Anh Đức Blog

HPI: The patient is a 2-1/2-year-old Hispanic female who presents today for evaluation of abdominal pain, constipation and anorexia that had been present for approximately eight weeks. She arrives with her parents who report that her symptoms started slowly at first with some anorexia and then slowly they began to notice that she was constipated more frequently and had complaints of abdominal pain. The parents note that the patient ' s stools are normal in appearance, other than being somewhat hard and round. She has had no episodes of rectal bleeding or melena. She had no complaints of nausea and has not been vomiting. The patient has not had regular medical care but has received immunizations at a local health department. The family lives in a house built in the 1930s. They have been remodeling the home over the past year and a half including tearing down walls and refinishing the flooring. The house still has its original windows. The father works in the construction business and mainly does the initial demolition prior to putting up a new structure. Mother stays home and watches the patient. They have a school age child who is six years of age. There are no pets in the house. They have city water. The patient herself has never had trouble with constipation or anorexia prior to this time. The patient ' s gross motor development has been normal up until this point and she has been meeting her developmental milestones. The patient spends all of her time at home. She does not go outside of the home for day care.

1 – How to approach this case:

This is a 2-1/2-year-old child presenting with anorexia, abdominal pain, and constipation. The differential diagnosis is rather broad and constipation is an exceedingly common problem in the pediatric population. However, this child has some red flags that might make one want to pursue a slightly different course in the workup of her constipation symptoms. First, she has not had routine health check-ups so she has not had a screening hemoglobin level to identify iron deficiency anemia nor has she presumably had a screening lead level to identify children who are high risk of lead poisoning. Both of these studies should be obtained on this patient as part of her constipation workup.

Orders: Complete physical exam

2 – Results: General: The patient is well developed and well nourished, in no acute distress. HEENT: Slightly pale conjunctivae, otherwise normal. Cardiovascular, and Lungs: Normal. Abdomen: Bowel sounds are present but slightly diminished. Belly is soft, nontender, and slightly distended with stools felt in the left lower quadrant. Extremities are normal. Neurologic: Nonfocal and appropriate for age.

The patient is a 2-1/2-year-old with constipation so one would want to at least treat that problem. Orders should include a bowel regimen to improve the constipation symptoms. Hypercalcemia and occult urinary tract infection may present with constipation.

Orders:

Fingerstick lead level (Unfortunately this is not available in CCS software; So you can directly obtain

Blood lead, quantitative’),

CBC with differential, routine

Basic metabolic panel, routine

Calcium level, routine

Urinalysis,

Treat constipation

Milk of magnesia 10 cc QD,

Docusate 20 mg QD,

Follow up appointment in three to five days to review laboratory studies and see if improved.

3 – Results: Fingerstick lead of 70 mcg/dl, Hemoglobin is 10.7, hematocrit is 33, MCV is slightly low at 76 cl/cell. U/A – WNL

Discussion: This patient has an elevated fingerstick lead. The current guidelines indicate that any level over 9 is considered elevated. The patient also has a mild decrease in her MCV and her hemoglobin and hematocrit are slightly decreased suggesting microcytic anemia. Both iron deficiency and lead poisoning can induce a microcytic anemia. As the first test to follow up with the patient ' s elevated fingerstick lead level, one should obtain a venous blood lead level.

Order: Venous blood lead level.

Serum iron, ferritin, and TIBC

4 – Results: 54 mcg/dl.

Discussion:

This patient has an elevated blood lead level at a level sufficiently high to warrant treatment. Treatment is aimed at assessing the patient ' s environment to see what sources of lead may be contaminating the patient ' s environment; changing the child ' s behaviors, particularly hand-mouth behavior which can contribute to the ingestion of lead dust; ensuring that the child has adequate nutrition, particularly calcium and iron to decrease lead absorption; and lowering the patient ' s whole body lead level through chelation therapy.

In general, chelation therapy is warranted when the blood lead level is greater than 45 mcg/dl. Monotherapy is indicated up to 69 mcg/dl; greater than 69 mcg/dl warrants two-drug chelation therapy.

Orders:

‘Lead paint assay at home’ = Home inspection for sources of lead

Dietary recommendations to increase calcium in the diet to approximately 1 gram of calcium per day. This may be obtained either through milk and other dairy products or calcium-fortified orange juice as well as recommendations for iron therapy since the patient has iron deficiency or simply add an iron-containing multivitamin if the patient does not have iron deficiency.

For treatment and SE lab

Succimer (DMSA) chelation therapy, oral continuous

Liver function tests,

Erythrocyte protoporphyrin – baseline prior to succimer therapy

Follow up in one month

 

If inspection reveals the home as the source of lead poisoning, then lead abatement (Type, ‘Lead abatement agency’) within the home is also a necessary part of this patient ' s plan, and the patient should be removed from the home while the abatement is occurring and while the family is remodeling.

Succimer, also known as DMSA, is the first drug of choice for children who have elevated lead levels in the 45-100 mcg/dl range, at a dosage of 350 mg/M2 per dose every eight hours orally for five days and every 12 hours for another 14 days. Toxicities associated with succimer include GI distress, rashes, elevated liver function tests and depressed white blood cell count. Therefore when ordering succimer further orders include CBC and hepatic panel. One should obtain these at baseline as well.

5 – Results: Patient has completed the chelation therapy without any side effects. Iron studies were normal. Baseline liver functions were normal. Erythrocyte protoporphyrin level was elevated. Her constipation has improved and she no longer needs the milk of magnesium or docusate.

