Transcript Slide 1

AM Report 6/23/2010
Amy Auerbach
Q16: A 45 year old woman who has a 3-day history of
progressive earache and fever is hospitalized after becoming
unresponsive. Medical history is unremarkable; she has no
allergies and she takes no medications.
On physical examination on admission, temperature is 40
degrees celcius, HR=120, RR=32, BP=80/50. The patient is
obtunded and has meningismus. The leukocyte count is
25,000 with 25% band forms and the platelet count is 20,000.
Lumbar puncture is performed; CSF examination shows the
following:
Appearance: Cloudy
Leukocyte Count: 2500 with 99% neutrophils
Glucose:20
Protein: 230
Gram stain of CSF demonstrates gram positive diplococci.
a)
b)
c)
d)
e)
PCN plus dexamethasone
Ceftriaxone plus dexamethasone
Vancomycin plus dexamethasone
Vancomycin plus ceftriaxone plus dexamethasone
Vancomycin plus ceftriaxone
Bacterial Viral
TB
1000-5000 50-1000 50-300
WBC
count
Diff
PMN
Glu
<40
Pro
100-500
Lymph
>45
<200
Lymph
<45
50-300
Crytpo
20-500
Lymph
<40
>45
TREATMENT OF MENINGITIS
Age 2-50
S. pneumo, N.
meningitides
Vanc +3rd gen
cephalosporin
Age >50
S. pneumo, N. men,
Listeria, GN bacilli
Vanc +3rd gen
cephalosporin +
ampicillin
Basillar skull fracture
S. pneumo, H.influ,
group A strep
Vanc + 3rd gen
cephalosporin
Post-NSG or trauma
Staph, Gram negative: Vanc + either ceftaz,
Pseudomonas
cefepime, or
meropenem
CSF shunt
Staph aureus, CONS,
GNR
Vanc + either ceftaz,
cefepime, or
meropenem
Q9: A 42 year old woman has a one year history of progressive
fatigue without dyspnea, chest pain, or other systemic
symptoms. She sleeps well at night and does not have
features of sleep apnea. The patient has hypothyroidism,
managed with levothyroxine, and dysmenorrhea, treated with
an estrogen/progesterone combination.
On physical exam, the thyroid is slightly enlarged but
nontender. Xanthomas are present on the extensor surfaces.
Abdominal examination discloses mild hepatomegaly.
Lab Studies:
CBC: Normal
TSH: Normal
AST=25/ALT=32/AP=278
Total bilirubin=1.1
In addition to a fasting serum lipid profile, which of the
following studies would most likely establish a diagnosis?
a)
Antimitochondrial antibody assay
b)
Serum 25-hydroxyvitamin D
c)
ERCP
d)
Abdominal ultrasonography
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Often see xanthomas and elevated AP
Anti-mitochondrial antibody titer 1:40 or
more occur in >90% patients with PBC
Primarily in women between age 40-60
Also associated with metabolic bone disease,
hypercholesterolemia, and fat-soluble
vitamin deficiencies
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Inflammation, fibrosis and strictures of the
medium and large intra- and extrahepatic
biliary ducts
90% with PSC have underlying UC
5% prevalence in those with UC
Men> women 3:1
Increased risk of cholangiocarcinoma
About 50% +pANCA
Diagnose: ERCP or MRCP (“a string of beads”
pattern of intra- and extra- hepatic ducts)
Q 44. A 44 yo man with h/o nephrolithiasis requests nonpharmaceutical
interventions for stone prevention. His last symptomatic kidney stone
was 2 years ago. He does not recall the exact type of stone that he
formed but believes that it contained calcium. Previous labs have
showed normal renal function and normal levels of Ca, Phos and uric
acid. A plain abdominal X-ray performed 1 year ago revealed no GU
calcifications. He does not have a FH of nephrolithiasis but wishes to
reduce his chances of developing further kidney stones.
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In addition to increasing fluid intake to >2L/d, which of the following is
the best initial therapy for this patient?
A.
B.
C.
D.
Increase dietary calcium intake
Decrease dietary sources of citrate
Increase dietary animal protein intake
Increase dietary sodium intake
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Predominantly calcium, but also uric acid, struvite and cystine.
