k********n
发帖数: 756 | 1 young lady stayed in hospital for the eval of her vaginal bleeding.
Gyn called that patient is act weird, anxious and her eyes are rolling up.
Patient has been also complaining nausea.
Physcial exam: alert, oriented, anxious, sitting, flat affect, saying I feel
weird, eyes looking at the ceiling.
What would you ask/do in next 5 seconds? | V*****G
发帖数: 337 | 2 Ask: LMP, alcohol history/substance abuse, past bleeding history or not,
family abused or not, measure Vital signs, glucose and ABG,electrolyte, oxygen saturation.
feel
【在 k********n 的大作中提到】
: young lady stayed in hospital for the eval of her vaginal bleeding.
: Gyn called that patient is act weird, anxious and her eyes are rolling up.
: Patient has been also complaining nausea.
: Physcial exam: alert, oriented, anxious, sitting, flat affect, saying I feel
: weird, eyes looking at the ceiling.
: What would you ask/do in next 5 seconds?
| k********n
发帖数: 756 | 3 None of them are relevant.
Nausea has something to do with it | V*****G
发帖数: 337 | 4 I don't think this is a complete note yet,
Is this a walk in appointment patient, or ER patient?
Onset, duration, related symptoms, ........
Symptoms:
1. vaginal bleeding needs to be asked,
2. Nausea as you said, needs to be asked,
3. Axious, eyes rolling up (is that nystagmus, or patient just look up?)
So are you asking us to complete the patient note?
【在 k********n 的大作中提到】
: None of them are relevant.
: Nausea has something to do with it
| h**s
发帖数: 1757 | 5 Ask: LMP, pelvic/abdominal pain or/not, social life
Do: PE and b-HCG. | s********o
发帖数: 3319 | | s********o
发帖数: 3319 | | h**s
发帖数: 1757 | 8 没事儿，这没现过眼哪能当医生啊。。。嘿嘿，什末时候公布正确答案？期待中。。。 | a******0
发帖数: 238 | | s******t
发帖数: 579 | 10 Look for papilledema.
Parinaud's syndrome? Could be pineal gland tumor which press the corpora
quadrigemina area. | | | t****x
发帖数: 126 | 11 sounds like Parinaud's Syndrome, I would go head for MRI Brain wo + w
contrast
most likely 2/2 to either pinealoma (intracranial germinomas) or MS in 20s
female
feel
【在 k********n 的大作中提到】
: young lady stayed in hospital for the eval of her vaginal bleeding.
: Gyn called that patient is act weird, anxious and her eyes are rolling up.
: Patient has been also complaining nausea.
: Physcial exam: alert, oriented, anxious, sitting, flat affect, saying I feel
: weird, eyes looking at the ceiling.
: What would you ask/do in next 5 seconds?
| s********o
发帖数: 3319 | 12 感觉不是妇科的病，妇科已经束手无策才转过来的病人哈 | s********o
发帖数: 3319 | 13 嗯，水晶和topmax好像和我想的差不多 LOL | y**s
发帖数: 165 | 14 Oculargyric Crisis?
Ask any recent meds change? | s********o
发帖数: 3319 | 15 这个也是我想到先哈 LOL
【在 y**s 的大作中提到】
: Oculargyric Crisis?
: Ask any recent meds change?
| V*****G
发帖数: 337 | 16 各位大牛，给提个醒，楼主的问题是：
What would you ask/do in next 5 seconds? | V*****G
发帖数: 337 | 17 看来该问用药历史，是否服用抗精神病用药。可能这是楼主想考的吧。不过这vaginal bleeding是不是就不管了？这毕竟是主诉呀.
Oculogyric crisis (OGC) is the name of a dystonic reaction to certain drugs
and/or medical conditions. The term "Oculogyric" refers to rotating of
eyeballs,
Causes
Drugs that can trigger an oculogyric crisis include neuroleptics (such as
olanzapine),[2] amantadine,[citation needed] benzodiazepines,[citation
needed] carbamazepine, chloroquine, cisplatin, diazoxide, influenza vaccine,
[citation needed] levodopa,[citation needed] lithium, metoclopramide,
domperidone, nifedipine, pemoline,[citation needed] phencyclidine ("PCP"),[
citation needed] reserpine, tetrahydrocannabinol (the intoxicating
constituent of the plant Cannabis sativa),[citation needed] and tricyclic
antidepressants.
