{"id":1976,"date":"2017-11-09T12:08:02","date_gmt":"2017-11-09T17:08:02","guid":{"rendered":"https:\/\/www.roshreview.com\/?p=1976"},"modified":"2017-11-09T12:08:02","modified_gmt":"2017-11-09T17:08:02","slug":"ep-35-shigellosis-ischemic-colitis-suicide-esophageal-foreign-bodies-toxic-megacolon-myasthenia-gravis","status":"publish","type":"post","link":"https:\/\/www.roshreview.com\/blog\/ep-35-shigellosis-ischemic-colitis-suicide-esophageal-foreign-bodies-toxic-megacolon-myasthenia-gravis\/","title":{"rendered":"Podcast Ep 35: Shigellosis, Ischemic Colitis, Suicide, &amp; More"},"content":{"rendered":"\n<figure class=\"wp-block-audio\"><audio controls src=\"https:\/\/media.blubrry.com\/thereveal\/s\/media.blubrry.com\/roshcast\/s\/content.blubrry.com\/roshcast\/Ep_35_Roshcast_Emergency_Board_Review.mp3\"><\/audio><\/figure>\n\n\n\n<blockquote class=\"wp-block-quote is-layout-flow wp-block-quote-is-layout-flow\"><p>Reach for it. Push yourself as far as you can.<\/p><cite>-Christa McAuliffe<\/cite><\/blockquote>\n\n\n\n<h6 class=\"wp-block-heading\">Welcome back to Roshcast Episode 35!&nbsp;It was great chatting with a bunch of listeners at ACEP last week. We received a lot of excellent feedback. <\/h6>\n\n\n\n<hr class=\"wp-block-separator\" \/>\n\n\n\n<p class=\"wp-block-paragraph\">This week, we&#8217;ll be doing a couple of diarrhea questions to link up with the last <a rel=\"noreferrer noopener\" aria-label=\" (opens in a new tab)\" href=\"emclerkship.com\" target=\"_blank\">EM Clerkship<\/a> episode, in addition to a few randomly generated questions. Don&#8217;t forget that we are still running a trauma ring tone contest. Listen closely for a ring tone in an upcoming episode&nbsp;<span>and e-mail us at <a href=\"mailto:roshcast@roshreview.com\">roshcast@roshreview.com<\/a> or tweet to us at <a href=\"twitter.com\/roshcast\">@Roshcast<\/a> the exact time of the ring tone to win a prize, which will certainly come in handy as we get closer to the in-training exam. Let&#8217;s get started with a review from <a rel=\"noreferrer noopener\" aria-label=\"recent (opens in a new tab)\" href=\"https:\/\/www.roshreview.com\/blog\/rapid-review\/rapid-review-pterygium\/\" target=\"_blank\">recent<\/a> <a rel=\"noreferrer noopener\" aria-label=\"posts (opens in a new tab)\" href=\"https:\/\/www.roshreview.com\/blog\/rapid-review\/rapid-review-retinal-detachment\/\" target=\"_blank\">posts<\/a> on the <a rel=\"noreferrer noopener\" aria-label=\" (opens in a new tab)\" href=\"roshreview.com\/blog\" target=\"_blank\">Rosh Review Blog<\/a>.<\/span><\/p>\n\n\n\n<div class=\"wp-block-image\"><figure class=\"aligncenter\"><img loading=\"lazy\" decoding=\"async\" width=\"178\" height=\"66\" src=\"https:\/\/www.roshreview.com\/wp-content\/uploads\/RapidReview_50.png\" alt=\"\" class=\"wp-image-1608\" \/><\/figure><\/div>\n\n\n\n<ul class=\"wp-block-list\"><li><strong>Pterygium<\/strong> is a <strong>fleshy<\/strong>&nbsp;<strong>triangular growth<\/strong> from the <strong>medial canthus<\/strong> <strong>towards the<\/strong> <strong>cornea<\/strong>. They are usually <strong>slow growing<\/strong> and seen in those with <strong>excessive sunlight<\/strong> <strong>exposure<\/strong>. They are <strong>managed<\/strong> with <strong>artificial tears<\/strong>.<\/li><li><strong>Pterygium<\/strong> typically <strong>doesn&#8217;t require surgery<\/strong> but <strong>may need excision<\/strong> if it is causing a <strong>visual disturbance<\/strong>. Make sure the patient is already following with an <strong>ophthalmologist<\/strong> or give them a referral if needed.<\/li><li><strong>Retinal detachments<\/strong> present with <strong>painless loss of vision<\/strong>, <strong>floaters<\/strong>, <strong>flashing lights,<\/strong> or as a <strong>curtain lowering sensation<\/strong>. On physical, you may see a <strong>hazy gray<\/strong> <strong>retina<\/strong> with <strong>whitish folds<\/strong>.