Anh Đức Blog: Case 30 39.html

30/ Location: Emergency room . C.C: Chest pain Vitals: Blood pressure: 130/80 mm Hg; Heart rate: 82/minute; Temperature: 38.7 C; Respiratory rate: 16/minute

HPI: A 47-year-old white male who has a past medical history significant for two years of hypertension presented to your office with the chief complaint of chest pain of one day duration. The patient states that he had a flu-like illness with nasal congestion and mild cough one week ago, which resolved with symptomatic treatment without antibiotics. The patient states that the chest pain has been occurring for the past 24 hours, is primarily retrosternal, increases in intensity with inspiration, and is relieved by sitting up and leaning forward. He says that the pain is 4-5/10 in severity and radiates to back and both arms. For the last two days, the patient has been feeling febrile but he denies any nausea, vomiting, or abdominal pain. He denies any history of shortness of breath, orthopnea, or PND. He has been on a low salt diet and hydrochlorothiazide 25 mg PO BID for his hypertension. His past medical history is significant for the flu-like illness three weeks ago and hypertension for the past two years. FH: Father had an MI at 60. SH: He smokes one to two packs of cigarettes per day. He occasionally drinks alcohol, especially on the weekends. All: He has no known allergies.

Based on this history, how would you approach this patient? This is a presentation of acute pericarditis. Severe constant pain that localizes over the anterior chest, radiates to the arm, shoulder, back, epigastrium or neck, is intensified with inspiration, and relieved by sitting up and leaning forward is a classic picture of acute pericarditis. The pain is often difficult to differentiate from myocardial infarction because often the pain is very severe, short, and sometimes a very constricting pain that radiates either to one or both arms. However, pain which is relieved by sitting up and leaning forward and is intensified by inspiration or lying supine is characteristic of acute pericarditis. Acute pericarditis has a very broad differential diagnosis. The causes are primarily infectious, noninfectious or secondary to hypersensitivity or autoimmunity. The most common infectious causes are Coxsackie virus A and B, mumps, adeno, hepatitis, and HIV. The other common infectious causes are usually pyogenic for example: Pneumococcus, Streptococcus, Staphylococcus, Listeria, and Legionella. Tuberculosis can also cause pericarditis but it is usually of chronic origin rather than acute. In those patients the pain is less severe or absent. Fungal infections such as histoplasmosis, coccideal mycosis, candida, and blastomycosis, have been known to cause pericarditis. The most common noninfectious causes of acute pericarditis are: acute myocardial infarction; renal failure resulting in uremia; neoplastic disorders which infiltrate the pericardium such as breast cancer, lymphomas, and leukemia; endocrine abnormalities (hypothyroidism or myxedema); and radiation. Pericarditis could also be due to autoimmunity or hypersensitivity reactions. This is especially true with rheumatic fever, collagen vascular diseases such as SLE, rheumatoid arthritis, ankylosin! g spondylitis, or scleroderma. Acute pericarditis may be due to drug toxicity, especially hydralazine, procainamide, and minoxidil. Other common causes of pericarditis are postmyocardial infarction (also called Dressler ' s syndrome), post pericardiotomy, posttraumatic or cardiovascular surgery.

1-Start with a focused physical examination. General examination HEENT/Neck Heart Lungs Abdomen Extremities Skin

Here are the results: The general examination shows that the patient is alert, awake, and oriented times three. The patient is in pain but not in any acute distress. His heart examination revealed normal S-1, S-2. There is a pericardial friction rub present, but there are no murmurs. Lung examination is within normal limits. Abdominal is benign. Extremities are within normal limits.

2-How would you approach this patient now?

Begin by ruling out myocardial infarction.

Pulse oximetry, stat

Oxygen inhalation, stat

IV access, stat

Cardiac monitor, stat

Results: 98% on room air

Order:

12 lead EKG, stat

Chest X-ray, PA and lateral, stat

CK-MB, stat and repeat in 8 hours x 2 – Troponin I, stat and repeat in 8 hours x 2

CBC with a differential, stat

BMP, stat (elevated BUN or creatinine may reveals the underlying uremia as the cause of acute pericarditis.)

ESR, stat

Blood cultures, stat

Aspirin, oral, stat, one time

Ok here are the results: CBC with differential shows mild leukocytosis with a WBC count of 12,000 with 2% bands and 50% polymorphs. There is a mild lymphocytosis. ESR is elevated to 40. The BMP reveals normal electrolytes, BUN, and creatinine. The CK is mildly elevated at 300 but MB is normal. Troponin I is normal. The CXR shows cardiac enlargement, an indication that fluid has collected. The classic findings of pericarditis on EKG are: Diffuse ST segment elevation with upward concavity at J point. No new Q waves PR segment elevation in aVR with PR depressions in other leads.

3-Now, how would you approach this patient?

The presence of above clinical, EKG, and other lab findings strongly suggest that this patient has acute pericarditis.

The following approach is recommended to all patients presenting with signs and symptoms of acute pericarditis in whom there is no apparent cause such as clear URI, uremia, post myocardial infarction, or prior cardiac surgery. (If you can't identify a cause, then do these tests: Order antinuclear antibody titer, tuberculin skin test, and HIV serology.

Obtain blood cultures in febrile patients.

Routine viral cultures are not indicated as the yield is low and it doesn’t affect the management.

