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realruby2000

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    Originally posted by Kalel
    Good explanation soujah, pericarditis is correct, probably secondary to uremia. Pericarditis secondary to uremia can occur with a BUN over 100, or it can occur at lower levels when the change in BUN is sudden; it is an indication for immediate emergency hemodialysis.

    does anyone know mneumonic for the causes of pericarditis??

    i know it goes TUMOR with T being trauma, U being uremia....i dont know ther rest
     
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    BellKicker

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      Originally posted by jaeida8
      There is elevated ACTH due to ectopic production so ACTH would cause hyperpigmentation. In Addison's ACTH is elevated due to adrenal insufficiency. So both have elevated ACTH levels that will lead to hyperpigmentation but for different reasons.

      Yes but like Jakstat said, the hyperpigmentation doesn't come from ACTH itself but from MSH, which is cleaved of from their common precursor protein. I think it would be very unusual for an ectopic to produce the precursor.
       

      BellKicker

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        Originally posted by realruby2000
        does anyone know mneumonic for the causes of pericarditis??

        i know it goes TUMOR with T being trauma, U being uremia....i dont know ther rest

        Don't know the mnemonic but would it be:

        Trauma
        Uremia
        Myocardial infarction (both 2-3 days post and dressler's syndrome)
        Operation
        Radiation

        Then we have all the infectious causes, of course.
         

        jakstat33

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          Originally posted by BellKicker
          Yes but like Jakstat said, the hyperpigmentation doesn't come from ACTH itself but from MSH, which is cleaved of from their common precursor protein. I think it would be very unusual for an ectopic to produce the precursor.

          BK- it is not unusual for some MSH to be secreted with ectopic ACTH, you may find this reference useful
          http://edrv.endojournals.org/cgi/content/full/22/1/75
           

          BellKicker

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            Jakstat33, I give you points for finding such an article but I actually didn't see anything in there about POMC and hyperpigmentation from ectopics. Anyway, I didn't read the whole thing so if you find some definite proof in there, I'll be happy to eat my own words.

            Anyway, I asked an endocrinologist today whether hyperpigmentation was seen in Cushing's and he gave me a blank stare like what is this idiot talking about. He told we that was Addison's, the exact opposite of Cushing's. I pretty much presented our discussion to him and he believed that, yes, some tumors could produce POMC rather than ACTH but in any case the MSH level was too low to cause hyperpigmentation.
             

            souljah1

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              Bellkicker,

              So that endocrinologist didn't think that a pituitary adenoma causing cushing's could cause hyperpigmentation? I thought hyperpigmentation could happen with adrenal insufficiency, pituitary adenoma, and ectopically. I guess I might be wrong about the ectopic ACTH and hyperpigmentation connection. Anyway, glad to know that the case I posted has lead to so much discussion!


              Case:

              A 37yo AA male presents to the ED hypotensive, tachycardic and febrile. He is documented to have sickle cell anemia and has been in before numerous times to be treated for pain. CBC showed a normal white blood cell count, but 45% lymphocytes. He is profoundly anemic, thrombocytopenic, and has elevated D-dimers. He is thought to have sepsis with subsequent DIC. Blood cultures show Gram positive diplococci that are optichin sensitive alpha hemolytic.

              Why is this patient prone to this infxn? Why are the lymphocytes elevated?
               

              GiJoe

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                Originally posted by souljah1
                Bellkicker,

                So that endocrinologist didn't think that a pituitary adenoma causing cushing's could cause hyperpigmentation? I thought hyperpigmentation could happen with adrenal insufficiency, pituitary adenoma, and ectopically. I guess I might be wrong about the ectopic ACTH and hyperpigmentation connection. Anyway, glad to know that the case I posted has lead to so much discussion!


                Case:

                A 37yo AA male presents to the ED hypotensive, tachycardic and febrile. He is documented to have sickle cell anemia and has been in before numerous times to be treated for pain. CBC showed a normal white blood cell count, but 45% lymphocytes. He is profoundly anemic, thrombocytopenic, and has elevated D-dimers. He is thought to have sepsis with subsequent DIC. Blood cultures show Gram positive diplococci that are optichin sensitive alpha hemolytic.

                Why is this patient prone to this infxn? Why are the lymphocytes elevated?

                This poor guy is pretty much asplenic which means he is more susceptible to capsular bacteria. (pnemococcus in this case). I have no idea why he has lymphocytosis

                does anyone know when to expect lymphocytosis besides in a viral inf?
                 

                jakstat33

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                  Originally posted by BellKicker
                  Jakstat33, I give you points for finding such an article but I actually didn't see anything in there about POMC and hyperpigmentation from ectopics. Anyway, I didn't read the whole thing so if you find some definite proof in there, I'll be happy to eat my own words.

