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AFP – Dec 15 th 2013

AFP – Dec 15 th 2013. Thara Vidyasagaran. Photo Quiz. An 18-year-old athlete presented to the emergency department after he was hit in the face during football practice. He had pain over his nose, but no blurred vision or loss of consciousness. He had no relevant medical history.

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AFP – Dec 15 th 2013

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  1. AFP – Dec 15th 2013 Thara Vidyasagaran

  2. Photo Quiz • An 18-year-old athlete presented to the emergency department after he was hit in the face during football practice. He had pain over his nose, but no blurred vision or loss of consciousness. He had no relevant medical history. • Physical examination revealed bleeding from his nostrils and pain over the nasal bridge. His neurologic examination was unremarkable. Radiography and computed tomography of the facial bones revealed a nasal fracture and an intracranial abnormality. Magnetic resonance imaging (MRI) without contrast media was performed for better evaluation of this abnormality

  3. Based on the patient's history, physical examination, and imaging findings, which one of the following is the most likely diagnosis? • A. Arachnoid cyst. • B. Choroid plexus cyst. • C. Epidural hematoma. • D. Meningioma.

  4. I

  5. Choroid plexus cyst

  6. Epidural Hematoma

  7. Meningioma

  8. Testicular Torsion • Twisting of spermatic cord and it’s contents • Surgical emergency • 3.8/100,000 < 18 yrs annually • 10-15% acute scrotal disease • Orchiectomy rate 42% • Bimodal- neonatal and puberty

  9. Neonatal- antenatal/early post-natal • Extra-vaginal- entire cord including PV • Painless scrotal swelling +/- inflammation • RF: term infant, prolonged delivery • Poor testicular viability- 9%, contralateral orchipexy

  10. Older children- intra-vaginal (within tunica vaginalis) • Bell-clapper deformity

  11. Pathogenesis • Twisting of spermatic cord • Increase venous pressure/congestion • Decrease in arterial blood flow and ischemia • Bilateral anatomic condition

  12. Differential- acute scrotum • Sudden painful swelling + local signs/systemic symptoms • High index of suspicion for torsion • Non-specific s/s in children = late presentation • All limit therapeutic index for testicular salvage

  13. History and Physical • Sudden onset unilateral pain, N/V- classic • Fever, urinary problems. Trauma, strenous physical activity • Scrotal skin- indurated/erythematous/warm • High riding testicle- short spermatic cord • Horizontal orientation • Cremasteric reflex • Comparison

  14. Intermittent and chronic intermittent- Urology • Appendix testes and epididymis- blue dot sign, local tenderness- superior pole • Pre-pubertal- epididymitis- GU abnormality/recent viral infection

  15. Imaging • 2/2 exam • False negative rates of studies • Neg surgical exploration preferred • Doppler US- 89% sensitive, 98.8% specific, 1% false negative • Radio-nucleotide imaging- hot spots in epididymitis, cold spots in torsion

  16. Management • 4-8 hour window before morphological and histo-pathological changes affecting spermatogenesis • Viability cannot be predicted- surgery even beyond window • Viability- 90-100% within 6 hours • 50%- >12 hours • <10% after 24 hours

  17. Manual de-torsion- medial to lateral- turn hands like opening a book • IV sedation, spermatic cord block • 360 degrees or more • Subjective end point- alleviation of pain • Objective- return of blood flow doppler (relative hyperemeia)

  18. Operative- pre-op counseling for orchiectomy • Trans-scrotal approach • Necrotic- orchiectomy 39%- 71% (RF: age, time to surgery) • Orchiopexy, Contralateral orchiopexy with permanent suture (80% bilateral bell clapper)

  19. SORT Recommendations

  20. Which one of the following statements about testicular torsion in neonates is correct? (check one) • Extravaginaltorsion with twisting of the entire cord predominates. • Torsion typically presents as painful scrotal swelling. • Testicular salvage rates are high, and contralateral orchiopexy is unnecessary. • Difficult or prolonged deliveries have no effect on the risk of testicular torsion.

  21. Which one of the following statements about management of testicular torsion is correct? (check one) • A. There is typically a 24-hour window before significant ischemic damage develops. • B. All altered semen parameters will normalize immediately after blood flow is restored to the testicle. • C. Manual detorsion should be attempted if surgery is not an immediate option. • D. Contralateral orchiopexy is unnecessary if the viability of the affected testicle is good.