Orders:

CBC,

Repeat lead level, (Type blood lead, quantitative)

Erythrocyte protoporphyrin today.

Discussion:

Exposure to lead can cause subtle cognitive defects in children. Currently the accepted level for the threshold of concern is a blood lead level greater than 9 mcg/dl. Because of increased public awareness of the toxicities associated with lead, screening programs that routinely screen for lead as well as anemia have been able successfully to identify children who have increased exposure to lead and possible toxicity from it.

Patient populations who are at increased risk of high lead levels include immigrant families, particularly Hispanic ones, who may use ceramic ware glazed with lead paint; children who live in poverty; who are younger than six years of age; who are African-American; or who dwell within a city. Children can have increased exposure if they live in a house or spend considerable time in a structure built before 1950 when use of lead-based paint was prevalent. Children whose family members work in areas that may have elevated lead levels (including metal refineries, battery recycling plants, maintenance workers on bridges and boats, and demolition workers) may receive " second hand " dust exposure from contaminated clothing. Other sources include window blinds, zippers, painted furniture and mineral supplements, particularly ones that have been brought to this country from a country in which lead levels are not vigorously monitored. Lead dust is a particular problem for children as it usually accumulates in places such as windowsills where paint along the window is frequently rubbed with the release of dust particles; toddlers who, because of their developmental stage, tend to mouth objects including windowsills, toys, and their hands become exposed to this dust. Because of monitoring, most children present with asymptomatic lead poisoning that is noted on screening laboratory tests.

The fingerstick lead level is the initial screening test; however, because of contamination problems, this level is frequently higher than a venous blood level and therefore any fingerstick screen that is elevated should be followed up in 48 hours with a venous blood lead level.

Erythrocyte protoporphyrin levels may be elevated and can be followed to see a response to chelation.

GI symptoms occur at approximately 50 mcg/dl; however, some data suggest that nearly half of children who have blood level levels in the 20-45 mcg/dl range may also have GI symptoms which may be misinterpreted.

Encephalopathy secondary to lead poisoning usually does not occur unless the level is exceedingly high such as over 100 mcg/dl and this will be an indication for prompt chelation therapy..

There are currently four different chelating agents available in the United States for lead poisoning. They are succimer, calcium edetate, BAL/dimercaprol, and D-penicillamine. As noted above, chelation therapy is recommended for levels greater than 45 mcg/dl with monotherapy being recommended for levels between 45 and 69.

Children who undergo chelation therapy can expect to have their blood lead level rebound about four to six weeks post chelation, presumably due to the release of lead from bone stores. Those children who have levels above 100 mcg are likely to have a rebound blood lead level greater than 45 mcg/dl which would warrant a second round of chelation therapy. Those children who have levels greater than 45 will generally have a rebound in their level to about two-thirds of what it had been prior to chelation therapy, and they may or may not warrant further chelation therapy. Therefore, it is important to do followup blood lead level measurements on these children.

Order review:

Followup appointment in one 4-6 weeks with

erythrocyte protoporphyrin level

blood lead level.

Repeat chelation if still warranted.

Continue multivitamin with iron.

Continue calcium supplementation in the diet.

 

Primary diagnosis: Lead poisoning.

 

Note: You may get a case of lead poisoning with a different presentation. For example, child may present with fatigue, lethargy, not doing well in school; and on exam he has pallor. You order a CBC, which shows microcytic anemia and basophilic stippling etc.

 

 

 

54/ Location: Outpatient Clinic. Vital signs: Blood pressure:137/79 supine, 124/68 erect; Heart rate: 85/min, regular; Respirations: 16/min; Temperature 38.8C. C.C: Cough.

HPI: The patient is a 65-year-old white male with a past medical history significant for COPD with a 60-pack-year smoking history. He continues to smoke cigarettes occasionally, although he has recently cut back. He presents with a five-day history of increasing cough, increased sputum production and fever up to 38.7 for the last two days. He has dyspnea on exertion and currently has some mild dyspnea. He ' s had decreased appetite, poor PO intake and a ten pound weight loss over the past two months. ROS: He denies any chills, hemoptysis, chest pain, pleuritic chest pain, abdominal symptoms/pain, diarrhea, constipation, blood per rectum, or melena. He denies any neurologic symptoms. The rest of his review of systems is negative. He had a similar illness approximately seven to eight weeks ago which was treated with cefuroxime and azithromycin, and the patient reports that after that course of treatment he got better and has been well for the past three weeks until the last five days when he had return of the cough, increased sputum production and fever. FH: Nothing significant. Medications: Takes albuterol puffs as needed. Allergies: None

1 – How to approach this case:

The patient is an elderly man with a significant history of COPD now presenting with a second pneumonia in the course of about two months. He needs an evaluation right now of his O2 saturation, physical exam, and then an exploration into the etiologies behind his recurrent pneumonia. The suspicion for malignancy is very high given his 60-pack-year smoking history, the weight loss noted in the review of systems, and the recurrence of a pneumonia, particularly if the pneumonia is in the same place as the prior one.

Orders:

Pulse oximetry Results: O2 saturation 90% on room air

Order:

Physical exam: HEENT/Neck, lungs, heart, abdomen, and extremities,

2 – Results: General: Elderly white male in no acute distress with temporal wasting. HEENT shows a clear oropharynx with upper and lower dentures. There is no neck lymphadenopathy. Temporal wasting is present. Conjunctivae are slightly pale. Cardiovascular is normal. Lungs: Decreased breath sounds throughout with rales present on the right upper lung fields posteriorly and decreased breath sounds in the right upper lung anteriorly. Increased anterior posterior distance on the chest with barrel chest habitus, and mild supraclavicular retractions. Abdomen: Slightly obese but otherwise normal. Extremities: There is bilateral tenderness of wrists, with nails more curved longitudinally and base of nail bed fluctuant in all fingers. Right index finger and middle finger show nicotine staining.

