How Does an ER Doctor Spend a Workday?

By Shiromi Nassreen, eHow Contributor

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Job Description - Emergency Room Physician bout ER Doctors

1. No S ch !hing as a !ypical Day

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!any emergency room "octors woul" say there#s ne$er an a$erage wor%"ay at an ER& 'or%"ays will "epen" on the specialty o( the emergency room physician, how busy the emergency room is an" the time o( "ay& Since most emergency rooms are open )* hours a "ay, + "ays a wee%, ER "octors must wor% night shi(ts as well as "ay shi(ts& ,he typical shi(t length (or an ER "octor is about -. to -) hours, although a resi"ent ER "octor can sometimes wor% )* hours straight& ,hese )*-hour shi(ts (eature much o( the same type o( care as the "ay an" night shi(ts, e/cept that the care is continuously gi$en by the same "octor& 0t use" to be that a(ter wor%ing )* hours straight, the ER "octor woul" then go straight into his ne/t regular -)-hour shi(t& Howe$er, regulations in )..1 put a cap on "octors wor%ing more than a 1.-hour shi(t& Recommen"ations (rom the 0nstitute o( !e"icine suggest limiting shi(ts to no more than -2 hours&

Day Shi"t
o

,he "octor will arri$e in the morning to ta%e o$er (rom those wor%ing the night shi(t& During the han"o$er, the "octor will get caught up, (in" out i( there ha$e been any changes in the con"ition o( her patients, or i( there are any acute patient nee"s she nee"s to be aware o(& ,hen the "octor has to get rea"y (or hospital roun"s& 3nce roun"s are complete", the "octor will spen" the rest o( the morning co$ering the war" an" ta%ing care o( patients& (ter lunch, the "octor may spen" the rest o( the "ay managing her patients, getting lab results, "ischarging patients, ta%ing me"ical histories, rea"ing 4-rays an" many other tas%s that may be re5uire" "uring the "ay&

Nigh Shi"t
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"octor can be assigne" a night shi(t or can e/clusi$ely wor% night shi(ts& ,he night shi(t "octor will come in aroun" -. p&m& an" won#t lea$e until aroun" 6 the (ollowing morning& 7i%e the morning shi(t, there will be a han"o$er with sign-out roun"s, which entail the "octor going to e$ery patient in the ER an" learning those situations so that the night shi(t "octor is able to continue caring (or the patient as though he ha" been caring (or the patient all along& !ost night shi(t "octors are generally %ept busy, an" rarely ha$e time to e$en ha$e a meal "uring the shi(t& ,he "octor will see a $ariety o( patients throughout the night, ranging (rom into/icate" patients to hea" trauma cases to patients with a (e$er or rashes&

Sponsore" 7in%s -& eHow )& Careers 1& !e"ical Pro(essions Careers *& Physician 8& ER Physician Duties

ER Physician D ties
By 9J Hen"erson, eHow Contributor

Print this article ER physicians pro$i"e emergency patient care&

n emergency room :ER; physician is a me"ical "octor who pro$i"es imme"iate care to patients& Employe" in a hospital emergency room or trauma center, this in"i$i"ual treats a wi"e range o( ailments, inclu"ing poisoning, heart attac%s an" motor $ehicle acci"ents& Employment in this occupation re5uires a me"ical "egree as well as state licensing& 0n a""ition, some employers re5uire up to (our years o( emergency e/perience& 0n ).-., compensation sur$ey pro$i"er Salary&com in"icate" that the a$erage salary pai" to these pro(essionals in the <nite" States is =)11,-1>&

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ER Doctor Job Duties

ER Physician Job Description

1. E#a$ination
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'hen a patient is a"mitte" into a (acility (or emergency treatment, an ER physician must (irst per(orm a thorough e/amination& 0n instances when the patient is conscious, she as%s 5uestions regar"ing the purpose o( the $isit& ?or e/ample, i( the patient complains o( chest pains, the ER physician may as% how long the pain has persiste" an" what (oo"s ha" most recently been consume"& 'hen a patient is unable to communicate, she 5uestions any witnesses or in"i$i"uals accompanying the patient, such as a parent or guar"ian& ,he ER physician e/amines any ob$ious woun"s& 'hen in@uries are se$ere, such as those resulting (rom a gunshot, she imme"iately treats it& She also ta%es the patientAs $ital signs, such as his bloo" pressure an" pulse& ?ollowing a thorough physical e/amination, she or"ers tests such as bloo" an" urine samples& Base" upon these results, she "iagnoses the patientAs ailment&

