http://stanfordmedicine25.stanford.edu/the25/nvwf.html for a good description of the jugular venous waveform

Great Discussion!

We went over a fascinating case of MSSA endocarditis in the setting of immunosuppression. Below are some of the clinical pearls:

1. Modified Duke Criteria for infective endocarditis

• Major criteria
  • Positive blood cultures
    • Typical microorganism from two separate blood culture
    • Single positive blood culture for Coxiella burnetii
    • Persistently positive blood cultures
  • Echocardiogram findings of vegetation
  • New valvular regurgitation
• Minor criteria
  • Predisposing heart condition or IVDU
  • Fever >38C
  • Vascular phenomena
    • Major arterial emboli
    • Septic pulmonary infarcts,
    • Mycotic aneurysm
    • intracranial hemorrhage
    • conjunctival hemorrhages
    • Janeway Lesions
  • Immunologic phenomena
    • glomerulonephritis
    • Osler nodes
    • Roth spots
    • Rheumatoid factor
• Clinical Diagnosis
  • 2 Major criteria OR
  • 1 major and 3 minor criteria OR
  • 5 minor criteria

2. Surgical Indications for treatment of endocarditis:

• Valve dysfunction causing heart failure
• Para-valvular involvement causing abscess, fistula or heart block
• Difficult to treat organisms (fungal)
• Persistent bacteremia
• Recurrent septic emboli with vegetations despite appropriate antibiotic therapy

3. Most common bacteria associated with endocarditis

• Viridans streptococci
• Staphylococcus (MRSA or MSSA)
• Enterococci

Thanks to Zach, one of the Stanford ophthalmology residents, for teaching us about the eye today at morning report! Here are some of the highlights:

• Eye Pain: Usually related to pathology with the ANTERIOR segment of the eye. If pain resolves with topical anesthetic, think about dry eyes/external irritant.
• Photophobia: Usually caused by ciliary body spasm
• Inflammation from outside to inside:
  • Blepharitis: Eyelid inflammation
  • Conjunctivitis: Bacterial/viral/allergic
  • Scleritis/Episcleritis: Can be associated with collagen vascular disease (RA common)
  • Keratitis: Corneal inflammation, HSV classic cause
  • Iritis: Inflammation of the Iris
  • Uvea = Ciliary body + Choroid + Iris
    • Anterior Uveitis
    • Posterior Uveitis
  • Retinitis: Pt’s may report flashing lights
• Retinal Detachment is classically described as a curtain over the eyes
• Cherry red spot is seen in central retinal artery occlusion 

Great session with our pulmonary critical care attendings Dr. Friedenberg and Dr. Gohil. This is our safe environment to practice rapid response/code scenarios and receive feedback which we do monthly. Thanks to everyone who participated!

Clinical Pearls: 

• ABCDEFG: ABCs…don’t ever forget glucose! Make sure to check the fingerstick glucose during codes. It’s quick, easy, and can save lives!
• During a code, no “air orders” and make sure to close the loop
• As the code leader, be concrete with your instructions and delegation of tasks
• Carry your code cards and take a look at the H’s and T’s when you are stuck
• Remember that patients who are altered and unable to protect their airways are not good candidates for BIPAP, these patients often just need intubation
• Post-intubation codes: Remember that sedation, hypotension from decreased preload/positive pressure ventilation, air-trapping from hyperventilation, and ventilator dysynchrony can lead to post-intubation code situations.

Clinical Pearls:

• Guillan-Barre Miller Fisher Variant: Classical triad is ophthalmoplegia, ataxia, areflexia but all three are not necessary. About 25% of these patients will have limb weakness. Additionally, you can see a descending paralysis rather than ascending paralysis.
• Romberg Test: Maintaining balance while standing requires 2 out of 3 of the following – Proprioception, vision, vestibular apparatus. Patient’s with cerebellar ataxia will generally be unable to balance with their eyes open so the Rhomberg’s test is not a test of cerebellar function.
• Albumino-cytologic dissociation on LP, preceding viral URI or Gastroenteritis, 30% Campylobacter
• TCA Toxicity can cause numbness, tingling, transaminitis, extrapyramidal symptoms, ataxia.