AM Report 6/23/2010Amy Auerbach

Q16: A 45 year old woman who has a 3-day history of progressive earache and fever is hospitalized after becoming unresponsive. Medical history is unremarkable; she has no allergies and she takes no medications.

On physical examination on admission, temperature is 40 degrees celcius, HR=120, RR=32, BP=80/50. The patient is obtunded and has meningismus. The leukocyte count is 25,000 with 25% band forms and the platelet count is 20,000.

Lumbar puncture is performed; CSF examination shows the following: Appearance: CloudyLeukocyte Count: 2500 with 99% neutrophilsGlucose:20 Protein: 230

Gram stain of CSF demonstrates gram positive diplococci.

a) PCN plus dexamethasoneb) Ceftriaxone plus dexamethasonec) Vancomycin plus dexamethasoned) Vancomycin plus ceftriaxone plus dexamethasonee) Vancomycin plus ceftriaxone

BacterialBacterial ViralViral TBTB CrytpoCrytpo

WBC WBC countcount

1000-50001000-5000 50-100050-1000 50-30050-300 20-50020-500

DiffDiff PMNPMN LymphLymph LymphLymph LymphLymph

GluGlu <40<40 >45>45 <45<45 <40<40

ProPro 100-500100-500 <200<200 50-30050-300 >45>45

Age 2-50Age 2-50 S. pneumo, N. S. pneumo, N. meningitidesmeningitides

Vanc +3Vanc +3rdrd gen gen cephalosporincephalosporin

Age >50Age >50 S. pneumo, N. men, S. pneumo, N. men, Listeria, GN bacilliListeria, GN bacilli

Vanc +3Vanc +3rdrd gen gen cephalosporin + cephalosporin + ampicillinampicillin

Basillar skull fractureBasillar skull fracture S. pneumo, H.influ, S. pneumo, H.influ, group A strepgroup A strep

Vanc + 3Vanc + 3rdrd gen gen cephalosporincephalosporin

Post-NSG or traumaPost-NSG or trauma Staph, Gram negative: Staph, Gram negative: PseudomonasPseudomonas

Vanc + either ceftaz, Vanc + either ceftaz, cefepime, or cefepime, or meropenemmeropenem

CSF shuntCSF shunt Staph aureus, CONS, Staph aureus, CONS, GNRGNR

Vanc + either ceftaz, Vanc + either ceftaz, cefepime, or cefepime, or meropenemmeropenem

TREATMENT OF MENINGITIS

Q9: A 42 year old woman has a one year history of progressive fatigue without dyspnea, chest pain, or other systemic symptoms. She sleeps well at night and does not have features of sleep apnea. The patient has hypothyroidism, managed with levothyroxine, and dysmenorrhea, treated with an estrogen/progesterone combination.

On physical exam, the thyroid is slightly enlarged but nontender. Xanthomas are present on the extensor surfaces. Abdominal examination discloses mild hepatomegaly.

Lab Studies:CBC: NormalTSH: NormalAST=25/ALT=32/AP=278Total bilirubin=1.1

In addition to a fasting serum lipid profile, which of the following studies would most likely establish a diagnosis?

a) Antimitochondrial antibody assayb) Serum 25-hydroxyvitamin Dc) ERCPd) Abdominal ultrasonography

Often see xanthomas and elevated AP Anti-mitochondrial antibody titer 1:40 or

more occur in >90% patients with PBC Primarily in women between age 40-60 Also associated with metabolic bone

disease, hypercholesterolemia, and fat-soluble vitamin deficiencies

Inflammation, fibrosis and strictures of the medium and large intra- and extrahepatic biliary ducts

90% with PSC have underlying UC 5% prevalence in those with UC Men> women 3:1 Increased risk of cholangiocarcinoma About 50% +pANCA Diagnose: ERCP or MRCP (“a string of

beads” pattern of intra- and extra- hepatic ducts)

Q 44. A 44 yo man with h/o nephrolithiasis requests nonpharmaceutical interventions for stone prevention. His last symptomatic kidney stone was 2 years ago. He does not recall the exact type of stone that he formed but believes that it contained calcium. Previous labs have showed normal renal function and normal levels of Ca, Phos and uric acid. A plain abdominal X-ray performed 1 year ago revealed no GU calcifications. He does not have a FH of nephrolithiasis but wishes to reduce his chances of developing further kidney stones.

In addition to increasing fluid intake to >2L/d, which of the following is the best initial therapy for this patient?

A. Increase dietary calcium intake B. Decrease dietary sources of citrate C. Increase dietary animal protein intake D. Increase dietary sodium intake

Predominantly calcium, but also uric acid, struvite and cystine.

Fluid intake is key. Risk factors:

◦ high sodium and protein intake and low calcium intake, low fluid intake

◦ Hypercalciuria, hypocitraturia, hyperuricosuria, hyperoxaluria

◦ Gout, obesity, RTA, sarcoidosis, primary hyperPTH, medullary sponge kidney, horseshoe kidney, HIV/AIDs with protease inhibitors, type 2 DM

◦ PCKD, Dent’s disease, cystinuria, primary hyperoxaluria

Uric acid stones: radiolucent: cannot be seen on XR (association- gout)

Calcium oxalate stones: Associated with low Ca diet (lack of intestinal Ca available for oxalate binding) and malabsorption syndromes that increase oxalate absorption in the gut and prolonged use of Abx that alter enteric flora that degrade oxalate.

