A*******s
发帖数: 9638 | 1 A 67 years old female with only history of DM presented with one day history
of involuntary movement in her left arm. She could not control her left
hand due to intermittent jerking. There were no other symptoms associated
with the jerking. Her PCP called me so she was brought in right away for
assessment.
PMH: DM only, last glucose a week ago was 120.
SH: No smoking/ETOH/drugs
FMH: DM
ROS: unremarkable.
PE: VSS normal.
Except left hand myoclonus, and mild ataxia, all others were wnl.
Labs/imaging/EEG: none
What is the very first test you are going to order? |
N****a
发帖数: 100 | 2 太好了，请尽可能post些case。
Labs/imaging/EEG: none， 是做了negative 还是没做？ |
M***D
发帖数: 249 | 3 难道是Alien hand syndrome? I will get a CT to look for cerebral infarct. |
N****a
发帖数: 100 | 4 I also agree HCT to see if any focal change
【在 M***D 的大作中提到】
: 难道是Alien hand syndrome? I will get a CT to look for cerebral infarct.
|
N****a
发帖数: 100 | 5 since the jerking movement still going on, EEG is the 2nd after HCT |
A*******s
发帖数: 9638 | 6 没有做
★ 发自iPhone App: ChineseWeb 8.6
【在 N****a 的大作中提到】
: 太好了，请尽可能post些case。
: Labs/imaging/EEG: none， 是做了negative 还是没做？
|
A*******s
发帖数: 9638 | 7 CT is good for bleeding but not sensitive for recent infarct or small
infarct.
★ 发自iPhone App: ChineseWeb 8.6
【在 M***D 的大作中提到】
: 难道是Alien hand syndrome? I will get a CT to look for cerebral infarct.
|
A*******s
发帖数: 9638 | 8 A reasonable test to order but not the answer.
★ 发自iPhone App: ChineseWeb 8.6
【在 N****a 的大作中提到】
: since the jerking movement still going on, EEG is the 2nd after HCT
|
N****a
发帖数: 100 | 9 then MRI :))
【在 A*******s 的大作中提到】
: CT is good for bleeding but not sensitive for recent infarct or small
: infarct.
:
: ★ 发自iPhone App: ChineseWeb 8.6
|
r*****2
发帖数: 309 | |
|
|
A*******s
发帖数: 9638 | 11 What do you look for?
★ 发自iPhone App: ChineseWeb 8.6
【在 r*****2 的大作中提到】
: Check BMP and Ca level
|
A*******s
发帖数: 9638 | 12 Insurance has to precert.:)
★ 发自iPhone App: ChineseWeb 8.6
【在 N****a 的大作中提到】
: then MRI :))
|
M***D
发帖数: 249 | 13 Agree, but CT is a quick and easy test to start a stoke work up. If cannot
get precert from the patient's insurance for a MRI, I will check lipid
profiles, UDS, ESR, ANA, and will the patient's insurance approve a carotid
echo?
【在 A*******s 的大作中提到】
: CT is good for bleeding but not sensitive for recent infarct or small
: infarct.
:
: ★ 发自iPhone App: ChineseWeb 8.6
|
n*******c
发帖数: 501 | 14 Acute onset of focal myoclonus jerking without weakness in a 67year old
female
It lasted already for a day, would be unusual for a stroke presentation
I would probably work up for seizures. Electrolyte would be first thing and
apart from glucose, sodium and calcium would be worth knowing
It also worths doing a brain ct to exclude a mass lesion.
I would also take a good look at the left arm. Last time I saw a patient had
similar problem after some injection. I suspect there was a extravasation
of iv med causing persistant nerve irritation...
history
【在 A*******s 的大作中提到】
: A 67 years old female with only history of DM presented with one day history
: of involuntary movement in her left arm. She could not control her left
: hand due to intermittent jerking. There were no other symptoms associated
: with the jerking. Her PCP called me so she was brought in right away for
: assessment.
: PMH: DM only, last glucose a week ago was 120.
: SH: No smoking/ETOH/drugs
: FMH: DM
: ROS: unremarkable.
: PE: VSS normal.
|
A*******s
发帖数: 9638 | 15 Very good assessment.
I would like to have one single test which goes straightly to the diagnosis.
Hint: I sent her directly to ER.
Any resident in training? Or someone wants to impress the attendings?
and
had
★ 发自iPhone App: ChineseWeb 8.6
【在 n*******c 的大作中提到】
: Acute onset of focal myoclonus jerking without weakness in a 67year old
: female
: It lasted already for a day, would be unusual for a stroke presentation
: I would probably work up for seizures. Electrolyte would be first thing and
: apart from glucose, sodium and calcium would be worth knowing
: It also worths doing a brain ct to exclude a mass lesion.
