Last week I was first in line at my hospital to receive this year's influenza vaccine. Flu shots must be given every year as influenza virus strains change frequently. Influenza virus is capable of antigenic drift and antigenic shift. Think of people who alter their appearance by dying their hair or wearing disguises. This would represent antigenic drift. Now imagine if a criminal could change his or her DNA. That would be similar to antigenic shift. Human and animal influenza strains can swap genetic material and recombine to form novel strains against which, we poor humans, have no immunity. Remember last year's H1N1, the swine flu. Strains that appear in the southern hemisphere and in Asia are used to make the new vaccine for any given year. All health care workers, teachers, first responders, transportation workers, people with chronic medical conditions and those who believe in an ounce of prevention, should get yearly flu shots.
Most upper and lower respiratory tract infections are caused by viruses. These life forms are little more than a piece of DNA or RNA inside an envelope. They require the cellular mechanisms of another higher life form to replicate. The list of respiratory viruses includes influenza and parainfluenza viruses. Parainfluenza is the leading cause of croup. Is there anything more frightening to a parent than waking in the night to the sounds of your child having a cough like a seal's bark and the stridor (loud audible inspiratory and sometimes expiratory sound) that is croup?
Adenovirus, coronavirus and rhinovirus are among the hundreds of viral strains that cause colds. The symptoms of the common cold are familiar: sneezing, coughing, congestion, disturbed sleep and general misery. Differentiating between colds and the flu can be tricky. In general influenza has all the symptoms of a cold but is accompanied by high fever, severe body aches (even your hair seems to hurt), severe sore throat and lasts greater than a week.
RSV is a particularly nasty respiratory virus. The S stands for syncytial. RSV spreads cell to cell down the respiratory tract along intracytoplasmic bridges, e.g. syncytia. RSV cause bronchiolitis and viral pneumonia in infants and toddlers. Their small airways can become plugged by the RSV infection and lead to low oxygen levels. A somewhat effective anti-viral medication is administered to those children with RSV and low oxygen levels. Endotracheal intubation and respiratory support may become necessary.
The gastrointestinal tract is the other target of common human viral infections. Enteroviruses include coxsackie virus, echovirus and poliovirus. Thankfully poliovirus, which lead to paralysis is not seen except in a few countries in the world, because of nearly universal immunization with oral polio vaccine. In addition to the vomiting and diarrhea of gastroenteritis, enteroviruses can cause "hand, foot and mouth" disease. They are also the cause of many cases of viral myocarditis. I recently treated a young man, 16 years of age, for fever, body aches and headaches. His blood work was unremarkable. I suspected Lyme disease and sent off the blood test. Two days later he returned with his mother because he developed a dry cough and had become very short of breath. A chest x-ray revealed an enlarged heart and congested lungs. My partner, who is very adept at ultrasound, showed me that the patient's heart chambers were dilated and hypokinetic and that there was a small amount of fluid in the pericardial sac. We transfered this young man to a pediatric hospital and the offending agent was an enterovirus.
Most patients with viral gastroenteritis do well with sips of clear fluids and a slow progression of their diet. High fevers, weakness, lethargy, dry mucous membranes, decreased urine output and a sunken appearance (in infants) of the fontanel (soft spot on the top of the head) should alert the patient or the parent that dehydration is occuring and an ER visit is necessary.
Rotavirus, norovirus and Norwalk-like virus are all capable of causing localized and severe out breaks of gastroenteritis. Their have been episodes of hundreds of people on a cruise ship coming down with norovirus gastroenteritis. How would you like to be the ship's doctor and nurse on that cruise? An effective and relatively safe vaccine is now available to prevent rotavirus.
Herpes viruses deserve a section of their own. Cold sores, chicken pox, shingles, genital herpes, mononucleosis, and roseola are all diseases caused by members of the family of herpes viruses. Although most cases of herpes infection are self limited, this group of viruses can last a lifetime. Shingles is a recurrence of herpes zoster. The chicken pox infection one had as a child may cause you to harbor the virus in a dormant state in the nervous system. When this dormant virus awakens, it causes a rash and severe pain along a nerve in the body. This can occur anywhere from the face to the toes. Herpes simplex 1 and 2 can cause recurrent painful sores in the mouth and/or genitals. The practice of orogenital sex has blurred the distinction between these 2 strains and the regions they afflict.
