All posts by vmcimchiefs

Morning Report

Pleural effusions – 7/25/17

July 25, 2017 vmcimchiefs Leave a comment

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

Morning Report

Heart Block 07/24/2017

July 24, 2017 vmcimchiefs Leave a comment

Heart Block 1 Heart 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 4 Heart Block 5 Heart Block 6

Morning Report

Tuberculosis 07/18/2017

July 19, 2017 vmcimchiefs Leave a comment

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

Morning Report

Endocarditis – 7/17/17

July 19, 2017 vmcimchiefs Leave a comment

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

Morning Report

Dizziness – 7/19/17

Image July 19, 2017 vmcimchiefs Leave a comment

Morning Report

Myasthenia Gravis 07/13/2017

July 19, 2017 vmcimchiefs Leave a comment

Definition
1. Two clinical forms of myasthenia
  1. Ocular
    - Limited to the eyelids and exraocular muscles
  2. Generalized
    - Affects the ocular muscles and variable combinations of bulbar, limb, and respiratory muscles
Pathogenesis
1. Auto-antibodies directed against acetylcholine receptors (AChR)
  - Autoantibodies are present in 90% of patients

Epidemiology
1. Can happen at any age, but there is a Bimodal distribution
  1. Early peak –> 20-30s
    - Female predominance
  2. Late peak –> 60-80s
    - Male predominance

Presenting symptoms
1. Occular symptoms (Ptosis and/or diplopia) –> 50% of patients
2. Bulbar Sx (dysarthria, dysphagia, fatigable chewing –> 15% of patients
3. Muscle weakness that worsens throughout the day
4. Respiratory muscles
  1. Most feared symptom –> Can lead to respiratory failure (“myasthenic crisis”)

Diagnosis
1. Bedside tests
  1. Ice pack test
    - Bag of ice is placed on the eyelid for 2 minutes then removed. –> Improvement in ptosis is measured
    - 80% sensitivity
  2. Tensilon (Edrophonium) test
    - 2mg doses of edrophonium are given –> improvement in symptoms measured
2. Lab tests
  1. Two Auto-antibodies:
    - Acetylcholine receptor antibody (AChR-Ab)
      - Present in 85% of patients with generalized disease
    - Muscle specific receptor tyrosine kinase (MuSK)
      - Present in up to 50% of patients who are AChR-Ab negative.
3. Electrophysiological studies
  1. Repetitive nerve stimulation (RNS)
    - 75% sensitive
    - Most frequently used due to wide availability
  2. Single-fiber EMG
    - Used if RNS is negative because it is 95% sensitive
    - Less widely available

Associated conditions
1. Thymic tumors
  1. 75% of patients with AChR-antibodies have thymic abnormalities (70% hyperplasia vs 10% thymoma)
  2. CT vs MRI to evaluate
2. Autoimmune disorders
  1. Thyroid disease (5%)
  2. RA
  3. SLE

Treatment
1. Acetylcholinesterase inhibitors
  - Pyridostigmine (mestinon)
    - Some patients only need this
    - Cholinergic side effects
2. Immunomodulator drugs
  1. Chronic immunomodulators
    - Glucocorticoids
    - Azathioprine, mycophenolate, cyclosporine
  2. Rapid
    - Useful in myasthenic crisis or preoperatively before thymectomy à not useful long term
      - IVIG
      - Plasmapharesis
3. Thymectomy

Morning Report

AM report 7/12 – Skin Rashes

Image July 12, 2017 vmcimchiefs Leave a comment

Rashes

Morning Report

Alcoholic Hepatitis 07/11/2017

July 11, 2017 vmcimchiefs Leave a comment

Risk Factors
- Mean intake of 100g/day for 10-20 years
  - Standard drink of ETOH = 14g pure alcohol
    - 12oz beer
    - 5oz wine
    - 5 oz of 80 proof liquor (“Shot”)
- Binge drinking
  - Men = 5 drinks in 1 sitting
  - Women = 4 drinks
Pathophysiology
- Standard alcohol metabolism in cells
  - Alcohol dehydrogenase (ADH) plus cytochrome P-450 2E1 (CYP2E1) convert ethanol into acetaldehyde which is then converted to acetate
  - CYP2E1 releases reactive oxygen species leading to inflammation
  - NAD+ is used as oxidizing agent for ADH and is converted to NADH
    - Excess alcohol creates an imbalance of NAD/NADH
    - Excess NADH decreases oxidation of fatty acid oxidation
  - While acetate increases fatty acid synthesis
    - Both leading to steatosis
Presentation
- Pts often present between 40-50 years of age
- Classic presenting features
  - Jaundice
  - Scleral icterus
  - Anorexia
  - Fever
  - Tender RUQ
  - Hepatomegaly
  - Abdominal distention due to ascites
  - Hepatic encephalopathy
  - Bruit can be appreciated over the liver due to increased hepatic blood flow

