8/31/15 Morning Report – Staghorn Calculi and Proteus Pyelonephritis!

  • Urea splitting organisms include Proteus, Klebsiella, Pseudomonas, and Enterobacter
  • Xanthogranulomatous pyelonephritis can occur in patients with chronic pyelonephritis with recurrent urinary tract infections causing accumulation of granulomatous tissue containing lipid-laden macrophages which can destroy a kidney. Usually this is unilateral and the treatment is nephrectomy. Look for a bear paw on CT!
Kidney Stones Composition PH Visibility on Xray
Calcium Stones (80%)

   

Calcium Oxalate 90%

Calcium Phosphate 10%

Insoluble in Acidic pH (except Ca phosphate) Radiopaque
Struvite (<10%) Magnesium Ammonium Phosphate

Calcium Carbonate Apatite

Insoluble in Alkaline PH Radiopaque (but can be variable)
Uric Acid Stones (~10%) Uric Acid Crystals Insoluble in Acidic pH Radiolucent
Cystine (rare) Cystine (Congenital Cystinuria) Insoluble in Acidic PH Radiolucent

8/26/15 Morning Report

  • The differential for wide complex tachycardia includes ventricular tachycardia, SVT with aberrancy, and SVT with a bypass track (WPW).
  • Characteristics of V tach include capture/fusion beats, AV dissociation, Northwest axis, precordial concordance.
  • Akhtar Criteria: In patients with a history of MI, new onset wide complex tachycardia is >95% ventricular tachycardia
  • Remember Idiopathic V-Tach (often from the right ventricular outflow tract) and Arrhythmogenic right ventricular dysplasia as causes of V-tach in a young person

8/20/15 The All-of-Endocrinology-in-ONE-hour AM Report!

Clinical Pearls:

  • Over 90% of hypercalcemia is caused by primary hyperparathyroidism or malignancy.
  • Malignancy etiologies could be due to bone metastasis and/or PTHrP
  • Granulomatous diseases can cause hypercalcemia by expressing 1a-hydroxylase, which induces production of active Vitamin D.
  • Severe hypercalcemia (over 13mg/dL) is usually associated with malignancy and is most commonly seen in the inpatient setting
  • Mild to moderate hypercalcemia (11-13mg/dL) is usually seen in patients with primary hyperparathyroidism. It is most commonly seen in the outpatient setting.
  • Metastatic tumors to the hypothalamus/pituitary space are usually caused by lung or breast cancer
  • Management of hypercalcemia
    • IV Fluids to improve GFR immediately for calcium excretion.
    • Calcitonin intermediate onset of 4-6 hours. Be aware of tachyphylaxis
    • IV bisphosphonates, onset 24-48 hours (pamidronate, zolendronate)
  • A normal to high level of PTH in a patient with hyperparathyroidism almost always suggests primary hyperparathyroidism as the etiology.
  • V1 receptors are present in the blood vessels whereas V2 receptors are present in the collecting tubule. Activation of V2 receptors causes aquaporin channels within the membrane to allow reabsorption of water.
  • The hypernatremia from Diabetes insipidus may be masked until the patient is unable to satisfy their thirst or if they are unable to access water (for example, outpatients with DI usually don’t have hypernatremia because they can obtain free water from the most powerful sensing mechanism – thirst)
  • The etiologies for hypernatremia include poor water intake (inability to access water) versus diabetes insipidus.
  • Central DI will respond appropriately to ddAVP whereas nephrogenic DI will have a suboptimal response
  • Nephrogenic DI can be caused by electrolyte abnormalities (hypercalcemia, hypokalemia), medications (lithium, demeclocycline, etc), and genetic factors
  • Prolactin levels will INCREASE with pituitary stalk compression due to the lack of inhibition from hypothalamic dopamine, while all other anterior pituitary hormones (FSH, LH, ACTH, TSH, GNRH) would decrease.

A Very Special Thank you to Dr. Crapo for joining us!!! Also a special thank you to Dr. Kevin Ku for bringing in yummy bagels!

8/19/15 Morning Report

Clinical Pearls!

  • Dengue fever can present as a separate clinical entity called Dengue Hemorrhagic Fever which presents with shock from plasma leakage syndrome, marked thrombocytopenia, and spontaneous bleeding
  • Fever Pattern with Dengue infection: Continuous or occasionally the fever abates for a day and then returns, a pattern referred to as “saddleback fever”
  • Lab abnormalities in Dengue Fever Include: Thrombocytopenia, Leukopenia, Anemia is less common, AST elevation

Morning Report 8/13/15: Serotonin Syndrome

Great Discussion!

  NMS Serotonin Syndrome
Etiology Too Little Dopamine Too much serotonin
Onset Days to Weeks Usually < 24 hours (more acute than NMS)
Neuromuscular Findings Bradyreflexia, severe muscular rigidity Hyperreactivity (tremor, myoclonus, reflexes, ocular clonus)
Pupils Normal Dilated
Treatment Supportive care, consider bromocriptine Benzodiazepines, cyproheptadine in certain cases
Resolution Days to weeks < 24 hours