Vaccination is our best weapon against viral infections. Mumps, measles, "German measles", chicken pox, hepatitis B, influenza, polio and rotavirus vaccines have saved countless lives and made childhood much less dangerous. There is no evidence that vaccinations cause autism. I would urge all parents to follow the recommendations of the American Academy of Pediatrics with regards to immunizations for their children. To my fellow older folk, there is a vaccine for herper zoster, that is recommended at age 60 to decrease the incidence and intensity of shingles. I highly recommend that you receive this vaccine.
The next chapter of Germs will deal with the deadlier viruses that bedevil humans.
Friday, September 24, 2010
Friday, September 17, 2010
Germs, Chapter 1
Germs! Viruses, bacteria, fungi. Never mind the parasites. Bacteria are very much in the news lately. The headlines scream: "Flesh eating, superbugs, resistant to all antibiotic". The problem is real and getting worse all the time. As the great philosopher Walt Kelly (writer of the comic strip Pogo) phrased it, "we have met the enemy and he is us".
Bacteria live in us and on us. The human gastrointestinal tract harbors up to a trillion bacteria. A newborn ingests bacteria along with mother's milk. The bacteria in our gut are beneficial. They help us digest and absorb nutrients. They even produce nutrients that we need to survive. They deter the growth of pathogenic bugs. Our skin, including the the sweat and oil glands and hair follicles, swarm with bacteria. the respiratory system including the nostrils, sinuses, air ways and lungs are also home to innumerable bacteria.
Companies that sell cleaning products have made us all germophobes. Hand soap, shower products, kitchen and bathroom cleaners and now even clothing contain antibacterial chemicals. Yes, you can buy socks that have silver impregnated fibers to kill the bacteria that make your feet stink. Children's toys are touted to have antibacterial compounds in the plastic. My kitchen cleaner will kill 99.9% of germs. The problem is that 0.1%.
Bacteria reproduce rapidly, if conditions are right. The bugs not killed by the cleaner are resistant to the antibacterial chemical. Random mutations or environmentally induced mutations will allow a few bacteria to survive. The offspring of these resilient bugs are all resistant.
Antibiotics have saved millions of lives. Before penicillin and sulfa, any wound often led to a lethal infection. Today few bacteria are susceptible to these antibiotics. At first the answer was to increase the dose of the antibiotic. Higher doses of penicillin could overcome early resistance in strep and staph bacteria. Bacteria evolved. A mutation led to the bacteria producing an enzyme that deactivated the penicillin molecule.
Humans are also resilient. Chemical manipulation of the penicillin molecule by adding a B-lactam ring produced methcillin. Mankind gave the bugs a new challenge. B-lactamase was the bugs response. MRSA is methcillin resistant Staphylococcus Aureus. One of the superbugs is now resistant to the antibiotics that was designed to kill this menace. A recent patient in the ER was noted on his nursing home records to have MRSA and VRE (vancomycin resistant enterococcus). The nurses gowned up and followed the infectious disease recommendation to try and minimize the chances of this bug spreading to our other patients.
In this war between bacteria and humans, the bugs are winning. NDM-1 (New Delhi metallo-beta-lactamase-1) is the latest and greatest superbug. Be afraid, be very afraid. The bacteria are developing resistance faster than the drug companies can modify old antibiotics or formulate new drugs.
Tuberculosis is as old as mankind. Human remains from our earliest ancestors show evidence of Tb infections. Public health initiatives in the late 19th and early 20th centuries along with effective antibiotics and forced quarantine, made Tb rare in the USA. Laws still exist that allow the confinement of Tb patients, if necessary, to force completion of their treatment.
Enter MRDTb and XDRTb. Multi-drug resistant and extreme-drug resistant Tb have become a scourge in many countries. Tb was once curable with one or two antibiotics. As resistance developed, additions drugs were added to the treatment regimen. MDR and XDR have rendered standard treatment ineffective.
Resistance develops as the few survivors of our antibiotic bombardments reproduce new generations of resistant bugs. Resistance based on a enzyme defense may be encoded on a plasmid. This piece of genetic material can be swapped between bacteria of different species. The bugs can pass on their defenses leading to superbugs. Bacteria also like to hang together. In our bodies pathogenic bacteria produce biofilms. This material screens the bugs from the physician's assault weapons. The antibiotics can't even get at the bugs.
What went wrong? Physicians and patients are to blame. Doctors prescribe antibiotics for conditions that are caused by viruses, or that will resolve without antibiotics. 80% of ear infections resolve without antibiotics. When I try and explain this to the mother of a 2 year crying because of his or her booboo ear, I am met with hostility. The mother insists that she must be given a prescription for amoxicillin or azithromycin. Her child's pediatrician always gives her a script.