Discussion:

The patient has hypertrophic osteoarthropathy noticed on examination. It is characterized as chronic proliferative periostitis of long bones, clubbing of fingers and synovitis. It is more related with squamous and adenocarcinoma of the lungs. Symptoms of this condition may occur before the actual manifestation of lung carcinoma. As a No.1 killer Cancer in USA, it remains very important to know the different manifestations of lung carcinoma. This patient ' s finding of hypertrophic osteoarthropathy is significant for lung carcinoma in the context of his recurrent pneumonia and dyspnea.

Orders:

Shift to hospital ward.

Begin supplemental oxygen therapy at 2 lpm by nasal cannula (Type oxygen inhalation) IV access IV fluids at 100 cc an hour with normal saline

Urine outputs, Q 4 hours

Vitals: Every 4 hours

Pulse oximetry every 4hours

Activity: Bed rest with bathroom privileges

Test for lung infection

Chest X-ray, PA and lateral, stat

Blood cultures, stat

Coughed sputum sample for gram stain, culture and cytology.

baseline

CBC with differential, stat

Basic metabolic panel, stat

treat

Begin antibiotic therapy with Levofloxacin (Levaquin) orally or IV after cultures obtained

Albuterol and ipratropium nebulized treatments Q6 H and

albuterol Q2H PRN for shortness of breath.

3 – Results:

Chest X ray shows an infiltrate in the right upper lobe with some elevation of the transverse/minor fissure anteriorly. There are no effusions. There is evidence of hyperinflation and chronic lung changes.

Whenever Ca lung is suspected on the basis of clinical features and initial diagnostic tests, we need to perform advanced imaging procedures and other tests to establish the tissue diagnosis of lung cancer. CT scan of chest is done for mediastinal and pleural extension of the suspected lung tumor.

For tissue diagnosis of the lung Ca following diagnostic modalities are available:

Sputum cytology

Biopsy of suspicious lymph nodes

Flexible fiberoptic bronchoscopy: Biopsy specimens are taken when any endobronchial lesion is noted

Pleural biopsy if pleural effusion is present

Mediastinoscopy and anterior mediastinotomy when there is suspicion of mediastinum involvement by the tumor

Transthoracic FNA biopsy under

CT or fluoroscopic guidance when a peripheral pulmonary nodule is present

Order review:

Spiral CT scan of the chest

Arrange for bronchoscopy

Consult Pulmonary Medicine/cardiovascular surgery for bronchoscopy

CBC/diff with basic metabolic panel daily

Continue supplemental oxygen therapy

4 – Results:

The patient undergoes bronchoscopic examination the following day. He tolerates the procedure well. Broncho Alveolar Lavage (BAL) samples are sent for cytology, gram stain, culture, AFB smear, and fungal culture. The patient continues to show slight improvement in his oxygen saturations and overall function with the levofloxacin therapy. His IV fluids can be discontinued. His supplemental oxygen can be weaned to room air. Results of the bronchoscopy showed an endobronchial lesion in the takeoff of the right superior bronchus. The area was biopsied and brushed. Cytology reveals malignant cells consistent with a bronchogenic carcinoma and cytology reveals small cell carcinoma of the lung.

Order:

Pulmonary Function Tests (PFT)

Liver Function Tests (LFT)

CT of the abdomen and pelvis

MRI brain with and without contrast

Serum calcium , stat

Bone scan

Treat and consult

Consult oncology

Consult radiation oncologist

Quit tobacco use

Supplement diet with high protein nutritional shakes

Consider changing albuterol/ipratropium nebulizer to MDI (Metered dose Inhalers)

 

Primary diagnosis: Bronchogenic carcinoma presenting as obstructive pneumonia

 

Discussion:

Lung cancer incidence is about 3-5 per 1000 persons per year and the majority of patients are symptomatic at presentation. Local symptoms include cough (70%), hemoptysis (40%), dyspnea (40%), chest pain, hoarseness, superior vena cava obstruction, and wheezing. Systemic symptoms include weight loss, anorexia, weakness, and fever. Signs on exam include bone pain, hepatic dysfunction, lymphadenopathy, and neurological or cranial nerve involvement. Almost all patients diagnosed have constitutional symptoms, such as the case above. Lung cancers typically metastasize to bone, liver, lymphnodes, brain, and soft tissue. Unfortunately, screening with chest radiography and sputum cytology in patients at risk has not been found to decrease cancer mortality although it may detect disease at an earlier stage.

Work up of suspected cases includes bronchoscopy for cytology and visualization, as well as High Resolution CT (HRCT) of the chest.

If small cell lung cancer is found, then an MRI or CT of the brain, CT of the abdomen and pelvis, and bone scan should be performed in all patients because of the high incidence of micro/macro metastasis by the time of diagnosis. Bone marrow aspiration/biopsy is warranted in patients of SCLC (small cell carcinoma of the lungs) when there is cytopenia or increased LDH. This workup is also indicated in patients of NSCLC in whom involvement of the specific organs is suspected.

PFT ' s with diffusion capacity, spirometry, and oxygen saturations should be obtained early on. After staging has been completed, about 30-40% of patients will have limited stage disease and 60-70% will have extensive disease.