                  Anyway, I asked an endocrinologist today whether hyperpigmentation was seen in Cushing's and he gave me a blank stare like what is this idiot talking about. He told we that was Addison's, the exact opposite of Cushing's. I pretty much presented our discussion to him and he believed that, yes, some tumors could produce POMC rather than ACTH but in any case the MSH level was too low to cause hyperpigmentation.

                  hey BK, good discussion. as it says in the reference, MSH levels released from tumors may vary, but in general with release of ectopic ACTH and precursors there can be hyperpigmentation associated with cushing's syndrome. obviously, this isn't clinically relevant and purely academic. if you're truly interested you may want to speak with a pathologist at your school, and show the article to the endocrinologist to see what he has to say about it...
                   
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                  carrigallen

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                    Sorry I'm a first year so I know nothing..but I knew someone with Cushings...so I just wanted to chip in:

                    Cushings gives you a flushed ruddy, chubby face, whereas Addisons gives you actual dark "hyperpigmentation" of the skin. Typical Cushings signs present with limb muscle wastage, buffalo fat hump on back, chipmunk ruddy cheeks. Cortisol or catabolic steroid excess I think. Frequent anti-inflammatory steriod side-effect.


                    Ok..I'll try one based on a patient I knew..

                    50 y/o male presents with hematouria. Urine reveals high creatinine levels. Mild CVA enlargement. No other symptoms. History of second-hand smoke exposure.
                     

                    coconut lime

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                      what was the answer to this?

                      carrigallen said:
                      Sorry I'm a first year so I know nothing..but I knew someone with Cushings...so I just wanted to chip in:

                      Cushings gives you a flushed ruddy, chubby face, whereas Addisons gives you actual dark "hyperpigmentation" of the skin. Typical Cushings signs present with limb muscle wastage, buffalo fat hump on back, chipmunk ruddy cheeks. Cortisol or catabolic steroid excess I think. Frequent anti-inflammatory steriod side-effect.


                      Ok..I'll try one based on a patient I knew..

                      50 y/o male presents with hematouria. Urine reveals high creatinine levels. Mild CVA enlargement. No other symptoms. History of second-hand smoke exposure.
                       
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                      Backpacker-DO2B

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                      In a van down by the River!!
                        A 25 y/o female presents with a pericardial effusion after returning from backpacking in Australia. You learn by reviewing an old chart that she had a postive RPR test for syphilis on her pre-travel physical. She claims that she had a great trip, but claims to have felt tired by the end and states, "that Australian sun sure is bright."
                         

                        Backpacker-DO2B

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                        In a van down by the River!!
                          "88 y/o WF who hates banaanas comes to the ER with visual changes, fatigue, weight loss and light headedness. She has a history of renal insufficency and CHF. ECG is abnormal.

                          What's drug is she taking and how to you fix her problem??"



                          Pt. is probably hypokalemic secondary to a loop diuretic (or possibly thiazide) she takes for her CHF, and her lack of any potassium replacement (hates bananas). The EKG would show a "U" wave with t waves in the same lead, possible st depression, and t wave flattening.
                          Tx is KCL unless pt has concurrent diabetic keto acidosis (quite possible with this presentation) , where one would use KPO4 . THis is dripped at 30mEq per hour to achieve a 3.5mEq/L level of K. AM I right?
                           

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                            Backpacker-DO2B said:
                            Tx is KCL unless pt has concurrent diabetic keto acidosis (quite possible with this presentation) , where one would use KPO4 . THis is dripped at 30mEq per hour to achieve a 3.5mEq/L level of K. AM I right?


                            'Am I right?' :rolleyes:

                            You mean Googling 'Rx for hypokalemia' might actually be wrong? :laugh:

                            j/k pal..
                             

                            Backpacker-DO2B

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                              I was referring to the presentation signs and symptoms rather than the specific patient. As well, if we are going to play that game, then well not all 80 years olds are type II's , not likely that a type I will make it that long but its possible with insanely strict glycemic control (remember normal blood sugar equals your normal - don't forget Poppy's words)....my grandmother did it until 72 as a Type I. Never considered that did you....not all olds are type II (although 88 might be stretching it I agree, but you forget I love the minutiae world of internal medicine.) Find that with history....and Speaking of slipping whats up with your polycystic nonsense...and not knowing what CVA means, your making our school look bad.

                              you crazy reptile......
                               

