let's play some more

1. you get a 30 y.o. male who has been experiencing severe pruritus (itching) for the past 2 weeks. he has a history of ulcerative colitis (UC) for the past seven years, and is on sulfasalazine and cortisone enemas. he has diffuse excoriations on his extremities and trunk. his labs reveal a mild iron deficiency anemia and normal electrolytes. LFTs are normal, except for an increase in alkaline phosphatase: 322 U/L (normal <110 U/L). What is the most likely explanation for his symptoms?
   
   Primary Sclerosing Cholangitis (PSC)
   the patient has had longstanding UC and has now developed pruritus in the setting of an elevated alkaline phosphatase. this sclerosing process involves both the intra- and extrahepatic ducts and is diagnosed by ERCP.
   
   PSC occurs most often in young men and is commonly associated with IBDs, especially UC. PSC has a triad of progressive fatigue, pruritus and jaundice. there may also be upper quadrant pain, fever, hepatosplenomegaly or cirrhosis.
   
   complications of PSC include progression to decompensated cirrhosis, PHT, ascites, and liver failure. treatment is generally supportive and include antibacterial treatment for superimposed bacterial cholangitis.
   
   Primary biliary cirrhosis also presents with pruritus and an elevated alkaline phosphatase, but it is typically seen in middle-aged women and has no association with ulcerative colitis, thus ruling it out from the differential.
   
   
2.  this case is a gem: a 64-year-old man who is currently undergoing chemotherapy, experiences the occasional nausea and vomiting, for which he is given IV prochlorperazine to help ease the symptoms. after several days of therapy, he complains that he feels restless, agitated and he cannot stop moving his legs. what medication should you have given to him at the beginning of his therapy to prevent this reaction? choose between Haloperidol and Lorazepam.
   
   LORAZEPAM.
   
   why? because this patient has akathisia, a syndrome characterized by unpleasant sensations of "inner" restlessness that manifests itself with an inability to sit still or remain motionless (definition from wiki). this the feeling of restlessness sometimes occurs as a side effect of neuroleptic drugs, such as prochlorperazine and haloperidol. akathisia can be prevented by administering IV benzodiazepines, such as lorazepam, concomitantly with the neuroleptic drug. this is especially vital in a patient whose immune system and metabolic activity is compromised.
   
   
3. here's an obstretic pearl. let's say a pregnant woman comes for her antenatal check up. everything is a ok, except her urine dipstick shows bacteriuria (asymptomatic because she doesn't have dysuria, increased frequency, a temperature or increased urgency). whaddya do?
   
   asymptomatic bacteriuria is present in about 5% of pregnant women. because it may cause preterm delivery/low birth weight, it is vital that all pregnant women be screened for asymptomatic bacteriuria early in the pregnancy and be treated if affected by it.
   
   e. coli is the main organism most of the time. other gram-negative organisms (e.g: klebsiella, enterobacter, and proteus species) and gram-positive cocci (e.g: enterococci and group B strep) may be responsible as well.
   
   treatment choices include: trimethoprim-sulfamethoxazole, nitrofurantoin, and cephalexin. ampicillin and amoxicillin may be administered as well (bear in mind though that e.coli may be resistant to these drugs).
   
   10 days after completing the course of antibiotics, the patient should have a follow-up urine culture to make sure the causative agent of bacteriuria has been eradicated.
   
   
4. ok, bonus question. you have to be able to answer this (or it's time to hit those patho books again): pitituary adenomas, what hormone level will be elevated?
   
   PROLACTIN!
   
   
5. all right, i know most of us didn't like public health/ public service medicine too much as a subject, but statistics play a big role in diagnosing a patient right too.
   
   let's go back to 2 basic points before i give you the question:
   
   
   
   • sensitivity = (positive)/ (positive + false negative) x100.
     a sensitive screening test detects DISEASED individuals.
     usually used to screen for disease with low prevalance.
     remember: sensitivity rules out. (SnOUT).
   • specificity = (negative)/ (negative +  false positive) x 100.
     a specific screening test detects HEALTHY individuals.
     usually used as a confirmatory test after a positive sensitive test.
     remember: specificity spins in (SpIN).
   
   now...you get a 70 y.o male come to you to complain about his very red and swollen right toe, that hurts severely. he is not on any medications and denies abusing alcohol. you know it's gout, but which method will you use to make that diagnosis? pick from colchicine response or checking his uric acid levels.
   
   colchine response. u.a levels may be elevated in gout, but it is also increased at tumor lysis syndrome and other diseases. so the results won't be specific enough.
   
   so give oral colchicine hourly until the patient develops improvement in joint pain and inflammation.
   
   
   
   
   
   of course the most specific method of diagnosis, would be joint aspiration and seeing negatively birefringent needle shaped crystals under the microscope. but think CHEAP, get the right diagnosis and your chief of medicine will love you for saving his the bucks.
   
   
   
   until the next round folks =)