 

 

55/ Location: Emergency room Vitals: B.P: 110/70 mmHg; P.R:100/minute; Temperature: 102 0 F; R.R: 15/minute. C.C: Fever and chills.

HPI: A 54-year-old retired businessman is brought into the emergency room. Family members report that he has had a mild fever, chills, and body aches, for two days. However, this morning the patient exhibited a high-grade fever with chills, rigors, altered mental status, and a severe headache. He is nauseated and had non-bloody vomiting. The patient denies any neck pain, sensory changes in his extremities, weakness, seizures, or visual changes. His bowel and bladder functions are intact. PMH: Significant for hypertension the last ten years and has been taking atenolol 50 mg. once daily. SH: He denies smoking or drinking alcohol. He has no known allergies. FH: Nothing significant. ROS: No H/O head trauma. Rest is unremarkable.

1 – How would you approach this patient?

This is a 54-year old male with a two to three day history of high-grade fever with chills, severe headache, vomiting, and altered mental status. The most likely diagnosis is either meningitis or encephalitis. It is difficult to differentiate encephalitis from meningitis, on clinical grounds alone. All patients should be treated as having meningitis, until proven otherwise.

Order physical examination:

HEENT/Neck CNS Heart Lungs Abdomen Extremities Skin

2 – Results:

On general examination the patient appears alert, awake, and oriented to time, place, and person. The patient appears mildly confused, and sleepy. He appears very ill. The only positive findings on exam are neck stiffness and Kernig sign. No focus of infection or other abnormalities are found. Fundoscopy did not reveal any papilledema. Orders:

Pulse oximetry, stat and every two hours

IV access IVNS, 100 cc/hr

NPO except medications

Hold his atenolol

Complete bed rest

DVT prophylaxis (Type ‘Pneumatic compression stockings’)

Vitals Q 2 hours

Urine output every two hours

Head elevation

Labs for dx

CBC with diff, stat and Q day

BMP, stat and Q day

PT/INR, stat PTT, stat

Blood cultures, stat

Urinalysis, stat

Urine culture and sensitivity, stat

treat

Phenergan, IV PRN for vomiting

Acetaminophen, oral, PRN for headache and fever

Once the blood cultures are obtained:

IV ceftriaxone, continuous

IV vancomycin, continuous

Lumbar puncture, stat

Send the CSF for cell count, protein, glucose, Gram stain, Fungal stain, culture, and sensitivity

3 – Results:

Gram stain of the CSF shows Gram positive cocci CBC showed elevated white count with left shift BMP is normal PT/INR/PTT is within normal limits

Review orders:

Change the antibiotic according to the organism and sensitivities.

Do not forget to stop the initial or unnecessary antibiotics.

Order interim history and focused physical exam every four hours until you see improvement, then Q12 hours.

Once the mentation is improved start clear liquids, then advance the diet.

Order ‘out of bed to chair’.

D/C daily CBC with diff, and BMP when no longer required.

 

Discussion:

Basically, this patient is showing signs and symptoms of meningitis. He needs to be hospitalized immediately because of his altered mental status. The patient should be kept NPO. Start IV with normal saline because the patient is on NPO and his diastolic blood pressure is 70, in spite of having a history of hypertension. Blood should be drawn immediately and sent for CBC with a differential, BMP, blood cultures, and coagulation studies (PT, INR and PTT to rule out the possibility of DIC and to obtain his baseline coagulation studies). Immediately after ordering these investigations, intravenous antibiotics should be started which are mostly empirical. The use of prior imaging studies, like a CT scan of the brain, is not necessary to proceed with a lumbar puncture.

In a patient with a normal level of consciousness, without any focal neurological signs, a lumbar puncture can be safely performed even without prior imaging studies. We recommend starting intravenous antibiotics, even before obtaining a lumbar puncture. Antibiotic therapy for several hours, prior to lumbar puncture, will not significantly alter the CSF, WBC count, glucose concentration, or the results of culture . However, blood cultures should be obtained prior to starting antibiotics. CSF should be sent for gram stain, culture and sensitivity, protein, glucose, and cell count with a differential.

If the patient has a history of seizures, with focal neurological signs, herpes simplex should be considered and empirical IV acyclovir should be started along with IV antibiotics.

In all HIV patients, CSF should be sent for cryptococcal antigen assay to rule out cryptococcal meningitis. In acute bacterial meningitis, the CSF, WBC count will be elevated and red blood cells will be absent unless there is a traumatic tap. Glucose is usually low (less than 40 mg/dl) and the protein is elevated (more than 40 mg/dl). Gram stain is usually positive in 70-90% of untreated patients and culture is positive in around 80% of cases.

The use of empirical antibiotics depends on the patient’s age and risk factors.

In infants of less than three months, cefoxitin plus ampicillin should be given. Cefoxitin covers most of the gram negatives and ampicillin is to cover Listeria meningitis. Dexamethasone has been indicated for H. influenza meningitis.

Immunocompetent children of more than three months to adults age of less than 50 years should receive a third generation cephalosporin, preferably ceftriaxone plus vancomycin.

Adults of more than 50 years of age and individuals with alcoholism or other debilitating illnesses should receive ceftriaxone plus vancomycin plus ampicillin (to cover Listeria).

Meningitis, which develops after head trauma, or neurosurgical procedures, or in patients with neutropenia, should receive vancomycin plus ceftazidime. Ceftazidime covers gram-negative organisms, preferably Pseudomonas.

Once the organism has been identified on gram stain, antibiotics should be directed against a specific organism.