                              Halaljello

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                                Backpacker-DO2B said:
                                "88 y/o WF who hates banaanas comes to the ER with visual changes, fatigue, weight loss and light headedness. She has a history of renal insufficency and CHF. ECG is abnormal.

                                What's drug is she taking and how to you fix her problem??"



                                Pt. is probably hypokalemic secondary to a loop diuretic (or possibly thiazide) she takes for her CHF, and her lack of any potassium replacement (hates bananas). The EKG would show a "U" wave with t waves in the same lead, possible st depression, and t wave flattening.
                                Tx is KCL unless pt has concurrent diabetic keto acidosis (quite possible with this presentation) , where one would use KPO4 . THis is dripped at 30mEq per hour to achieve a 3.5mEq/L level of K. AM I right?


                                I was thinking digoxin toxicity
                                 

                                Backpacker-DO2B

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                                In a van down by the River!!
                                  As I know you know the answer to my last question, I'll wait for someone else to answer, and in the mean time I have a presentation just for you Idiopathic (you always miss the simple stuff).....



                                  A 68 y/o man in the late stages of Parkinson's disease is diagnosed with Renal cell Carcinoma and has multiple areas of density in a chest x-ray. The man is placed on hospice and 2 months later you are called and the pts daughter claims the pt is "breathing strangely, and it scares her." You examine the pt and find he is breathing slowly and deeply and complains of what you interpret (as he is showing signs of mild dementia) as diffuse, colicky abdominal pain, particularly in the lower quadrants. You talk to his young and attractive nurse aid who has a cute squint to her eyes as she flirts with you. She claims that there is no acute change in his status, as he usually lies there quietly, but occasionally groans that his stomach hurts." What is the diagnosis and susequent treatment if any?
                                   
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                                  Backpacker-DO2B

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                                  In a van down by the River!!
                                    I think that dig toxicity is certianly high on the Diff, but hypokalcemia oftens precipitates arrythmias in pts taking Dig if that is the case (as does verapamil). I think that this is a good thought, as diuretic induced hypokalemia causing dig toxicity can account for more of the s/s. Although I am curious if Beta blockers are not becoming more in vogue for heart failure as they do not require tight control as dig with its narrow therapeutic window. Thus making loop diuretic induced hypokalemia more likely. Either way I think it relates to potassium.




                                    Don't forget about my 26 y/o backpacker returning from Australia. Its some interesting facts to know for boards.
                                     

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                                      Backpacker-DO2B said:
                                      As I know you know the answer to my last question, I'll wait for someone else to answer, and in the mean time I have a presentation just for you Idiopathic (you always miss the simple stuff).....



                                      A 68 y/o man in the late stages of Parkinson's disease is diagnosed with Renal cell Carcinoma and has multiple areas of density in a chest x-ray. The man is placed on hospice and 2 months later you are called and the pts daughter claims the pt is "breathing strangely, and it scares her." You examine the pt and find he is breathing slowly and deeply and complains of what you interpret (as he is showing signs of mild dementia) as diffuse, colicky abdominal pain, particularly in the lower quadrants. You talk to his young and attractive nurse aid who has a cute squint to her eyes as she flirts with you. She claims that there is no acute change in his status, as he usually lies there quietly, but occasionally groans that his stomach hurts." What is the diagnosis and susequent treatment if any?


                                      Too much morphine. Naloxone or naltrexone, depending on the presentation (acute vs. chronic) right?
                                       

                                      Backpacker-DO2B

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                                        Sorry guy I can only give you half credit for this one....your slacking a little. The patient has constipation secondary to overmedication with opiates because his nurse aid is too vain to use the glasses she needs to read the presciption's directions, and has overmedicated him. The respiratory depression was merely meant to give you a clue to the constipation. Rx is withdrawl of opiates temporarily until respiratory supression subsides (and of course narcan if needed), and a digital exam for impaction. A laxative might be needed, such as docusate sodium, or manual assistance in relief of the impaction. That is one elusive cup of coffee my friend.



                                        "Descartes said the pineal gland being the only unilateral structure in the brain was the seat of the soul. As the pineal calcifies with age I contend that people die from calcification of the soul. Reptiles have no soul, therefore I am immortal."
                                        - Idiopathic
                                         

                                        DOtobe

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                                          Idiopathic said:
                                          And you also know that 90 year olds do not get DKA, silly boy. No ketosis in type II. Yer' slipping.