<\/li><li>The <strong>most common location<\/strong> for an <strong>ectopic pregnancy<\/strong> is the <strong>fallopian tube<\/strong>.<\/li><\/ul>\n\n\n\n<p class=\"wp-block-paragraph\"><strong>Now onto this week\u2019s podcast<\/strong><\/p>\n\n\n\n<hr class=\"wp-block-separator\" \/>\n\n\n\n<p class=\"wp-block-paragraph\"><strong>Question<\/strong><strong> 1<\/strong><\/p>\n\n\n\n<p class=\"wp-block-paragraph\">A 2-year-old girl presents after a witnessed seizure. The parents state that she has not been to daycare in two days, as she has bloody diarrhea and a fever. Her vitals on presentation are T 103.1\u00b0F, HR 167\/min, BP 73\/43 mm Hg, RR 48\/min, and oxygen saturation 96%. Currently, the patient has a normal neurologic exam and minimal abdominal tenderness. There are no rashes. Labs show a WBC of 19,000, and urinalysis reveals an elevated specific gravity. Which of the following is the most appropriate next step in management?<\/p>\n\n\n\n<p class=\"wp-block-paragraph\"><span>A. Acetaminophen for fever and follow-up with primary care provider<\/span><\/p>\n\n\n\n<p class=\"wp-block-paragraph\"><span>B. Blood and stool cultures, IV antibiotics, and admission<\/span><\/p>\n\n\n\n<p class=\"wp-block-paragraph\"><span>C. Neurology consultation and admission <\/span><\/p>\n\n\n\n<p class=\"wp-block-paragraph\"><span>D. Oral antibiotics and follow-up with primary care provider<\/span><\/p>\n\n\n\n<p class=\"wp-block-paragraph\"><a href=\"https:\/\/www.roshreview.com\/wp-content\/uploads\/Ep35-Empiric-Therapy-Suspected-Shigellosis.jpg\">Teaching Image<\/a><\/p>\n\n\n\n<hr class=\"wp-block-separator\" \/>\n\n\n\n<p class=\"wp-block-paragraph\"><strong>Question<\/strong><strong> 2<\/strong><\/p>\n\n\n\n<p class=\"wp-block-paragraph\">An 82-year-old nursing-home resident is sent to the emergency department with lower abdominal pain and bloody diarrhea. He has a history of vascular dementia, hypertension, and hyperlipidemia. On examination he is afebrile, and a nasogastric aspirate is negative for evidence of bleeding. Which of the following is the most likely cause of this patient\u2019s bleeding?<\/p>\n\n\n\n<p class=\"wp-block-paragraph\"><span>A. Angiodysplasia<\/span><\/p>\n\n\n\n<p class=\"wp-block-paragraph\"><span>B. Diverticular bleeding <\/span><\/p>\n\n\n\n<p class=\"wp-block-paragraph\"><span>C. Ischemic colitis <\/span><\/p>\n\n\n\n<p class=\"wp-block-paragraph\"><span>D. Peptic ulcer disease<\/span><\/p>\n\n\n\n<p class=\"wp-block-paragraph\"><a href=\"https:\/\/www.roshreview.com\/wp-content\/uploads\/Ep35-Ischemic-Colitis.jpg\">Teaching Image<\/a><\/p>\n\n\n\n<hr class=\"wp-block-separator\" \/>\n\n\n\n<p class=\"wp-block-paragraph\"><strong>Question<\/strong><strong> 3<\/strong><\/p>\n\n\n\n<p class=\"wp-block-paragraph\">Which of the following is considered a risk factor for suicide?<\/p>\n\n\n\n<p class=\"wp-block-paragraph\"><span>A. Female<\/span> sex<\/p>\n\n\n\n<p class=\"wp-block-paragraph\"><span>B. First-trimester pregnancy <\/span><\/p>\n\n\n\n<p class=\"wp-block-paragraph\"><span>C. First year of marriage <\/span><\/p>\n\n\n\n<p class=\"wp-block-paragraph\"><span>D. Recent incarceration<\/span><\/p>\n\n\n\n<hr class=\"wp-block-separator\" \/>\n\n\n\n<p class=\"wp-block-paragraph\"><strong>Question<\/strong><strong> 4<\/strong><\/p>\n\n\n\n<p class=\"wp-block-paragraph\">Which of the following scenarios is most appropriate to safely discharge home a 2-year-old who has swallowed a coin?