Myxedema Coma – 7/27/17

Most common presentation

  • Altered mental status
  • Hypothermia
  • Precipitating event
  • **Myxedema and coma do not have to be present**

Physical exam findings

  • Hypothermia
  • Bradycardia
  • Hypotension
  • Cool skin
  • Diffuse soft tissue swelling without pitting
  • Altered mental status

Lab abnormalities

  • Hyponatremia
  • Elevated CK
  • Elevated transaminases
  • Hypoglycemia
  • Elevated TSH with frankly low T4 level

Treatment

  • IV levothyroxine
  • Use of T3 is controversial
  • Stress dose steroids because of concern for precipitating adrenal insufficiency
  • Supportive measures

Pleural effusions – 7/25/17

Symptoms: Dyspnea, cough, and pleuritic chest pain

Exam: Decreased breath sounds, dullness to percussion, decreased tactile fremitus

Indications for thoracentesis: Any new unexplained effusion

Light’s criteria:

  • Pleural protein/Serum protein > 0.5
  • Pleural LDH/Serum LDH > 0.6
  • Pleural LDH > 2/3 ULN

Examples of transudates:

  • Heart failure
  • Nephrotic syndrome
  • Hepatic hydrothorax
  • Low albumin

Examples of exudates:

  • Parapneumonic effusions
  • Malignancy
  • TB
  • PE
  • Autoimmune disease (RA, SLE)

Uncomplicated effusion – pH > 7.2, glucose > 60, free flowing, < 1/2 hemithorax – treat the underlying cause, no need for chest tube

Complicated effusion – pH < 7.2, glucose < 60, can be > 1/2 hemithorax or loculated – treat the underlying cause and would benefit from chest tube

Empyema – complicated effusion with positive gram stain and culture – place a chest tube

Malignant effusions – if re-accumulating rapidly, can place a long-term chest tube or do a pleurodesis with talc

Heart Block 07/24/2017

Heart Block 1Heart Block 7

Heart Block 8

  • Two General Indications for permanent pacemaker (PPM) implantation 
    • 1) Symptomatic sinus bradycardia with rate <40bpm
    • 2) High grade or symptomatic AV block
  • Pacing is generally not indicated in asymptomatic sinus bradycardia

Heart Block 2

Heart Block 3

  • There are Four main rhythms that are seen with DDD
    • 1) Normal sinus rhythm
      • pacemaker is totally inhibited due to acceptable intrinsic sinus rate and AV conduction
    • 2) Atrial sensing and ventricular pacing
      • Sinus rate is above the set rate (inhibited atrial pacing) with prolonged AV conduction (triggered ventricular pacing)
    • 3) Atrial pacing, normally conducted to the ventricle with native QRS
      • Atrial pacing is triggered by sinus bradycardia in the setting of normal AV conduction (inhibited ventricular pacing)
    • 4) AV sequential pacing
      • Both atrial and ventricular pacing are triggered due to sinus brady and prolonged AV conduction

Heart Block 4Heart Block 5Heart Block 6

Tuberculosis 07/18/2017

  • Definitions
    • Primary Tuberculosis
      • 1-5% of cases
      • Infection directly after inoculation by airborne particles
      • Symptoms
        • Fever (70%)
        • Pleuritic chest pain (25%)
      • 90% of immunocompetent patient enter latent state
        • 10% develop TB pneumonia or progress to distant sites
          • Usually those with poor immune responses (HIV, CKD, DM2, immunosuppressants)
    • Latent TB (LTBI)
      • Non-contageous, quiescent state
      • Only manifestation is positive PPD or Quantiferon (IGRA – interferon gamma release assay)
    • Reactivation TB
      • 90% of adult cases in non-HIV patients
      • Classic symptoms
        • Cough, fatigue, fever, night sweats, weight loss
          • Sometimes hemoptysis –> usually in the setting of cavitary disease
  • Risk Factors
    • For exposure
      • Foreign born
      • Homeless
      • Incarceration
      • Health care workers
    • For reactivation
      • Immunocompromised
        • HIV, malignancy, steroids, DM2
      • Prior untreated or inadequately treated disease
      • Lifetime risk for reactivation
        • Immunocompetent -> 10% lifetime risk
        • Immunocompromised -> 10% per year
  • Physical finding –> non-specific and usually absent in mild-moderate disease
  • Labs
    • Sputum samples
      • AFB smear/culture
        • Obtained by coughing vs induced (inhalation of hypertonic saline from nebulizer)
        • 3 specimens at least 8 hours apart
        • Most rapid and inexpensive test
          • 45-80% sensitive
        • AFB positive smear can represent non-tuberculosis mycobacteria (NTM) as well
          • Must confirm with culture and nucleic acid amplification
      • Nucleic acid amplification (NAA) tests
        • Xpert MTB/RIF Test
          • Detects MTB DNA and rifampin resistance mutations
            • But cannot provide specific sequence information
          • Smear positive sample –> 95% sensitive, 98% specific
          • Smear negative sample –> 80% sensitive, 95% specific
          • Negative Xpert cannot exclude active TB!
          • Watch out for false positives from recent previously treated infection
      • Sequencing assays
        • Sequencing assays provide specific sequence mutations and predicts drug resistance with greater accuracy
          • Not approved by FDA; Remains investigational
    • Tuberculin Skin Test (TST) and quantiferon
      • Only used to diagnose latent TB infection, not active TB!
      • Positive result supports Dx; negative result cannot be used to rule out
  • Imaging
    • CXR
      • Primary TB
        • Hilar and peritracheal lymphadenopathy (65%)
        • Small homogeneous lobar vs perihilar infiltrates (30%)
        • Pleural effusion (30%)
      • Reactivation TB
        • Normal hosts
          • apical-posterior infiltrates (85%)
            • MTB prefers higher O2 tensions in the apical lung areas
            • poor lymphatic flow in apices results in poor organism clearance
          • cavitation
        • Immunocompromised (AIDS) Pts –> Atypical findings
          • Diffuse disease (military)
          • Mid/lower lung zones
          • Hilar and mediastinal LAD
        • CT
          • More sensitive than plain CXR for early or subtle parenchymal and nodal disease
  • Management
    • General approach
      • 6 months of treatment in 2 phases
        • Intensive phase –> 2 months
          • First line drugs –> “RIPE”
            • Rifampin, INH, pyrazinamide, ethambutol
        • Continuation phase –> 4 months
          • Rifampin
          • INH
    • Watch out for hepatotoxicity!
      • Rifampin, INH, and pyrazinamide are all associated with hepatotoxicity
    • All pts in INH should get vit B6
    • Avoid fluoroquinolones in suspected TB cases!
      • Avoid resistance from TB monotherapy

Endocarditis – 7/17/17

Risk Factors for developing Endocarditis

  • Dental procedure that penetrates the gums
  • Prior endocarditis
  • Prosthetic valves
  • IVDU
  • Immunosuppression

Common Organisms

  • Staph
  • Strep
  • Enterococcus
  • HACEK

Symptoms/Signs

  • Fever (most common)
  • Murmur
  • Splinter hemorrhages
  • Janeway lesions (non-tender erythematous macules on palms and soles)
  • Osler nodes (tender, subcutaneous nodules, on pads of fingers and toes)
  • Roth spots (exudative edematous hemorrhages in the retina)

Indications for surgical repair

  • New heart failure
  • Perivalvular abscess/extension
  • Conduction abnormalities
  • Persistent bacteremia
  • Prosthetic valves
  • Septic emboli
  • Large vegetation > 10-15 mm
  • Resistant organisms