Morning Report 10/28 – PFTs

Teaching Pearls:

  • FEV1/FVC Ratio <0.7 suggestive of obstructive parenchymal disease
  • DLCO – ability for gas to diffuse across alveolar capillary membrane.  CO (inhaled) – CO (exhaled). CO has a high affinity for Hb. If CO (exhaled) is higher than expected, DLCO is low and this is suggestive of diffusion problem.
    • False Positive
      • Anemia
      • Pulmonary hypertension
    • False Negative
      • Pulmonary hemorrhage
  • Pulmonary Function Tests
      FEV1 FVC FEV1/FVC DLCO TLC RV F-V
    Emphysema Decrease Decrease/No change <70% Decrease Normal/increase Normal/increase C
    Chronic Bronchitis Decrease Decrease/No change <70% Normal Normal/increase Normal/increase C
    ILD

     

    Normal/Decrease Normal/Decrease Normal/Increase Decrease Decrease Decrease A
    Tracheal stenosis Decrease Decrease/normal Decrease Normal Normal Normal B
    Resp muscle weakness Decrease Decrease Normal Normal Decrease Increase D

    A.  Restrictive

    B. tracheal stenosis

  • C. obstructive
  • D. resp weakness

10/27/15 Morning Report SLE

Teaching Pearls: 

  • ANA negative lupus, check SSA/SSB which are associated with neonatal lupus and congenital heart block
  • ANA positive in 99% of patients with lupus, but low specificity
  • double stranded DNA antibodies are used to monitor disease severity in lupus
  • check C3, C4, and double stranded DNA to work up possible lupus flare
  • Drug induced lupus: Look for positive ANA and anti-histone antibodies. Also look for exposure to procainamide, hydralazine, chlorpromazine, PTU, phenytoin, minocycline, and TNF inhibitors.
Steroid Duration Equivalent Dosing
Dexamethasone Long-acting 1 mg
Methylprednisolone Intermediate-acting 4 mg
Prednisone Intermediate-acting 5 mg
Hydrocortisone Short-acting 20 mg

10/22/15 Morning Report Hyperthyroidism

  • Pathophysiology of T4 secretion: TSH secreted in the anterior pituitary and stimulates the TSH receptor in the thyroid to secrete thyroid hormone
  • Clinical presentation of Hyperthyroidism: Hyperdefecation (not diarrhea), osteoporosis, oligomenorrhea in pre-menopausal females, hair changes, palpitations, arrhythmias
  • Etiologies of hyperthyroidism
    • Grave’s Disease (most common cause of hyperthyroidism)
    • Destructive thyroiditis (subacute, silent, postpartum)
    • Multinodular Goiter/Toxic Adenoma
    • Medication-induced (amiodarone, lithium, IFN-a, etc)
    • Factitious
  • Antibodies
    • Anti-TPO and anti-thyroglobulin Ab seen with Hashimoto’s Disease (hypothyroidism)
    • TSI (thyroid stimulating immunoglobulin) and TBII associated with Graves Disease.
      • TSI binds to TSH receptors on thyroid gland, stimulating production of thyroid hormone.
      • TSI also binds to TSH receptors located on fibroblasts, stimulating proliferation and glycosaminoglycan production in retro-orbital space.
  • Clinical Presentation specific to Graves include pretibial myxedema (5% patients with Graves), exophthalmos (25% of patients with Graves)
  • Work-up of Hyperthyroidism
    • If evidence for Graves Disease, then GD likely diagnosis.
    • Evidence of nodules on physical Exam:
      • If None: Perform RAI uptake scan and antibody studies.
        • If increased uptake, elevated thyroid hormone due to over-synthesis
          • If diffuse uptake, think Graves Disease
          • If patchy uptake, think toxic multinodular goiter
        • If decreased uptake, think of factitious or destructive causes (subacute, silent, postpartum.
      • If Present: Get RAIU scan and thyroid ultrasound to distinguish TNG vs TA and/or evidence of cold nodules. Check for any concerning factors for thyroid cancer.
    • Thyroglobulin: Precursor to thyroid hormone production. Combined with iodine to produce T4.
      • May be used to differentiate factitious vs destructive thyroiditis, surveillance for thyroid cancer.
  • Treatment Options:
    • Thionamides – Methimazole versus PTU
      • Watch for drug rash and/or agranulocytosis
    • Radioactive iodine ablation
      • Do not use in patients with Graves Disease with severe ophthalmopathy as this can worsen symptoms.
    • Surgery
  Grave’s Disease Multinodular Goiter Subacute Thyroiditis
Clinical Course/Exam

 

 

Exophthalmos

Pre-tibial Myxedema

Hyperthyroid symptoms

Palpable nodules

Preceded by URI sx, Pain around the neck, pain with palpation, initially hyperthyroid (6 weeks) but progresses to hypothyroid (6 weeks), then normalizes
Diagnosis Tests

 

 

 

Low TSH

High Free T4

TSI

RAIU

TSH/T4

RAI

Thyroid US

TSH, Free T4

RAI – low uptake

Thyroid US – diffuse enlargement

Treatment

 

 

 

PTU

Methimazole (don’t use in 1st trimester of pregnancy). Watch for agranulocytosis.