%. Proced res
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0n situations where the patientAs health or li(e relies on imme"iate action, an ER physician per(orms the appropriate proce"ure& ?or e/ample, he may per(orm a tracheotomy, cutting a hole in a bloc%e" trachea, allowing a patient to breathe& He may also per(orm other minor, non-li(e-threatening proce"ures, such as ban"aging woun"s an" a"ministering intra$enous :0B; therapy& 3nce the patient has been stabiliCe", the ER physician "etermines the best course o( treatment& 0( in@uries are se$ere, the patient is a"mitte" into the hospital& 0n instances o( minor ailments, the patient is release"&

Ad$inistration
o

n ER "octor may be re5uire" to per(orm $arious a"ministrati$e tas%s& He must up"ate each patient#s chart with her health status& ,his inclu"es "ocumenting respecti$e me"ical histories, pro(iles an" pro$i"ing a "etaile" summary o( the "iagnosis an" prescribe" treatment& She also writes prescriptions (or any re5uire" me"ications, in"icating the proper "osage&

E!, an" Parame"ic D Emergency Room Career 3ptions an" E"ucation Re5uirements

E$ergency Roo$ &areer Options and Ed cation Re' ire$ents

Pro$i"ing patients with "iagnosis an" treatment, emergency rooms are primary care (acilities that han"le a wi"e range o( urgent con"itions& 0n ERs, emergency me"ical technicians bring patients into the care o( "octors an" nurses& Careers in emergency me"icine re5uire $arious amounts o( e"ucation& Health care pro$i"ers in emergency rooms wor% un"er time constrictions an" per(orm triage, the prioritiCation o( patients an" me"ical supplies& Biew )) Popular Schools

E$ergency Roo$ Physicians

0n emergency rooms :ERs;, "octors per(orm me"ical tests on patients in or"er to "iagnose con"itions such as poisoning or heart attac%& Emergency room physicians also write prescriptions an" per(orm complicate" me"ical proce"ures, such as suturing "eep cuts& 3ne o( the most important (unctions o( emergency room "octors is triageE e$aluating patients to "etermine who nee"s help most urgently& ,his allows them to ma/imiCe the e((iciency o( treatment an" me"ical supplies&

&areer (n"or$ation
,here are relati$ely (ew ER "octors& ccor"ing to the merican !e"ical ssociation :www.ama.org;, nearly (our percent o( "octors are emergency me"icine physicians& Employment opportunities (or physicians may e/pan" signi(icantly in the near (uture& ,he <&S& Bureau o( 7abor Statistics pre"icts that the number o( "octors wor%ing in the <&S& will grow ))F between )..6 an" ).-6&

Ed cation Re' ire$ents

Someone intereste" in becoming an emergency room physician must complete substantial amounts o( (ormal e"ucation& Stu"ents applying to me"ical school generally earn a bachelor#s "egree in a science (iel", li%e chemistry or biology& Near the en" o( their

un"ergra"uate coursewor%, stu"ents must ta%e the !e"ical College "mission ,est :!C ,; as they apply to me"ical school& !e"ical school applications are strongly competiti$e& ccor"ing to the ssociation o( merican !e"ical Colleges, in )..>, only *1&8F o( me"ical school applicants became me"ical stu"ents& Stu"ents pursuing a Doctor o( !e"icine :!&D&; "egree ta%e intensi$e courses in anatomy, biochemistry an" pharmacology& ?ollowing me"ical school, emergency room-boun" "octors complete an emergency me"icine resi"ency program lasting three or more years&

)icens re and &erti"ication "or E$ergency Roo$ Doctors

(ter (inishing all e"ucation an" resi"ency re5uirements, aspiring "octors are re5uire" to maintain e/tensi$e licensing re5uirements& ll physicians must pass the <nite" States !e"ical 7icensing E/amination :<S!7E;& ,hey commonly maintain licensure with their state#s go$ernment e$ery (ew years by submitting proo( o( continuing e"ucation stu"y they per(orme"& Specialty certi(ication through the merican Boar" o( Emergency !e"icine : BE!; re5uires "octors to complete written an" oral e/aminations& ,hey recei$e either the Emergency !e"icine 0nitial Certi(ication :E!0C; or the Emergency !e"icine Continual Certi(ication :E!CC;&