Sinusitis, ear infections, colds influenza and gastroenteritis are all treated with often unnecessary antibiotics. Patients given prescriptions for antibiotics, whether needed or not, rarely take the medication as prescribed. If the patient feels better in a few days, he or she will stop taking the antibiotic despite the doctor's admonition to finish the entire treatment course. The unused pills are kept in the medicine cabinet, only to be taken later when the next cold hits.
Physicians must take the lead in preventing the development and spread of antibiotic resistant bacteria. Educate your patients. Patients must become informed consumers. Read about antibiotic resistance. Don't demand antibiotics unless the healthcare provider says that they are truly necessary. If you are prescribed antibiotics, take them on time and until you complete the treatment.
In many countries, antibiotics may be purchased without a prescription either legally or on the black market. I treated a young Cambodian woman in the ER for weakness. Her blood tests revealed aplastic anemia. Her bone marrow had stopped producing red and white blood cells and platelets. She had treated a cold with an antibiotic she purchased in her local ethnic market. Chloramphenicol is an antibiotic that may cause aplastic anemia. This past week, a patient from Brazil was taking tetracycline bought at the local bodega.
Are we doomed? Have the bacteria won? New antibiotics will be created. Better infectious disease protocols will be formulated and applied. The ultimate weapon may be bacteriophages (bacteria eaters). These are viruses that kill bacteria. A patient with a life-threatening bacterial infection may be inoculated with a bacteriophage instead of being given an antibiotic. This treatment is being used in Russia and may be coming to your local hospital.
Bacteria live in us and on us. The human gastrointestinal tract harbors up to a trillion bacteria. A newborn ingests bacteria along with mother's milk. The bacteria in our gut are beneficial. They help us digest and absorb nutrients. They even produce nutrients that we need to survive. They deter the growth of pathogenic bugs. Our skin, including the the sweat and oil glands and hair follicles, swarm with bacteria. the respiratory system including the nostrils, sinuses, air ways and lungs are also home to innumerable bacteria.
Companies that sell cleaning products have made us all germophobes. Hand soap, shower products, kitchen and bathroom cleaners and now even clothing contain antibacterial chemicals. Yes, you can buy socks that have silver impregnated fibers to kill the bacteria that make your feet stink. Children's toys are touted to have antibacterial compounds in the plastic. My kitchen cleaner will kill 99.9% of germs. The problem is that 0.1%.
Bacteria reproduce rapidly, if conditions are right. The bugs not killed by the cleaner are resistant to the antibacterial chemical. Random mutations or environmentally induced mutations will allow a few bacteria to survive. The offspring of these resilient bugs are all resistant.
Antibiotics have saved millions of lives. Before penicillin and sulfa, any wound often led to a lethal infection. Today few bacteria are susceptible to these antibiotics. At first the answer was to increase the dose of the antibiotic. Higher doses of penicillin could overcome early resistance in strep and staph bacteria. Bacteria evolved. A mutation led to the bacteria producing an enzyme that deactivated the penicillin molecule.
Humans are also resilient. Chemical manipulation of the penicillin molecule by adding a B-lactam ring produced methcillin. Mankind gave the bugs a new challenge. B-lactamase was the bugs response. MRSA is methcillin resistant Staphylococcus Aureus. One of the superbugs is now resistant to the antibiotics that was designed to kill this menace. A recent patient in the ER was noted on his nursing home records to have MRSA and VRE (vancomycin resistant enterococcus). The nurses gowned up and followed the infectious disease recommendation to try and minimize the chances of this bug spreading to our other patients.
In this war between bacteria and humans, the bugs are winning. NDM-1 (New Delhi metallo-beta-lactamase-1) is the latest and greatest superbug. Be afraid, be very afraid. The bacteria are developing resistance faster than the drug companies can modify old antibiotics or formulate new drugs.
Tuberculosis is as old as mankind. Human remains from our earliest ancestors show evidence of Tb infections. Public health initiatives in the late 19th and early 20th centuries along with effective antibiotics and forced quarantine, made Tb rare in the USA. Laws still exist that allow the confinement of Tb patients, if necessary, to force completion of their treatment.
Enter MRDTb and XDRTb. Multi-drug resistant and extreme-drug resistant Tb have become a scourge in many countries. Tb was once curable with one or two antibiotics. As resistance developed, additions drugs were added to the treatment regimen. MDR and XDR have rendered standard treatment ineffective.