Echocardiography is indicated in the following

1. If tamponade or purulent pericarditis are suspected

2. CXR shows cardiomegaly

3. If there is concern about myocarditis

4-After the diagnosis is made, treatment is usually symptomatic. The treatment of choice is aspirin or other NSAID. The primary goal of therapy is to provide prompt pain relief. These agents do not alter the course of the disease. Corticosteroids should not be used unless the patient is clearly refractory to NSAID’s and all the possible causes for the pericarditis has been excluded.

Tapping is indicated in:

1. Febrile patient with pericardial effusion.

2. Persistent symptomatic pleural effusion. Fluid should be sent for gram stain, culture, sensitivity and cell count.

Antibiotics are indicated for suspected bacterial infection.

Review orders:

Admit to floor Regular diet Ambulate at will Vitals Q 4 hours

Echocardiogram, stat

Telemetry

· Indomethacin, oral, continuous

D/C Oxygen

Once the echo is clear (small fluid) i.e. no evidence of tamponade

Reassurance

Patient counseling No smoking No alcohol Seat belt use Safe sex Regular exercise

D/C to home Follow up appointment in two weeks

Primary diagnosis Acute pericarditis

31/ Location: Emergency room C.C: Pain and swelling in the right lower extremity Vitals: Temperature is 39.5 0 C, H.R 110/minute and regular, B.P – 110/64 mmHg, Respiratory rate 22/minute.

HPI: A 62-year-old white male with a past medical history significant for poorly controlled diabetes mellitus type II presents to your office with a three-day history of painful swollen, right lower leg. The patient reports that he has had an ulcer on the anterior aspect of the right lower extremity for two months but did not seek medical attention because it was not painful and had no discharge. There has been no increase in the size of the ulcer, but for the last two to three days the patient has been having a moderate to severe throbbing pain. This morning he noticed fever, chills, rigors, increased redness, and swelling . The patient denies any trauma, nausea or vomiting, bowel or bladder dysfunction. He has no history of peripheral vascular disease. The patient has not been exposed to salt water and has not eaten crustaceans or shellfish. He has no allergies. Family History: Mom had a heart attack. Dad had a stroke. He denies any smoking, alcohol or IV drug abuse. ROS are unremarkable. PMH: Type 2 diabetes mellitus treated with diet modification and oral hypoglycemics. He has no history of hospitalizations. He takes metformin 500 mg twice daily.

1-How do you approach this patient?

First do physical examination General HEENT /Neck Lungs Heart Abdomen

Extremities

Skin

Lower extremity motor and sensory exam

Here are the results of the examination:

General exam showed patient is alert, awake, and oriented x 3. He looks very ill and is in moderate to severe leg pain. HEENT, heart, lungs and abdomen are all within normal limits. Extremities: There is diffuse erythema and swelling of the right lower leg from below the knee down to the metatarsal joints. A small 2-3 cm ulcer with a pustular base is noted on the shin. Bullae are present but there is no demonstrable crepitus or discharge. The area is very tender. Peripheral pulses are intact.

2- Review Orders:

· Pulse oxy, stat

IV access

IV NS, continuous

· Admit in medicine floor/ward Vitals Q 4 hours Bed rest with leg elevation NPO except medications (as he may require surgery if there is any evidence of gangrene)

· CBC with differential, stat

Basic metabolic profile, stat

· Plain X-ray of the leg, stat

Blood cultures x 2, stat

Gram stain and culture of the aspirated material and the wound swabs

· HBA1C, routine Accu checks, 2 – 3 times daily

D/C metformin Sliding scale insulin (Type ‘regular insulin’)

3- Once the blood cultures are obtained, start:

· Clindamycin, IV Q 8 hours

Ciprofloxacin, IV Q 12 hours

Analgesia, stat and prn Acetaminophen, stat and Q 6hours prn 1gram

· Daily CBC with diff and BMP

Check the patient ' s leg, (Interval history and physical) every 4 hours until you see improvement

· D/C NPO if there is no need of surgical intervention

Start diabetic diet

Here are the results: CBC revealed a WBC of 15,000 with 85% polymorphonuclear cells and 10% bands. Basic metabolic profile is normal except for blood sugar of 346. Plain X-ray of the leg shows soft tissue swelling. No evidence of gas, abscess, or bone infection is noted. Blood and wound cultures are pending.

Order review:

We usually give at least two days of IV antibiotics.

· Switch to Ciprofloxacin PO BID and Clindamycin po TID

D/C IV fluids

D/C sliding scale insulin

D/C Accu checks TID

· Accu checks BID

Patient education

Diabetic diet Regular exercise Weight reduction (if obese)

Restart metformin Medication compliance

Diabetic foot care

D/C to home

Follow up appointment in 2 weeks

Discussion: Cellulitis is primarily a clinical diagnosis. In most of the patients blood cultures, wound cultures, and skin biopsy specimens do not provide microbial etiology. So, in general we do not recommend any of the above-mentioned cultures.

However, blood cultures are indicated in the following circumstances Patients who appears toxic. 1. Failure to respond to initial antibiotic regimen 2. Patients with recurrent infections 3. We usually do not recommend/ perform streptococcal serologies. The patient should be admitted to the general medicine service for treatment of cellulitis and uncontrolled diabetes mellitus. This patient has bullae without crepitance.