Other causes can include postencephalitic Parkinson's, Tourette's syndrome,
multiple sclerosis, neurosyphilis, head trauma, bilateral thalamic
infarction, lesions of the fourth ventricle, cystic glioma of the third
ventricle, herpes encephalitis, kernicterus and juvenile Parkinson's. | s********o
发帖数: 3319 | 18 我砰你一个大砖头！居然敢影射我 ：）
【在 V*****G 的大作中提到】
: 各位大牛，给提个醒，楼主的问题是：
: What would you ask/do in next 5 seconds?
| A*******s
发帖数: 9638 | 19 LZ seems to be a neurology resident. And this is not a stroke.
【在 V*****G 的大作中提到】
: 各位大牛，给提个醒，楼主的问题是：
: What would you ask/do in next 5 seconds?
| s********o
发帖数: 3319 | 20 哎 前辈，没人说这是stroke，年纪轻轻，没有感觉运动障碍
【在 A*******s 的大作中提到】
: LZ seems to be a neurology resident. And this is not a stroke.
| | | l********y
发帖数: 2295 | 21 哈哈，我也准备挖空心思弄个难case，看有没有人再跳坑和那个啥～～
【在 s********o 的大作中提到】
: 我砰你一个大砖头！居然敢影射我 ：）
| s******t
发帖数: 579 | 22 How can she appear anxious and be with flat affect at the same time? | s********o
发帖数: 3319 | | V*****G
发帖数: 337 | 24 new case
被版主一个大砖头打倒在地，神志短暂模糊，头皮血肿，what to ask/do in the next 5 seconds?
【在 s********o 的大作中提到】
: 我砰你一个大砖头！居然敢影射我 ：）
| y**s
发帖数: 165 | 25 啪啪几个耳光，肯定马上翻身而起
next 5 seconds?
【在 V*****G 的大作中提到】
: new case
: 被版主一个大砖头打倒在地，神志短暂模糊，头皮血肿，what to ask/do in the next 5 seconds?
| s********o
发帖数: 3319 | 26 住院医嘛，写错点病例是难免的 ：）
aplus 前辈的病历写得真的挺好的，一眼看过去就知道问题在哪里
【在 s******t 的大作中提到】
: How can she appear anxious and be with flat affect at the same time?
| V*****G
发帖数: 337 | 27 对了，主诉是留给妇科的哈。咱们是来会诊的。还没有进入临床的分工，总想着神马都
管。
vaginal bleeding是不是就不管了？这毕竟是主诉呀.
drugs
vaccine,
【在 V*****G 的大作中提到】
: 看来该问用药历史，是否服用抗精神病用药。可能这是楼主想考的吧。不过这vaginal bleeding是不是就不管了？这毕竟是主诉呀.
: Oculogyric crisis (OGC) is the name of a dystonic reaction to certain drugs
: and/or medical conditions. The term "Oculogyric" refers to rotating of
: eyeballs,
: Causes
: Drugs that can trigger an oculogyric crisis include neuroleptics (such as
: olanzapine),[2] amantadine,[citation needed] benzodiazepines,[citation
: needed] carbamazepine, chloroquine, cisplatin, diazoxide, influenza vaccine,
: [citation needed] levodopa,[citation needed] lithium, metoclopramide,
: domperidone, nifedipine, pemoline,[citation needed] phencyclidine ("PCP"),[
| f*****w
发帖数: 1451 | 28 only 5 sec, I would check vitals.
feel
【在 k********n 的大作中提到】
: young lady stayed in hospital for the eval of her vaginal bleeding.
: Gyn called that patient is act weird, anxious and her eyes are rolling up.
: Patient has been also complaining nausea.
: Physcial exam: alert, oriented, anxious, sitting, flat affect, saying I feel
: weird, eyes looking at the ceiling.
: What would you ask/do in next 5 seconds?
| A*******s
发帖数: 9638 | 29 look at this:
20s
Stroke is one of the cause of Parinaud's Syndrome.
To me, it is benzo withdrawal syndrome including seizure. Ask her if she
abuses Xanax. If so, give her a dose of ativan.
【在 t****x 的大作中提到】
: sounds like Parinaud's Syndrome, I would go head for MRI Brain wo + w
: contrast
: most likely 2/2 to either pinealoma (intracranial germinomas) or MS in 20s
: female
:
: feel
| s********o
发帖数: 3319 | 30 忘了妇科病吧，只是出血，没说大出血
【在 f*****w 的大作中提到】
: only 5 sec, I would check vitals.
:
: feel
| | | f*****w
发帖数: 1451 | 31 赫赫,没办法,老毛病了.主要是原来遇见过内似的,就是大出血休克.其实并非出血很多,
就月经量大了点.每个人阈值不一样.