E$ergency Roo$ N rses

!uch o( the wor% in emergency rooms is actually per(orme" by s%ille" nurses& Emergency room nurses are tas%e" with general patient care in a busy, (ast-pace" scenario& ,hey %eep trac% o( me"ical recor"s an" "istribute me"ication to patients& Nurses also assist "octors in the "iagnosis an" management o( patients "uring triage& ,hey must %now how to care (or patients with se$ere trauma, such as hea" or spinal in@uries, without (urther in@uring them&

&areer (n"or$ation
,ypical salaries (or emergency room nurses across the country range" (rom =2.,... to =++,... in early ).-., reports SalaryExpert.com& ,he nursing wor%(orce is e/pecte" to grow signi(icantly in the ne/t (ew years& ,he B7S says the number o( a$ailable @obs (or registere" nurses will li%ely increase ))F between )..6 an" ).-6&

Ed cation Re' ire$ents

People who want to try emergency room nursing are re5uire" to earn either an associate#s "egree or a bachelor#s "egree& ,he Commission on Collegiate Nursing E"ucation an" the National 7eague (or Nursing ccre"iting Commission are the two agencies which can con(er accre"itation on nursing programs&

E$ergency Roo$ N rse )icens re and &erti"ication

<pon completion o( un"ergra"uate e"ucation, registere" nurses must pass a licensing e/amination a"ministere" by the National Council o( State Boar"s o( Nursing& Nursing licenses can typically be renewe" through continuing e"ucation courses& Specialty certi(ication (or wor% in emergency rooms is a$ailable by passing an e/amination& ,he Certi(ie" Emergency Nurse cre"ential is con(erre" by the Emergency Nurses ssociation :EN ;&

E$ergency *edical !echnicians

Emergency me"ical technicians :E!,s; are responsible (or transporting trauma $ictims an" patients to the emergency room in ambulances& E!,s also attempt to stabiliCe se$erely in@ure" patients i( the nee" arises&

&areer (n"or$ation
,he o$erall employment outloo% (or emergency me"ical technicians is $ery stable& ,he B7S e/pects @ob openings (or E!,s to increase nine percent between )..6 an" ).-6& Emergency me"ical technicians earne" a me"ian hourly wage o( =-*&-. in !ay )..6&

Ed cation Re' ire$ents

woul"-be emergency me"ical technician nee"s to gra"uate (rom high school& Bocational schools an" community colleges are both goo" places to get E!, e"ucation& n emergency me"ical technician can procee" through three le$els o( training programsE E!,-Basic, E!,-0nterme"iate an" E!,-Parame"ic& E!,-Basic training is a necessity (or applicants to parame"ic programs& ll in"i$i"uals intereste" in becoming emergency me"ical technicians must complete a licensing e/am to begin pro(essional practice&

!he e$ergency roo$ in syste$ic rhe $atic diseases

G Slobo"in, Hussein, ! RoCenbaum, an" 0 Rosner uthor in(ormation H rticle notes H Copyright an" 7icense in(ormation H Go toE

A+stract
Complications o( systemic rheumatic "iseases (re5uently ha$e protean mani(estations an" may present a "iagnostic problem& Patients with connecti$e tissue "iseases an" $asculiti"es may ha$e "angerous or li(e threatening con"itions, which must be recognise" an" treate" promptly to pre$ent rapi"ly e$ol$ing morbi"ity an" mortality& 9nowle"ge o( possible emergencies in the conte/t o( a "e(ine" rheumatic "isease may ai" in promoting a high in"e/ o( suspicion an" contribute signi(icantly to the timely "iagnosis o( many potentially "angerous con"itions& ,his re$iew is written (or the emergency room physician an" "iscusses the early recognition o( selecte" emergencies in the conte/t o( a "e(ine" rheumatic "isease& ,eywords- emergency, systemic rheumatic "isease Patients with rheumatic complaints may account (or up to 6F o( all emergency room :ER; $isits&- ,hose patients with connecti$e tissue "iseases an" $asculiti"es may present with "angerous or li(e threatening con"itions, which must be recognise" an" treate" promptly to pre$ent rapi"ly e$ol$ing morbi"ity an" mortality& ,hese emergencies may present protean mani(estations, at times mimic%ing other con"itions or mislea"ing with an illusory innocent clinical picture& misse" presentation o( some o( these threatening con"itions may erroneously lea" ER personnel to "irect the patient bac% to their rheumatologist (or (urther outpatient wor% up, which may result in signi(icant "elays in "iagnosis& ,here(ore, %nowle"ge o( possible emergencies in the conte/t o( a "e(ine" rheumatic "isease may ai" in promoting a high in"e/ o( suspicion an" contribute signi(icantly to the timely "iagnosis o( many potentially "angerous con"itions& ,he literature usually re$iews rheumatic emergencies using the problem oriente" approach& ,his approach is pre(erable in patients with "e(ine" organ or system in$ol$ement, such as $asculopathy o( the central ner$ous system :CNS; in systemic lupus erythematosus or Behcet#s syn"rome, or ab"ominal emergencies in $asculiti"es& Howe$er, in this re$iew we use the "isease oriente" approach, "escribing selecte" li(e threatening emergencies o( the most common "e(ine" rheumatic "isor"ers which are more li%ely to be misse"& 3ther rheumatic emergencies, which ha$e been re$iewe" recently or elaborate" in stan"ar" emergency me"icine te/tboo%s, are not "iscusse"& ,he re$iew is written (or the ER physician in an attempt to (acilitate early "iagnosis, which may be arri$e" at or at least suspecte" in the ER& 0t shoul" be a""e" that almost all o( the "escribe" emergencies may also be the initial mani(estations o( the systemic "iseases "iscusse"& Go toE