Empirically, give a broad-spectrum antibiotic to cover gram-positive and gram-negative as well as anaerobic organisms. The best combination of drugs is ciprofloxacin and clindamycin (based on our clinical experience), or third generation cephalosporins like ceftriaxone. Clindamycin is affective in treating beta-hemolytic streptococci and S. aureus infections. In contrast to beta-lactam antibiotics, clindamycin has a unique property of preventing toxin production. IV nafcillin or cefazolin are the drugs of choice for staphylococcal or beta hemolytic streptococcus infections. Vancomycin can be given in patients with penicillin allergy and isolates of methicillin resistant S. aureus. If the gram stain shows gram-negative rods then the most likely organism is E. coli. The treatment of choice is IV ceftriaxone.

A diabetic patient who has chronic non-healing plantar foot ulcers usually requires broad-spectrum antibiotics to cover gram positives, gram negatives, and anaerobes. Cultures should be obtained in all patients. Ampicillin and sulbactam and imipenem are the drugs of choice.

Usually, within the first ten days of osteomyelitis, a plain X-ray of the bone is negative. However, this does not rule out osteomyelitis. A technetium bone scan is a more sensitive test and it will detect osteomyelitis in the earlier stages. IV antibiotics should be continued for six-eight weeks for cases of osteomyelitis.

If the infection is extensive and there are areas of necrotic skin or tissue, surgical debridement may be necessary . In diabetic patients, osteomyelitis can be due to atypical organisms such as gram-negative bacilli like Pseudomonas or E. coli. Therefore, administer antibiotics that cover Pseudomonas (ciprofloxacin, IV ceftazidime, or piperacillin). The patient’s extremities should be immobilized for severe pain or for joint instability. Hyperbaric oxygen can be used if an anaerobic infection is suspected or if the blood cultures grow anaerobic organisms.

Primary Diagnosis Cellulitis

32/ Location: A 29-year-old female presents with 7 day H/O dry cough and breathlessness. Vitals: B.P 130/75 mm Hg, Pulse 92/min, regular, Temp 99.9F, R.R 24/min, Height: 70 inches (175 cm), Weight: 65 Kg (143 lbs)

HPI: A 29-year-old white female presents with the complaints of a dry cough and breathlessness for the last one week. Her other complaints are weight loss of 15 lbs over the last few months and low-grade fever for the last few weeks. There is no personal or family history of asthma or other atopic disorder. She is not taking any prescribed or recreational drugs. She has been sexually active with multiple male and female partners for the last several years and does not use any barrier or other method of contraceptive. She has never been tested for HIV. She was once treated for gonorrhea. She has no known allergies. Her vaccinations are up-to-date. FH: Father died at the age of 70 yrs due to MI. Mother is diabetic. SH: She is a widow as of the last five years and has many boyfriends. She is a waitress in a restaurant. She likes parties and traveling. She is a non-smoker but drinks alcohol heavily. ROS: she has no previous history of STD or UTI. Denies chest pain, expectoration, hemoptysis, orthopnea or PND. Rest of the ROS are unremarkable.

How do you approach this case? Her symptoms of dry cough, dyspnea, and low-grade fever indicate lung infection. Her high-risk sexual behavior puts her at an increased risk for HIV. A lung infection might be some opportunistic infection of AIDS. There fore, we will do a complete physical examination of this patient with special attention to the respiratory system. We will also do staining and culture of expectorated or induced sputum and chest radiography for her lung infection. Her high-risk sexual behavior is an indication of HIV testing which is done after getting informed consent from the patient.

1- ORDER: Any suspected HIV/AIDS patient should have a complete physical exam. Complete physical examination

RESULT OF PE: Lung examination is significant for scattered rhonchi and crackles. Otherwise, the rest of the physical exam is within normal limits.

2-LABS:

Pulse oxy, stat

ABG is indicated if the patient is having hypoxemia or significant respiratory distress

CBC with differential, routine

Basic metabolic panel, routine

Gram staining and culture of sputum, routine

Methenamine silver staining of induced sputum (Wright-Giemsa stain or direct fluorescent antibody (DFA) for Pneumocystis if PCP is strongly suspected)

Acid-fast staining of sputum

CXR-PA and lateral view, routine

HIV testing by ELISA

RESULTS OF LABS: CBC shows Leukocytosis BMP is within normal limits Gram staining and culture of sputum is negative. Acid-fast staining of sputum is negative CXR shows diffuse bilateral interstitial infiltrates Silver staining is positive for PCP

HIV testing is positive

DISCUSSION: Pulmonary infections in HIV patients has broad differential diagnosis. Suspect bacterial infection if an HIV patient presents with acute onset, high-grade fever, and pleural effusion. Pneumococcus is the MC organism. Mycobacterium tuberculosis: Patients presents with chronic cough, fever and weight loss. Disseminated fungal infection: Miliary pattern or nodular infiltrates on chest X-ray. Kaposi sarcoma: Present with mild a cough and chest X-ray shows pulmonary nodules. Pneumocystis carinii pneumonia presents with dry cough and dyspnea; pleural effusion is not a feature. PCP is confirmed by silver staining or direct fluorescent antibody of induced sputum. If sputum induction is nondiagnostic or cannot be performed, then fiberoptic bronchoscopy with bronchoalveolar lavage (BAL) is recommended, with or without a transbronchial biopsy.

Repeatedly positive ELISA should be confirmed with western blot to make the diagnosis of HIV. PCP is often associated with CD4 count of less than 200 cells/mm3 and an elevated lactate dehydrogenase level (LDH). The TMP-SMX remains the initial drug of choice. Mild PCP is treated oral trimethoprim-sulfamethoxazole. Patients with severe pneumonia or those who cannot tolerate the drug orally should receive intravenous therapy. High-dose therapy is associated with hyperkalemia (Trimethoprim acts as a potassium sparing diuretic).