: I would also take a good look at the left arm. Last time I saw a patient had
: similar problem after some injection. I suspect there was a extravasation
: of iv med causing persistant nerve irritation...
:
|
w******z
发帖数: 1872 | 16 check for clots, venous/arterial Doppler for the left upper arm. |
w******z
发帖数: 1872 | 17 and point of care blood sugar level. |
A*******s
发帖数: 9638 | 18 What disease is in your mind?
★ 发自iPhone App: ChineseWeb 8.6
【在 w******z 的大作中提到】
: and point of care blood sugar level.
|
M***D
发帖数: 249 | 19 如果怀疑是左臂local nerve 受压引起the involuntary movement, I will also
check the left arm muscular pressure. I remember there are case reports of
spontaneous compartment syndrome in DM patients.
【在 w******z 的大作中提到】
: check for clots, venous/arterial Doppler for the left upper arm.
|
i*d
发帖数: 2640 | 20 低血糖。
history
【在 A*******s 的大作中提到】
: A 67 years old female with only history of DM presented with one day history
: of involuntary movement in her left arm. She could not control her left
: hand due to intermittent jerking. There were no other symptoms associated
: with the jerking. Her PCP called me so she was brought in right away for
: assessment.
: PMH: DM only, last glucose a week ago was 120.
: SH: No smoking/ETOH/drugs
: FMH: DM
: ROS: unremarkable.
: PE: VSS normal.
|
|
|
A*******s
发帖数: 9638 | 21 Do you need ER to deal with hypoglycemia? :)
★ 发自iPhone App: ChineseWeb 8.6
【在 i*d 的大作中提到】
: 低血糖。
:
: history
|
i*d
发帖数: 2640 | 22 那就是高血糖。
【在 A*******s 的大作中提到】
: Do you need ER to deal with hypoglycemia? :)
:
: ★ 发自iPhone App: ChineseWeb 8.6
|
w******z
发帖数: 1872 | 23 DMII HHNK (for 67yrs old, more possible) or DMI DKA (less likely). |
w******z
发帖数: 1872 | 24 L arm symptoms are due to diabetic neuropathy:) |
A*******s
发帖数: 9638 | 25 Her glucose was 720, at ER was 850. Interestingly she has never been
formally diagnosed as DM.
So what do you call it?
★ 发自iPhone App: ChineseWeb 8.6
【在 i*d 的大作中提到】
: 那就是高血糖。
|
M***D
发帖数: 249 | 26 Agree, 我也一直往neuropathy 上想。没想到这个病人的PCP没做finger stick, 我们
这儿的PCP查一个DM 病人的VSS都会包括一个finger stick，现在发现我们这儿的PCP真
挺好！
【在 w******z 的大作中提到】
: L arm symptoms are due to diabetic neuropathy:)
|
N****a
发帖数: 100 | 27 anyone please explain the pathophysiology, Why we were not tempted to think
blood sugar the cause? |
M***D
发帖数: 249 | 28 我想是我一开始就以为病人的PCP已经查了她的finger stick, 然后就把你们后面的几
位引岔道上去了：）
有的paper 认为hyperglycemia--->basal ganglia dysfunction--->chorea/
involuntary movement.
think
【在 N****a 的大作中提到】
: anyone please explain the pathophysiology, Why we were not tempted to think
: blood sugar the cause?
|
N****a
发帖数: 100 | 29 这是不是一个well established 说法？
从她的clinical presentation 上，如何rule out seizure？如果没有先做任何检查，
包括finger stick，各位大夫会最想用什么手段锁定diagnosis？能有几个人会想到是
blood sugar 出了问题？
i
【在 M***D 的大作中提到】
: 我想是我一开始就以为病人的PCP已经查了她的finger stick, 然后就把你们后面的几
: 位引岔道上去了：）
: 有的paper 认为hyperglycemia--->basal ganglia dysfunction--->chorea/
: involuntary movement.
:
: think
|
w***e
发帖数: 269 | 30 hyperglycemic hyperosmolar syndrome. |
|
|
N****a
发帖数: 100 | 31 还有一点很有趣，她的其他physical unremarkable。也没有AMS... |
A*******s
发帖数: 9638 | 32 A good question, I guess that 24 hrs residency training limit is the culprit
to blame. :)
think
★ 发自iPhone App: ChineseWeb 8.6
【在 N****a 的大作中提到】
: anyone please explain the pathophysiology, Why we were not tempted to think
: blood sugar the cause?
|
A*******s
发帖数: 9638 | 33 Yes, she has no mental status change noted.