Rhe $atoid arthritis .RA/

Septic arthritis in the RA patient

'hile a suspicion o( septic arthritis is always high in any patient with acute monoarthritis, an in(ecte" @oint in an R patient is (re5uently o$erloo%e", particularly "uring the earlier stages o( the in(ection, "ue to the presumption that this merely represents a (lare up o( the un"erlying "isease& Delay in the "iagnosis o( septic arthritis in these patients a$erages -I1wee%s an" (re5uently lea"s to irre$ersible @oint "amage with poor (unctional outcome&) ,he mortality rate o( ).I11F in this setting un"erlines the signi(icance o( prompt "iagnosis an" treatment& ny monoarticular or oligoarticular (lare up in these patients shoul" be promptly e$aluate" (or the possibility o( septic arthritis& Re"ness o$er a swollen @oint, rather unusual in R , may raise the suspicion o( an in(ecte" @oint& ?actors inhibiting the correct "iagnosis o( septic @oint in R inclu"e the (re5uently reporte" insi"ious onset o( the complication, the absence o( (e$er in 8.F o( patients, an" the polyarticular pattern o( @oint in$ol$ement in up to ).I1.F o( patients&) ,he pre$alence o( septic arthritis is increase" particularly in R patients with prolonge" erosi$e "isease an"Dor treate" with glucocorticosteroi"s& ,reatment with ,N?J bloc%ers may be also associate" with a higher rate o( septic arthritis as well as with in(ection by opportunistic or rare pathogens&1 Prompt @oint aspiration o( the septic @oint will typically re$eal nucleate" cell counts abo$e 8. ...Dmm1 with neutrophilic pre"ominance, while lower syno$ial white bloo" cell counts may be seen rarely, especially in the early stages& ,he presence o( low syno$ial (lui" glucose le$els may suggest the "iagnosis& Direct smear with Gram stain shoul" be per(orme" an" the "raine" (lui" culture"& ,he "i((erential "iagnosis o( septic @oint usually inclu"es crystalline in"uce" arthritis& ,hough in(re5uently reporte" in the literature, both gout an" pseu"ogout are regularly seen in clinical practice in R patients, so e/amination o( the syno$ial (lui" (or crystals is essential& KPseu"oseptic arthritisL o( R is another con"ition mimic%ing an in(ecte" @oint& ,he clinical presentation o( pseu"oseptic arthritis is in"istinguishable (rom septic arthritisM howe$er, negati$e cultures an" the short :)*I*6h; course o( the (lare up which resol$es without antibiotics "i((erentiate between the two entities& ny R patient with suspecte" in(ectious arthritis shoul" be hospitalise" (or appropriate in$estigations, (ollow up, an" treatment&

(nsta+ility o" the cer0ical spine ."ig 1A1&/

Cer$ical spine ra"iological in$ol$ement is a (re5uent (in"ing in R patients,* with atlantoa/ial sublu/ations particularly "angerous because o( the ris% o( cer$ical myelopathy& tlantoa/ial sublu/ations appear typically in patients with erosi$e seropositi$e longstan"ing R , with a (orwar" "islocation being the most common :occurring in *1F o( patients with R o( mean "uration o( -)years8; an" a $ertical "islocation being the most ominous&