Resistance develops as the few survivors of our antibiotic bombardments reproduce new generations of resistant bugs. Resistance based on a enzyme defense may be encoded on a plasmid. This piece of genetic material can be swapped between bacteria of different species. The bugs can pass on their defenses leading to superbugs. Bacteria also like to hang together. In our bodies pathogenic bacteria produce biofilms. This material screens the bugs from the physician's assault weapons. The antibiotics can't even get at the bugs.
What went wrong? Physicians and patients are to blame. Doctors prescribe antibiotics for conditions that are caused by viruses, or that will resolve without antibiotics. 80% of ear infections resolve without antibiotics. When I try and explain this to the mother of a 2 year crying because of his or her booboo ear, I am met with hostility. The mother insists that she must be given a prescription for amoxicillin or azithromycin. Her child's pediatrician always gives her a script.
Sinusitis, ear infections, colds influenza and gastroenteritis are all treated with often unnecessary antibiotics. Patients given prescriptions for antibiotics, whether needed or not, rarely take the medication as prescribed. If the patient feels better in a few days, he or she will stop taking the antibiotic despite the doctor's admonition to finish the entire treatment course. The unused pills are kept in the medicine cabinet, only to be taken later when the next cold hits.
Physicians must take the lead in preventing the development and spread of antibiotic resistant bacteria. Educate your patients. Patients must become informed consumers. Read about antibiotic resistance. Don't demand antibiotics unless the healthcare provider says that they are truly necessary. If you are prescribed antibiotics, take them on time and until you complete the treatment.
In many countries, antibiotics may be purchased without a prescription either legally or on the black market. I treated a young Cambodian woman in the ER for weakness. Her blood tests revealed aplastic anemia. Her bone marrow had stopped producing red and white blood cells and platelets. She had treated a cold with an antibiotic she purchased in her local ethnic market. Chloramphenicol is an antibiotic that may cause aplastic anemia. This past week, a patient from Brazil was taking tetracycline bought at the local bodega.
Are we doomed? Have the bacteria won? New antibiotics will be created. Better infectious disease protocols will be formulated and applied. The ultimate weapon may be bacteriophages (bacteria eaters). These are viruses that kill bacteria. A patient with a life-threatening bacterial infection may be inoculated with a bacteriophage instead of being given an antibiotic. This treatment is being used in Russia and may be coming to your local hospital.
Saturday, September 11, 2010
Delirious
It has been 2 weeks since my last blog. My wife and I spent Labor Day weekend in Newport,RI having the joy of watching our youngest niece get married. We were deliriously proud and happy!
Delirium is an acute condition of confusion. The causes of delirium include medications, infections, vascular problems, metabolic disorders, endocrine diseases, and toxins. When an elderly patient arrives in the ER with a "change in mental status", the hunt for the cause of their delirium begins.
My beloved wife has had to deal with my own episodes of delirium. General anesthesia caused me to have paranoid delusions as I awoke in post-op. I told her that people were after me and had injured my abdomen. I had visual hallucinations induced by Dilaudid, a narcotic pain medication. I saw bunnies and giraffes in the patterns of the ceiling tiles. Another Dilaudid fueled delirium had me speaking French and not being aware of why my wife couldn't understand what I was saying.
Many prescription and non-prescription medication can lead to delirium. Benadryl, if taken in excess can cause confusional states. A mnemonic for diphenhydramine overdose is "red as a beet, dry as a bone, hot as a hen and mad as a hatter". As mentioned in a previous blog, mercury was used by hat makers to work the felt. The mercury, a neurotoxin, was absorbed through the skin and caused injury to the brain, thus "mad as a hatter". Drugs that have anticholinergic properties, narcotics (morphine, etc), benzodiazepines (valium, ativan, etc.) and many other medications can lead to delirium.
Alcohol can cause delirium when ingested and for habitual users as a symptom of withdrawal. Delirium tremens is the shaking and confusion seen in alcoholics as they withdraw. Street drugs such as ecstacy, LSD, GHB, PCP, ketamine and cocaine can all cause acute delirium.
Hyper and hypo: glycemia (blood sugar), natremia (sodium), calcemia (calcium), magnesemia, hypoxia (low oxygen), and hypercarbia (high carbon dioxide) are all potential causes of delirium. Liver failure, leading to elevated ammonia level,s and kidney failure, with resulting high urea levels, may both cause delirium as these toxic products of normal body functioning affect the brain.