When to use steroids? Corticosteroids along with TMP-SMX have significantly decreased the mortality associated with PCP, when used in moderate to severe cases of PCP. It is used when a Pa O 2 is 70 mmHg or less, and/or an A-a O 2 gradient of 35 mmHg or more on room air

When to admit the patient?

Mild-to-moderate disease – Patients are usually have milder symptoms and nontoxic in appearance. They are not hypoxic; CXR may even be a normal. Outpatient TMP-SMX is the treatment of choice.

Moderate-to-severe disease – Patients presents with severe respiratory distress, and hypoxemia. CXR may be markedly abnormal. Inpatient management with IV TMP-SMX should be considered. Admit patient to ward for moderate to severe disease (ICU if patient unstable).

3- ORDER REVIEW:

ABG, stat

LDH, routine

Western blot testing for HIV

TMP-SMX, PO (use IV if hypoxemia is present)

RESULTS: PaO2 is 77mmHg Positive western blot for HIV

DISCUSSION: Once the diagnosis of HIV infection has been established, CD 4 count and viral load should be measured to assess the severity of the disease and rate of progression. All HIV patients should get the following investigations: CBC with diff, at the time of diagnosis and for every 3-6 month intervals (30-40 % of HIV patients will have anemia, leukopenia, lymphopenia, and thrombocytopenia) SMA 12 should be obtained initially as it will be useful as baseline. Yearly VDRL or RPR – Because of high association of coinfection All patients should be checked for hepatitis serology, which include HBsAg, anti-HBc, and anti-HCV. Toxoplasma serology is useful to begin prophylaxis and to differentiate it from other neurological complications. The CDC recommends routine testing with PPD initially and annually in high risk patients if the initial test is negative. CDC recommends a PAP smear at the time of diagnosis and every 6 months to one year thereafter. Influenza and Pneumococcal vaccine should be given to all HIV patients. Antiretroviral therapy is started in HIV-infected patients if the CD4 count is less than 500 ( some say less than 350) or viral load by PCR greater than 20,000 copies/ml.

4- ORDER REVIEW:

CD4 count

PCR for HIV RNA

LFTs

PPD testing

Anti-HCV HBsAg Anti-HBc

Toxoplasma serology, serum

Pap smear

Influenza vaccine Pneumococcal vaccine

Zidovudine, oral Didanosine, oral Indinavir, oral

Medication compliance

Counsel about limit alcohol intake and safe sex practices

HIV support group

Report positive result to Department of Health and Human services

Regular follow up visits

5-PRIMARY DIAGNOSIS: PCP

34/ Location: Office A 50-year-old man presents with 10-day H/O constipation, extreme weakness. Vitals: B.P 138/80 mm Hg, Pulse 80/min, regular, R.R 22/min, Temp 98.6 F, Weight: 50 Kg, Height: 160 cm

HPI: A 50-year-old white male presents with 10 day H/o constipation. He has been having abdominal discomfort and feeling nauseated. He says he has been experiencing fatigue for the past few months but from the past few days he is having severe weakness. He feels that he doesn ' t have the energy to carry out the routine activities. He complaints of weight loss for the last 4 months. His other complaints are increased urinary frequency, persistent right flank discomfort and on & off night sweats for the last 2 months. Recently, he started using over-the-counter vitamin supplements. He hasn ' t had feelings of anhedonia, guilt, suicidal thoughts, or lack of concentration. Nor has he complained of cold intolerance, diarrhea or polyphagia. He never had jaundice. He was never admitted in the hospital. He has no known allergies. He takes acetaminophen for headaches. FH: Mother died at the age of 56 due to CVA. Father alive and healthy at the age of 65 yrs, he has diabetes and hypertension. SH: The patient has been married for 20 years and has no kids. He has been smoking 20 cigarettes for the last 20 years and drinks alcohol on weekends. He is sexually active in a monogamous relationship with his wife. ROS: There is no blood in the urine, hesitancy, dysuria, or urethral discharge. He has complaints of persistent flank discomfort the last two months. The rest of the ROS are unremarkable.

1-How do you approach this patient?

This 50 yr old, known smoker presents with several months H/O constitutional symptoms, extreme fatigue, constipation, frequency of urination, and persistent right flank discomfort. So, the most important thing to rule out in this patient is malignancy.

Order physical exam: Complete physical examination

Here are the results: The patient is looking ill and pallor. He is in no obvious discomfort. No lymph nodes are palpable. Lungs and heart are clear to auscultation. Abdomen: Bowel sounds are diminished. No abdominal tenderness. Right flank discomfort is noted with deep palpation. No organomegaly. No masses palpable. No shifting dullness or fluid thrill. Genitals: No masses, rash or ulcer. Rectal exam: Sphincter tone normal, No tenderness, and no ulcer. Prostate not enlarged. Stool color brown. No occult blood.

2-Order:

CBC with differential, stat

Basic metabolic panel, stat

LFTs, stat

U/A, stat

Here are the results: CBC showed HB of 9, MCV of 88. BMP showed calcium of 20 mg/dL, BUN of 60 and creatinine of 2.3. LFTs are WNL U/A showed moderate amount of blood.

3-Discussion: Constipation is the MC GI complaint n patients with hypercalcemia.

