M&M - Dr. Zahn

Dr. Zahn - The Zahn-inator

CASE 1 - Pupura, Diffuse Lymphadenopathy, Fatigue, Arthralgia, 20lb weight Loss.

DDx: HUGE and includes: HIV/AIDs, syphilis, tick borne disease, endocarditis, meningococcemia, thrombocytopenia

Core Concept: LUPUS

1. Rheumatology patients are complicated with multiple organ systems usually involved.
2. Must consider side effects of medications including but not limited to immunosuppression.
3. Anti-dsDNA and smith Ab are more specific than ANA
4. SLE: Check CBC, UA, CMP.  Pleural and pericardial effusions require admission.  Low dose prednisone taper if stable.  Leave autoimmune markers to inpatient team.
   

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CASE 2 - 55yo with n/v/d after eating fast food. Hx of previous CVA, TIAs, and Mitral Valve Repair.  Is this Acute Gastroenteritis?

Nope - Imaging: right vertebral artery occlusion with posterior CVA.

Core Concepts: Posterior CVA

1. Posterior circulation strokes are exceedingly difficult to diagnose. 
2. The 5 D's: Dizzy, Diplopia, Dysarthria, Dysmetria
   
3. Keep a high degree of suspicion in order to not miss subtle presentations.
   
4. Keep vertebral artery dissection on the differential in young patients.
   
5. CT has extremely poor sensitivity in the diagnosis of posterior fossa lesions.
   
6. MRI much better test yet can miss early presentations. HINTS testing likely useful yet never studied when performed by EM providers.
7. And... BE AWARE OF INTRACTABLE VOMITING

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CASE 3 - Teenager with complains of persistent shoulder pain, Normal x-rays, Tachycardic. Later found to have Hypoxia!
Initially he looked well... then he didn't. Found to have CA-MRSA subperiosteal abscess.

Core Concepts - CA-MRSA

1. Increasing incidence of CA-MRSA in previously healthy pediatric populations.
   
2. Majority of these are soft tissue infections that result in significant morbidity and mortality.
   
3. Keep a high degree of suspicion in patients with a possible source and any abnormality of vital signs.
   
4. Vancomycin needs to be given early.
   
5. Patients with systemic illness often will have co-existing DVT near site of infection and high likelihood of septic emboli.