Both overactive and underactive thyroid hormone levels may cause an altered mental state. Addison's disease (low levels of cortisol) and patients taking corticosteroids chronically, who cease taking these medication abruptly, may present as acute delirium. Malnutrition from anorexia, wasting diseases (such as cancer), and in chronic alcoholism often have deficiencies if vitamin B12, thiamine, folic acid, and niacin. These deficiencies may all lead to delirium.
Dehydration from lack of water intake in nursing home patients, heat exposed patients, and patients with water loss from vomiting and diarrhea may develop a change in mental functioning, i.e. delirium.
A very wise, part time ER doctor told me that when an elderly woman presented with a change in mental status, I should always check for a urinary tract infection. Any systemic infection from UTI's to pneumonia to skin and other soft tissues, may lead to delirium. Infections of the central nervous system (CNS) such as meningitis and encephalitis almost always cause alterations in consciousness.
Sensory and sleep deprivation and stress, as with a patient in a hospital ICU, may develop psychosis. Severe hypertension may cause hypertensive encephalopathy. Auto-immune diseases such as Lupus and vasculitis are potential causes of delirium. Certain forms on nonconvulsive seizures may present as acute delirium.
Whew! Do you get the picture. The work up of a patient with acute delirium is challenging. The medical description of delirium includes hyperactivity and hypoactivity. The patient may be agitated, even assaultive or lethargic. They often have altered wake and sleepy cycles. They may have perceptual deficits involving their hearing, vision, touch, etc. Symptoms of psychosis such as visual, auditory and olfactory hallucinations and delusions (false beliefs) are often present. Impaired memory is common.
Let's consider a few patients that I have recently treated in the ER. Joe is an alcoholic. He is in his 50's and is a life long abuser of alcohol. Food is eaten infrequently and of low nutritional value. He falls frequently. It is summer and he is often outdoors during the heat of the day. He presents with a temp of 103, pulse of 130, BP 160/90, shaky and very confused. He babbles about the aliens who are monitoring his thoughts. Infection, alcohol withdrawal, liver disease, malnutrition, hyperthermia, dehydration, electrolyte abnormalities, CNS injury ...
Mary arrives from the NH. The report says she is more confused than usual. Mary is a diabetic, has had a stroke that prevents her from walking, and has mild dementia. She has a low grade fever, is "picking the bugs" off of her clothes. She kicks and scratches the nurses as they try to take her vital signs and obtain blood and urine for testing. Infection, dehydration, CVA (stroke), low or high blood sugar, medication reaction ...
Jim is an obese diabetic with chronic bronchitis on prednisone. He has sleep apnea. He has been known to have a few drinks every day. His daughter found his medication bottles empty and a month out of date. His CPAP machine for his sleep apnea has cobwebs. Glucose abnormal, hypoxic, elevated CO2, low cortisol from not taking his prednisone, infection, alcohol elevated or withdrawal...
Susan is a 20 year old college student brought in by ambulance for acute psychosis. She is clearly having auditory and visual hallucinations. She responds to my questions with paranoid delusions. Is this schizophrenia or bipolar disorder with mania and psychosis? Before calling the psychiatrist, I have to medically clear her. Infection, metabolic disorder, drug use ...
A patient presenting with delirium is challenging for the ER staff. Information from family, EMS, friends, caretakers and prior records is invaluable. A thorough examination of the patient is crucial. Labs, imaging studies, and diagnostic procedures may all be utilized to arrive at the cause of the delirium. The treatment of delirium is to treat the underlying cause. Simple. NOT.
Delirium is an acute condition of confusion. The causes of delirium include medications, infections, vascular problems, metabolic disorders, endocrine diseases, and toxins. When an elderly patient arrives in the ER with a "change in mental status", the hunt for the cause of their delirium begins.
My beloved wife has had to deal with my own episodes of delirium. General anesthesia caused me to have paranoid delusions as I awoke in post-op. I told her that people were after me and had injured my abdomen. I had visual hallucinations induced by Dilaudid, a narcotic pain medication. I saw bunnies and giraffes in the patterns of the ceiling tiles. Another Dilaudid fueled delirium had me speaking French and not being aware of why my wife couldn't understand what I was saying.