★ 发自iPhone App: ChineseWeb 8.6
【在 N****a 的大作中提到】
: 还有一点很有趣，她的其他physical unremarkable。也没有AMS...
|
p****r
发帖数: 117 | 34 When a DM patient come to complain anything why don't you check glucose
first? We all thought it was checked and normal. But I really didn't know
hyperglycemia can cause this jerk problem. |
A*******s
发帖数: 9638 | 35 This patient does not have a formal diagnosis of DM so I guess his PCP did
not check her for Glucose. She had a glucose 120 a week ago not sure if it'
s fasting. I put DM there as a clue for answer in purpose.
【在 p****r 的大作中提到】
: When a DM patient come to complain anything why don't you check glucose
: first? We all thought it was checked and normal. But I really didn't know
: hyperglycemia can cause this jerk problem.
|
A*******s
发帖数: 9638 | 36 The diagnosis is nonketotic hyperlycemia, or HHNS
http://www.ncbi.nlm.nih.gov/pubmed/2600393 |
n*******c
发帖数: 501 | 37 Not really. The case described here looks more like focal seizure rather
than chorea.
【在 M***D 的大作中提到】
: 我想是我一开始就以为病人的PCP已经查了她的finger stick, 然后就把你们后面的几
: 位引岔道上去了：）
: 有的paper 认为hyperglycemia--->basal ganglia dysfunction--->chorea/
: involuntary movement.
:
: think
|
n*******c
发帖数: 501 | 38 It is a seizure!
Should always consider metabolic causes in seizures.
【在 N****a 的大作中提到】
: 这是不是一个well established 说法？
: 从她的clinical presentation 上，如何rule out seizure？如果没有先做任何检查，
: 包括finger stick，各位大夫会最想用什么手段锁定diagnosis？能有几个人会想到是
: blood sugar 出了问题？
:
: i
|
n*******c
发帖数: 501 | 39 Thanks for sharing. This is a very interesting and important case,
especially for ED trainees ;-)
The real question of the case, in my opinion, is DDz of focal seizures. It's
not uncommon for focal seizures, usually partial motor seizures to be first
presentation of HONK. And for a new onset of focal seizure metabolic cause
should always be ruled out first because they are easy to do and easy to
correct and then change outcome quickly, no matter if the patient has
relevant history or not.
Another take home message is never assume other people has done anything.
Even if PCP has done some thing you still need to repeat it if you doubt it
because she is YOUR patient now ;-)
it'
【在 A*******s 的大作中提到】
: This patient does not have a formal diagnosis of DM so I guess his PCP did
: not check her for Glucose. She had a glucose 120 a week ago not sure if it'
: s fasting. I put DM there as a clue for answer in purpose.
|
N****a
发帖数: 100 | 40 确实是一个精彩的case，谢谢posting和great discussion！学习了！ |
|
|
z**********4
发帖数: 467 | |
M***D
发帖数: 249 | 42 不敢苟同。Focal seizure 有postictal symptoms such as left arm weakness or
paresis, 这个病人没有。还有这个病人的血糖一个星期前120，见A++时是720，到ER时
是850，她的focal seizure应该越来越严重，such as her focal seizure 扩散到其它
部位或发作episode延长，这个病人也没有。
's
first
cause
it
【在 n*******c 的大作中提到】
: Thanks for sharing. This is a very interesting and important case,
: especially for ED trainees ;-)
: The real question of the case, in my opinion, is DDz of focal seizures. It's
: not uncommon for focal seizures, usually partial motor seizures to be first
: presentation of HONK. And for a new onset of focal seizure metabolic cause
: should always be ruled out first because they are easy to do and easy to
: correct and then change outcome quickly, no matter if the patient has
: relevant history or not.
: Another take home message is never assume other people has done anything.