If you find gram-negative bacilli on the gram stain, ceftriaxone again is the drug of choice.

If you find a Pseudomonas on the gram stain and the culture, the drug of choice is IV ceftazidime.

If you find gram-positive cocci in clusters (staphylococcus), IV nafcillin is the drug of choice. First generation cephalosporins should not be used for staphylococcus infections because they do not have high permeability into the CSF. IV vancomycin is the drug of choice for penicillin allergic patients and methicillin resistant Staph aureus.

If the Gram stain shows Haemophilus influenza, IV ceftriaxone is the drug of choice.

If the patient is having meningococcal meningitis, the patient should be placed in respiratory isolation and the patient can be tested for terminal component complement deficiencies (C6-C9).

If you identify Listeria monocytogenes and the patient is an immunocompromised or undergoing dialysis, IV ampicillin plus IV gentamicin should be given for at least three to four weeks. Usually the period of antibiotic doses is in between 10-14 days of intravenous antibiotics.

 

Primary diagnosis: Bacterial meningitis

 

 

56/ Location: Office Vitals: B.P: 140/80 mm Hg; P.R: 88/min; R.R: 18min; Temperature: 38.1C. C.C: Pain and swelling of the right leg.

HPI: A 38-yr old white female, who is otherwise healthy, presents to office with two to three day history of pain and redness of the right leg. The pain continues despite applying heat and elevating the legs. There is a mild fever today. She denies any trauma, tick or insect bites, joint pains, or prior episodes of similar problems. She has no other medical problems except menstrual abnormalities. Her gynecologist placed her on oral contraceptive pills. FH: Her mother has a H/O rheumatoid arthritis. SH: She smokes less than half a pack of cigarettes per day. Drinks alcohol on the weekends. SxH: Sexually active with her husband. ROS: unremarkable.

1 – How do you approach this case?

Consider differential diagnosis:

Deep vein thrombosis

Superficial thrombophlebitis

Cellulitis/Lymphangitis

Rupture of the Bakers cyst

Hematoma

Order physical examination:

General HEENT/Neck Lungs Heart Abdomen Extremities Skin

2 – Results:

Exam is remarkable for a palpable cord, edema, warmth, and superficial venous dilation of the right lower extremity. There is no source of infection noted on careful examination of foot. Rest of the exam is unremarkable.

Order:

Transfer to ER

Pulse oximetry, stat

labs

Compressive ultrasonogram of the right leg (Type ‘Venous doppler, lower leg’), stat

D-dimer, stat

CBC with diff, stat

 

3 – Results:

Pulse oximetry shows 95% on room air USG shows deep vein thrombosis of the popliteal vein CBC shows Hb of 14, WBC of 12,000 with no bandemia, and platelet count of 220,000.

Order:

Rectal exam FOBT, stat

PT/INR, stat PTT, stat

D/C Oral contraceptive pills R

4 – Results:

Rectal exam is normal FOBT is negative PT is 13.6; INR is 0.9 PTT is 24

Order:

LMWH (Enoxaparin), stat and Q 12 hours, sub cutaneously

Acetaminophen and oxycodone for pain as needed

Anticoagulation teaching (Type ‘patient education’)

No smoking

Discharge to home with follow up in office next day

Review:

Brief physical exam and interim history

Coumadin/warfarin (5 to 7.5 mg) oral, continuous

PT/INR, every day until the INR is therapeutic

Appointment with anticoagulation clinic to follow PT/INR (Option is not available in software, so you have to follow every day with PT/INR)

Platelet count, in day 3 and 5 of heparin treatment

 

Discussion:

DVT is classified into proximal vein and calf vein thrombosis. This classification is important because proximal vein thrombosis is often associated with embolic phenomena (Board question). Even though contrast venography is the gold standard test for diagnosis of DVT, it is not recommended for screening purposes because it is invasive, associated with patient discomfort, and technically difficult.

The two commonly used noninvasive tests for the diagnosis of DVT are compression ultrasonography and impedance plethysmography. Studies have shown that compression ultrasonography was superior to impedance plethysmography in guiding therapeutic strategy in patients with DVT. However, impedance plethysmography is the preferred test for the evaluation of suspected recurrent DVT because it normalizes more quickly after a previous episode than compression ultrasonography.

Measurement of D-dimers is useful in excluding thromboembolic phenomena because of its high negative predictive value. However, the presence of elevated D-dimer alone cannot establish a diagnosis of DVT. D-dimers should be correlated with clinical probability, and noninvasive tests in guiding the diagnosis.

Simple DVT can be managed as an outpatient. Low molecular weight heparin (LMWH) is the treatment of choice for acute DVT. Enoxaparin is the most commonly used LMWH. Warfarin can be started within 24 hours. PT/INR should be measured daily until the therapeutic range (2.0 to 3.0) is reached. Heparin is stopped in day five or six if the INR is therapeutic for at least two consecutive days.

A platelet count should be obtained on day three and five to monitor HIT (heparin induced thrombocytopenia). Heparin should be stopped if there is a >50% reduction in platelet count or a total count of less than <100,000/µL.

How long should you treat DVT?