Many prescription and non-prescription medication can lead to delirium. Benadryl, if taken in excess can cause confusional states. A mnemonic for diphenhydramine overdose is "red as a beet, dry as a bone, hot as a hen and mad as a hatter". As mentioned in a previous blog, mercury was used by hat makers to work the felt. The mercury, a neurotoxin, was absorbed through the skin and caused injury to the brain, thus "mad as a hatter". Drugs that have anticholinergic properties, narcotics (morphine, etc), benzodiazepines (valium, ativan, etc.) and many other medications can lead to delirium.
Alcohol can cause delirium when ingested and for habitual users as a symptom of withdrawal. Delirium tremens is the shaking and confusion seen in alcoholics as they withdraw. Street drugs such as ecstacy, LSD, GHB, PCP, ketamine and cocaine can all cause acute delirium.
Hyper and hypo: glycemia (blood sugar), natremia (sodium), calcemia (calcium), magnesemia, hypoxia (low oxygen), and hypercarbia (high carbon dioxide) are all potential causes of delirium. Liver failure, leading to elevated ammonia level,s and kidney failure, with resulting high urea levels, may both cause delirium as these toxic products of normal body functioning affect the brain.
Both overactive and underactive thyroid hormone levels may cause an altered mental state. Addison's disease (low levels of cortisol) and patients taking corticosteroids chronically, who cease taking these medication abruptly, may present as acute delirium. Malnutrition from anorexia, wasting diseases (such as cancer), and in chronic alcoholism often have deficiencies if vitamin B12, thiamine, folic acid, and niacin. These deficiencies may all lead to delirium.
Dehydration from lack of water intake in nursing home patients, heat exposed patients, and patients with water loss from vomiting and diarrhea may develop a change in mental functioning, i.e. delirium.
A very wise, part time ER doctor told me that when an elderly woman presented with a change in mental status, I should always check for a urinary tract infection. Any systemic infection from UTI's to pneumonia to skin and other soft tissues, may lead to delirium. Infections of the central nervous system (CNS) such as meningitis and encephalitis almost always cause alterations in consciousness.
Sensory and sleep deprivation and stress, as with a patient in a hospital ICU, may develop psychosis. Severe hypertension may cause hypertensive encephalopathy. Auto-immune diseases such as Lupus and vasculitis are potential causes of delirium. Certain forms on nonconvulsive seizures may present as acute delirium.
Whew! Do you get the picture. The work up of a patient with acute delirium is challenging. The medical description of delirium includes hyperactivity and hypoactivity. The patient may be agitated, even assaultive or lethargic. They often have altered wake and sleepy cycles. They may have perceptual deficits involving their hearing, vision, touch, etc. Symptoms of psychosis such as visual, auditory and olfactory hallucinations and delusions (false beliefs) are often present. Impaired memory is common.
Let's consider a few patients that I have recently treated in the ER. Joe is an alcoholic. He is in his 50's and is a life long abuser of alcohol. Food is eaten infrequently and of low nutritional value. He falls frequently. It is summer and he is often outdoors during the heat of the day. He presents with a temp of 103, pulse of 130, BP 160/90, shaky and very confused. He babbles about the aliens who are monitoring his thoughts. Infection, alcohol withdrawal, liver disease, malnutrition, hyperthermia, dehydration, electrolyte abnormalities, CNS injury ...
Mary arrives from the NH. The report says she is more confused than usual. Mary is a diabetic, has had a stroke that prevents her from walking, and has mild dementia. She has a low grade fever, is "picking the bugs" off of her clothes. She kicks and scratches the nurses as they try to take her vital signs and obtain blood and urine for testing. Infection, dehydration, CVA (stroke), low or high blood sugar, medication reaction ...
Jim is an obese diabetic with chronic bronchitis on prednisone. He has sleep apnea. He has been known to have a few drinks every day. His daughter found his medication bottles empty and a month out of date. His CPAP machine for his sleep apnea has cobwebs. Glucose abnormal, hypoxic, elevated CO2, low cortisol from not taking his prednisone, infection, alcohol elevated or withdrawal...
Susan is a 20 year old college student brought in by ambulance for acute psychosis. She is clearly having auditory and visual hallucinations. She responds to my questions with paranoid delusions. Is this schizophrenia or bipolar disorder with mania and psychosis? Before calling the psychiatrist, I have to medically clear her. Infection, metabolic disorder, drug use ...
A patient presenting with delirium is challenging for the ER staff. Information from family, EMS, friends, caretakers and prior records is invaluable. A thorough examination of the patient is crucial. Labs, imaging studies, and diagnostic procedures may all be utilized to arrive at the cause of the delirium. The treatment of delirium is to treat the underlying cause. Simple. NOT.
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