Podcast Ep 10: Gout, Glaucoma, Bronchitis, Spider Bites, & More

Fear is the great extinguisher of dreams… Conversely, it can be your best mentor and source of motivation. –Paula Amato

Welcome back to episode 10! This week we review some key ophthalmologic findings with excellent teaching images for you to see. We also hit the lung, the joints, the extremities, and even spend time on scorpions, snakes, and spiders. 

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We begin each episode with a rapid review of the previous week’s highlights then dive into the Q&A and wrap up with another rapid review of the covered content. Let’s get started.

• The most common cause of pneumonia in an alcoholic is Streptococcus pneumoniae.
• Radial nerve palsy is a peripheral nerve lesion caused by compression of the radial nerve in the axilla. The most common findings are wrist drop and hand numbness over the first to third digits. It is managed conservatively with a wrist splint.
• IV drug abusers are at risk for tricuspid endocarditis. The most commonly implicated organism is staph aureus.
• Colchicine overdoses cause severe GI distress, bone marrow suppression, rhabdomyolysis, renal failure, metabolic acidosis, and even ARDS.
• The mainstay of treatment for herpes zoster is pain control. Acyclovir may be prescribed within the first 72 hours of onset of the lesions.

Now onto this week’s podcast

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Question 1

A 43-year-old man is currently undergoing palliative radiation therapy for pancreatic cancer. He presents to the emergency department with a 4-day history of gradually worsening left lower extremity pain. Pain is localized to the calf and made worse with ambulation. Exam shows mild edema of the left calf without erythema or warmth. Which of the following is the most likely diagnosis?

A. Cellulitis

B. Deep venous thrombosis

C. Peripheral artery disease

D. Superficial thrombophlebitis

Teaching image

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Question 2 

A 25-year-old man presents to the ED with right eye pain, tearing, and photophobia. After instilling fluorescein into the affected eye, you see the above on slit lamp exam. Which of the following is the most likely prognosis of this condition?

A. Complete resolution within 24–72 hours

B. Corneal erosion and perforation

C. Diminished unilateral visual acuity

D. Recurrent lesions with viral reactivation

Teaching image

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Question 3

In which setting is allopurinol contraindicated for the treatment of gout?

A. Acute attack of gout

B. Alcoholic patient

C. Hyperuricemia greater than 8.0

D. In combination with colchicine

Teaching image

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Question 4 

A 52-year-old man presents with a red right eye that is associated with severe pain and blurred vision. On exam, there is some cloudiness to the cornea. Pupils are 5 mm OD and 3 mm OS. Which of the following is the most likely diagnosis?

A. Acute glaucoma

B. Conjunctivitis

C. Iritis

D. Keratitis

Teaching image 1

Teaching image 2

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Question 5

Heightened sensitivity to touch in the area of the sting, along with local numbness and weakness, is associated with which of the following animals?

A. Black widow spider

B. Brown recluse spider

C. Pit viper

D. Scorpion

Teaching image

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Question 6

What is the most common symptom seen in acute bronchitis?

A. Chest pain

B. Cough

C. Fever

D. Sputum

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• DVTs typically present with non-specific symptoms including unilateral limb swelling, pain, redness, warm, or even distended collateral veins.
• Predisposing risk factors for DVT include malignancy, immobilization, recent surgery, obesity, smoking, oral contraceptives, recreational drugs, and hypercoagulable states.
• Corneal abrasions typically resolve within 24-72 hours. They are most commonly caused by ocular trauma or an ocular foreign body. Corneal abrasions are treated with a topical antibiotic such as erythromycin or ciprofloxacin. Tetanus vaccination should be given to patients who are not up to date.
• Allopurinol is contraindicated in an acute presentation of gout. The first-line therapy is NSAIDs.
• Negatively birefringent crystals are seen in gout and positively birefringent crystals are seen in pseudogout. Gout is typically seen in the first metatarsophalangeal joint, whereas pseudogout most commonly affects the larger joints like the knees and ankles.
• Acute glaucoma often classical presents as a red, painful eye with blurry vision and asymmetric pupils.
• Acute angle-closure glaucoma is caused by closure of the anterior chamber. Treatment should begin with topical beta-blockers, carbonic anhydrase inhibitors, steroids, and miotics.
• Scorpion stings produce local redness and edema with a heightened sensitivity to touch in the area of the sting with numbness and weakness of the affected area. Systemic symptoms include fasciculations, disconjugate gaze, temperature reversal, and pancreatitis.
• Black widow spider bites cause a local papule with a halo. Severe systemic symptoms include a peritonitic abdomen, muscle fasciculation’s, and diaphoresis. Black widow spiders have a red hourglass on their abdomen and can be found throughout the entire United States.
• Brown recluse spiders are found in the Midwest. They cause a papule that later blisters and may necrose. Systemic symptoms include renal failure, pulmonary edema, and shock.
• Pit viper snakebites cause local swelling and oozing from the wound. Severe envenomations can lead to a DIC-like coagulopathy and hemorrhagic bullae.
• The most common symptom of acute bronchitis is a cough. The most common cause is a viral illness that should be treated with supportive care.

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Need to beef up on your colchicine toxicity knowledge? Check out last week’s episode

Don’t forget that the high-yield questions, explanations, and images can be found in the Rosh Review Emergency Medicine Qbank. We will be taking some time off over the holidays, but be ready to go with us in 2017, since the in-service exam will only be a few weeks away.

Happy Holidays from the Roshcast team as well as everybody from Rosh Review!

Jeff, Nachi, and Adam