不过只有5秒,难道不应该检查vitals 吗?问那么多病史5秒不够啊
【在 s********o 的大作中提到】
: 忘了妇科病吧，只是出血，没说大出血
| s********o
发帖数: 3319 | 32 我觉得他的意思是问你的第一反应是什么？
多,
【在 f*****w 的大作中提到】
: 赫赫,没办法,老毛病了.主要是原来遇见过内似的,就是大出血休克.其实并非出血很多,
: 就月经量大了点.每个人阈值不一样.
: 不过只有5秒,难道不应该检查vitals 吗?问那么多病史5秒不够啊
| V*****G
发帖数: 337 | 33 版主的砖头是把病人给打倒了。
你这耳光是对着砖头去练铁砂掌的吧？:)
【在 y**s 的大作中提到】
: 啪啪几个耳光，肯定马上翻身而起
:
: next 5 seconds?
| k********n
发帖数: 756 | 34 Oculogyric crisis, acute dystonia....by compazine zofran she received
there is nothing wrong taking thourough history and full exam complete ddx
but we only have several minutes most of time. | V*****G
发帖数: 337 | 35 I agree with you.
【在 A*******s 的大作中提到】
: LZ seems to be a neurology resident. And this is not a stroke.
| V*****G
发帖数: 337 | 36 Prochlorperazine (Compazine, Stemzine, Buccastem, Stemetil, Phenotil) is a
dopamine (D2) receptor antagonist that belongs to the phenothiazine class.
Zofran (ondansetron) is used to prevent nausea and vomiting caused by
surgery or cancer medicines.
ddx
【在 k********n 的大作中提到】
: Oculogyric crisis, acute dystonia....by compazine zofran she received
: there is nothing wrong taking thourough history and full exam complete ddx
: but we only have several minutes most of time.
| k********n
发帖数: 756 | 37 All right you are right | b****e
发帖数: 227 | 38
ddx
学习了.有意思的case 多谢baobao
顺带又看了看Parinaud's syndrome,
找了个视频觉得很不错,总结了Parinaud's syndrome的重要表现,有文字有影像,让人印
象深刻.可惜不会贴youtube,就把链接发这儿把:
http://www.youtube.com/watch?v=u7D1-zj98l8
【在 k********n 的大作中提到】
: Oculogyric crisis, acute dystonia....by compazine zofran she received
: there is nothing wrong taking thourough history and full exam complete ddx
: but we only have several minutes most of time.
| A*******s
发帖数: 9638 | 39 When you present a case, you'd better mention the relavant info. In this
case, Zofran usually does not cause EPS. It was a serotonin agent( which
very rare causes EPS). Reglan/compazine are D2 antagonist.
If you do not consider Seizure as a differential diagnosis, your
consultation is incomplete. D2 antagonist lowers seizure threshould and
ocular movement could be aura or non-convulsive event(not necessorily affect
MS). It is very possible when you just leave the OB/GYN after you tell
them stopping Compazine and doing nothing else, someone pages you back: She
is having a grand mal.
Anyway, if Zofran is listed as only meds for nausea which is very common,
you'd better look for other causes.
ddx
【在 k********n 的大作中提到】
: Oculogyric crisis, acute dystonia....by compazine zofran she received
: there is nothing wrong taking thourough history and full exam complete ddx
: but we only have several minutes most of time.
| f*****w
发帖数: 1451 | 40 Thanks,blulue. I learned it one more time too.
【在 b****e 的大作中提到】
:
: ddx
: 学习了.有意思的case 多谢baobao
: 顺带又看了看Parinaud's syndrome,
: 找了个视频觉得很不错,总结了Parinaud's syndrome的重要表现,有文字有影像,让人印
: 象深刻.可惜不会贴youtube,就把链接发这儿把:
: http://www.youtube.com/watch?v=u7D1-zj98l8
| | | n**********u
发帖数: 14 | 41 OK. I never know that. Could you give me the database you use to make the
conclusion on Zofran and Compazine? I spent 2 minutes with patient, 2
minutes with Gyn, 1 minute giving Benadryl and the lady who had suffered for
2 hours believed I was the God.
I don't believe playing knowledge of medicine is the way practicing art of
medicine. The information I presented here was the information I got when I
walked into the room. And I believe this is the real life of being 1st year
neurology resident.
affect
She
【在 A*******s 的大作中提到】
: When you present a case, you'd better mention the relavant info. In this
: case, Zofran usually does not cause EPS. It was a serotonin agent( which
: very rare causes EPS). Reglan/compazine are D2 antagonist.