<\/p>\n\n\n\n<p class=\"wp-block-paragraph\"><span>A. The child is not drooling<\/span><\/p>\n\n\n\n<p class=\"wp-block-paragraph\"><span>B. The child is tolerating oral sips and the parents are reliable<\/span><\/p>\n\n\n\n<p class=\"wp-block-paragraph\"><span>C. The coin is in the stomach<\/span><\/p>\n\n\n\n<p class=\"wp-block-paragraph\"><span>D. The coin is oriented in the sagittal plane at the level of the clavicular heads<\/span><\/p>\n\n\n\n<p class=\"wp-block-paragraph\"><a href=\"https:\/\/www.roshreview.com\/wp-content\/uploads\/Ep35-Coin-in-Trachea.jpg\">Teaching Image<\/a><\/p>\n\n\n\n<hr class=\"wp-block-separator\" \/>\n\n\n\n<p class=\"wp-block-paragraph\"><strong>Question<\/strong><strong> 5<\/strong><\/p>\n\n\n\n<p class=\"wp-block-paragraph\">A 35-year-old-man with a history of occasional bloody diarrhea and abdominal pain presents with acute onset severe abdominal pain. Vital signs are significant for a temperature of 39\u00b0C, heart rate 140\/min, and blood pressure 82\/55 mm Hg. On physical exam, his abdomen is distended and tympanic. Which of the following diagnostic studies is indicated first at this time?<\/p>\n\n\n\n<p class=\"wp-block-paragraph\"><span>A. Abdominal radiograph<\/span><\/p>\n\n\n\n<p class=\"wp-block-paragraph\"><span>B. Barium enema<\/span><\/p>\n\n\n\n<p class=\"wp-block-paragraph\"><span>C. CT scan of the abdomen pelvis with IV contrast<\/span><\/p>\n\n\n\n<p class=\"wp-block-paragraph\"><span>D. Sigmoidoscopy<\/span><\/p>\n\n\n\n<p class=\"wp-block-paragraph\"><a href=\"https:\/\/www.roshreview.com\/wp-content\/uploads\/Ep35-Toxic-Megacolon.png\">Teaching Image<\/a><\/p>\n\n\n\n<hr class=\"wp-block-separator\" \/>\n\n\n\n<p class=\"wp-block-paragraph\"><span><strong>Question 6<\/strong><\/span><\/p>\n\n\n\n<p class=\"wp-block-paragraph\">A 45-year-old woman complains of two days of fluctuating diplopia and dysphagia. Her exam reveals a left cranial nerve VI palsy, ptosis, and proximal muscle weakness in her extremities. What is the pathophysiology of her disease?<\/p>\n\n\n\n<p class=\"wp-block-paragraph\"><span>A. Antibodies to the acetylcholine receptor at the neuromuscular junction<\/span><\/p>\n\n\n\n<p class=\"wp-block-paragraph\"><span>B. Inhibition of acetylcholine release at the synapse<\/span><\/p>\n\n\n\n<p class=\"wp-block-paragraph\"><span>C. Mutation of superoxide dismutase causing cell death<\/span><\/p>\n\n\n\n<p class=\"wp-block-paragraph\"><span>D. Reduced number of dopamine receptors in the midbrain<\/span><\/p>\n\n\n\n<p class=\"wp-block-paragraph\"><a href=\"https:\/\/www.roshreview.com\/wp-content\/uploads\/Ep35-Myasthenia-Gravis.jpg\">Teaching Image<\/a><\/p>\n\n\n\n<hr class=\"wp-block-separator\" \/>\n\n\n\n<div class=\"wp-block-image\"><figure class=\"aligncenter\"><img loading=\"lazy\" decoding=\"async\" width=\"178\" height=\"66\" src=\"https:\/\/www.roshreview.com\/wp-content\/uploads\/RapidReview_50.png\" alt=\"\" class=\"wp-image-1608\" \/><\/figure><\/div>\n\n\n\n<ul class=\"wp-block-list\"><li>Patients with <strong><em>Shigella<\/em><\/strong> often present with <strong>fever<\/strong>, <strong>abdominal cramps<\/strong>, and <strong>diarrhea with mucus or blood<\/strong>. &nbsp;<strong>Infants<\/strong> with <em>Shigella<\/em> are also at <strong>risk<\/strong> for <strong>seizures<\/strong>.<\/li><li><strong>Shigellosis<\/strong> should be treated <strong>supportively<\/strong>. &nbsp;Patients who are <strong>immunocompromised<\/strong>, have <strong>bacteremia<\/strong>,&nbsp;<strong>attend daycare<\/strong>, or live in a <strong>nursing home<\/strong> require treatment with <strong>antibiotics<\/strong>. <strong>Children<\/strong> should be treated with <strong>ceftriaxone<\/strong>, 50 mg\/kg in a once-daily dose up to a max of 1.5g for 5 days.<\/li><li><strong>Ischemic colitis<\/strong> is caused by <strong>inadequate blood flow<\/strong> through the <strong>mesenteric vessels<\/strong>. It often affects the <strong>watershed regions<\/strong>.