Reversible risk factors (surgery, oral contraceptive pills) – 3 months
Idiopathic first time DVT – 6months
Recurrent idiopathic DVT, and patients with continuing risk factors (malignancy, inherited thrombophilia) – 12 months or more

 

Primary Diagnosis DVT

 

57/ Location: Office Vital signs: PR: 72/min; B.P: 136/80 mm Hg; Temperature: 98.6 F; R.R 20/min; Height: 130 cm; Weight 60 kg. C.C: A 53-year-old woman comes to you with the complaint of abdominal distention

HPI: A 53-year-old African American comes to you with abdominal distention. She noticed it one week ago. Her symptoms started with the complaint of anorexia, early satiety, and abdominal discomfort the past several weeks. She is very worried something is terribly wrong inside her stomach. Her other complaints include exertional shortness of breath and orthopnea. She never had postmenopausal bleeding, jaundice, fever, pruritus, or abdominal pain. She has never received a blood transfusion nor traveled outside USA. Her bowel movements and bladder function are normal. She has no history of contact with a jaundice patient. She had her menarche at age 13 and menopause at age 51. Her family history is significant for breast cancer in her mother at age 65. She has been smoking less than half a pack of cigarettes per day since 30 years. During that same amount of time, she generally has a couple of beers per week. She denies any IV drug abuse. She has had a total of four sexual partners in her life. She has no known allergies. ROS is unremarkable.

1 – Order physical emanation:

General; HEENT/Neck; Lymph nodes; Breast; Lungs; Heart; Abdomen/Rectal; Extremities; Skin

2 – Results:

There is no lymphadenopathy. No JVD. Lungs: There are decreased breath sounds, and a dullness to percussion note is noted at the right base. Abdomen: Bowel sounds present. Abdomen is nontender. Rebound tenderness is negative. Flank and shifting dullness is present. Pelvic exam: Eternal genitalia are healthy. Solid, fixed, irregular right adnexal mass is palpable. Rest of the exam is unremarkable.

Review order:

Admit to floor/ward

Pulse oximetry, stat and Q 12 hours

Vitals, Q 12 hours

Regular diet

Labs

CBC with diff, stat

Comprehensive metabolic panel (CMP), stat

UA, stat

Abdominal ultrasonogram, stat

Chest – X ray, PA and lateral, stat

FOBT, stat

PT/PTT, routine

3 – Results:

Pulse oxymetry showed 93% on room air. CBC showed Hb of 11, WBC of 9,000 with normal differential, and a platelet count of 190,000. Comprehensive metabolic panel is WNL. Chest X-ray shows mild to moderate right sided pleural effusion. USG showed solid, irregular right ovarian mass, and ascites. U/A is WNL and FOBT is negative. PT/PTT are WNL

Review order:

Paracentesis, diagnostic (consider ‘therapeutic’ if the patient has respiratory distress at rest)

Send fluid for cell count and diff, protein, glucose, and cytology

CT of the abdomen, routine

CT chest, routine

Mammogram, routine

PAP smear, routine

CA 125, routine

After results place a consult for Gynecologic oncology Medical oncology

CCS do not have options for surgical/gynecologic oncology. So, just type ‘oncology’ and ‘general surgery’ or ‘gynecology’

 

Discussion:

This patient has the main complaint of abdominal distention. Presence of flank dullness is the single most significant finding to make the clinical diagnosis of ascites. However, at least 1500 ml of fluid should be present to get the flank dullness. The common causes of ascites include, cirrhosis (most common), cancer, heart failure, nephrotic syndrome, tuberculosis, dialysis, and pancreatitis. The most cost effective imaging modality to confirm the diagnosis of ascites is an ultrasonogram. The other advantage of USG over CT is it is noninvasive and does not require contrast.

Appropriate ascitic fluid analysis is required in all patients, to confirm the ascites and diagnose the underlying cause. Abdominal paracentesis is a very safe procedure and can be done even in patients with advanced liver disease. There are no clear coagulation parameters beyond which the procedure should be avoided. However, it is contraindicated in patients with active bleeding secondary to DIC. Fluid should be sent for cell count with differential, protein, glucose, and cytology. Gram stain, culture, AFB staining, amylase, and bilirubin levels are indicated for individual patients based on the clinical suspicion. Ascitic fluid pH, lactate, and ‘humoral tests of malignancy’ such as fibronectin, cholesterol etc. are useless and not indicated.

The presence of solid, fixed, irregular pelvic/ovarian mass associated with ascites is almost always malignancy until proven otherwise. USG examination and abnormal tumor markers (CA 125) usually differentiates between malignant and benign tumors.

However, the definitive diagnosis usually requires surgery for histological examination. Surgery is also necessary for proper staging and cytoreduction/debulking. Preoperative evaluation should include complete pelvic examination, PAP smear (cervical cytology), and CT of the abdomen and chest. Exclude other potential primary sites (breast and GI tract), which can give metastatic disease to the ovaries.

If the FOBT is positive, a colonoscopy should be performed. If a patient has any symptoms suggestive of upper GI malignancy, an endoscopy should be performed.
A bilateral mammogram should be performed, especially when there is a palpable lump.
Patients who have irregular menses or postmenopausal bleeding should have an endocervical curettage and endometrial biopsy to exclude the presence of endocervical or endometrial cancer that may be metastatic to the ovary.

Bone scan, liver-spleen scan, and brain imaging are not required unless the patient has signs and symptoms suggestive of involvement of these organs. CA 125 levels are elevated in more than 80% of patients with epithelial tumors.

When a germ cell tumor is suspected (solid pelvic mass in a premenarchal or adolescent female), the other associated tumor markers are helpful. Alpha-fetoprotein – endodermal sinus tumor Lactate dehydrogenase – dysgerminoma Human chorionic gonadotropin – nongestational choriocarcinoma

Is screening of general population recommended? No method is recommended for screening of ovarian malignancy. Pregnancy and oral contraceptives significantly decrease the risk of ovarian cancer probably by decreasing the number of ovarian cycles.

