Kamsi
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A 57-year-old woman presents to the emergency department with the sudden onset of severe midabdominal pain of one hour in duration with nausea and vomiting. She describes this pain as the worst pain she's ever had. She states that over the last three months, she has had a low-grade fever, fatigue, malaise, and progressive numbness of her feet. Over the last several months, she has developed frequent episodes of diffuse abdominal pain, associated with occasional nausea and vomiting, approximately thirty minutes after meals. She has lost 25 pounds over the last two months. There has been no change in her bowel habits. She has a history of chronic hepatitis B, diagnosed four years ago. She has no history of atherosclerotic heart disease or atrial fibrillation. Six weeks ago, the patient developed mild inflammatory polyarthritis of her hands. She also has physical signs suggesting a mononeuritis in the left median nerve distribution. On physical examination, her abdomen is relatively soft and nontender without any signs of peritonitis. The stool is guaiac positive. Which of the following tests is the most useful in establishing the correct diagnosis?
(A) Abdominal CT scan
(B) Enteroscopy
(C) Colonoscopy
(D) Abdominal angiogram
(E) Plain abdominal film
(F) Skin biopsy
(G) P-ANCA
A 45-year-old man with no significant past medical history was recently diagnosed with condylomata lata at a nearby clinic. He was given a single intramuscular injection of benzanthine penicillin 2.4 million units. One hour after the injection, the patient began to feel ill while in the waiting room. He tells the doctor that he has a headache and feels flushed. He has no allergies. He feels cold and is short of breath. His blood pressure is 90/60 mm Hg, with a heart rate of 120/min, a respiratory rate of 26/min, and a temperature of 102.6 F. He has a flushed appearance. His RPR was positive at 1:128. What is the best management for this patient?
(A) Aspirin
(B) Steroids
(C) Diphenhydramine, steroids, and oxygen
(D) Intensive care unit monitoring for 24 hours
(E) Switch the penicillin to doxycycline
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| sukhs
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1...i think its PAN...so a skin biopsy is wat i think
2...its jerix reaction, i think...so A
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| Justice
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(D) Abdominal angiogram
(C) Diphenhydramine, steroids, and oxygen
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| Justice
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sukhs wrote:
1...i think its PAN...so a skin biopsy is wat i think
2...its jerix reaction, i think...so A
Did you mean Jarisch reaction?
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| dermatology
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second one is jarisch herxheimer reaction treatment is supportive .... usually patient's are given aspirin or nsaid never give steroids as it will stop action of antibiotics which are working since patient got this reaction .....
its good to have this reaction in syphilis( penicillin is working ) but not having reactions doesnt mean its not working ...
A aspirin is for supportive care.
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| sukhs
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yup...The jarisch herxheimer reaction...
Could you please explain your answer....
Thanks
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| dermatology
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can anyone explain 1st question's answer ...
thank you
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| peraspera
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1. it looks like PAN, patients often have + ANCA titer. But biopsy is the gold standard for diagnosis.
2.I think D. Because:
The reaction starts between 1 and 12 hours after the first injection of antibiotics and lasts for a few hours or up to a day, and is not seen with subsequent treatment. There is malaise, slight to moderate pyrexia, a flush due to vasodilation, tachycardia, and leucocytosis, and existing lesions become more prominent. Hyperventilation and tachycardia are accompanied by hypertension, and then by a drop in blood pressure due to vasodilation and declining peripheral resistance. In some patients with early syphilis, a secondary rash may become visible which was absent before treatment. Usually, the reaction resolves over a period of 6 to 12 hours.It is customary to give corticosteroids in late symptomatic syphilis starting A DAY BEFORE the first penicillin injection and tailing it off the day after the first injection. A dose of around 30mg prednisolone is typical.
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| sukhs
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kamsi...give us the ans plz...
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| Kamsi
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I . D
Abdominal angiogram to confirm mesenteric ischaemia as a result of PAN
2 A
Jarisch - Herxheimer reaction.occurs 24 hrs after initial treatment of syphilis with effective antibiotics.this id due to release of heat stable pyrogen fro spirocheates.Self limiting can be treated with aspirin.Add steriods if it occurs in pregnancy or those with cardiovascular or symptomatic neurosypilis
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| sukhs
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Thanks and btw nice questions kamsi..keep coming 'em up
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| Dr.D
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Kamsi, Are these Q's from UW?
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