<\/li><li><strong>Ischemic colitis<\/strong> can be treated <strong>supportively<\/strong> with <strong>bowel rest<\/strong> and<strong> IV fluids<\/strong> unless there are signs of peritonitis or infarction.<\/li><li><strong>Risk factors<\/strong> for <strong>suicide<\/strong> include <strong>male<\/strong> sex, <strong>age<\/strong>, history of <strong>mental illness<\/strong>,&nbsp;<strong>personal or family history of a suicide attempt<\/strong>, <strong>poor financial situation<\/strong>, <strong>unemployment<\/strong>, <strong>poor physical health<\/strong>, being <strong>Caucasian<\/strong>, and <strong>isolation<\/strong>.<\/li><li>With respect to <strong>suicide<\/strong>,&nbsp;<strong>marriage<\/strong>, and <strong>first-trimester pregnancy<\/strong> are both <strong>protective<\/strong>.<\/li><li><strong>Swallowed foreign bodies<\/strong> that do<strong> not pass through the esophagus<\/strong>, which <strong>occurs 2%<\/strong> of the time, have a <strong>risk for esophageal perforation or erosion<\/strong>.<\/li><li><strong>Emergent endoscopy<\/strong> is indicated if the <strong>swallowed foreign body<\/strong> is a <strong>battery<\/strong>, is <strong>sharp<\/strong>, or if there are <strong>signs of obstruction<\/strong>.<\/li><li><strong>Coins<\/strong> in the <strong>sagittal plane<\/strong> on<strong> X-ray<\/strong> are more likely to be in the <strong>trachea<\/strong> than in the esophagus.<\/li><li><strong>Toxic megacolon<\/strong> presents with <strong>colonic dilatation<\/strong> and <strong>systemic toxicity<\/strong>. &nbsp;Patients usually present after having <strong>symptoms of colitis for several days<\/strong>.<\/li><li>If there is concern for <strong>toxic megacolon<\/strong>, an <strong>abdominal X-ray<\/strong> should be the <strong>first imaging study<\/strong> to look for <strong>colonic dilatation<\/strong>, to a <strong>diameter greater than 6 cm<\/strong>.<\/li><li><strong>Toxic megacolon<\/strong> can be <strong>precipitated by IBD<\/strong>, <strong>pseudomembranous colitis<\/strong>, <strong>CMV colitis<\/strong>, and <strong>bacterial colitis<\/strong>.<\/li><li><strong>Myasthenia gravis<\/strong> is caused by <strong>antibodies<\/strong> to the <strong>acetylcholine receptor<\/strong> at the neuromuscular junction.<\/li><li><strong>Ptosis<\/strong> and <strong>diplopia<\/strong> are the <strong>most common first symptoms<\/strong> of a <strong>myasthenic crisis<\/strong>. &nbsp;This is <strong>followed by proximal muscle weakness<\/strong>, <strong>dysphagia<\/strong>, and <strong>dyspnea<\/strong>. &nbsp;<strong>Respiratory failure<\/strong> can be seen in the <strong>later stages<\/strong>.<\/li><li><strong>Myasthenia gravis<\/strong> can be diagnosed by the <strong>edrophonium<\/strong> or <strong>Tensilon test<\/strong>.<\/li><li><strong>Myasthenia gravis<\/strong> can be treated with <strong>plasma exchange<\/strong> and <strong>IVIG<\/strong>. &nbsp;<strong>Ice<\/strong> <strong>decreases symptoms<\/strong> but is not a permanent solution.<\/li><\/ul>\n\n\n\n<p class=\"wp-block-paragraph\">That wraps up Episode 35.&nbsp;Don\u2019t forget to follow us on Twitter <a href=\"https:\/\/twitter.com\/roshcast?lang=en\">@Roshcast<\/a> and <a href=\"https:\/\/twitter.com\/roshreview?lang=en\">@RoshReview<\/a>. We can also be reached by email at <a href=\"mailto:roshcast@roshreview.com\">roshcast@roshreview.com<\/a> and are open to any feedback, corrections, or suggestions. You can help us pick questions by identifying ones you would like us to review. To do so, write \u201cRoshcast\u201d in the submit feedback box as you go through the question bank. And finally, if you have a minute, make sure to rate us and leave comments on <a href=\"https:\/\/itunes.apple.com\/us\/podcast\/roshcast\/id1156487141?mt=2\" target=\"_blank\" rel=\"noreferrer noopener\" aria-label=\" (opens in a new tab)\">iTunes<\/a> to help spread the word about Roshcast.