Fluid intake is key.
Risk factors:
◦ high sodium and protein intake and low calcium intake, low
fluid intake
◦ Hypercalciuria, hypocitraturia, hyperuricosuria,
hyperoxaluria
◦ Gout, obesity, RTA, sarcoidosis, primary hyperPTH,
medullary sponge kidney, horseshoe kidney, HIV/AIDs with
protease inhibitors, type 2 DM
◦ PCKD, Dent’s disease, cystinuria, primary hyperoxaluria
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Uric acid stones: radiolucent: cannot be seen
on XR (association- gout)
Calcium oxalate stones: Associated with low Ca
diet (lack of intestinal Ca available for oxalate
binding) and malabsorption syndromes that
increase oxalate absorption in the gut and
prolonged use of Abx that alter enteric flora
that degrade oxalate.
Staghorn calculi: associated with proteus or
klebsiella infection. Do NOT further alkalinize
with potassium citrate.
Q 99: A 38 y/o woman with hypertriglyceridemia is admitted to
the intensive care unit from the emergency department where
she presented with acute respiratory distress syndrome
associated with severe pancreatitis and required intubation,
Initially, her oxygenation had been adequate on FiO2=60%,
PEEP of 7cm H20 but her oxygen saturation dropped to the
low 80% level despite an increase in FI02 to 100%.
On physical exam, she is intubated; examination of the lungs
reveals diffuse crackles and rhonchi; cardiac examination is
normal except for tachycardia (HR=112); abdomen is very
tender with diminished bowel sounds; and she has 2+
peripheral edema. Chest radiograph shows diffuse bilateral
infiltrates. She is being ventilated with a “lung protective
strategy” using an assist/control mode with a tidal volume of
6mL/kg and plateau pressure of 25cm H20.
Which of the following strategies for positive endexpiratory pressure (PEEP) would be most appropriate
for this patient?
a)
PEEP should be increased in 2-3 cm increments to
lower FiO2 to at most 60% if possible, and maintain
an arterial oxygen saturation of >88% and <95%
b)
PEEP should be set below the lower inflection point
on a pressure volume curve of the lung
c)
PEEP should be set to correspond to the expiratory
pressure that minimizes compliance of the lung
d)
PEEP should be at least 14cm H2O and PEEP up to
20cm H2O for FiO2 of 0.5 to 0.8 as long as cardiac
output is monitored using a pulmonary artery
catheter
Type
PaO2/FiO2
CXR
Other
Acute Lung
Injury
<300
Bilateral
infiltrates
No CHF
Acute lung
failure
<300
Any infiltrates
No CHF
Acute
respiratory
distress
syndrome
<200
Bilateral
infiltrates
No CHF
Acute hypoxic
respiratory
failure
<200
Any finding
No COPD
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Studied in ARMA trial
Showed reduction in ARDS mortality from 40% to 30% with a low
(6ml/kg) rather than high (12ml/kg) tidal volume
Established "lung protective" ventilator strategies to avoid
ventilator-associated lung injury resulting from excessive
stretching of the lung during mechanical ventilation
ALVEOLI study showed no advantage of a higher PEEP compared
to a lower PEEP, both adjusted to maintain adequate oxygenation
Current recommendation is to use either a volume- or pressurelimited mode with a low tidal volume (6ml/kg) while monitoring
plateau pressure that should be kept <30cm H2O.
PaCO2 is allowed to rise if necessary to achieve these goals
(permissive hypercapnea) and PEEP is adjusted to maintain FiO2
<60% with SaO2 >88%
If hypoxemia persists, prone positioning or high frequency
oscillation are sometimes used, but no studies have yet
demonstrated improved outcomes
Q 68: A 22 year old woman is evaluated for a 12 month history of
gradually worsening low back stiffness that is present for 2
hours after awakening in the morning. She has significant
fatigue but no fever, chills, night sweats or weight loss. She
does not have pains in the peripheral joints but does have
bilateral buttock pain throughout the day with sitting. One year
ago, she also had a two week episode of uveitis of the right eye
which responded to corticosteroid eye drops.
On physical examination, vital signs are normal. She appears
healthy but walks with a mild forward bending of her spine.