Differential diagnosis of hypercalcemia is very broad. However, upto 90% of the cases belong to primary hyperparathyroidism and cancer. Primary hyperparathyroidism is the most frequent cause in ambulatory patients. The degree of hypercalcemia provides useful diagnostic clues. Hypercalcemia in primary hyperparathyroidism is mild (often <11 mg/dL) while it is more marked in cases of malignancy (>13 mg/dL).

Careful history taking and examination and a few lab tests are usually sufficient to establish the cause of hypercalcemia.

These tests include chest x-ray (for malignancy or sarcoidosis), serum protein electrophoresis (M. Myeloma) and intact serum PTH assay. Because of the higher incidence of associated hyperparathyroidism in patients with malignancy it is reasonable to obtain an intact PTH even in a patient with known malignancy.

Review orders:

Admit the patient in ward/floor (2 reasons 1. For the treatment of hypercalcemia with IVNS, 2. Workup for the underlying cause of his hypercalcemia)

IV access

IV NS, bolus (2 liters) (Please do not give diuretics without prior hydration; We have treated a Ca of 24 without giving any diuretics)

IV NS, 150 cc/hr, continuous

Serum ferritin, routine

TIBC, routine

Serum iron levels, routine

Repeat BMP next morning

PTH intact, routine

SPEP serum protein electrophoresis

Serum alkaline phosphatase

Chest – X ray, routine (PA view)

USG of the abdomen

Review orders:

CT of the abdomen and chest (If the USG showed renal mass suspicious for malignancy). Do not give IV contrast if the renal function is not improved with IV fluids. To give the contrast creatinine should be <1.5.

Bone scan (If the alkaline phosphatase is elevated)

Monitor serum calcium level every day and adjust the IV NS

Consult oncology

Discussion:

Hyperparathyroidism should be suspected in any patient with the following features: Family history of hyperparathyroidism Family or personal H/O MEN (multiple endocrine neoplasia) syndromes H/O pancreatitis Prolonged asymptomatic hypercalcemia

This patient is most likely having renal cell carcinoma. Bladder cancer is usually associated with irritative voiding symptoms and hematuria.

Renal cell carcinoma is often associated with paraneoplastic symptoms. Constitutional symptoms include fever, anorexia, weight loss are common and should make the physician think about malignancy. Moderate to severe anemia is common. Iron studies usually reveal anemia of chronic disease.

Hepatic dysfunction is commonly seen in patients with renal cell carcinoma even without hepatic metastasis (termed Stauffer’s syndrome).Nephrectomy usually relieves the hepatic dysfunction, but persistent or recurrent dysfunction indicates local recurrence or metastatic disease.

Long-acting bisphosphonates, such as pamidronate or zolendronate, are the drugs of choice for the treatment of hypercalcemia. They have also shown a reduction in bony metastases and an improvement in survival.

One the diagnosis of renal cell carcinoma id made the next step is to evaluate the presence/extent extra renal disease. Ct of the chest and abdomen is part of the routine staging procedure. Bone scan is indicated if the patient has elevated alkaline phosphatase or complains of bone pain.

Criteria using the size of the tumors to differentiate between benign and malignant tumors are no longer used. Histological criteria should be used to confirm the diagnosis. Biopsy of the metastatic lesion is the preferred way of obtaining histologic diagnosis. However, if there is an isolated, solid resectable renal mass is present complete or partial nephrectomy is the preferred way of making the diagnosis and treatment.

Preoperative needle biopsies are not recommended in a patient with resectable tumors because of the risk of peritoneal seeding.

Primary Diagnosis RCC

35/ Location: Office C.C: Vaginal discharge Vitals: BP 130/70 mm Hg, HR 76/min, RR 18/min, and Temperature is 36.8C.

HPI: A 39-yr old Caucasian female presents to your office with a 1-week history of foul smelling vaginal discharge. She also complains of pruritus of vulva. She denies any abdominal pain, nausea, vomiting, or fever. She also denies any vaginal bleeding. Her only medications are inhaled betamethasone and albuterol for bronchial asthma. She had a similar problem 6 months ago and it went away after applying over-the-counter antifungal cream. She doesn ' t use any other medications. Her appetite, bowel movements, and bladder functions are not affected. She is not allergic to anything. FH: Mother has diabetes and father has hypertension. SH: She doesn ' t smoke or drink. She has never used recreational drugs. GYN: She is G2 P2 and her LMP was 25 days ago. She is sexually active with her husband only. He’s had a vasectomy. She had her PAP smear one and half years ago.

1- How do you approach this case?

Order physical exam: Abdomen Pelvic exam Extremities

Here are the results? Pelvic examination reveals curdy white discharge with white patches along the vaginal walls. There is a significant erythema noted over the vulva. There is no uterine or adnexal tenderness. No cervical discharge is noted. The rest of the examination is within normal limits.

2-What would be your approach? Based on the inflammatory findings this patient has vaginitis. This could be due to Candida (most likely), or Trichomonas (very less likely). Vaginosis (no inflammation) is very unlikely with the signs of inflammation. You have to keep in mind that there may be a coexistent vaginosis, especially in a patient with a recurrent infection. One more thing that we can say at this stage is that the chance of PID is also very unlikely without adnexal or uterine tenderness and cervical discharge.