RAIA, then will require

Surgical. Don’t use RAIA for patients with exophthalmos.

If compressive sx (dysphagia, etc) then surgery

If no compressive symptoms, can treat with RAIU. Toxic patients can also be treated with thionamides

NSAIDS, supportive

Then Prednisone if poor response

Symptomatic treatment, such as propranolol or beta blockers

Thionamides not indicated

Intern Report 10/20 – Bloody Diarrhea

Teaching Pearls

  • Duration of Diarrhea
    • Acute < 14 days
    • Chronic >4 weeks
  • Types of Diarrhea
    • Secretory
      • Stool osmole gap <50
    • Osmotic
      • Stool osmole gap >100
    • Inflammatory
      • Evidence of blood and/or mucoid stools
    • Malabsorption
      • Protein-losing enteropathy
      • CHO malabsorption
      • Fat malabsorption
  • Bacterial Causes of Blood Diarrhea
    Source Presentation Complications Treatment
    STEC (EHEC) Uncooked hamburger meat.

    Fecal-oral route

    Abd pain with bloody diarrhea +/- fever HUS No antibiotics indicated; supportive care
    Shigella Shellfish, fecal oral route Dysentery (bloody mucoid stools), tenesmus, fever, abdominal pain Reiters Disease Flouroquinolone; 3rd generation cephalosporin
    Salmonella Undercooked raw eggs, chicken, fruits Fever, abdominal pain, occult/overt bleeding Bacteremia, aortitis, osteomyelitis in those with sickle cell disease Only treat when symptoms are severe
    Campylobacter Poultry Occult bleeding Reiters disease, Guillain-Barre Syndrome Treat only if severe with macrolides

10/17/15 – Valley Residents Present at ACP in San Francisco!

A shout out to our poster presenters and brave Jeopardy Team! It wouldn’t have been possible without all our housestaff who graciously covered our presenters – thank you very much!  Saloni, Courtney, and Joe Li advanced to the finals in the poster competition. Three fascinating ID cases (cutaneous blastomycosis, rat bite fever, and pseudallescheria boydii) which is testament to all the cool ID we see here at Valley! 

Alex

SaloniCrazypic 3

Morning Report 10/14/15 Obscure Occult and Overt??

Teaching Pearls:

MKSAP Boards Question Review – Bipap has been shown to decrease mortality, decrease need for intubations, and decrease hospital stay in select patients with COPD exacerbations.

  • Definitions
    • Overt Bleeding – GI bleed that is clinically evident. Hematemesis, hematochezia, melena, etc
    • Occult Bleeding – Slow bleed manifested by iron deficiency anemia and/or positive guiac tests
    • Obscure Bleeding – Evident GI bleed without clear source of bleed despite standard work-up
  • Common etiologies for obscure occult GI bleed
    • Angioectasia
    • Cameron lesions
    • NSAID ulcer
    • Malignancy
  • Common etiologies for obscure overt GI bleed
    • Dieulafoy lesion
    • Meckel’s diverticulum
    • Angioectasia
    • Colonic diverticulum
  • Tachycardia suggests blood loss of 15-30%. Patients develop hypotension once blood loss >30%.
  • If unable to find source with EGD/colo, next step is to perform EGD and/or colonoscopy again as 30-50% can be identified
  • Capsule – can detect lesions without active bleeding. Diagnostic in 50-75% of cases. Only offers diagnostic benefits
  • Tagged RBC scan – good sensitivity but poor specificity. Does not offer therapeutic intervention. Ideal for bleeds 0.1-0.5cc/min.
  • Angiography – best for overt bleeding (>1cc/min), allows for immediate therapy.
  • Chronic Hepatitis B Treatment Goals:
    • Treat HBeAg Positive patients if:
      • ALT>2xULN
      • HBV DNA >20,000IU/ml
    • Treat HBeAg Negative patients if:
      • ALT>2xULN
      • HBV DNA >2,000IU/ml

Morning Report 10/13/15: COPD and Acid/Base

Teaching Pearls:

  • Only two interventions shown to reduce the progression of COPD: Smoking cessation and supplemental O2
  • Stepwise Approach to Acid Base: 
    • Acidic or Alkalotic?
    • Primary Disturbance? Respiratory or Metabolic
    • Calculate the Anion Gap
    • If Anion Gap present, calculate the Delta Gap
    • If metabolic acidosis present, use Winter’s formula to calculate whether there is appropriate respiratory compensation
  • For every 10 increase in pCO2, the bicarb should increase by 1 in acute respiratory acidosis and 3.5 in chronic respiratory acidosis
  • BIPAP can be used to improve respiratory acidosis, increase pH, decrease risk of intubation, and to reduce the pCO2
  • Contraindications of BIPAP include respiratory arrest, CV instability, altered mental status, aspiration risk/significant secretions, nasopharyngeal abnormalities, cranofacial trauma
  • Right Bundle Branch Block: Causes include RVH, cor pulmonale, PE, ischemic HD, myocarditis. Look for Broad QRS > 120ms, RSR prime in V1-V3, wide slurred S in the lateral leads V5-V6