Image of the Week 09/23/2014

Which is the healthiest cereal choice? How do you know?

Surgery in the Clinic

Tonight's presentation was by Kyle Checchi, MSIV, on surgery in the clinic. We see a lot of surgery in the OB/GYN setting but there are other instances in which surgery is done.

Case Study #1:
A 37 year old female with a BMI of 30 has abdominal pain with the following:

• RUQ
• steady and severe
• nausea/vomiting
• diminished appetite, worse with fatty food
• 1+ hr after meal, prolonged > 4-6 hrs). 
• Unremarkable medical history.  

 Based on this information, we think it is obstruction of the cystic duct.

Cholecystitis:

• RUQ pain with contraction of gallbladder against stone in the cystic duct
• colicky pain after fatty intake
• no signs of obstruction or infection
• fear of perforation of gallbladder

Reasons to send in to be seen:

• Cannot maintain PO intake
• Pain not adequately controlled
• Charcot's triad (fever, jaundice, RUQ pain)
• Reynolds pentad (triad plus shock and altered mental status)

Case Study #2:

A 25 year old male complains of discomfort and bulge in the abdominal wall.

• Heaviness and dull discomfort
• History of open appendectomy
• Located at scar
• Cosmetic concern
• Appearance and discomfort worsened with coughing or straining
• Distinguish hernia from ischemic pain

Rational clinical abdominal exam:

• Murphy's signs: cessation of inspiration when pressure applied over gallbladder
• Rovsing's signs: pain in RLQ with deep palpation of LLQ
• Psoas sign: pain with passive/ active extension and flexion at hip, lie on side and grab leg, flex/extend at hip joint and check for discomfort. Bring leg in and kick out to move core muscles, see if anything on the peritoneal muscles inflamed.
• Obturator sign: pain with adduction and external rotation at hip
• Peritoneal signs:
• rebound: increase in pain with quick withdrawal of hand from deep palpation
• guarding: tensing of the abdominal muscles at initiation of palpation
• tap tenderness: pt reacts when percussing

Other Surgery in Clinic:

• Scratch test (hepatomegaly)
• Assessing size of liver, for hepatitis
• Used instead of percussing.

• Drains from surgery such as a mastectomy. If red, swollen, warm, tender skin, it could be fluid or an infection.

Image of the Week 09/16/2014

A 63-year-old white female presents to the ER confused. The patient’s history is positive for alcoholism. A pathology resident diagnoses megaloblastic anemia given the history information and the peripheral blood evaluation below. About which vitamin deficiencies should the medical student caring for the patient be concerned?

Image of the Week 09/09/2014

A missionary returning from Africa is brought to the emergency room one evening for high fever, vomiting, headache, confusion, and bloody diarrhea. The patient is found to be febrile, slightly hypotensive, has a nonpruritic rash on the neck and arms, and a nosebleed. What sort of precautions should the ER physicians take if this patient is infected with the virus shown below?

Live Blog: Diabetes Examination

This week we welcomed back Dr. Paige Comstock, PGY3, for a talk on the diabetic examination. 

At the start of a diabetic exam, the vital signs-- specifically blood pressure targeted at 130/80-- are the most important.

Skin findings in diabetics:

• Velvety, hyperpigmented areas called Acanthosis Nigracans
• Diabetic dermopathy found in 50% of diabetics. They have microvascular complications like neuropathy.

Eye complications of diabetes:

• diabetic retinopathy
• cataract
• glaucoma.

The foot examination:

• Necessary because there is a 25% lifetime risk to develop ulcers due to neuropathy, deformity, and trauma.
• Look for 
• sweating
• ABI (Ankle Brachial Index) if indicated
• callouses because of neuropathy
• nail dystrophy
• paronychia
• areas of abnormal erythema
• check interdigitally.
• Deformities (rigidity, claw toe, hammer toe, charcot foot) lead to increased pressure in some points of the foot which leads to more trauma. 
• For the neurologic exam, perform the microfilament test on various pressure points on the foot. 
• Other neurologic tests include ankle reflexes, pin prinks, and tuning fork on the foot.
• Vascular exam includes palpating the distal pulses to check whether there is poor blood supply. This is a risk factor for recurrent ulcerations.

Image of the Week 09/02/2014

A 25-year old white male presents with the pruritic, rapidly evolving rash below. What type of hypersensitivity reaction is this?