Order:

Vaginal PH

Wet mount preparation (Saline + KOH)

Gram staining of discharge

Pap smear, routine

GC, culture Chlamydia, culture

CBC with differ

U/A

Workup:

All patients presents with vaginal discharge should have vaginal pH measurement. This is the single most important test that differentiates candida form the other 2 common infections. A pH above 4.5 suggests bacterial vaginosis or trichomoniasis, and excludes candida vulvovaginitis. Wet mount preparation with saline and KOH (destroys cellular elements) should be ordered on all patients. Saline microscopy is helpful in identifying candidal hyphae, motile trichomonads, clue cells (epithelial cells studded with adherent coccobacilli), and PMNs. Culture for candida and trichomonas is usually not indicated unless the microscopy is negative.

Cervical culture for Neisseria gonorrhoeae or Chlamydia trachomatis, must always be performed in any women with purulent vaginal discharge.

Patients with high-risk sexual behavior should have screening for syphilis, HIV, hepatitis B, and other STDs.

Candidiasis: Diagnosis: White curdy patches with inflammatory signs on exam. Mycelia on KOH preparation. Presence of inflammatory cells on Gram stain. Treatment: Miconazole / Clotrimazole suppositories or vaginal cream for 2 weeks. If no response give a single oral dose of oral fluconazole.

Trichomonas vaginalis: Patents usually present with purulent, malodorous, thin greenish frothy vaginal discharge with associated burning, pruritus, dysuria, and dyspareunia. Physical examination reveals inflammatory signs (erythema of the vulva and vaginal mucosa). In 2% of patients punctate hemorrhages may be visible on the vagina and cervix. Treatment: Non pregnant – Metronidazole 500 mg BD for 7 days (or) 2 gm single dose. Pregnant – 1 st TM – Clindamycin cream; 2 nd – 3 rd TM – again metronidazole. Many physicians are now using metronidazole in 1st TM also, as CDC no longer discourages its use in 1st TM. Advice: Patients should be advised not to drink alcohol (at least 48 hours) because of a disulfiram-like (Antabuse effect) reaction with metronidazole. Treatment is required for partner. Safe sex.

Bacterial vaginosis: Diagnosis is made by: “Fishy smelling” discharge especially after unprotected intercourse. Clue cells (epithelial cells studded with bacteria) on saline wet mount. Positive whiff-amine test – The presence of a fishy odor when 10 % KOH is added to vaginal discharge samples. No inflammatory signs on examination. No inflammatory cells on the Gram stain smear. Treatment: The treatment of choice is 500 mg twice daily for 7 days. Topical vaginal therapy with metronidazole gel for 5 days is as effective as oral metronidazole. The use of single-dose therapy with 2 g of metronidazole is controversial, as it has shown a higher rate of relapse is some studies. There is no need to treat partner.

Advise to all the above patients:

Patient education Safe sex No alcohol No smoking No recreational drugs

Pap smear annually

Annual mammogram from the age of 50 yrs

Annual FOBT and colonoscopy for every 10 years from the age of 50 yrs

Lipid profile for every 5 yrs from the age of 20 yrs

Primary Diagnosis Candida Vagnitis

36/ Location: Office C.C: High blood pressure is noted in a 55 year-old male patient during his routine medical check-up. Vitals: Pulse: 72/min; B.P.160/95 mm Hg; Temp. 98.5 0 F; R.R: 17/min.

HPI: A 55-year-old white male comes to the doctor ' s office for his routine medical check-up which shows high blood pressure. He denies any headache, chest pain, shortness of breath, palpitations, leg swelling, dizziness, or syncope. His bowel movements are regular and his bladder function is good. He has no other complaints. He has no known allergies. He is not taking any medication. For the last 25 years he has smoked 10 cigarettes per day. He drinks alcohol occasionally and does not use illegal drugs. He is sexually active with his wife. FH: Father died at the age of 50 due to MI. Mother is 85, alive, and healthy. The rest of his ROS are unremarkable.

1-How would you approach this case?

Diagnosis of HTN is made when high blood pressure is confirmed on three separate occasions. Once the diagnosis has been made, one should determine cardiovascular risk factors, cause of HTN (secondary and curable causes), and target organ damage. Physical examination: It is done to find out the cause of HTN and to assess the target organ damage. Ophthalmoscopy, palpation of pulses, and abdominal examination for bruits provide useful information.

Order: Complete physical examination (Because the patient is stable and needs an assessment for end-organ damage).

Results of your examination: Complete physical examination is within normal limits.

2-Therefore, order the following tests and ask the patient to return in one week for reevaluation of his BP. When evidence of end-organ damage is found on examination, start antihypertensive therapy immediately.

Laboratory testing: All patients who are found to have hypertension should have routine hematocrit, urinalysis, lipid profile, 12-lead EKG, serum electrolytes, serum creatinine, and blood glucose. Other tests are indicated only in certain settings. Ambulatory blood pressure monitoring is required when blood pressure readings in the office setting are high and they are normal in ambulatory settings. Limited echocardiography (more cost effective than complete echocardiogram) may be performed to detect left ventricular hypertrophy when blood pressure values are borderline. Plasma renin activity is determined when primary hyperaldosteronism is suspected (unexplained hypokalemia). Workup up for renovascular hypertension is performed when history is suggestive and when corrective measures are being considered. Intra-arterial digital subtraction angiogram or spiral CT can be used for this purpose. Thus we will perform the following examination and lab testing in this patient.

3-LABS:

CBC, routine (no need of differential)

BMP, routine

Urinalysis, routine

Lipid profile, routine

EKG, 12 lead, routine

Follow up visit in one week

The patient returns one week later with lab results, which are all normal.