: Even if PCP has done some thing you still need to repeat it if you doubt it
|
N****a
发帖数: 100 | 43 问过问题，常规下，在纠正她的blood sugar 的同时但jerking还未消失，应不应该做
一个head CT 排除brain focal lesion呢，还是押宝其jerking就是由于高血糖所致？ |
A*******s
发帖数: 9638 | 44 说说你的想法？
【在 z**********4 的大作中提到】
: 嘻嘻， 应该先问问他最近吃生牛肉了吗
|
A*******s
发帖数: 9638 | 45 这个问题比较复杂， navada提问了pathophysiology的问题，显然hyperosmolarity是
合理的解释， 但为什么jerking只是在一侧呢？
很多paper认为是focal seizure， 长时间的focal seizure叫epilepticus partialis
continua, 也有观点认为是movement disorder， 包括dystonia或者myoclonus。
我相信这种jerking的发生与病人大脑本身的陈旧病变/先天畸形有关，比如如果这个病
人有过陈旧的中风病灶， 高渗的环境可以触发focal seizure。 而如果病变/畸形在
basal ganglion， dystonia就可以解释了。
因为病变/畸形往往在一侧，所以jerking经常局限在一侧而不是高渗状态下双侧大脑受
影响而引起的全身反应。
【在 M***D 的大作中提到】
: 不敢苟同。Focal seizure 有postictal symptoms such as left arm weakness or
: paresis, 这个病人没有。还有这个病人的血糖一个星期前120，见A++时是720，到ER时
: 是850，她的focal seizure应该越来越严重，such as her focal seizure 扩散到其它
: 部位或发作episode延长，这个病人也没有。
:
: 's
: first
: cause
: it
|
A*******s
发帖数: 9638 | 46 这个病人肯定需要brain scan， 接下来的问题：
在ER, CT of brain w/o contrast显示hypertensity in right hemisphere. On
call radiologist reading是脑出血， 你的第一反应是什么？
Maowei or other radiologists， what do you think?
★ 发自iPhone App: ChineseWeb 8.6
【在 N****a 的大作中提到】
: 问过问题，常规下，在纠正她的blood sugar 的同时但jerking还未消失，应不应该做
: 一个head CT 排除brain focal lesion呢，还是押宝其jerking就是由于高血糖所致？
|
z**********4
发帖数: 467 | 47 sorry, 我没有看完所有的讨论。普通出血的一般是AMS,一般不会是focal seizure.如
果只是focal seizure没有AMS, CT不是最好的initial imaging modality.
hypertensity in right frontal cortex没看到片片，不好下结论。hypertensive出血
一般是extending from basal ganglion to the frontal lobe with
intraventricular extension.
如果是focal right frontal cortex hyperdensity 的differential是tumor (
including ganglioglioma, PXA,or GBM), DNET, carvernoma. 或者老年人有没有
amyloid angiopathy hemorrhage. 或者是不是这人抽的时候摔到了，把脑袋给跌了，
focal cerebral contusion?
order 个MR with contrast see see la.
【在 A*******s 的大作中提到】
: 这个病人肯定需要brain scan， 接下来的问题：
: 在ER, CT of brain w/o contrast显示hypertensity in right hemisphere. On
: call radiologist reading是脑出血， 你的第一反应是什么？
: Maowei or other radiologists， what do you think?
:
: ★ 发自iPhone App: ChineseWeb 8.6
|
A*******s
发帖数: 9638 | 48 说得不错，你仔细看一下这个case， 这个病人的glucose是720，你有没有别的想法？
★ 发自iPhone App: ChineseWeb 8.6
【在 z**********4 的大作中提到】
: sorry, 我没有看完所有的讨论。普通出血的一般是AMS,一般不会是focal seizure.如
: 果只是focal seizure没有AMS, CT不是最好的initial imaging modality.
: hypertensity in right frontal cortex没看到片片，不好下结论。hypertensive出血
: 一般是extending from basal ganglion to the frontal lobe with
: intraventricular extension.
: 如果是focal right frontal cortex hyperdensity 的differential是tumor (
: including ganglioglioma, PXA,or GBM), DNET, carvernoma. 或者老年人有没有
: amyloid angiopathy hemorrhage. 或者是不是这人抽的时候摔到了，把脑袋给跌了，
: focal cerebral contusion?
: order 个MR with contrast see see la.
|
z**********4
发帖数: 467 | 49 extrapontine myelinolysis?
It is very rare.. I think that hyperdensity in the frontal lobe and
hyperglycemia in this case are unrelated. |
A*******s
发帖数: 9638 | 50 如果这个hyperdensity是在右侧的basal ganglion呢？
★ 发自iPhone App: ChineseWeb 8.6
【在 z**********4 的大作中提到】
: extrapontine myelinolysis?
: It is very rare.. I think that hyperdensity in the frontal lobe and
: hyperglycemia in this case are unrelated.
|
|
|
d******a
发帖数: 99 | 51 I guess non-ketotic hyperglycemic chorea. intereting.
【在 A*******s 的大作中提到】
: 如果这个hyperdensity是在右侧的basal ganglion呢？
:
: ★ 发自iPhone App: ChineseWeb 8.6
|
A*******s
发帖数: 9638 | 52 Very good. It is not hemorrhage.
