disease (no pun) and the test would be a PET scan or SPECT for frontal lobe lesions or atrophy. However, is a PET scan or SPECT covered by insurance? (A CT and MRI can also be done). In Pick's Disease, one of the early symptoms is a disregard for social decorum. Quote Link to comment Share on other sites More sharing options...
jmj11 Posted September 15, 2005 Share Posted September 15, 2005 I will take a stab at Pick's Disease (no pun) and the test would be a PET scan or SPECT for frontal lobe lesions or atrophy. However, is a PET scan or SPECT covered by insurance? (A CT and MRI can also be done).In Pick's Disease, one of the early symptoms is a disregard for social decorum. You win the trip for two to . . . the wonderful Baghdad Hilton! You are right. In Pick's or fronto-temporal dementia, behavioral (esp. disinhibition) can be the presenting signs. In this case, I did a PET scan and was able to show the fronto-temporal hypo-activity consistant with Pick's. I'll paste more below: Pick's disease is a rare disorder similar to senile dementia/Alzheimer's type. What differentiates it from Alzheimer's disease is that it seems to affect predominantly circumscribed areas of the brain, not all regions. Alzheimer's disease is a more diffuse process that can affect any part of the brain as it progresses. Pick's disease affects about 1 out of 100,000 people. It is more common in women than men. It may occur in people as young as 20, but usually begins between ages 40 and 60. The average age of onset is 54. The onset is usually slow and insidious. The disorder involves shrinking of the tissues (atrophy) of the frontal and temporal lobes of the brain, "fronto-temporal dementia." The neurons (nerve cells) in the affected areas contain abnormal material (Pick's bodies). These are tangles made of tau protein. The exact cause is unknown. The symptoms may be similar to Alzheimer's, with aphasia (loss of language abilities), agnosia (loss of ability to recognize objects or people), and apraxia (loss of skilled movement abilities). Behavioral changes are prominent with loss of inhibition and change in personality, as opposed to Alzheimer's Disease where memory loss is often the primary feature. Risk factors may include a having a personal or family history of Pick's disease or senile dementia, though the genetic basis of the disease has not yet been determined. Quote Link to comment Share on other sites More sharing options...
Marlene G Posted September 15, 2005 Share Posted September 15, 2005 I love behavioral med and neurology. I truly hope that along the way in my career, I have the opportunity to work with some neurologists. I find this area of medicine most fascinating. By the way, you may be my guest at the Baghad Hilton. LOL! Quote Link to comment Share on other sites More sharing options...
Moderator EMEDPA Posted September 15, 2005 Moderator Share Posted September 15, 2005 list 3 urgent/emergent indications for glucagon...... hint: only 1 is related to a common endocrine disorder Quote Link to comment Share on other sites More sharing options...
Guest pac4hire Posted September 15, 2005 Share Posted September 15, 2005 i know it can be given to relax smooth muscle while performing endoscopy(i don't believe tht is an emergent reason though). and of couse hypoglycemia Quote Link to comment Share on other sites More sharing options...
JenGintheED Posted September 15, 2005 Share Posted September 15, 2005 i know it can be given to relax smooth muscle while performing endoscopy(i don't believe tht is an emergent reason though). and of couse hypoglycemia ileus & fb stuck in lower esophagus? i know we learned emergent uses related to smooth muscle relaxation... Quote Link to comment Share on other sites More sharing options...
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