Carolinas Case COnference - Dr. Reyner

Pseudoaneurysms
- Definitions:
    1. Outpouching of a blood vessel, involving a defect in the 2 innermost layers (tunica intima and media) with continuity of the outermost layer (adventitia)
     2.  Alternatively, all three layers are damaged and bleeding is contained by blood clot or surrounding structures
- Etiologies are multifactorial, including post traumatic, iatrogenic (post catheterization), infection and inflammation, IV drug use, septic emboli and MI
-  Clinical Presentation: 
     - Increased swelling which may be pulsatile over site of previous needle puncture, surgery or trauma; Anemia in cases of significant blood loss; significant pain
- Look for characteristic yin yang sign on doppler
- EAST Guidelines in Trauma:
     - Level 2 recommendation: Patients without signs of hard vascular injury who have abnormal physical examination findings and or ABI <0.9 should have further evaluation to rule out a vascular injury
- Consider vascular imaging in patients with delayed (>1wk) bleeding, pain or swelling after a traumatic injury

Hiccups:
- An involuntary, spasmodic contraction of the diaphragm and intercostal muscles.  Diaphragm contraction results in sudden inspiration and ends with abrupt closure of the glottis, generating the “hic” sound
- Thorough history and physical exam is key in patients with persistent hiccups (48h to 1 month)
- Etiology is broad. Most common causes include GI (overeating, gastric distention, GERD); post operative; diaphragmatic processes (subdiaphragmatic abscess). 
- CNS processes are a more serious cause. In patients with neurologic symptoms, consider MRI imaging. Patients with dorsal medullary strokes can have hiccups for up to 1 year that are debilitating and recalcitrant to medications. 

Sign of Lesar Trelat
- Explosive onset of multiple pruritic seborrheic keratoses
- Rapid increase in size and number
- Often have an inflammatory base
- An ominous sign of gastrointestinal carcinomas
- Most commonly pancreatic, stomach, liver, and colorectal 

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