★ 发自iPhone App: ChineseWeb 8.6
【在 d******a 的大作中提到】
: I guess non-ketotic hyperglycemic chorea. intereting.
|
z**********4
发帖数: 467 | 53 hemiballismus. But anyway this man needs MRI. |
A*******s
发帖数: 9638 | 54 You definitely can make the recommendation in your report.:)
I had one patient before with similar presentation and a positive CT/MRI
finding. The treatment for hyperglycemia was both effective on patient's
symptoms and CT hyper density. I am not sure about this patient .
★ 发自iPhone App: ChineseWeb 8.6
【在 z**********4 的大作中提到】
: hemiballismus. But anyway this man needs MRI.
|
A*******s
发帖数: 9638 | 55 A 67 years old female with only history of DM presented with one day history
of involuntary movement in her left arm. She could not control her left
hand due to intermittent jerking. There were no other symptoms associated
with the jerking. Her PCP called me so she was brought in right away for
assessment.
PMH: DM only, last glucose a week ago was 120.
SH: No smoking/ETOH/drugs
FMH: DM
ROS: unremarkable.
PE: VSS normal.
Except left hand myoclonus, and mild ataxia, all others were wnl.
Labs/imaging/EEG: none
What is the very first test you are going to order? |
M***D
发帖数: 249 | 56 难道是Alien hand syndrome? I will get a CT to look for cerebral infarct. |
A*******s
发帖数: 9638 | 57 没有做
★ 发自iPhone App: ChineseWeb 8.6
【在 N****a 的大作中提到】
: 太好了，请尽可能post些case。
: Labs/imaging/EEG: none， 是做了negative 还是没做？
|
A*******s
发帖数: 9638 | 58 CT is good for bleeding but not sensitive for recent infarct or small
infarct.
★ 发自iPhone App: ChineseWeb 8.6
【在 M***D 的大作中提到】
: 难道是Alien hand syndrome? I will get a CT to look for cerebral infarct.
|
A*******s
发帖数: 9638 | 59 A reasonable test to order but not the answer.
★ 发自iPhone App: ChineseWeb 8.6
【在 N****a 的大作中提到】
: since the jerking movement still going on, EEG is the 2nd after HCT
|
r*****2
发帖数: 309 | |
|
|
A*******s
发帖数: 9638 | 61 What do you look for?
★ 发自iPhone App: ChineseWeb 8.6
【在 r*****2 的大作中提到】
: Check BMP and Ca level
|
A*******s
发帖数: 9638 | 62 Insurance has to precert.:)
★ 发自iPhone App: ChineseWeb 8.6
【在 N****a 的大作中提到】
: then MRI :))
|
M***D
发帖数: 249 | 63 Agree, but CT is a quick and easy test to start a stoke work up. If cannot
get precert from the patient's insurance for a MRI, I will check lipid
profiles, UDS, ESR, ANA, and will the patient's insurance approve a carotid
echo?
【在 A*******s 的大作中提到】
: CT is good for bleeding but not sensitive for recent infarct or small
: infarct.
:
: ★ 发自iPhone App: ChineseWeb 8.6
|
n*******c
发帖数: 501 | 64 Acute onset of focal myoclonus jerking without weakness in a 67year old
female
It lasted already for a day, would be unusual for a stroke presentation
I would probably work up for seizures. Electrolyte would be first thing and
apart from glucose, sodium and calcium would be worth knowing
It also worths doing a brain ct to exclude a mass lesion.
I would also take a good look at the left arm. Last time I saw a patient had
similar problem after some injection. I suspect there was a extravasation
of iv med causing persistant nerve irritation...
history
【在 A*******s 的大作中提到】
: A 67 years old female with only history of DM presented with one day history
: of involuntary movement in her left arm. She could not control her left
: hand due to intermittent jerking. There were no other symptoms associated
: with the jerking. Her PCP called me so she was brought in right away for
: assessment.
: PMH: DM only, last glucose a week ago was 120.
: SH: No smoking/ETOH/drugs
: FMH: DM
: ROS: unremarkable.
: PE: VSS normal.
|
A*******s
发帖数: 9638 | 65 Very good assessment.
I would like to have one single test which goes straightly to the diagnosis.
Hint: I sent her directly to ER.
Any resident in training? Or someone wants to impress the attendings?
and
had
★ 发自iPhone App: ChineseWeb 8.6
【在 n*******c 的大作中提到】
: Acute onset of focal myoclonus jerking without weakness in a 67year old
: female
: It lasted already for a day, would be unusual for a stroke presentation
: I would probably work up for seizures. Electrolyte would be first thing and
: apart from glucose, sodium and calcium would be worth knowing
: It also worths doing a brain ct to exclude a mass lesion.
: I would also take a good look at the left arm. Last time I saw a patient had
: similar problem after some injection. I suspect there was a extravasation
: of iv med causing persistant nerve irritation...
