Morning ReportMorning Report

November 17, 2009

What term is used to describe this finding?What term is used to describe this finding?

0% 0% 0%0%0%

1. Hyphema

2. Hypopyon

3. Iridocyclitis

4. Iridodonesis

5. Synechia

Answer:

Image Challenge

What term is used to describe this finding? Q:

1. Hyphema

Layering of blood in the anterior segment is termed hyphema. Hypopyon refers to pus in the anterior segment. Iridocyclitis refers to inflammation of the iris. Iridodonesis is a quivering of the iris when the patient moves the eye. Synechia is an adhesion between the iris and the lens.

Read More: N Engl J Med 2008;358:2265

What is the diagnosis?

1. D

erm

atopa

thia

p...

2. L

ichen

pla

nus

3. P

soria

sis

4. R

ubella

5. K

erat

oderm

a ble

n...

0% 0% 0%0%0%

1. Dermatopathia pigmentosa reticularis

2. Lichen planus3. Psoriasis4. Rubella5. Keratoderma blennorrhagicum

Answer:

Image Challenge

What is the diagnosis? Q:

5. Keratoderma blennorrhagicum

These vesiculopustular waxy lesions are most consistent with keratoderma blennorrhagicum. This finding should prompt diagnostic testing for sexually transmitted or gastrointestinal pathogens.

Read More: N Engl J Med 2008;358:2160

This rash appeared following treatment for leukemia. What is the diagnosis?

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1. Cryoglobulinemia2. Leukemia cutis3. Herpes zoster4. Graft-versus-host disease5. Urticaria pigmentosa

Answer:

Image Challenge

This rash appeared following treatment for leukemia. What is the diagnosis? Q:

4. Graft-versus-host disease

There is hyperpigmentation and hypopigmentation of the skin, cutaneous atrophy, telangiectasia, and ulcerations. This is most consistent with graft-versus-host disease of the skin.

Treatment with which one of the following medications is associated with this clinical

finding?

1. E

rlotin

ib

2. L

eflu

nomid

e

3. M

etho

trexa

te

4. P

egvi

som

ant

5. P

sora

len

0% 0% 0%0%0%

1. Erlotinib 2. Leflunomide 3. Methotrexate 4. Pegvisomant 5. Psoralen

Answer:

Image Challenge

Treatment with which one of the following medications is associated with this clinical finding?

Q:

1. Erlotinib

Erlotinib, a tyrosine kinase inhibitor of the epidermal growth factor receptor, induces characteristic hair alterations. Trichomegaly, curling, elongation, and trichorrhexis are typical; these reverse after discontinuation of therapy. The pictured changes are not typical of leflunomide, methotrexate, pegvisomant, or psoralen.

Read More: N Engl J Med 2008;358:1175

What is the diagnosis?

0% 0% 0%0%0%

1. Dental abscess2. Neurofibromatosis type 13. Cleft jaw4. Hemiatrophy syndrome5. Mandibular fracture

Answer:

Image Challenge

What is the diagnosis? Q:

5. Mandibular fracture

This patient developed a comminuted fracture of the left and right mandible after being struck on his right lower jaw. The open fracture allowed upward displacement of the left half of the mandible.

Read More: N Engl J Med 2008;358:512

80s Flashback! What was 80s Flashback! What was Madonna’s first #1 hit?Madonna’s first #1 hit?

Pap

a Don

’t Pre

ach

Lik

e A V

irgin

Holid

ay

Cher

ish

0% 0%0%0%

1. Papa Don’t Preach

2. Like A Virgin

3. Holiday

4. Cherish

Physical ExamPhysical ExamVS: T 97.2F, BP 116/84, HR 120, RR 19, O2S 95% RA

Gen: Agitated and lying in bed. Opens eyes to voice intermittently. Tremulous and diaphoretic.

HEENT: Normocephalic and atraumatic. PERRL. Pt will not cooperate with opening mouth for OP exam.

Neck: No masses. Trachea midline. Carotids 2+Lungs: CTA bil, no wheezing or ralesCV: Tachycardic, regular. S1 and S2 normal, no m/r/gAbd: soft/nt/nd. Bowel sounds normal to hyperactive. Ext: 1-2+ pitting edema in RLE. LLE without edema. Right hip surgical

site is c/d/I with mild serosanginous drainage. DP and PT pulses 2/2. Neuro: Not able to follow commands. Opens eyes to pain, voice and

touch. Visible tremors in bil lower extremities. Spontaneous clonus in RLE, inducible clonus with multiple beats in bil LE, but R>L. Patellar reflexes 3+ bilateral. Biceps reflexes 2-3+ bil. Bil LE exhibit rigidity bilaterally. Unable to illicit babinski sign due to rigiditiy.

ImagingImaging

LabsLabs

• CBC: WBC 10.9 (normal diff), HGb 9.2, Plt 256

• BMP: Na+ 138, K+ 4.0, Chl 107, CO2 25, BUN 12, Crt 0.8, Ca2+ 8.0

• Utox: preliminary presumed pos for amphetamines and THC

• CK 662

EKGEKGSinus Tachycardia

Serotonin SyndromeSerotonin Syndrome

Serotonin SyndromeSerotonin Syndrome

• Described in all age groups.

• In 2004, the Toxic Exposure Surveillance System identified 48,204 exposures to SSRI that resulted in mod-major outcomes in 8187 patients and death in 103 patients.

• Diagnosed based on clinical findings; Hunter Diagnostic Toxicity Criteria Rules.

MechanismMechanism• Due to excess of serotonergic activity at CNS and

peripheral serotonin receptors. – Produce autonomic, cognitive and somatic effects.

• Drugs that may contribute:– Anti-depressants (SSRIs, MAOIs, SNRIs, trazodone )– Opiods (tramadol, fentanyl, oxycodone )– CNS stimulants (cocaine, methylphenidate)– 5-HT agonists (triptans)– Psychedellics (LSD, MDA)– Herbs (St. Johns Wort, ginseng, nutmeg)– Others including:tryptophan, L-dopa, valproate, lithium

linezolid, ondesetron, metoclopramide, dextromethorphan

(AND MORE!)

Hunter CriteriaHunter Criteria• Must have taken a serotonergic agent and

1+ of the following:– Spontaneous clonus– Indicible clonus + agitation or diaphoresis– Ocular clonus + agitation or diaphoresis– Tremor and hyperreflexia– Hypertonia– Temp >38C + ocular clonus or inducible clonus

*Findings often more pronounced in LE.

TreatmentTreatment• Discontinue serotonergic agent. • Sedate using benzodiazepines. • Supportive cares: oxygen, IV fluids, cardiac

monitoring. • Anticipate complications, VS can fluctuate

widely. • If benzos and supportive cares not adequate, may

need to use cyproheptadine. • Treat temperatures >41C with standard measures

including intubation and sedation but try to avoid APAP.

PrognosisPrognosis

• Good! (Unlike an attack by a slap bracelet )

– Patients usually respond within 24 hours.

However, the difficulty can be a co-ingestion as this is often seen with serotonin syndrome.

How does serotonin syndrome How does serotonin syndrome effect you?effect you?

On that note… DON’T FORGET TO LOG YOUR WORK HOURS!

Announcements!Announcements!

• Noon Conference: Atrial Fibrillation with Dr. Smalley.

• 1pm Med I Lecture: ABGs with Sarah