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Morning Report !! Friday the 13 th …. AAAaaah !!!. Speaks English !! . CASE.

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morning report friday the 13 th aaaaaah
Morning Report !!

Friday the 13th …. AAAaaah !!!

slide2
Speaks English !!

CASE

65 Years old Chinese woman presented to the ED for severe Abdominal pain !!  Abdominal pain : Colicky intermittent severe, estimated 8/10 started progressively over 4 hours PTA diffuse  Nausea  Vomiting  Fever  Diarrhea  Chest pain

Ask me questions !

slide3
CASE

65 Years old Chinese woman presented to the ED for severe Abdominal pain !!PMH: Medications: HTN Aspirin DM Lisinopril PVD MetforminSH:Somking 2 PPD “since I was born” ETOH Occasionally (which turned out to be every other day !!!)Sexual Activity Active, no protection, multiple partners (“Why are you asking ? “)

Ironically, she watches her diet and exercise !!!

slide4
CASE

65 Years old Chinese woman presented to the ED for severe Abdominal pain !!Physical Exam: Vitals BP: 164/85 HR: 89 RR: Cooper 20 PO2: 96% Abdominal exam:Bowel sounds present and symmetric Soft Abdomen Mildly tender to palpation Mildly Distended No Guarding No Rebound Tenderness Negative Murphy / Negative McBurney’s

Otherwise Unremarkable…

Ask me details… if needed !

slide5
CASE

65 Years old Chinese woman presented to the ED for severe Abdominal pain !!Labs: CBC LFTs Normal WBC 14.000 Amylase Normal Hb 15.1 Lipase Normal Platelets 365.000 INR Normal Chem7 Na 138 Cl 98 BUN 16 K 5.4 Co2 20 Creat 1.2 Glucose 89

Reflex Cooper ED Lactate: 0.9

slide6
CASE

65 Years old Chinese woman presented to the ED for severe Abdominal pain !!Imagery: Abdominal CT Dilated and Thickened loops of small bowel Mild AscitesSubobstructionECG T wave Inversions in Lateral leads

What do you wana do next ?

slide7
CASE

65 Years old Chinese woman presented to the ED for severe Abdominal pain !!In ED: GI consult Surgery Consult => No surgical issues Cardiology Consult => No cardiac issues(Enzymes were pending) Patient was transferred to the DUMPING ZONE => Medicine ! 

Fortunately for the patient…

Differential Diagnosis ?

slide8
CASE

65 Years old Chinese woman presented to the ED for severe Abdominal pain !!On Medicine floor: The following day… Pain is improved No more nausea/vomiting VS , Physical exam and Labs unchangedBUT… New Lower lips edema… huge… not present on admission… Associated tongue edema… No Urticaria or rash No Itching

What the… diagnosis… is going on ?

slide9
CASE

65 Years old Chinese woman presented to the ED for severe Abdominal pain !!Final Diagnosis: ANGIOEDEMA secondary to Ace Inh !!C4 level and C1 inhibitor were normalLisinopril was stopped… switched to Diovan.Patient clinically improved and was d/c

GAME OVER !

angioedema associated with ace inhibitors
Angioedema associated with Ace Inhibitors

2 types of Angioedema: 1. Mast cell-mediated Allergic Reactions (IgE-mediated) Direct mast cell release (Opiates, Contrast…) Aspirin and NSAIDs Chronic Urticaria 2. Bradykinin-mediated Ace Inhibitors (ACE degrades Bradykinin…) ARB ( small chance…) Hereditary and acquired angioedema (Young age…) Estrogen (Weird ! )

ARB ? … The patient will be back soon !! 

angioedema associated with ace inhibitors11
Angioedema associated with Ace Inhibitors

Anatomic Sites: Larynx Skin and Mucous membranes Bowel wallDiagnosis: Clinically (HISTORY +++)Physical Exam: Look for signs of AllergiesLabs: CBC , Chem7 , LFTs , C4 , C3

Labs are normal in majority of cases !

angioedema associated with ace inhibitors12
Angioedema associated with Ace Inhibitors

Differential Diagnosis of CutaneousAngioedema: Contact Dermatitis Cellulitis and Erysipelas Facial Lymphedema Autoimmune conditions Eyelid Edema Parasitic Infections Hypothyroidism Hyperthyroidism SVC syndromeCheilitisgranulomatosa and Mekersson-Rosenthal syndrome Idiopathic edema

What’s Mekersson-Rosenthal syndrome ?

angioedema
Angioedema

TREATMENTAngioedema in or near the airway Airway managementAngioedema in anaphylaxis IM epi O2 IVF Acute allergic Angioedema H1 & H2 blockers, Steroids C1-Inh Deficiency (Hereditary Angio) Purified C1 inh Concentrate FFP, Bradykinin B2recep inh Ace inh & ARB induced Angioedema Discontinuation of drug

Antihistamines and glucocorticoids will likely be ineffective if the angioedema is bradykinin-mediated !!

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