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Morning Report !! Friday the 13 th …. AAAaaah !!!

Morning Report !! Friday the 13 th …. AAAaaah !!!. Speaks English !! . CASE.

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Morning Report !! Friday the 13 th …. AAAaaah !!!

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  1. Morning Report !! Friday the 13th …. AAAaaah !!!

  2. Speaks English !!  CASE 65 Years old Chinese woman presented to the ED for severe Abdominal pain !!  Abdominal pain : Colicky intermittent severe, estimated 8/10 started progressively over 4 hours PTA diffuse  Nausea  Vomiting  Fever  Diarrhea  Chest pain Ask me questions !

  3. CASE 65 Years old Chinese woman presented to the ED for severe Abdominal pain !!PMH: Medications: HTN Aspirin DM Lisinopril PVD MetforminSH:Somking 2 PPD “since I was born” ETOH Occasionally (which turned out to be every other day !!!)Sexual Activity Active, no protection, multiple partners (“Why are you asking ? “) Ironically, she watches her diet and exercise !!!

  4. CASE 65 Years old Chinese woman presented to the ED for severe Abdominal pain !!Physical Exam: Vitals BP: 164/85 HR: 89 RR: Cooper 20 PO2: 96% Abdominal exam:Bowel sounds present and symmetric Soft Abdomen Mildly tender to palpation Mildly Distended No Guarding No Rebound Tenderness Negative Murphy / Negative McBurney’s Otherwise Unremarkable… Ask me details… if needed !

  5. CASE 65 Years old Chinese woman presented to the ED for severe Abdominal pain !!Labs: CBC LFTs Normal WBC 14.000 Amylase Normal Hb 15.1 Lipase Normal Platelets 365.000 INR Normal Chem7 Na 138 Cl 98 BUN 16 K 5.4 Co2 20 Creat 1.2 Glucose 89 Reflex Cooper ED Lactate: 0.9

  6. CASE 65 Years old Chinese woman presented to the ED for severe Abdominal pain !!Imagery: Abdominal CT Dilated and Thickened loops of small bowel Mild AscitesSubobstructionECG T wave Inversions in Lateral leads What do you wana do next ?

  7. CASE 65 Years old Chinese woman presented to the ED for severe Abdominal pain !!In ED: GI consult Surgery Consult => No surgical issues Cardiology Consult => No cardiac issues(Enzymes were pending) Patient was transferred to the DUMPING ZONE => Medicine !  Fortunately for the patient… Differential Diagnosis ?

  8. CASE 65 Years old Chinese woman presented to the ED for severe Abdominal pain !!On Medicine floor: The following day… Pain is improved No more nausea/vomiting VS , Physical exam and Labs unchangedBUT… New Lower lips edema… huge… not present on admission… Associated tongue edema… No Urticaria or rash No Itching What the… diagnosis… is going on ?

  9. CASE 65 Years old Chinese woman presented to the ED for severe Abdominal pain !!Final Diagnosis: ANGIOEDEMA secondary to Ace Inh !!C4 level and C1 inhibitor were normalLisinopril was stopped… switched to Diovan.Patient clinically improved and was d/c GAME OVER !

  10. Angioedema associated with Ace Inhibitors 2 types of Angioedema: 1. Mast cell-mediated Allergic Reactions (IgE-mediated) Direct mast cell release (Opiates, Contrast…) Aspirin and NSAIDs Chronic Urticaria 2. Bradykinin-mediated Ace Inhibitors (ACE degrades Bradykinin…) ARB ( small chance…) Hereditary and acquired angioedema (Young age…) Estrogen (Weird ! ) ARB ? … The patient will be back soon !! 

  11. Angioedema associated with Ace Inhibitors Anatomic Sites: Larynx Skin and Mucous membranes Bowel wallDiagnosis: Clinically (HISTORY +++)Physical Exam: Look for signs of AllergiesLabs: CBC , Chem7 , LFTs , C4 , C3 Labs are normal in majority of cases !

  12. Angioedema associated with Ace Inhibitors Differential Diagnosis of CutaneousAngioedema: Contact Dermatitis Cellulitis and Erysipelas Facial Lymphedema Autoimmune conditions Eyelid Edema Parasitic Infections Hypothyroidism Hyperthyroidism SVC syndromeCheilitisgranulomatosa and Mekersson-Rosenthal syndrome Idiopathic edema What’s Mekersson-Rosenthal syndrome ?

  13. Angioedema TREATMENTAngioedema in or near the airway Airway managementAngioedema in anaphylaxis IM epi O2 IVF Acute allergic Angioedema H1 & H2 blockers, Steroids C1-Inh Deficiency (Hereditary Angio) Purified C1 inh Concentrate FFP, Bradykinin B2recep inh Ace inh & ARB induced Angioedema Discontinuation of drug Antihistamines and glucocorticoids will likely be ineffective if the angioedema is bradykinin-mediated !!

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