GCS E3V4M5 BP 13870 P 118 Temp 383 Hstix 65 Patients mother stated patient was unhappy and took 50 tabs of Sertraline What is the most probable diagnosis Serotonin syndrome Name 3 ID: 935305
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Slide1
JCM
2021
Slide2Case 1
22/F
Presented to AED with drowsiness and pyrexia
GCS E3V4M5
BP 138/70
P 118
Temp 38.3
Hstix
6.5
Patient’s
mother
stated patient
was unhappy and took 50 tabs of Sertraline.
Slide3What is the most probable diagnosis?
Serotonin syndrome
Slide4Name 3
important differential
diagnoses
CNS infection / Sepsis
Heat related illnesses
eg
heat stroke
Thyroid storm
Autoimmune disorders,
eg
, SLE
Malignant hyperthermia
Toxicology:
Sympathomimetic
toxidrome
Anticholinergic
toxidrome
Neuroleptic
malignant syndrome
Slide5Name
5
important physical signs to look for
Pupil size
Muscle tone
Reflex
Spontaneous / inducible clonus
/ ocular clonus
Skin condition (
eg
, skin rash, flushed skin, diaphoresis
etc
)
Goitre
/ thyroid eye signs
Neck rigidity
Slide6What is the diagnostic criteria?
SS is clinical diagnosis
Hunter toxicity criteria
a patient must have taken a serotonergic agent and meet
ONE
of the following conditions:
Spontaneous clonus
Inducible clonus PLUS agitation or diaphoresis
Ocular clonus PLUS agitation or diaphoresis
Tremor PLUS hyperreflexia
Hypertonia PLUS temperature above 38ºC PLUS ocular clonus or inducible clonus
Slide7Name one physical sign that helps you to differentiate the above diagnosis from neuroleptic malignant syndrome
Reflex
Hyperreflexia – SS
Bradyreflexia
- NMS
Slide8How do you management the patient?
Supportive care
Airway protection
IV fluid resuscitation
Sedation with
benzodiazepines
Antidote
Cyproheptadine
(
histamine-1 receptor antagonist with nonspecific 5-HT1A and 5-HT2A antagonistic properties )
Slide9Case 2
59/F
R foot sprain 2/7 ago
Able to walk
Slide10Slide11Slide12Widening of 1
st
and 2
nd
metatarsal interspace (~ 5mm on the film compared to 2mm on unaffected side)
Fleck sign
Name 2 most important findings
Slide13Fleck sign
Considered pathognomonic for
Lisfranc
injury
It is an avulsion fracture of insertion or origin of the
Lisfranc
ligament
Slide14What is the diagnosis
Tarsometatarsal
joint complex injury (
Lisfranc
injury)
Slide15Describe the pathology of the injury
“
Lisfranc
ligament” consists of three distinct ligaments: the dorsal ligament,
interosseus
ligament, and plantar ligament
Each of the three runs obliquely from the medial border of the second metatarsal to the lateral aspect of the medial cuneiform
There is no transverse ligament attaching the first metatarsal to the second metatarsal, contributing to the first metatarsal's propensity to displace when the “
Lisfranc
ligament” are injured
Slide16Name one pathognomonic physical finding of the injury
Plantar ecchymosis
Slide17How do you classify the injury
Slide18How do you increase sensitivity of plain radiographs when the films are inconspicuous?
Weight-bearing films
Slide19Name one preferred investigation modality in additional to plain radiography
MRI (SEN 94% SPE 75% in one study)
Slide20How do you dispose the patient?
Conservative treatment for non-bony injury is acceptable
Surgical intervention for bony injuries is preferred (54% of patients experienced further displacement on conservative treatment with a median time ~ 18 days)
Slide21Name 4 complications?
Acute
Acute compartment syndrome
Chronic
Chronic mid foot pain
Early osteoarthritis
Chronic instability
Slide22Case 3
35/M
Right knee pain for 5 days
Right knee contusion during a basketball game 4 weeks ago
Tenderness over medial side with decreased range of movement
Slide23Slide24Describe the X-rays
Anterior-Posterior and lateral view of right knee X-rays which show a curvilinear radio-opacity adjacent to the medial femoral condyle
Slide25What is the lesion called and what is your diagnosis
It is called
Pelligrini
Stieda
lesion and the diagnosis is
Pelligrini
Stieda
syndrome
Slide26How is the lesion formed?
It is formed by delayed ossification of the medial collateral ligament adjacent to the margin of the medial femoral condyle secondary to avulsion injury
Slide27What is the management for patients with severe and refractory symptoms?
Surgical excision of the lesion and medical collateral ligament repair
Slide28What other important structure injuries are associated with medical collateral ligament injury
Medical meniscus and anterior cruciate ligament injuries (
O'Donoghue
unhappy triad )
Slide29Case 4
M/70
Dizziness and palpitation for 1 day
GCS 15
BP 80/40
ECG was done
Slide30Slide31What is the ECG diagnosis?
Bidirectional ventricular tachycardia
Slide32Name 3 causes of such ECG phenomenon
Myocardial infarction
Myocarditis
Familial Catecholaminergic VT
Digoxin poisoning
Aconite poisoning
Slide33If the patient visited a herbalist one day before, what is the most likely cause?
Aconite poisoning
Slide34I
f the patient has history of CHF and, what is the most likely cause?
Digoxin Poisoning
Slide35What specific treatment can be given for this patient?
Digoxin specific antibody fragments
Known ingestion amount, no. of vial = ingestion amount in mg x 1.6
Empiric dosing
Acute overdose: 10 vials
Chronic overdose: 4 vials
Slide36Case 5
M/53
A stranger stabbed the patient’s chest wall by scissors
BP 121/80 Pulse 125
SaO2 98% RA
Slide37Slide38What is the most alarming finding in the X-rays?
Presence of Pneumopericardium
Slide39Name 3 other causes of this condition
Positive pressure ventilation
Thoracic surgery
Pericarditis with gas-producing organisms
Fistula between
oesophagus
and pericardium
Slide40Sudden increase SOB, BP 70/40, pulse 150 SaO2 82% on 2L Oxygen
oxygen
with elevated JVP
What is the most likely diagnosis?
Tension pneumopericardium
Slide41What immediate treatment can be done for this patient?
Pericardiocentesis