                                          Actually, I did an endocrine rotation and we had a few type II diabetics come in with DKA. It is rare in type II diabetics, but it can happen.
                                           

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                                            Backpacker-DO2B said:
                                            Sorry guy I can only give you half credit for this one....your slacking a little. The patient has constipation secondary to overmedication with opiates because his nurse aid is too vain to use the glasses she needs to read the presciption's directions, and has overmedicated him. The respiratory depression was merely meant to give you a clue to the constipation. Rx is withdrawl of opiates temporarily until respiratory supression subsides (and of course narcan if needed), and a digital exam for impaction. A laxative might be needed, such as docusate sodium, or manual assistance in relief of the impaction. That is one elusive cup of coffee my friend.

                                            Yeah, but I was right.
                                             

                                            Backpacker-DO2B

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                                              A 22 y/o white man in acute distress presents to your ER in Atrial Fibrillation at a rate of 208 bpm when you are a third year resident. You know immediately that you are in trouble as your chief Backpacker-DO2B is not on call tonight and you are very weak at cardiology. In fact the charge nurse had to read the EKG correctly for you (its not an EEG I don't know what to do you think in panic). But being very well read you remember reading the article that rate control is now considered most important, more so than rhythm in A-fib. You immediately order verapamil for nodal block and to slow the rate. You think to yourself that you will allow the pt to stabilize and then call for a cardiology consult. After returning from a cup of coffee, a nurse yells at you the pt is in V-fib now and he can't find a pulse. You wet your pants and then call a code. After one futile attempt to intubate DrMom walks in and takes over running the code properly. What abnormality of the EKG did the charge nurse miss and what other clue did you miss as well. What thing should you have done differently if any, or was this just "an act of God". I mean something you would change besides not paging BackpackerDO2B?
                                               

                                              BellKicker

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                                                Backpacker-DO2B said:
                                                A 22 y/o white man in acute distress presents to your ER in Atrial Fibrillation at a rate of 208 bpm when you are a third year resident. You know immediately that you are in trouble as your chief Backpacker-DO2B is not on call tonight and you are very weak at cardiology. In fact the charge nurse had to read the EKG correctly for you (its not an EEG I don't know what to do you think in panic). But being very well read you remember reading the article that rate control is now considered most important, more so than rhythm in A-fib. You immediately order verapamil for nodal block and to slow the rate. You think to yourself that you will allow the pt to stabilize and then call for a cardiology consult. After returning from a cup of coffee, a nurse yells at you the pt is in V-fib now and he can't find a pulse. You wet your pants and then call a code. After one futile attempt to intubate DrMom walks in and takes over running the code properly. What abnormality of the EKG did the charge nurse miss and what other clue did you miss as well. What thing should you have done differently if any, or was this just "an act of God". I mean something you would change besides not paging BackpackerDO2B?

                                                I'll give it a shot.

                                                I guess 208 is high for AF, which might suggest an aberrant pathway. Maybe the nurse hadn't read up on WPW, short PQ and delta waves?

                                                OTOH, 22-year olds with AF usually have something else wrong with them. Hypertrophic cardiomyopathy? MI or cardiomyopathy induced by cocaine use?
                                                 

                                                Backpacker-DO2B

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                                                In a van down by the River!!
                                                  It is not very common to have OA in the MCP, this finding is more often associated with RA and would be a symmetrical finding (i.e. both hands). Anyway the difference is easy to prove with X-ray (gold standard) and serology for Rheumatoid factor and joint aspirate for inflammatory change (OA is a non inflammatory change and would have less than 2,000 cells in the aspirate as opposed to Ra which has above 5,000)
                                                   

                                                  Backpacker-DO2B

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                                                  In a van down by the River!!
                                                    Thats very good bellkicker, atrial rhythms above 200 typically involve an accessory pathway such as the bundle of kent in WPW. The use of verapamil and digoxin (nodal blockers) are contraindicated in WPW as they block the aV node encouraging use of the accessory pathway and leading to ventricular arrythmias.


                                                    By the way I think copenhagen is beautiful and the people are great, although it rains a lot. By the way have you been by Chriastiania lately? lol.
                                                     

                                                    BellKicker

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                                                      Backpacker-DO2B said:
                                                      By the way I think copenhagen is beautiful and the people are great, although it rains a lot. By the way have you been by Chriastiania lately? lol.

                                                      Backpacker, I live 2 minutes from Christinia but our right-wing government is shutting it down! Seriously, they are not only confiscating the drugs but are hauling away the marijuana stands, too. Soon they'll start charging property taxes and everything. I can't believe it.

                                                      Rain? Oh yeah.... In fact, my left nipple is currently bleeding from this evening's 10 miler in a wet t-shirt.
                                                       
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