 

Primary Diagnosis Ovarian Cancer

 

 

58/ Location: Emergency room Vitals: B.P: 130/70 mm Hg; P.R: 90/min; R.R: 20/min; Temperature: 37.8C. A 63 year old nursing home resident is brought to emergency room complaining of colicky abdominal pain.

Nursing home staff reports that for several hours he has been complaining of nausea, abdominal distention, and a colicky type of left lower quadrant abdominal pain. He says the pain is continuous and severe, with a superimposed colicky component. He has had no bowel movements the past three days. He has never had abdominal surgery. His other medical problems include schizophrenia, for which he is on haloperidol as needed. He is allergic to sulfa. Family history is nothing significant. SH: He denies smoking and alcohol.

1 – How do you approach this patient?

Consider differential diagnosis: Bowel obstruction, -carcinoma Pseudo-obstruction (ileus) Giant sigmoid diverticulum Constipation Sigmoid volvulus

Order physical examination: General appearance Lungs Heart Abdomen Rectal Extremities

2 – Results:

Examination reveals a tympanitic/distended abdomen. Bowel sounds are diminished. There is no rigidity or rebound. Mild to moderate tenderness is present. Rectal examination shows only an empty rectal ampulla.

Order:

IV access

IV NS@100 cc/hr

NPO

test

CBC with diff, stat – Leukocytosis (in some cases Leukocytosis may be absent)

SMA -7 or BMP, stat ( to evaluate any electrolyte abnormality)

X-ray of Abdomen, stat

3 – Results:

CBC showed mild leukocytosis SMA -7 is WNL Supine radiograph of abdomen shows a markedly distended loop of sigmoid colon with a convex superior margin projecting into the right upper abdomen. Impression: Sigmoid volvulus.

Order review:

Admit to ward

Continue IV fluid

NG tube suction

treat

GI consult (reason for consult: evaluation and decompression of sigmoid volvulus)

Sigmoidoscopy (decompression and untwisting of the sigmoid loop with placement of long soft tube)

Rectal tube

Monitor patient for 2-3 days after decompression for persistent abdominal pain and bloodstained stools, signs that may herald ischemia and indicate the need for surgical intervention.

Consult General surgery- Emergency surgery is reserved for patients in whom tube decompression fails or for those in whom signs of ischemia are suggested.

Discharge

After patient is stabilized, move patient home with office follow-up in 5-7 days.

Educate patient and family: Console patient to seek medical care if nausea, vomiting, rectal bleeding, or abdominal pain reoccur.

Low fat, high fiber diet.

 

Final Diagnosis: Sigmoid Volvulus

 

Explanation: Sigmoid volvulus is commonly seen in elderly patients who are institutionalized and debilitated from neurological and psychiatric diseases. Typically, patients present with left lower quadrant abdominal pain, nausea, abdominal distension, and constipation; Vomiting is less common and occurs late. The pain is usually continuous and severe, with a superimposed colicky component. Failure to diagnose and treat at the initial presentation causes colonic ischemia, gangrene, and perforation. Physical examination reveals a distended, tympanitic abdomen, and a palpable mass may be present. Bowel sounds are usually absent. Rectal examination shows empty rectal ampulla.

Severe pain, tenderness, rigidity, and rebound tenderness suggest peritonitis resulting from ischemia/perforation. In approximately 60% of patients, diagnosis of sigmoid volvulus can be made by using plain abdominal radiographic findings.

Supine radiograph of abdomen shows a markedly distended loop of sigmoid colon with a convex superior margin projecting into the right upper abdomen. Also, dilated gas-filled lumen, can result in a coffee bean–shaped structure; i.e. the coffee bean sign.

If diagnosis is questionable, a barium enema will confirm diagnosis but is contraindicated in suspected perforation.

The management of sigmoid volvulus involves relief of obstruction and the prevention of recurrent attacks. Sigmoidoscopy is the initial procedure of choice in patients with viable bowel. Sudden decompression is successful in 70-90% of cases. Many physicians subsequently place a rectal tube in situ. This non-operative approach is only a temporary measure, which allows further medical assessment, preoperative care, and bowel preparation.

 

59/ Location: Emergency room A 50-year old lady, with a history of chemotherapy post a successful breast surgery, came to the ER with a fever. Vital signs: B.P: 130/70 mm Hg; H.R: 80/min; R.R: 18/min; Temperature: 38.7ºC.

HPI: Patient was diagnosed with breast cancer three months earlier. She underwent surgery that was followed by two cycles of combination chemotherapy. She was advised to come back to the office immediately if she developed any fever. She denies any cough, cold, headache, neck stiffness, SOB, chest pain, diarrhea, abdominal pain, blood in the stools, ulcers, or burning urination. Her other medical problems include reflux disease and osteoarthritis. She takes lansoprazole QD, and acetaminophen as needed. She denies smoking, alcohol, and IV drug abuse. Family history is nothing significant. She is allergic to sulfa drugs, and codeine. ROS is unremarkable.

1 – Patient with history of chemotherapy and fever should make you think about possible infection secondary to immunocompromised status. First step is to get a good history and physical exam.)

Order physical examination:

General appearance Skin – check for skin lesions

Lymphnodes HEENT/Neck- evidence of fungal infection.

Chest/Lung- evidence of respiratory infection i.e. decreased breath sounds, rales, rhonchi.

Lungs are the most frequent site of infection in immunocompromised patients.