: If you do not consider Seizure as a differential diagnosis, your
: consultation is incomplete. D2 antagonist lowers seizure threshould and
: ocular movement could be aura or non-convulsive event(not necessorily affect
: MS). It is very possible when you just leave the OB/GYN after you tell
: them stopping Compazine and doing nothing else, someone pages you back: She
: is having a grand mal.
: Anyway, if Zofran is listed as only meds for nausea which is very common,
| A*******s
发帖数: 9638 | 42 Your PDA will tell you the side effects of Zofran and Compazine. Zofran
induced EPS is indirect and rare.
As a 1st year resident, as long as you can recognize this is a drug side effect,
this is good. At the first step, you need to look into the chart and find
what she got in the past 24 hours. 5 sec is not enough. But most commonly,
nurse would tell you that the patient developped the symptoms right after
the injection. So for 5 sec, you decided Benadryl. I guess this was what
happened.
D2 antagonists cause this type problems every single day.
Ok, I have a question, why Bendryl?
for
I
year
【在 n**********u 的大作中提到】
: OK. I never know that. Could you give me the database you use to make the
: conclusion on Zofran and Compazine? I spent 2 minutes with patient, 2
: minutes with Gyn, 1 minute giving Benadryl and the lady who had suffered for
: 2 hours believed I was the God.
: I don't believe playing knowledge of medicine is the way practicing art of
: medicine. The information I presented here was the information I got when I
: walked into the room. And I believe this is the real life of being 1st year
: neurology resident.
:
:
| s********o
发帖数: 3319 | 43 我砰一个砖先！跟前辈不应该以这种口气说话。
for
I
year
【在 n**********u 的大作中提到】
: OK. I never know that. Could you give me the database you use to make the
: conclusion on Zofran and Compazine? I spent 2 minutes with patient, 2
: minutes with Gyn, 1 minute giving Benadryl and the lady who had suffered for
: 2 hours believed I was the God.
: I don't believe playing knowledge of medicine is the way practicing art of
: medicine. The information I presented here was the information I got when I
: walked into the room. And I believe this is the real life of being 1st year
: neurology resident.
:
:
| V*****G
发帖数: 337 | 44 I think it is a little bit arguable with the way the case was presented.
1st it was not very clear what the chief complaint is. When you actually
look at the patient, you can tell her eyes are not normal. But with what you
mentioned in the case, you say vaginal bleeding, nausea, eyes roll up, then
say anxious, apathy, and look up in the ceiling. This confused me that, is
that because the patient is apathy and avoid eye contact, or there is
something wrong with the eyes. (in the actual scenario, you can ask patient,
and the patient will tell you that my eyes are not in my control, then it
becomes obvious that her eyes have problem). It will be clearer if in the
case, clearly point out what the chief complaint is. If it were mentioned
the eyes roll up is the chief reason the OB/GYN doctor ask you to come, and
then I bet everyone here will focus thinking on the eyes, not now, 3 things
all together, vaginal bleeding, nausea and possible eye problem (from the
way the case was presented). I bet when you were called by OB/GYN doctor,
the actual conversation was much better communicated than the few sentences presented
here. And you have a
clear idea what the chief reason for you to look at the patient. This is
the message was not delivered by the way the case was presented. For us,
it is hard to tell for sure what you are asking. As vaginal bleeding is the
chief complaint for us.
All in all, we learned. Just that we feel we may have a chance to work it
out ourselves at the 1st place if the case was clearer to us.
Anyway, thank you for the case, it is an interesting case. | n**********u
发帖数: 14 | 45 Don't get me wrong.
To A++,
Few people, even within Neurology, understand Zofran is not pure serotonin
antagonist.Check the pubmed. Its mechanism is not fully characterized.My opinion is that
never use PDA to check the SEs and mechanism of medication. I agree that compazine is the cause but the real clinic
picture is that she developed the symptoms after 8 hours of her last dose of Compazine, In addition, does it also surprise you that Zofran precipitated serotonin
syndrome under my watch?
To G
I believe that the way I presented was the real life of on call day. I have no clue when I got the report from GYN and I believed she has conversion disorder after I shouted at the GYN resident. Believe it or not. But hope it helped your future resident training. | V*****G
发帖数: 337 | 46 When did you realize her eyes have problem? When did you know the chief
problem is the eye? At least, at some point you are sure the eyes have the problem and IS the problem. But for us, or to me, I am not even sure her eyes actually have problem or not after
reading your case. that is where we feel not clearly presented. I have to admit that looking at the actual patient is different from looking at sentences on the paper. Anyway, we hope more cases from you, don't get us wrong. Just feel that give us a better picture, since we don't have opportunity to look at the actual patient, have to make judgement based on whatever we get here.