,he (irst clinical signs raising suspicion o( an unstable cer$ical spine may inclu"e new occipital pain an" tingling o( the (ingers& ,he neurological e/amination may be "i((icult an" sometimes unrewar"ing "ue to se$ere @oint "e(ormities, muscle wasting, an" entrapment neuropathies secon"ary to R & Sensory "isturbances in the e/tremities are ma@or pointers to a spinal cor" lesion& ,he "iagnosis is easy in most cases i( the in"e/ o( suspicion is high& Both (orwar" an" $ertical "islocations o( the atlantoa/ial @oint can be seen on a lateral ra"iograph o( the upper cer$ical spine in ma/imal acti$e anterior (le/ion&2 s a wor" o( caution, when e/amining R patients in general, it may be unwise to passi$ely (le/ their cer$ical spine ma/imally, as C-IC) sublu/ation may be initially clinically silent& ,his may be especially important to remember a(ter trauma such as (alls or $ehicular acci"ents& Su""en "eath has been reporte" in patients with R an" atlantoa/ial sublu/ation&+ Compute" tomography an", especially, magnetic resonance imaging :!R0; are use(ul whene$er plain ra"iographs lea$e any "oubt about the "iagnosis& !ost patients with atlantoa/ial "islocation associate" with myelopathy will bene(it (rom surgical treatment stabilising the cer$ical spine&6

2ig re 1 7ateral ra"iographs o( the cer$ical spine "uring e/tension : ; an" (le/ion :B; o( the patient#s nec%& Se$ere atlantoa/ial sublu/ation becomes e$i"ent in the (le/e" position where the "istance :arrows; between the posterior sur(ace o( ...

&ricoarytenoid arthritis .&A/

0n$ol$ement o( the cricoarytenoi" @oint has been reporte" in up to 1.F o( R patients,> but in most this in$ol$ement is probably asymptomatic& Clinical signs o( C in$ol$ement (re5uently appear secon"ary to laryngeal manipulation or in(ection an" inclu"e hoarseness, sensation o( a (oreign bo"y, (ullness, or tension in the throat, an" inspiratory stri"or&-. Concomitant wheeCing may lea" to a mista%en "iagnosis o( asthma or bronchitis& 7aryngoscopy, showing oe"ema, re"uce" $ocal cor" motility, an" arytenoi" cartilage asymmetry, an" compute" tomography :C,; imaging ha$e both been use" (or the "iagnosis o( C & 0n the nonemergency setting, treatment with systemic or locally

in@ecte" glucocorticosteroi"s is usually e((ecti$e& 0n patients with acute airway compromise intubation may be "i((icult an" traumatic, re5uiring tracheostomy&-. Go toE

Ankylosing spondylitis .AS/

Spinal "ract res
,he pathologically rigi" spine o( S patients gra"ually becomes osteoporotic an" is thus increasingly $ulnerable to (racture& 0t has been calculate" that up to -*F o( S patients will e/perience a $ertebral (ractures "uring their li(etime&-- Neurological complications are (re5uent an" about two thir"s o( these patients may not completely reco$er neurologically&-) ,he most common mani(estation o( spinal (racture is pain, usually localise", which is aggra$ate" on mo$ement an" thus "i((erent (rom the in(lammatory pain o( S& ,he localise" blee"ing an" oe"ema associate" with the (racture may create a mass e((ect with presentations o( acute ra"iculopathy an" myelopathy& Early "iagnosis, con(irme" by appropriate imaging stu"ies, shoul" lea" to urgent immobilisation an" surgical (i/ation in patients with $ertebral instability or bracing in patients with stable (ractures& ?actors associate" with a higher li%elihoo" o( misse" "iagnosis inclu"e the absence o( ma@or spinal trauma in more than 8.F o( S patients with $ertebral (racture-) an" (ailure o( stan"ar" imaging to "etect a (racture, usually o( the low cer$ical spine, "ue to non "isplacement o( these (ractures an" their small siCe when only syn"esmophytes are in$ol$e"&-1 ,he "i((erential "iagnosis inclu"es aseptic spon"ylo"iscitis o( S&-*

Atlantoa#ial s +l #ation
Patients with longstan"ing S may "e$elop instability o( the cer$ical spine "ue to atlantoa/ial sublu/ation with resulting myelopathy, similar to that o( R &-8 Go toE

