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!
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.
- 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
- Cameron lesions
- NSAID ulcer
- Common etiologies for obscure overt GI bleed
- Dieulafoy lesion
- Meckel’s diverticulum
- 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:
- HBV DNA >20,000IU/ml
- Treat HBeAg Negative patients if:
- HBV DNA >2,000IU/ml
A special thanks to the ID service for joining us today!
- Kernig and Brudinski’s sign (thanks to Dan for demonstrating!)
- PRES: Posterior Reversible Encephalopathy Syndrome presents as headaches, confusion, seizures, and visual loss often in the setting of elevated blood pressure. Thought to be secondary to problems in cerebral autoregulation. Associated with immunosuppression, renal failure, eclampsia, hypertension, lupus.
- Obtain a CT scan prior to an LP to evaluate for mass lesions that can cause brain herniation in the following patients:
- Age >60
- History of CNS disease
- Seizure within one week of presentation
- Empiric treatment for suspected bacterial meningitis includes Ceftriaxone (2gm IV q12 for CNS penetration), Vancomycin (resistant Strep pneumonia), and Ampicillin (immunocompromised and elderly patients for Listeria coverage, use Bactrim for penicillin allergies)
- Start IV Acyclovir to cover possible HSV meningitis/encephalitis. HSV-1 is associated with encephalitis while HSV-2 can cause recurrent aseptic meningitis (Mollaret’s meningitis).
- West Nile Virus
- Flavivirus which was first detected in the US in 1999, over 500 cases in California last year
- Asymptomatic in 80% of patients, symptomatic patients present with West Nile Fever (20%) or West Nile Neuroinvasive Disease (<1%)
- Can manifest with acute flaccid paralysis, extrapyramidal signs
- Detection of West Nile Virus IgM antibody in the CSF of symptomatic patients is diagnostic of West Nile Neuroinvasive Disease
- Serologic cross-reactivity with other flaviviruses can cause false-positives (for example recent Yellow Fever vaccination or dengue infection)
- Treatment of WNV is supportive
Nice work everyone! Thank you to Dr. Friedenberg and Dr. Gohil for running the case.
- Avoid Air Orders! Designate a “Code Leader” early on and stand at the head of the bed.
- For PEA, start CPR ASAP and go ahead and ask for 1mg of epinephrine
- During codes, make sure to ask for the Past Medical History, Medications, and Allergies.
- Start antibiotics early for neutropenic fever.
- Remember the sepsis core measures! If SBP < 90mmHg and/or MAP <65mmHg, recommend 30ml/kg of IVF bolus.
– Clinical presentation of platelet disorders vs factor disorder. Epistaxis and petechiae are more suggestive of platelet disorders. Factor deficiency is usually associated with larger bleeds such as hemoarthrosis.
– Palpable purpura….think Leukocytoclastic Vasculitis.
– Thrombocytopenia Framework: Decreased production, increased breakdown, sequestration, dilutional
– Treatment for APL is ATRA. Remember to consider ATRA differentiation syndrome which can present with pleural effusions, edema, shortness of breath, and fever. Treat ATRA differentiation syndrome with Prednisone.
– Causes of MAHA: DIC, TTP/HUS, malignant hypertension, mechanical valves, HELLP/Pre-eclampsia, Scleroderma renal crisis
– It is important to distinguish between TTP and DIC because the treatment is different. DIC – treat the underlying cause and supportive care. TTP – treat with Plasmapharesis.
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