:
|
w******z
发帖数: 1872 | 66 check for clots, venous/arterial Doppler for the left upper arm. |
w******z
发帖数: 1872 | 67 and point of care blood sugar level. |
A*******s
发帖数: 9638 | 68 What disease is in your mind?
★ 发自iPhone App: ChineseWeb 8.6
【在 w******z 的大作中提到】
: and point of care blood sugar level.
|
M***D
发帖数: 249 | 69 如果怀疑是左臂local nerve 受压引起the involuntary movement, I will also
check the left arm muscular pressure. I remember there are case reports of
spontaneous compartment syndrome in DM patients.
【在 w******z 的大作中提到】
: check for clots, venous/arterial Doppler for the left upper arm.
|
i*d
发帖数: 2640 | 70 低血糖。
history
【在 A*******s 的大作中提到】
: A 67 years old female with only history of DM presented with one day history
: of involuntary movement in her left arm. She could not control her left
: hand due to intermittent jerking. There were no other symptoms associated
: with the jerking. Her PCP called me so she was brought in right away for
: assessment.
: PMH: DM only, last glucose a week ago was 120.
: SH: No smoking/ETOH/drugs
: FMH: DM
: ROS: unremarkable.
: PE: VSS normal.
|
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A*******s
发帖数: 9638 | 71 Do you need ER to deal with hypoglycemia? :)
★ 发自iPhone App: ChineseWeb 8.6
【在 i*d 的大作中提到】
: 低血糖。
:
: history
|
i*d
发帖数: 2640 | 72 那就是高血糖。
【在 A*******s 的大作中提到】
: Do you need ER to deal with hypoglycemia? :)
:
: ★ 发自iPhone App: ChineseWeb 8.6
|
w******z
发帖数: 1872 | 73 DMII HHNK (for 67yrs old, more possible) or DMI DKA (less likely). |
w******z
发帖数: 1872 | 74 L arm symptoms are due to diabetic neuropathy:) |
A*******s
发帖数: 9638 | 75 Her glucose was 720, at ER was 850. Interestingly she has never been
formally diagnosed as DM.
So what do you call it?
★ 发自iPhone App: ChineseWeb 8.6
【在 i*d 的大作中提到】
: 那就是高血糖。
|
M***D
发帖数: 249 | 76 Agree, 我也一直往neuropathy 上想。没想到这个病人的PCP没做finger stick, 我们
这儿的PCP查一个DM 病人的VSS都会包括一个finger stick，现在发现我们这儿的PCP真
挺好！
【在 w******z 的大作中提到】
: L arm symptoms are due to diabetic neuropathy:)
|
M***D
发帖数: 249 | 77 我想是我一开始就以为病人的PCP已经查了她的finger stick, 然后就把你们后面的几
位引岔道上去了：）
有的paper 认为hyperglycemia--->basal ganglia dysfunction--->chorea/
involuntary movement.
think
【在 N****a 的大作中提到】
: anyone please explain the pathophysiology, Why we were not tempted to think
: blood sugar the cause?
|
w***e
发帖数: 269 | 78 hyperglycemic hyperosmolar syndrome. |
A*******s
发帖数: 9638 | 79 A good question, I guess that 24 hrs residency training limit is the culprit
to blame. :)
think
★ 发自iPhone App: ChineseWeb 8.6
【在 N****a 的大作中提到】
: anyone please explain the pathophysiology, Why we were not tempted to think
: blood sugar the cause?
|
A*******s
发帖数: 9638 | 80 Yes, she has no mental status change noted.
★ 发自iPhone App: ChineseWeb 8.6
【在 N****a 的大作中提到】
: 还有一点很有趣，她的其他physical unremarkable。也没有AMS...
|
|
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p****r
发帖数: 117 | 81 When a DM patient come to complain anything why don't you check glucose
first? We all thought it was checked and normal. But I really didn't know
hyperglycemia can cause this jerk problem. |
A*******s
发帖数: 9638 | 82 This patient does not have a formal diagnosis of DM so I guess his PCP did
not check her for Glucose. She had a glucose 120 a week ago not sure if it'
s fasting. I put DM there as a clue for answer in purpose.
【在 p****r 的大作中提到】
: When a DM patient come to complain anything why don't you check glucose
: first? We all thought it was checked and normal. But I really didn't know
: hyperglycemia can cause this jerk problem.
|
A*******s
发帖数: 9638 | 83 The diagnosis is nonketotic hyperlycemia, or HHNS
http://www.ncbi.nlm.nih.gov/pubmed/2600393 |
n*******c
发帖数: 501 | 84 Not really. The case described here looks more like focal seizure rather
than chorea.