Obviously you did a good job on this case.
have no clue when I got the report from GYN and I believed she has
conversion disorder after I shouted at the GYN resident. Believe it or not.
But hope it helped your future resident training. | A*******s
发帖数: 9638 | 47 Common things are common, and uncommon things are uncommon. When I worked at
ERs,
I saw many cases right after the compazine injection. You know pharmacology
, right?
If her symptoms developped 8 hrs after the compazine injection, your
diagnosis is fishy.
Benadryl is a H2 antagonist, why it works on Dopamine/serotonin systems?
This is the key, and you choose not to answer.
Let me tell you, Benadryl works on all crazy people very well.
opinion is that
compazine is the cause but the real clinic
of Compazine, In addition, does it also surprise you that Zofran
precipitated serotonin
have no clue when I got the report from GYN and I believed she has
conversion disorder after I shouted at the GYN resident. Believe it or not.
But hope it helped your future resident training.
【在 n**********u 的大作中提到】
: Don't get me wrong.
: To A++,
: Few people, even within Neurology, understand Zofran is not pure serotonin
: antagonist.Check the pubmed. Its mechanism is not fully characterized.My opinion is that
: never use PDA to check the SEs and mechanism of medication. I agree that compazine is the cause but the real clinic
: picture is that she developed the symptoms after 8 hours of her last dose of Compazine, In addition, does it also surprise you that Zofran precipitated serotonin
: syndrome under my watch?
: To G
: I believe that the way I presented was the real life of on call day. I have no clue when I got the report from GYN and I believed she has conversion disorder after I shouted at the GYN resident. Believe it or not. But hope it helped your future resident training.
| A*******s
发帖数: 9638 | 48 还是不要误伤革命同志吧， 挑战革命前辈是小将们应有的气概。
我当年被chairman挖苦， 第二天我把paper给他看， 他就非常高兴， 因为“You have
learned。”
在medi， 应该没有老将小将，只有真理谬误。
【在 s********o 的大作中提到】
: 我砰一个砖先！跟前辈不应该以这种口气说话。
:
: for
: I
: year
| L****n
发帖数: 12932 | 49 Hehe, this is so true. 通常碰到这种翻白眼的我都是先上Versed放倒了再说。
Common things are common, and uncommon things are uncommon. When I worked at
ERs,I saw m........
★ Sent from iPhone App: iReader Mitbbs 6.88 - iPhone Lite
【在 A*******s 的大作中提到】
: Common things are common, and uncommon things are uncommon. When I worked at
: ERs,
: I saw many cases right after the compazine injection. You know pharmacology
: , right?
: If her symptoms developped 8 hrs after the compazine injection, your
: diagnosis is fishy.
: Benadryl is a H2 antagonist, why it works on Dopamine/serotonin systems?
: This is the key, and you choose not to answer.
: Let me tell you, Benadryl works on all crazy people very well.
:
| s********o
发帖数: 3319 | 50 赞大度！：）
我只是想着息事宁人，担心这里发展成为又一个漩涡的中心 LOL
have
【在 A*******s 的大作中提到】
: 还是不要误伤革命同志吧， 挑战革命前辈是小将们应有的气概。
: 我当年被chairman挖苦， 第二天我把paper给他看， 他就非常高兴， 因为“You have
: learned。”
: 在medi， 应该没有老将小将，只有真理谬误。
| | | A*******s
发帖数: 9638 | 51 haha, versed works as well as benadryl.
Next time, would you give benadryl a try? It is much cheaper than Versed.
at
【在 L****n 的大作中提到】
: Hehe, this is so true. 通常碰到这种翻白眼的我都是先上Versed放倒了再说。
:
: Common things are common, and uncommon things are uncommon. When I worked at
: ERs,I saw m........
: ★ Sent from iPhone App: iReader Mitbbs 6.88 - iPhone Lite
| A*******s
发帖数: 9638 | 52 Hakuna matata.
LOL.
【在 s********o 的大作中提到】
: 赞大度！：）
: 我只是想着息事宁人，担心这里发展成为又一个漩涡的中心 LOL
:
: have
| L****n
发帖数: 12932 | 53
A++以猪皮著称， 放马过来。
【在 s********o 的大作中提到】
: 赞大度！：）
: 我只是想着息事宁人，担心这里发展成为又一个漩涡的中心 LOL
:
: have
|
|