Heart/CVS Abdomen Extremities

Neuro/Psych.- mental status evaluation looking for meningism or focal deficits

Note: Digital rectal exam is not routinely performed as trauma of these frail mucosal areas can precipitate infection. However, we generally inspect the peri anal areas for any focus of infection. If there is suspicion for prostatitis or perirectal abscess, it can be performed after the broad-spectrum antibiotics have been administered.

2 – Results:

Completely normal physical exam

Order:

IV access Continue lansoprazole

test

CBC with differential, stat

Comprehensive metabolic panel, stat

Urinalysis, urine culture & sensitivity, and Gram stain, stat

Blood culture, stat

Sputum Gram stain, and cultures (if the patient has symptoms)

Chest X-ray, PA, and lateral, stat

Treatment:

Admit to floor

Regular diet

Activity – As tolerated

Nursing – Vitals Q 4 hours

medi

Ceftazidime, IV, continuous

Acetaminophen, oral, as needed (Do not give continuously, as you have to monitor whether he is responding to antibiotics or not)

CBC with diff, daily

Consider PT/PTT for baseline if there is a risk of developing DIC.

Consider use of Neupogen (G-CSF) – Not in this patient

Re-examine the patient in six hours, obtain interim history, then see the patient Q 12 hours and monitor.

Consider changing the antibiotics according to the culture and sensitivities

3 – During discharge:

After 3 days D/C IV antibiotics

Start oral antibiotics

D/C daily CBC with diff

Counsel

Educate patient and family:

Console patient to avoid people with cold/flu

Console patient to seek medical help if a fever develops

 

Final Diagnosis: Febrile neutropenia secondary to chemotherapy

 

Discussion:

Fever in a neutropenic patient is a medical emergency. Febrile neutropenia is defined as a single temperature of >38.3ºC (101.3ºF), or a sustained temperature >38ºC (100.4ºF) for more than one hour. However, patients who are on corticosteroids may not develop fever. Neutropenia is defined as an absolute neutrophil count (ANC) <500 cells/mm3.

Disruption of the skin and mucosal barrier resulting from the chemotherapy often results in seeding of bacteria into the blood stream (bacteremia) and the most common site of mucositis is in gastrointestinal tract. Chemotherapy also results in impaired immunologic function. The frequently identified organisms in febrile neutropenic patients are Gram negatives, particularly P. aeruginosa. But there has been a recent increase in Gram positive infections for several reasons.

Although GI tract has abundant anaerobic organisms, anaerobic coverage is not indicated in the initial empirical antibiotic regimen. Anaerobic coverage is indicated if there is any evidence of necrotizing mucositis, periodontal abscess, perirectal abscess/cellulitis, intraabdominal or pelvic infection, typhilitis (necrotizing neutropenic colitis), or anaerobic bacteremia.

Evaluation should include CBC with diff, basic metabolic panel, LFTs, blood cultures, urine Gram stain and cultures, sputum Gram stain and cultures, and chest X-ray. Lumbar puncture is not routinely indicated unless the clinical features suggestive of meningitis present.

Other tests are indicated if the patient has localizing signs or symptoms. For example, patients with diarrhea should be evaluated with: Stool for Gram stain, culture, Clostridium difficile toxin, and ova and parasites. All central lines and catheters should be inspected carefully and may need to be removed if clinically infected and infection not responding to appropriate antibiotics. We generally repeat the blood culture if the fever persists for more than 48 hours. Chest x-ray should also be repeated for persistent pulmonary symptoms. The findings on chest X-ray may be subtle or absent even in a patient with pneumonia.

It is important to remember that the absence of neutrophils on sputum Gram stain, blood smear, or CSF does not exclude the presence of infection.

Treatment: The empirical antibiotic choice should cover the Gram negative organisms especially Pseudomonas. The following are the commonly used regimens. We usually prefer monotherapy. Monotherapy: Cefepime, ceftazidime, imipenem, or meropenem. Double coverage: Aminoglycoside + extended spectrum antipseudomonal penicillin.

When should I consider vancomycin? In general, vancomycin is added if there is no response to the above monotherapy in 2-3 days. The addition of vancomycin to the initial empiric antibiotic regimen should be considered in patients who present with hypotension, mucositis, skin or catheter site infection, history of MRSA colonization, or recent quinolone prophylaxis.

When to add antifungal therapy? Antifungal therapy with amphotericin B should be considered at five to seven days of neutropenia in patients with persistent fever.

When to use G-CSF: The benefit of colony stimulating factors as an adjuvant to antibiotic therapy in an uncomplicated febrile neutropenic patents is not proven and is not indicated. However, it is considered in patients with predictive poor outcome such as patients with ANC <100/µL, uncontrolled primary disease, pneumonia, hypotension, multiorgan dysfunction, or invasive fungal infection.

General approach to the therapy:

What is the initial antibiotic choice? Does the patient need vancomycin? If yes, order vancomycin + ceftazidime. If no, order ceftazidime or aminoglycoside + extended spectrum antipseudomonal penicillin.
If patient became afebrile in three days: change to oral antibiotics, either cefixime or quinolone. If patient is still febrile after three days: stop the vancomycin if added initially and cultures are negative; add vancomycin, if not administered initially, obtain repeat cultures, and chest X-ray.

Duration of therapy:

1.      If the source of the infection is identified, antibiotics should be continued for the standard duration (14 days for Staph aureus bacteremia).

2.      If the source is unknown, then the following approach is indicated: If the patient is afebrile in 3 days and the ANC is >500, stop antibiotics after 7 days; If the patient is afebrile and the ANC is less than 500 continue antibiotics.

 

 

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