<\/p>\n\n\n\n<p class=\"wp-block-paragraph\">Until next time,<br>Jeff and Nachi<\/p>\n","protected":false},"excerpt":{"rendered":"<p>Reach for it. Push yourself as far as you can. -Christa McAuliffe Welcome back to Roshcast Episode 35!&nbsp;It was great chatting with a bunch of listeners at ACEP last week. We received a lot of excellent feedback. This week, we&#8217;ll be doing a couple of diarrhea questions to link up with the last EM Clerkship <a href=\"https:\/\/www.roshreview.com\/blog\/ep-35-shigellosis-ischemic-colitis-suicide-esophageal-foreign-bodies-toxic-megacolon-myasthenia-gravis\/\">read more&#8230;<\/a><\/p>\n","protected":false},"author":11,"featured_media":851,"comment_status":"open","ping_status":"open","sticky":false,"template":"","format":"standard","meta":{"inline_featured_image":false,"footnotes":""},"categories":[2025,1999],"tags":[2038,2043,2162,2193,2215,2216,2224,2288,2342,2399,2409,2415,2444,2481,2506,2558,2561,2598,2611,2619,2621,2638,2652,2679,2698,2741,2852,2854,2861,2872,2903,2906,2912,3003,3023,3026,3080,3113,3137,3151,3161,3265,3319,3393,3400,3407,3458,3459,3518,3530,3531,3598,3603,3607,3631,3668,3672,3703,3760,3773],"coauthors":[],"class_list":["post-1976","post","type-post","status-publish","format-standard","has-post-thumbnail","hentry","category-emergency-medicine","category-podcast","tag-abdominal-cramping","tag-abdominal-x-ray","tag-antibiotic","tag-artificial-tears","tag-bacteremia","tag-bacterial-colitis","tag-battery","tag-bowel-rest","tag-ceftriaxone","tag-cmv-colitis","tag-coin","tag-colonic-dilitation","tag-cornea","tag-day-care","tag-diarrhea","tag-ectopic-pregnancy","tag-edrophonium","tag-endoscopy","tag-erosion","tag-esophageal-perforation","tag-esophagus","tag-fallopian-tube","tag-fever","tag-foreign-body","tag-gastroenterology","tag-gynecology","tag-ibd","tag-ice","tag-immunocompromised","tag-infants","tag-ischemic-colitis","tag-isolation","tag-ivig","tag-marriage","tag-mental-illness","tag-mesenteric-vessels","tag-myasthenia-gravis","tag-neurology","tag-nursing-home","tag-obstruction","tag-ophthalmology","tag-pediatrics","tag-plasma-exchange","tag-pseudomembranous-colitis","tag-psychiatry","tag-pterygium","tag-retina","tag-retinal-detachment","tag-seizure","tag-shigella","tag-shigellosis","tag-suicide","tag-sunlight","tag-surgery","tag-tensilon-test","tag-toxic-megacolon","tag-trachea","tag-unemployment","tag-visual-disturbance","tag-watershed"],"yoast_head":"<!-- This site is optimized with the Yoast SEO Premium plugin v28.2 (Yoast SEO v28.2) - https:\/\/yoast.com\/product\/yoast-seo-premium-wordpress\/ -->\n<title>Podcast Ep 35: Shigellosis, Ischemic Colitis, Suicide, &amp; More - RoshReview.com<\/title>\n<meta name=\"description\" content=\"Welcome to RoshCast (Ep. 35), the first question and answer style emergency medicine podcast. Listen and learn more.\" \/>\n<meta name=\"robots\" content=\"index, follow, max-snippet:-1, max-image-preview:large, max-video-preview:-1\" \/>\n<link rel=\"canonical\" href=\"https:\/\/www.roshreview.com\/blog\/ep-35-shigellosis-ischemic-colitis-suicide-esophageal-foreign-bodies-toxic-megacolon-myasthenia-gravis\/\" \/>\n<meta property=\"og:locale\" content=\"en_US\" \/>\n<meta property=\"og:type\" content=\"article\" \/>\n<meta property=\"og:title\" content=\"Podcast Ep 35: Shigellosis, Ischemic Colitis, Suicide, &amp; More\" \/>\n<meta property=\"og:description\" content=\"Welcome to RoshCast (Ep. 35), the first question and answer style emergency medicine podcast. 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