Syste$ic sclerosis .SSc/

Renal crisis
Sclero"erma renal crisis is associate" with appro/imately ).F mortality with an a""itional ).F o( patients remaining on chronic "ialysis treatment a(ter the crisis has resol$e"&-2 ,his complication usually "e$elops in patients with early :"uring the (irst * years a(ter "iagnosis; "i((use sclero"erma an" has a $ascular nonin(lammatory nature& Glucocorticosteroi"s ha$e been implicate" in precipitating renal crisis&-+ 0n its classic (orm, when an SSc patient presents with hea"ache, malignant hypertension, high serum creatinine, an" e$i"ence o( microangiopathic anaemia with thrombocytopenia, the

"iagnosis o( renal crisis is straight(orwar"& 0t shoul" be remembere", howe$er, that appro/imately -.F o( these patients "o not "e$elop ma@or hypertension& 0n these cases progressi$e (atigue may be a lea"ing complaint an" the "iagnosis suspecte" with the (in"ing o( raise" serum creatinine an"Dor microangiopathic haemolytic anaemia on peripheral bloo" smear&-6 ngiotensin con$erting enCyme inhibitors, e$en in the presence o( progressi$e renal "ys(unction an" "ialysis, are the cornerstones o( the treatment o( sclero"erma renal crisis& Go toE

Syste$ic l p s erythe$atos s .S)E/

Al0eolar hae$orrhage .AH/
H is a rare but gra$e complication o( S7E with mortality o( up to +.I>.F&-> ,he cause o( H in S7E is capillaritis, which is pathogenetically similar to lupus microangiopathy o( the %i"ney an" relate" to the "eposition o( immune comple/es&). ,he most (re5uent clinical (eatures on presentation are "yspnea with pulmonary in(iltrates :-..F; an" high (e$er :6)F;, while haemoptysis may be seen only in hal( o( these critically ill patients&),he "i((erential "iagnosis inclu"es in(ectious pneumonia an" acute lupus pneumonitis& 0n the absence o( haemoptysis, "ropping re" cell in"ices in the presence o( a "ense pulmonary in(iltrate an" concomitant progressi$e glomerulonephritis :in appro/imately +8F o( patients; are (re5uent pointers to the sometimes "i((icult appreciation o( H in S7E&)),)1 ,he "iagnosis in e5ui$ocal cases may ha$e to be con(irme" by bronchoscopy with bronchoal$eolar la$age, re$ealing haemosi"erin la"en or pigment la"en macrophages an" negati$e bacterial an" (ungal cultures&)) Early treatment with high "ose glucocorticosteroi"s, cyclophosphami"e, an"Dor plasmapheresis may be critical to patient sur$i$al&

!rans0erse $yelitis .!*/

,! is a "e$astating neuroin(lammatory "isor"er a((ecting appro/imately )F o( patients with S7E&)1 S7E associate" ,! can be cause" by CNS $asculitis or result (rom arterial thrombosis, relate" in some cases to antiphospholipi" antibo"ies : P7 ;&)* 0( not recognise" an" treate" promptly, ,! may lea" to irre$ersible paraplegia& ,his rapi"ly progressi$e "isor"er usually presents with wea%ness, paraesthesias, or neuropathic pain in the lower e/tremities, o(ten associate" with bac% pain an" bla""er "ys(unction& Sensory loss, usually at the mi"thoracic le$el, may be (oun" in most but not all S7E patients with ,!&)8 high le$el o( suspicion is nee"e" to correctly interpret the "i((use ,! relate" complaints o( S7E patients, particularly those with concurrent (ibromyalgia syn"rome or bac%Dra"icular pain&)2 E/amination by an e/perience" neurologist may be critical to the "iagnosis o( ,! in these patients& 'hen ,! is suspecte", !R0 shoul" be carrie" as soon as possible (or the characteristic (in"ing in ,! o( increase" signal intensity an" atrophy o( the spinal cor"& 3n the other han", a normal !R0 picture may be seen occasionally in patients with the characteristic clinical picture o( ,!&)8 Cerebrospinal (lui" showing pleocytosis or increase" 0gG in"e/ may be use" to con(irm the in(lammatory

pathogenesis o( ,! in patients with S7E relate" $asculitis o( the CNS& ,he presence o( P7 may point to a thrombotic pathogenesis o( ,! in some cases&