Labs

LFTs
- Moderate elevations of AST and ALT
  - Usually less than 300, rarely higher than 500
  - AST:ALT ratio >2
    - ALT is less due to alcohol induced deficiency of Pyridoxal 5-phosphate, which is a coenzyme of ALT. Thus the ratio reflects the failure to appropriately increase the ALT, rather than an inappropriate increase in AST.
  - Elevated Tbili and Dbili
CBC
- Leukocytosis (usually <20) with a neutrophil predominance
  - Extreme Leukemoid reaction (>50) is associated with a very poor prognosis.
- Macrocytosis
  - Reflective of poor nutritional status
- Thrombocytopenia
- Coags
  - Elevated INR
Imaging (show pics!)
- 1^st choice: Abdominal ultrasound
  - It’s quick, easy, and relatively cheap
  - Will help rule out Budd-Chiari, abscess, obstruction, or neoplasm
  - Will show fatty changes in liver vs underlying cirrhosis

Maddrey Discriminant Function
- DF >32 signifies severe alc hep and is associated with high short-term mortality
  - May benefit from glucocorticoid therapy
Treatment
- 3 main things
  - Alcohol cessation
  - Nutritional support
  - Steroids
    - Contraindicated for:
      - GI Bleed
      - Infection
      - Renal failure
      - Pancreatitis
    - Check Lille Score on day 7 to evaluate response
      - >.45 is associated with 6-month survival of 25% –> ok to stop steroids
      - <.45 is associated with 85% survival
- Pentoxyfilline –> little evidence!
  - The Steroids or Pentoxifylline for Alcoholic Hepatitis (STOPAH) trial was just published in the New England Journal in 2015.
    - They found a significant 28 day mortality benefit for prednisolone with an odds ratio of .61.
      - However, the mortality benefit was lost at 90 days and 1 year
    - On the other hand, pentoxifylline did not improve survival compared to placebo

Morning Report

AM Report 7/10/17 – Falciparum Malaria

July 10, 2017 vmcimchiefs Leave a comment

Most dangerous form of malaria – highest number of deaths
Transmitted by the female Anopheles mosquito (females feed on blood, males feed on nectar)
Most commonly seen along in Southeast Asia, Latin America, and Africa
Two phases – liver and RBC phase

Symptoms:
- Temperature paroxysms (alternating fevers and chills)
- Headache
- Diarrhea
- Jaundice
Considered severe infection if evidence of end organ damage (Falciparum is sticky and can cause ischemia and infarcts as the RBCs get more viscous!)
- Cerebral malaria – ischemia/infarcts in the brain
- ARDS
- Nephropathy
- Hypotension

Physical exam findings:
- Hepatomegaly (from the parasite replicating in the liver)
- Splenomegaly (from the spleen taking up the damaged RBCs)
- Pallor
- Jaundice and scleral icterus

Diagnosis:
- Thick and thin smears
  - Thick smears give a look at the RBCs in an overall sense to figure out if a parasite is present – are there parasites? If yes, look at thin smear.
  - Thin smears give a closer look at the TYPE of parasite – what type of parasite is it?
- Rapid detection test – blood test which looks at enzymes on the various parasites to determine the type – only available at certain hospitals

Treatment:
- Start immediately!
- Determined based on the type of plasmodium, whether the malaria is severe or not, and whether the organisms are from an area with high resistance
- Use 2-3 medications for treatment – consult ID immediately once you have a suspicion!

Prophylaxis
- Given to anyone going to an endemic area – start a few weeks before travel, continue during travel, and continue for some time after returning depending on the medication
- Wear long sleeves and pants
- Use DEET

House Points

June 30, 2017 – House Teal takes an early lead!

June 30, 2017 vmcimchiefs Leave a comment

With a strong showing at the intern scavenger hunt, Team Teal took 1st place, followed by Scarlet, and Gold. Check out the pics below!