Repeated blood pressure measurements, both at home and office over a period of two months, shows stage-1 HTN. A diagnosis of essential HTN is made. Essential HTN is not associated with end-organ damage in this case.

4-DISCUSSION: Non-pharmacologic measures should be advised to all patients for the treatment of HTN. These measures include regular exercise, weight reduction, reduced salt intake, and avoidance of excessive alcohol.

· Definitions: Blood pressure and hypertension are classified as follows:

Optimal blood pressure: systolic <120 mmHg and diastolic <80

Normal blood pressure: systolic 120-129 and diastolic 80-84

High-normal blood pressure: systolic 130-139 or diastolic 85-89

Hypertension: Stage 1: systolic 140-159 or diastolic 90-99

Stage 2: systolic 160-179 or diastolic 100-109

Stage 3: systolic >180 or diastolic >110

Recommendations:

· Borderline or high-normal blood pressure: They are treated with non-pharmacological measures and their blood pressure tested every year unless they have DM, target organ damage, or CVS disease.

· Stage 1: Nonpharmacological measures should be tried initially for up to 12 months (if no other risk factors are present) or 6 months (presence of other cardiovascular risk factors except DM). Treatment with antihypertensive drugs is indicated when there is associated end-organ damage, diabetes, or other vascular risk factors.

· Stage 2 and 3: Patients should be started on pharmacological therapy immediately.

General approach:

· Recommended approach for the pharmacological therapy of HTN is to start with either thiazides or beta-blockers. If low-dose thaizide is not effective, beta-blocker, calcium channel blocker, or ACE inhibitor can be added or substituted.

· ACE inhibitors are the first line antihypertensives for all diabetic hypertensive patients with or without evidence of end organ damage, symptomatic or asymptomatic left ventricular failure with an EF of <40, post myocardial infarction, and nondiabetic proteinuric chronic renal failure.

· ARBs are indicated when a patient can’t tolerate ACE inhibitor due to dry cough. It is also indicated in hypertensive patient with LVH, and in type 2 Diabetic patient with nephropathy.

This patient has stage 1 HTN without any target organ damage and clinical cardiovascular disease but has multiple risk factors including cigarette smoking, obesity, and family history of early CAD. Therefore, advise both pharmacological and non-pharmacological therapy.

5-Order review:

Oral atenolol, continuous

Patient education, medication compliance Diet, low sodium Diet, weight loss

Patient education, smoking cessation Patient education, regular exercise

Limit alcohol intake Safe sex counseling Seat belt use

Regular follow-ups

Primary diagnosis: Essential HTN

37/ Location: Office C.C: Short stature, and primary amenorrhea Vitals: B.P: 110/76 mm Hg; H.R: 76/min; R.R: 16/min; Temperature: 36.9C..

HPI: Her mother for evaluation of short stature brings a 13 yr old teen to your office. She is concerned about her daughter being shorter than her classmates. Her height is 4 foot 6 inches. She says that she and her husband were of normal height. She also concerned about her menarche. She says that her other (older) daughter had developed secondary sexual characters and menstruation by the age of 14. She denies any other complaints. The patient has shown age appropriate developmental skills and teeth eruption. At school she shows moderate to high performance in studies. Her past medical history is nothing significant except for ear and throat infections during childhood. She has no known allergies. Her family history is nothing significant. The mother denies any use of alcohol, smoking, or drugs while she was pregnant. Remaining ROS are unremarkable.

1-So how would you approach this case?

Basically, this patient is having short statute as a chief complaint. Even though she did not develop menarche or secondary sexual characters it is very premature to say that this patient is having problems. You have to wait at least until 14 to 16 years to assess the amenorrhea, and secondary sexual characters.

Basically the differential diagnosis in this patient is

Turner ' s syndrome,

familial short stature,

hypopituitarism, hypothyroidism,

constitutional growth delay,

derivational dwarfism,

and some other syndromes like Noonan ' s syndrome etc.

First, do a complete physical examination except rectal.

Also, order vitals that include blood pressure in both upper limbs and lower limbs.

Here are the results:

She has low occipital hairline, wide neck, high arched palate, and widened spaced nipples. No abnormalities in the rest of the examination.

Based on these findings the is most likely having Turner’s syndrome.

2-Discussion:

First confirm the diagnosis with serum FSH, LH (elevated), and karyotyping. Also order some other important investigations. Every girl with Turners syndrome must be screened for associated medical problems. At least 2D echo to detect heart defects, ultrasonography of the kidney (to detect renal problems), skeletal survey (to detect skeletal problems), and thyroid function tests. Hearing should be tested clinically regularly to detect hearing loss. Despite the short stature these patients do not have the growth hormone deficiency. So, the routine testing is not indicated. The metabolic syndrome comprises of hypertension, hyperlipidemia, type 2 DM, and obesity is more common among adults with Turner syndrome. So, all patients should have tested for blood glucose, BUN, serum creatinine, and urinalysis initially and once yearly thereafter because of the risks of diabetes mellitus and chronic renal failure.

Order the following:

· Serum FSH, serum Serum LH, routine

Karyotype, routine

· UA, routine

BUN, routine Creatinine, routine

· Fasting blood sugar, routine

· *Schedule an appointment in one week

Results:

UA, BUN, Cr, and blood sugar are normal. FSH and LH are elevated. Karyotyping is reported as 45XO.