【在 M***D 的大作中提到】
: 我想是我一开始就以为病人的PCP已经查了她的finger stick, 然后就把你们后面的几
: 位引岔道上去了：）
: 有的paper 认为hyperglycemia--->basal ganglia dysfunction--->chorea/
: involuntary movement.
:
: think
|
n*******c
发帖数: 501 | 85 It is a seizure!
Should always consider metabolic causes in seizures.
【在 N****a 的大作中提到】
: 这是不是一个well established 说法？
: 从她的clinical presentation 上，如何rule out seizure？如果没有先做任何检查，
: 包括finger stick，各位大夫会最想用什么手段锁定diagnosis？能有几个人会想到是
: blood sugar 出了问题？
:
: i
|
n*******c
发帖数: 501 | 86 Thanks for sharing. This is a very interesting and important case,
especially for ED trainees ;-)
The real question of the case, in my opinion, is DDz of focal seizures. It's
not uncommon for focal seizures, usually partial motor seizures to be first
presentation of HONK. And for a new onset of focal seizure metabolic cause
should always be ruled out first because they are easy to do and easy to
correct and then change outcome quickly, no matter if the patient has
relevant history or not.
Another take home message is never assume other people has done anything.
Even if PCP has done some thing you still need to repeat it if you doubt it
because she is YOUR patient now ;-)
it'
【在 A*******s 的大作中提到】
: This patient does not have a formal diagnosis of DM so I guess his PCP did
: not check her for Glucose. She had a glucose 120 a week ago not sure if it'
: s fasting. I put DM there as a clue for answer in purpose.
|
z**********4
发帖数: 467 | |
M***D
发帖数: 249 | 88 不敢苟同。Focal seizure 有postictal symptoms such as left arm weakness or
paresis, 这个病人没有。还有这个病人的血糖一个星期前120，见A++时是720，到ER时
是850，她的focal seizure应该越来越严重，such as her focal seizure 扩散到其它
部位或发作episode延长，这个病人也没有。
's
first
cause
it
【在 n*******c 的大作中提到】
: Thanks for sharing. This is a very interesting and important case,
: especially for ED trainees ;-)
: The real question of the case, in my opinion, is DDz of focal seizures. It's
: not uncommon for focal seizures, usually partial motor seizures to be first
: presentation of HONK. And for a new onset of focal seizure metabolic cause
: should always be ruled out first because they are easy to do and easy to
: correct and then change outcome quickly, no matter if the patient has
: relevant history or not.
: Another take home message is never assume other people has done anything.
: Even if PCP has done some thing you still need to repeat it if you doubt it
|
A*******s
发帖数: 9638 | 89 说说你的想法？
【在 z**********4 的大作中提到】
: 嘻嘻， 应该先问问他最近吃生牛肉了吗
|
A*******s
发帖数: 9638 | 90 这个问题比较复杂， navada提问了pathophysiology的问题，显然hyperosmolarity是
合理的解释， 但为什么jerking只是在一侧呢？
很多paper认为是focal seizure， 长时间的focal seizure叫epilepticus partialis
continua, 也有观点认为是movement disorder， 包括dystonia或者myoclonus。
我相信这种jerking的发生与病人大脑本身的陈旧病变/先天畸形有关，比如如果这个病
人有过陈旧的中风病灶， 高渗的环境可以触发focal seizure。 而如果病变/畸形在
basal ganglion， dystonia就可以解释了。
因为病变/畸形往往在一侧，所以jerking经常局限在一侧而不是高渗状态下双侧大脑受
影响而引起的全身反应。
【在 M***D 的大作中提到】
: 不敢苟同。Focal seizure 有postictal symptoms such as left arm weakness or
: paresis, 这个病人没有。还有这个病人的血糖一个星期前120，见A++时是720，到ER时
: 是850，她的focal seizure应该越来越严重，such as her focal seizure 扩散到其它
: 部位或发作episode延长，这个病人也没有。
:
: 's
: first
: cause
: it
|
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A*******s
发帖数: 9638 | 91 这个病人肯定需要brain scan， 接下来的问题：
在ER, CT of brain w/o contrast显示hypertensity in right hemisphere. On
call radiologist reading是脑出血， 你的第一反应是什么？
Maowei or other radiologists， what do you think?
