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Sthanu

@Sthanu5

Nov 17

Bullous myringitis

Defined by the presence of blisters on the tympanic membrane which has generally a severe otalgia as a first symptom of presentation.

This clinical picture sometimes may be accompanied by sensori-neural hearing loss

Bullous myringitis can be caused by a variety of viruses and bacteria, including:

Respiratory syncytial virus (RSV)
Influenza viruses
Streptococcus pneumoniae (pneumococcus)
Mycoplasma
Haemophilus influenzae
Moraxella catarrhalis
Group A Streptococcus
Staphylococcus aureus

Many microorganisms, especially viruses, m.pneumoniae, chlamydia may cause Bullous myringitis.

In the literature bullous myringitis cases that admitted to ED with sensori-neural hearing loss have been reported.

Diagnosis is made by clinical examination.

Pain control and mild compression may be sufficient for treatment.

If concomitant otitis media is present, antibiotics should be added to treatment.

Bullous myringitis

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Sthanu

@Sthanu5

Oct 11

Diagnosis?

Differential cyanosis in a patient with patent ductus arteriosus, severe PH, and right to left shunt (Eisenmenger syndrome).

Note the severe clubbing and cyanosis of the toes as compared to the lesser degree of clubbing and cyanosis of the fingers

Differential cyanosis

●A difference of at least 5% in oxygen saturation (O2 sat) or 20 mm Hg in partial pressure of oxygen (Pao2) between the arms and legs

●Can be a sign of a patent ductus arteriosus (PDA), persistent pulmonary hypertension of the newborn (PPHN), or left-heart abnormalities

■A rare variation of differential cyanosis is called reverse differential cyanosis, where the upper extremity oxygen value is less than the lower extremity oxygen value.

*This is most often associated with dextrotransposition of the great arteries (dTGA) with coarctation of the aorta/interrupted aortic arch or with PPHN

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Sthanu

@Sthanu5

Sep 29

This 25-yr-old male patient presented to the ED with 3 days of abdominal distension and vomiting.

There is a remote history of laparotomy after getting stabbed.

Thoughts?

Final diagnosis

Incarcerated diaphragmatic hernia with large bowel obstruction

*Radiograph

There is a left diaphragmatic hernia that contains a gas-filled viscus with an air-fluid level.

Right and transverse colon, and small bowel are abnormally dilated.

No gas in the rectum or left colon.

CT abdomen

The transverse and right colon, and ileum are grossly distended.

Cecum measures more than 10 cm in diameter on sagittal images

Left colon and rectum are collapsed

There is a transition point at a left diaphragmatic hernia (ostium 2 cm).

The hernia contains a short segment of the splenic flexure that is distended with gas and fluid.

The colon is thin-walled and there is no evidence or ischemia/strangulation.

There is some free intraperitoneal fluid, but no free intraperitoneal gas

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Sthanu

@Sthanu5

Aug 24

40-yr-old female with altered mental status and hypercalcemia.

Likely diagnosis?

Primary hyperparathyroidism

Skull x-ray (

* "salt and pepper" appearance, characterized by a granular texture that suggests a high turnover bone state,

*a classic sign of hyperparathyroidism

Shoulder x-ray:

Subchondral resorption at the clavicle, leading to widening of the articular space and an irregular, feathery articular surface.

These findings are less common and highlight the severity of bone resorption.

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Sthanu

@Sthanu5

Jul 18

Which of the following is the most likely diagnosis?

A. Erythema multiforme

B. Annular urticaria

C. Secondary syphilis

D. Fixed drug eruption

E. Polymorphous light eruption

A. Erythema multiforme.

Presents with target lesions favoring the extensor extremities.

Without a hx, one must discover distinguishing features in the clinical photo to arrive at the correct diagnosis.

On the dorsal hand, there are variable edematous urticarial papules, some of which feature three zones:

*a dusky center surrounded by two concentric rings of different colors

Although not all of the lesions are fully developed, based on the presence of typical targets, EM is the best answer

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Sthanu

@Sthanu5

Apr 20

A 20-wks pregnant patient is admitted to ICU with septic shock.

Culture reveals listeria.

The patient is known to have had severe anaphylactic reactions to penicillin

What is the drug of choice for this patient?

A) TMP-SMX

B) Clindamycin

C) Vancomycin

D) Ciprofloxacin

Answer:

A) TMP-SMX

In immunocompromised patients, including pregnant women, listeriosis can present as life-threatening sepsis and/or central nervous system (CNS) infection (invasive infection).

In this clinical setting, the mean incubation period is 11 days.

The manifestations of CNS infection include

meningoencephalitis,

cerebritis,

rhombencephalitis (infection and inflammation of the brain stem),

brain abscess, and

spinal cord abscess

●The first line of drugs in severe Listeriosis is ampicillin (or penicillin).

●Some experts add gentamicin, it is not advisable due to its potential toxicity.

●Trimethoprim/sulfamethoxazole (TMP-SMX), is the drug of choice if a pati
nt is PCN allergic.

●Unfortunately, this should be avoided in the first trimester and the last month of pregnancy.

●In the first trimester, this affects folic acid metabolism, and in the last month, it may cause kernicterus in the fetus.

●In those periods, meropenem can be used.

●This patient is way out of those risk periods for the drug, so the answer is A.

●Vancomycin has been proposed, but the failure rate is very high.

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