&atastrophic antiphospholipid syndro$e .&APS/

S7E patients as well as patients with primary antiphospholipi" syn"rome may "e$elop C PS, which is an e/treme $ariant o( the antiphospholipi" syn"rome with pre"ominant occlusion o( small $essels, mainly a((ecting parenchymal organs&)+ ,he most common %nown trigger o( C PS is in(ection, with trauma, surgery, oral contracepti$es, neoplasia, an" war(arin with"rawal also reporte"& 0n almost hal( o( the cases no ob$ious precipitating (actors ha$e been i"enti(ie"&)+ !ortality is appro/imately 8.F, an" "iagnosis may be "i((icult because o( the wi"e spectrum o( potential mani(estations o( C PS& Se$enty per cent o( patients present with renal "ys(unction, 22F with pulmonary complications : RDS an" pulmonary emboli being the most (re5uent;, an" 2.F with cerebral symptoms :in(arcts, seiCures, $enous occlusions;& 3ther (re5uent thrombotic mani(estations inclu"e myocar"ial in(arction an" s%in necrosis&)6 7i$e"o reticularis is an important (in"ing on physical e/amination, pointing to the potential "iagnosis& ,hrombocytopenia persists in more than 2.F o( patients an" is another signi(icant "iagnostic (eature o( C PS& ,he "i((erential "iagnosis inclu"es thrombotic thrombocytopenic purpura, marantic en"ocar"itis with multiple embolic e$ents, S7E $asculitis, an" heparin in"uce" thrombocytopeniathrombosis syn"rome&)+ High serum le$els o( P7 are characteristic o( C PS& 0mme"iate treatment shoul" inclu"e intra$enous heparin an" high "ose glucocorticosteroi"s, with intra$enous immunoglobulins an" plasma e/change being the secon" line therapies&)+

Pericardial ta$ponade
Signs an" symptoms o( pericar"itis in S7E patients are typical o( those o( pericar"itis in general&)> Car"iac tampona"e is a rare e$ent an" usually presents with progressi$e "yspnea& Pericar"ial in$ol$ement occurs pre"ominantly in patients with wi"esprea" acti$e S7E an" mani(ests as (atigue, Raynau"#s phenomenon, @oint pains, an" low serum le$els o( complement (actors C1 an" C*&1. low threshol" (or the re(erral o( S7E patients with chest pain an"Dor "yspnea alrea"y in the ER to echocar"iography may contribute to early "iagnosis an" success(ul treatment& ,he association o( large pericar"ial e((usions with acti$e nephritis, 7ibmanSac%s en"ocar"itis, an" myocar"ial "ys(unction was recently reporte" in S7E patients&1. Go toE

S3ogren4s syndro$e .S3S/

Hypokalae$ic paralysis
Distal renal tubular aci"osis :R, ; occurs in appro/imately 1.F o( patients with primary S@S& symptomatic in most patients, R, may lea" to symptomatic hypo%alaemia in

others& Hypo%alaemic paralysis lea"ing to 5ua"riparesis an", rarely, to respiratory arrest has been repeate"ly reporte" in S@S an" shoul" always be consi"ere" in a patient with S@S presenting to the ER with unusual wea%ness&1-,1) 7ow serum potassium le$els along with hyperchloraemic metabolic aci"osis an" abnormally aci"i(ie" urine may be "iagnostic& 0mme"iate treatment consists o( $igorous potassium replacement an" intensi$e monitoring an" support& Go toE

5iant cell .te$poral/ arteritis .5&A/

)oss o" 0ision
Bisual loss is the most (eare" complication o( GC & 0( it occurs, it is irre$ersible in most patients an" may e$en worsen "uring the (irst "ays (ollowing initiation o( treatment with high "ose glucocorticosteroi"s&11 ,he presence o( other ischaemic complications relate" to GC , ele$ate" thrombocyte count, an" $isual hallucinations ha$e been thought to pre"ict the "e$elopment o( irre$ersible blin"ness in these patients& 3( interest, a lower erythrocyte se"imentation rate :ESR; in"epen"ently pre"icte" a higher ris% o( $isual loss in GC patients&1*,18,12,1+ Possibly, an ESR that was only mil"ly ele$ate" (aile" to alert to the probability o( GC in these patients an" "issua"e" the atten"ing physicians (rom initiation o( steroi"s& 0mme"iate a"ministration o( glucocorticosteroi"s in a patient with a clinical picture o( GC is best to pre$ent permanent $isual loss& 3ptimally, these patients shoul" be hospitalise" (or a biopsy o( the temporal artery, which may be sa(ely per(orme" a(ter a (ew "ays o( treatment with glucocorticosteroi"s&