3- Order:

Skeletal survey, routine (short 4 th metacarpal)

Pelvic ultrasound, routine (streaked ovaries)

TSH, routine

Echocardiogram, routine – For Coarctation of aorta

Audiometry, routine (or) hearing testing, routine

4-Treatment:

Once the diagnosis of Turner’s syndrome is confirmed, consider the following:

· Growth hormone therapy, subcutaneous, continuous – It should be started as soon as the height falls below the 5th percentile (till epiphysis is closed).

· Once the girl reaches 9 yrs, combination therapy with growth hormone and an anabolic steroid like oxandrolone is recommended until the age of 12 yrs.

· Estrogen, conjugated, oral, continuous – If the patient is of pre-pubertal age group (< 13 years), continue till puberty is achieved.

If the patient is >13 years, then start combination of “estrogen and progestin”

· Vitamin D, therapy, oral, continuous; to prevent osteoporosis.

· Estrogen replacement counseling

Psychiatry consult – (Reason – IQ estimation)

Ob/Gyn consult – (Reason – Gonadal resection (Children with ' Y ' chromosome may have to be operated to remove their gonads to prevent cancer from occurring in the gonads), and for in vitro fertilization (if patient wants to have children.)

If there is any evidence of thyroid problem, treat accordingly.

Advice:

Patient counseling

Counsel parent Medication compliance No smoking No alcohol Safe sex No illicit drugs Regular exercise Regular diet Seat belt use

Make follow-up appointments:

Echocardiogram for every 2 years

Thyroid function tests for every one year

Annual complete physical examination

Primary diagnosis: Turner’s syndrome

38/ Location: Emergency Room C.C: A 65-year-old white male presents with fever and severe pain in the left lower abdomen

Vitals: BP: 110/70 mmHg; HR: 95/min; Temp: 37.7C(99.8C); RR: 16/min.. HPI: A 65-year-old male presents to the ER with fever, and abdominal pain. Pain started four days ago in the left lower abdomen and has progressively increased in severity. It does not radiate anywhere and is associated with nausea, vomiting, and low-grade fever. Pain is of 7-8/10 in severity now and it is a constant type of pain. There is no history of change in bowel habits or bleeding per rectum. He had similar episodes of pain in left lower abdomen in the past, which subsided spontaneously. However, he states that he has been suffering from constipation for the last 10 years. PMH: He had a cholecystectomy at the age of 50. He has no known allergies. FH: Mother died at the age of 60 due to MI. Father died from Alzheimer’s disease at the age of 85. SH: He quit smoking 20 years ago. He does not drink or use any recreational drugs. The remaining ROS is unremarkable.

1- How to approach this case?

This patient has presented with lower abdominal pain and fever. Here we are dealing with the DD of acute abdomen. We will perform abdominal examination and rectal examination, which will narrow the list of our differential diagnosis.

Order the physical examination: General HEENT/Neck Heart Lungs Abdomen Rectal examination Genitalia Extremities.

Results of PE: Patient is in moderate to severe pain. There is marked tenderness and a mass is felt in the left lower abdominal quadrant. No rigidity or guarding noted. Bowel sounds are present. Sphincter tone is normal with normal prostate, brown colored stools without any gross blood, no palpable masses. Rest of the exam is unremarkable.

Discussion: This is probably a straightforward case of acute diverticulitis, which is suggested by history of chronic constipation, episodic left lower quadratic pain, and by the presence of mass and tenderness in the left lower quadrant. But still diagnosis of acute diverticulitis needs to be confirmed and other causes of acute abdomen need to be excluded.

Treatment of acute diverticulitis depends upon its severity and the presence of complications.

· Patient with mild symptoms may be treated as outpatient with oral fluids and antibiotic coverage against gram-negative rods and anaerobes.

· Patients with more severe disease are hospitalized and given conservative therapy. They are maintained on NPO status, given IV fluids, and IV antibiotics covering both gram-negative bacteria and anaerobes. If patients fail to respond to conservative therapy, some sort of surgery needs to be done.

· Complications of diverticulitis include peritonitis, obstruction, fistula formation, and abscess, all of which need to be treated surgically. Abscess formation is an important complication of diverticulitis. It should always be suspected when a patient fails to respond to conservative therapy and CT scan confirms its presence. It is drained under CT guidance through abdominal wall, transgluteally, transvaginally, or transrectally, depending upon its location.

2- Orders:

IV access, stat

Pulse oximetry, stat (result- 96% on room air)

Normal saline, IV, continuous

EKG, 12 lead, stat

And chem

CBC with differential, stat (to establish infectious or inflammatory process)

BMP, stat (to see the impact of disease on renal function, as dehydration due to vomiting and loss of fluid in inflammatory exudate may result in pre-renal azotemia)

Serum amylase, stat (to exclude pancreatitis)

Serum lipase, stat

LFTs (to exclude hepatitis), stat

Urinalysis, stat (to exclude UTI)

FOBT, stat

Imaging

X-ray abdomen, acute series, stat (to exclude intestinal obstruction or peritonitis)

CT scan of abdomen, stat (to establish the diagnosis of acute diverticulitis and document its severity

medication

Metronidazole IV, continuous

Ciprofloxacin, IV continuous

Morphine, IV, one dose, stat

Phenergan (promethazine), IV, one time (for nausea)

monitor

*Repeat vitals and abdominal examination every hour

Anh Đức Blog

Thứ Bảy, 17 tháng 8, 2013

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