★ 发自iPhone App: ChineseWeb 8.6
【在 N****a 的大作中提到】
: 问过问题，常规下，在纠正她的blood sugar 的同时但jerking还未消失，应不应该做
: 一个head CT 排除brain focal lesion呢，还是押宝其jerking就是由于高血糖所致？
|
z**********4
发帖数: 467 | 92 sorry, 我没有看完所有的讨论。普通出血的一般是AMS,一般不会是focal seizure.如
果只是focal seizure没有AMS, CT不是最好的initial imaging modality.
hypertensity in right frontal cortex没看到片片，不好下结论。hypertensive出血
一般是extending from basal ganglion to the frontal lobe with
intraventricular extension.
如果是focal right frontal cortex hyperdensity 的differential是tumor (
including ganglioglioma, PXA,or GBM), DNET, carvernoma. 或者老年人有没有
amyloid angiopathy hemorrhage. 或者是不是这人抽的时候摔到了，把脑袋给跌了，
focal cerebral contusion?
order 个MR with contrast see see la.
【在 A*******s 的大作中提到】
: 这个病人肯定需要brain scan， 接下来的问题：
: 在ER, CT of brain w/o contrast显示hypertensity in right hemisphere. On
: call radiologist reading是脑出血， 你的第一反应是什么？
: Maowei or other radiologists， what do you think?
:
: ★ 发自iPhone App: ChineseWeb 8.6
|
A*******s
发帖数: 9638 | 93 说得不错，你仔细看一下这个case， 这个病人的glucose是720，你有没有别的想法？
★ 发自iPhone App: ChineseWeb 8.6
【在 z**********4 的大作中提到】
: sorry, 我没有看完所有的讨论。普通出血的一般是AMS,一般不会是focal seizure.如
: 果只是focal seizure没有AMS, CT不是最好的initial imaging modality.
: hypertensity in right frontal cortex没看到片片，不好下结论。hypertensive出血
: 一般是extending from basal ganglion to the frontal lobe with
: intraventricular extension.
: 如果是focal right frontal cortex hyperdensity 的differential是tumor (
: including ganglioglioma, PXA,or GBM), DNET, carvernoma. 或者老年人有没有
: amyloid angiopathy hemorrhage. 或者是不是这人抽的时候摔到了，把脑袋给跌了，
: focal cerebral contusion?
: order 个MR with contrast see see la.
|
z**********4
发帖数: 467 | 94 extrapontine myelinolysis?
It is very rare.. I think that hyperdensity in the frontal lobe and
hyperglycemia in this case are unrelated. |
A*******s
发帖数: 9638 | 95 如果这个hyperdensity是在右侧的basal ganglion呢？
★ 发自iPhone App: ChineseWeb 8.6
【在 z**********4 的大作中提到】
: extrapontine myelinolysis?
: It is very rare.. I think that hyperdensity in the frontal lobe and
: hyperglycemia in this case are unrelated.
|
d******a
发帖数: 99 | 96 I guess non-ketotic hyperglycemic chorea. intereting.
【在 A*******s 的大作中提到】
: 如果这个hyperdensity是在右侧的basal ganglion呢？
:
: ★ 发自iPhone App: ChineseWeb 8.6
|
A*******s
发帖数: 9638 | 97 Very good. It is not hemorrhage.
★ 发自iPhone App: ChineseWeb 8.6
【在 d******a 的大作中提到】
: I guess non-ketotic hyperglycemic chorea. intereting.
|
z**********4
发帖数: 467 | 98 hemiballismus. But anyway this man needs MRI. |
A*******s
发帖数: 9638 | 99 You definitely can make the recommendation in your report.:)
I had one patient before with similar presentation and a positive CT/MRI
finding. The treatment for hyperglycemia was both effective on patient's
symptoms and CT hyper density. I am not sure about this patient .
★ 发自iPhone App: ChineseWeb 8.6
【在 z**********4 的大作中提到】
: hemiballismus. But anyway this man needs MRI.
|
o******u
发帖数: 60 | 100 Persistent myoclonus needs MRI for sure after routine labs if it is all
normal.Generally, Nonketo hyperglycemia chorea will have lesions shows up on
the MRI and will explain the hemichorea. |
|
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A*******s
发帖数: 9638 | 101 这个case没人翻出来我都忘了，BBS就是比微信强大。LOL
on
★ 发自iPhone App: ChineseWeb 8.6
【在 o******u 的大作中提到】
: Persistent myoclonus needs MRI for sure after routine labs if it is all
: normal.Generally, Nonketo hyperglycemia chorea will have lesions shows up on
: the MRI and will explain the hemichorea.
|
o********r
发帖数: 193 | 102 Hemiballismus?
考虑是否 lacunar stoke , 所以 order brain MRI |
o********r
发帖数: 193 | 103 Hemiballismus?
考虑是否 lacunar stoke , 所以 order brain MRI |