6erte+ro+asilar ins ""iciency .67(/

GC is %nown to a((ect the e/tracranial part o( the $ertebral arteries in +8I-..F o( patients an" (re5uently causes neurological "e(icits in the $ertebrobasilar circulation territory&16 'hen a part o( the classic presentation o( GC with hea"ache, @aw clau"ication, scalp hypersensiti$ity, polymyalgia syn"rome, an" ele$ate" ESR, the signs o( BB0 are easily attributable to the "isease& Howe$er, the "iagnosis o( GC may be signi(icantly "elaye" in the el"erly patient presenting with gait "isturbance, "iCCiness or $ertigo, $omiting, an" sometimes slurre" speech, i( the classic symptoms o( the "isease are not apparent& ,reate" GC patients may also relapse "uring tapering o( glucocorticosteroi"s with only progressi$e neurological "e(icit, e$en i( the (irst presentation o( GC ha" ha" a (ull blown systemic character :unpublishe" personal "ata;& <ntreate" GC in these patients may progress to bilateral $ertebral artery occlusion, a con"ition with +8F mortality&16 ,hus, ESR as a screening test (or acti$e GC shoul" be promptly per(orme" in all %nown GC patients presenting with a new neurological symptom or any el"erly patient with possible BB0, particularly when accompanie" by hea"ache or (e$er& Con$entional or !R angiography may "i((erentiate GC in$ol$ement o( the $ertebral arteries (rom an atherosclerotic process $ia the "i((erent localisation o( narrowings&16 s in classic GC with temporal arteritis,

imme"iate high "ose glucocorticosteroi" treatment shoul" be a"ministere" to patients with symptomatic GC in$ol$ement o( the $ertebral arteries&

Aortitis ."ig %%/

GC may be associate" with a large artery complication in up to )+F o( patients, with aortic aneurysms, ruptures, an" "issections, aortic $al$e incompetence, an" aortic arch syn"rome reporte"&1> neurysms o( the ascen"ing thoracic aorta occurre" -+ times more o(ten in patients with GC than in a control group, while ab"ominal aortic aneurysms were )&8 times more (re5uent&*. ortic pain may be an early sign o( the catastrophic e$ent an" its timely recognition is o( primary importance& Best %nown is the pain o( acute thoracic aorta "issection, which is classically "escribe" as o( abrupt onset, anterior chest or posterior suprascapular in location with "ownwar"s ra"iation, searing or tearing in character, an" pulsating, sometimes with an o"" sensation in the legs& Sometimes partial aortic tears or an e$ol$ing aortic "issection may mas5uera"e as angina pectoris or atypical chest or upper bac% pain, with only a high le$el o( suspicion lea"ing to timely "iagnosis in these patients& Echocar"iography may be an e((ecti$e means o( e$aluation when "isease o( an ascen"ing aorta is suspecte"& C, or !R0 is usually re5uire" (or imaging o( the "escen"ent thoracic an" ab"ominal aorta when the clinical presentation suggests such in$ol$ement&*-

2ig re % C, angiograph showing aortic wall thic%ening :arrows; o( the aortic arch, compatible with aortitis, in a 2+year ol" patient complaining o( recurrent bouts o( upper chest an" bac% pain, in whom ESR was ele$ate" at 26mmDh& ... Go toE

Wegener4s gran lo$atosis .W5/

S +glottic stenosis .S5S/
SGS occurs in appro/imately ).F o( patients with 'G&*) 0t can mani(est with hoarseness, cough, "yspnea, an"Dor stri"or& irway obstruction results not only (rom the subglottic lesion itsel( but also (rom tracheobronchial secretions, trappe" at the le$el o( stenosis& 0nitial "iagnosis may be easily con(use" with respiratory symptoms (rom co e/istent pulmonary "isease, an" the stri"or may be mis"iagnose" as the wheeCe o( bronchial asthma&*1 ll patients in whom SGS is being consi"ere" shoul" be imme"iately e$aluate" by laryngoscopy& Close monitoring (or signs o( acute airway compromise is essential, with tracheostomy per(orme" promptly when in"icate"& 0t shoul" be mentione" that the SGS in 'G is not necessarily re(lecti$e o( o$erall "isease acti$ity an" is (re5uently resistant to systemic immunosuppressi$e therapy, with (ibrosis reporte" "espite aggressi$e treatment&*),*1 0ntratracheal "ilatation with intralesional in@ections o( glucocorticosteroi"s may be an e((ecti$e means o( treating SGS&*)