Deep pressure and palpation of the lumbar spine in the midline
and both sacroiliac joints elicits tenderness. Chest expansion in
the fourth intercostal space is 2cm, and she can only reach the
midcalf region when touching her fingers to the floor.
On laboratory studies, hemoglobin is 12.5, ESR is 85, CRP is 5.
Which of the following conditions does this
patient most likely have?
a) Sacral fracture
b) Ankylosing spondylitis
c) Osteoarthritis
d) Metastatic cancer
Ankylosing Spondylitis: male predominance, fatigue, anemia,
elevated CRP
- Affects spine and sacroiliac joints
- Complications: cauda equina snydrome, restrictive lung
disease, aortic insufficiency due to aortitis
Reactive arthritis: 1-3 weeks after infectious event
originating in GU or GI tract
- HLA B27 present in 80% pts with this condition
- Commonly affects peripheral joints
Psoriatic arthritis: multiple presentations: ass with psoriasis,
skin involvement typically precedes joint inflammation
- Use same agents as for RA
Enteropathic arthritis: associated with Crohn’s or UCresembles RA, occ spondylitis
Q 34: A 28 y/o woman is evaluated for headache, unprovoked
diaphoresis, and episodic hypertension. Fractionated plasma
metanephrines are three times the upper limit of normal. A 24hour urine metanephrines excretion is fourt times the normal
excretion. The patient notes that her mother is undergoing a
similar evaluation and that her mother underwent parathyroid
surgery several years ago. Her maternal grandfather had
pheochromocytoma and medullary thyroid cancer.
Pheochromocytoma is confirmed in the patient.
A positive RET mutation in this patient would indicate the presence
of which of the following disorders?
a)
Multiple endocrine neoplasia type 2A
b)
Multiple endocrine neoplasia type 1
c)
Primary aldosteronism
d)
Polyglandular endocrinopathy
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MEN type 2a: Medullary thyroid carcinoma,
Hyperparathyroidism, pheomchromocytoma
MEN type 1: neoplastic transformation of
pituitary, parathyroids, endocrine pancreas
Valve Defect
Murmur
AS
Louder with
Heart
Sounds
General
Notes
SEM at RUSB, Squatting,
diamond
Expiration
shaped
Absent S2,
Parodoxicall
y split S2
Slowed
carotid
upstroke.
MS
Diastolic
ruble
Same as
above
S1 enhanced
Large a
wave, weak y
descent
VSD
Holosystolic
at LLSB
Handgrip
ASD
SEM at LSB
Fixed split
S2.
O-Primum:
LAD, RBBB
OSecundum:
From P. Vidwan’s 2008 Cards Presentation RAD, RBBB
Post MI with
new murmur
BBB, no
prophylaxis
Abx for
ostium
secundum.
Look for AV
block with
Q 117:
42 y/o male with non-pruritic, non-painful spreading rash
Been outdoors and getting tan
OTC corticosteroid cream ineffective
On simvastatin for hyperlipidemia only
Labs:
Cholesterol level: 190 with LDL=110
Direct microscopy of skin: Large, blunt hyphae and thick-walled budding
spores in a “spaghetti and meatballs” pattern. LFTs are normal.
Which of the following is the most appropriate treatment?
a) Oral terbinafine
b) Oral itraconazole
c) Topical triamcinolone
d) Topical ketoconazole
e) Oral griseofulvin
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Ketoconazole for tinea versicolor: two weeks
and continuation of therapy at least one week
after resolution of symptoms
Griseofulvin, terbinafine, or itraconazole can
be used with tinea barbae: monitor liver
function in patients with hepatic impairment
or with prolonged therapy
Treat oncychomycosis in patients with PVD or
diabetes to prevent development of cellulitis
• 30 yr man
• Lifelong epistaxis + easy bruising
• Tooth extraction – bleeding for several days
• Adopted
• Hbg 13.0; MCV 78; plts. 250,000
• BT 13.5 min; PT 12 sec; aPTT 40 sec; TCT normal
• Platelet aggregation study normal
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1% of the population
Bruising and mucosal bleeding (after
extractions)
• Dx:
 von Willebrand factor activity
 factor VIII
 bleeding time, PFA100
von Willebrand factor multimers