  22. Which of the following physical signs are associated with testicular torsion? (check all that apply) • Nausea and vomiting. • High-riding testicle. • Erythema and warmth of the ipsilateral scrotal skin. • Abnormal vertical orientation of the affected testicle.

  23. Post traumatic stress disorder • 8% men and 20% women- traumatic event, combat veterans • Under-recognized and under-treated in primary care • Significant psycho-social morbidity, substance abuse, other negative health outcomes • Exposure to traumatic event + • Intrusion • Avoidance • Negative changes in mood/though • Chronic hyper-arousal • * > 1 month, <1mom with dissociation= acute stress

  24. Epidemiology • Lifetime risk of exposure to traumatic event- 60.7% men, 51.2% women • Among exposed, 8% men and 20% women develop PTSD • Lifetime prevalence- 8% • RF: genetic, environmental, biological. Physical injury during traumatic event • Sometimes years after exposure- typically 3-6 mos • 1/3rd PTSD- chronic

  25. Diagnostic approach • High suspicion for at risk patients • Screening- poor evidence, VA- initial visit and annual screening • Primary care PTSD screen, 17 item PTSD check-list, short screening scale for PTSD • Associated: substance abuse, mood and anxiety disorders • Screen for suicide: 1 in 5!

  26. Common symptoms • Behavioral: Anti-social acts, appetite, communication, sexual function, speech, alcohol, startle reflex, social withdrawl, suspiciousness • Cognitive: Blaming, confusion, hyper-vigilance, intrusion, memory problems, attention/ concentration/ decision making/ problem solving • Emotional: agitation, anxiety, apprehension, depression, fear, overwhelming grief, guilt, loss of control, irritability • Physical: chills, SOB, elevated BP, grinding teeth, fainting, palpitations, diaphoresis, nausea, twitching, weakness

  27. Management • Educate patient and family • Elicit patient preferences • Locally available resources, expertise of physician, severity • Trauma focused psycho and pharmaco-therapy + management of medical problems (sleep, pain) • Substance abuse: detox, dual diagnosis treatment program

  28. Psychotherapy • Trauma focused: narrative exposure, in-vivo exposure, cognitive re-structuring and relaxation techniques • Prolonged exposure, cognitive processing therapy, eye movement desentization and re-processing • Hypnosis, brief psychodynamic therapy, imagery rehersal • Family/Marital therapist

  29. Pharmacotherapy • First line • Optimize mono-therapy, 4 weeks • Switch agent, increasing dose (8 weeks) • Subjective and objective symptom reduction • Anti-depressants: SSRI/SNRI most evidence. FDA approved: sertraline and paroxetine • TCA/MAO, remeron- 2nd line

  30. Augmenting agents: Alpha blockers: prazosin (sleep disturbances) Beta blocker, clonidine- unknown • BZD: AVOID (previously used for hyper-arousal) • Anti-histamines/hypnotics: Zolpidem, Zaleplon- short term, trazodone for longer term. Buspirone- insuficient evidence • Mood stabilizers: violent, bipolar- conflicting evidence • Anti-psychotics: not recommended anymore

  31. Yoga, acupuncture- need more studies • Mobile apps • Websites- National center for PTSD, defense centers • Spiritual- chaplain, minister • Peer to peer, family support groups, local community resources

  32. A 30-year-old man presents with a two-month history of recurring nightmares, irritability, and problems with concentration that he traces back to being robbed at gunpoint six months ago. He is not interested in psychotherapy. Which one of the following medications is a first-line treatment for posttraumatic stress disorder (PTSD)? (check one) • Buspirone (Buspar) • Paroxetine (Paxil). • Mirtazapine (Remeron). • Imipramine (Tofranil).

  33. How long must symptoms of PTSD persist after the traumatic event before the diagnosis can be made? (check one) • Less than one month. • More than one month. • Three months. • One year.

  34. Which of the following are the most common psychiatric conditions associated with PTSD? (check all that apply) • Substance abuse. • Mood disorders. • Anxiety disorders. • Psychotic disorders.

  35. Arthropod Bites • Arachnids and insects • Latrodectus (widow spider)- muscle spamsms • Loxosceles (brown recluse)- skin necrosis • Most harmless- 80% other causes- MRSA • Cleansing, cold packs, TT

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