Staghorn calculi: associated with proteus or klebsiella infection. Do NOT further alkalinize with potassium citrate.

Q 99: A 38 y/o woman with hypertriglyceridemia is admitted to the intensive care unit from the emergency department where she presented with acute respiratory distress syndrome associated with severe pancreatitis and required intubation, Initially, her oxygenation had been adequate on FiO2=60%, PEEP of 7cm H20 but her oxygen saturation dropped to the low 80% level despite an increase in FI02 to 100%.

On physical exam, she is intubated; examination of the lungs reveals diffuse crackles and rhonchi; cardiac examination is normal except for tachycardia (HR=112); abdomen is very tender with diminished bowel sounds; and she has 2+ peripheral edema. Chest radiograph shows diffuse bilateral infiltrates. She is being ventilated with a “lung protective strategy” using an assist/control mode with a tidal volume of 6mL/kg and plateau pressure of 25cm H20.

Which of the following strategies for positive end-expiratory pressure (PEEP) would be most appropriate for this patient?

a) PEEP should be increased in 2-3 cm increments to lower FiO2 to at most 60% if possible, and maintain an arterial oxygen saturation of >88% and <95%

b) PEEP should be set below the lower inflection point on a pressure volume curve of the lung

c) PEEP should be set to correspond to the expiratory pressure that minimizes compliance of the lung

d) PEEP should be at least 14cm H2O and PEEP up to 20cm H2O for FiO2 of 0.5 to 0.8 as long as cardiac output is monitored using a pulmonary artery catheter

Type PaO2/FiO2 CXR Other

Acute Lung Injury

<300 Bilateral infiltrates

No CHF

Acute lung failure

<300 Any infiltrates No CHF

Acute respiratory distress syndrome

<200 Bilateral infiltrates

No CHF

Acute hypoxic respiratory failure

<200 Any finding No COPD

Studied in ARMA trial Showed reduction in ARDS mortality from 40% to 30% with a

low (6ml/kg) rather than high (12ml/kg) tidal volume Established "lung protective" ventilator strategies to avoid

ventilator-associated lung injury resulting from excessive stretching of the lung during mechanical ventilation

ALVEOLI study showed no advantage of a higher PEEP compared to a lower PEEP, both adjusted to maintain adequate oxygenation

Current recommendation is to use either a volume- or pressure- limited mode with a low tidal volume (6ml/kg) while monitoring plateau pressure that should be kept <30cm H2O.

PaCO2 is allowed to rise if necessary to achieve these goals (permissive hypercapnea) and PEEP is adjusted to maintain FiO2 <60% with SaO2 >88%

If hypoxemia persists, prone positioning or high frequency oscillation are sometimes used, but no studies have yet demonstrated improved outcomes

Q 68: A 22 year old woman is evaluated for a 12 month history of gradually worsening low back stiffness that is present for 2 hours after awakening in the morning. She has significant fatigue but no fever, chills, night sweats or weight loss. She does not have pains in the peripheral joints but does have bilateral buttock pain throughout the day with sitting. One year ago, she also had a two week episode of uveitis of the right eye which responded to corticosteroid eye drops.

On physical examination, vital signs are normal. She appears healthy but walks with a mild forward bending of her spine. Deep pressure and palpation of the lumbar spine in the midline and both sacroiliac joints elicits tenderness. Chest expansion in the fourth intercostal space is 2cm, and she can only reach the midcalf region when touching her fingers to the floor.

On laboratory studies, hemoglobin is 12.5, ESR is 85, CRP is 5.

Which of the following conditions does this patient most likely have?

a)Sacral fractureb)Ankylosing spondylitisc)Osteoarthritisd)Metastatic cancer

Ankylosing Spondylitis: male predominance, fatigue, anemia, elevated CRP

- Affects spine and sacroiliac joints- Complications: cauda equina snydrome, restrictive lung

disease, aortic insufficiency due to aortitisReactive arthritis: 1-3 weeks after infectious event

originating in GU or GI tract - HLA B27 present in 80% pts with this condition- Commonly affects peripheral joints Psoriatic arthritis: multiple presentations: ass with

psoriasis, skin involvement typically precedes joint inflammation

- Use same agents as for RAEnteropathic arthritis: associated with Crohn’s or UC-

resembles RA, occ spondylitis

Q 34: A 28 y/o woman is evaluated for headache, unprovoked diaphoresis, and episodic hypertension. Fractionated plasma metanephrines are three times the upper limit of normal. A 24-hour urine metanephrines excretion is fourt times the normal excretion. The patient notes that her mother is undergoing a similar evaluation and that her mother underwent parathyroid surgery several years ago. Her maternal grandfather had pheochromocytoma and medullary thyroid cancer. Pheochromocytoma is confirmed in the patient.

A positive RET mutation in this patient would indicate the presence of which of the following disorders?

a) Multiple endocrine neoplasia type 2Ab) Multiple endocrine neoplasia type 1c) Primary aldosteronismd) Polyglandular endocrinopathy

MEN type 2a: Medullary thyroid carcinoma, Hyperparathyroidism, pheomchromocytoma

MEN type 1: neoplastic transformation of pituitary, parathyroids, endocrine pancreas

Valve Defect Murmur Louder with Heart Sounds

General Notes

AS SEM at RUSB, diamond shaped

Squatting,Expiration

Absent S2, Parodoxically split S2

Slowed carotid upstroke.

MS Diastolic ruble

Same as above

S1 enhanced

Large a wave, weak y descent

VSD Holosystolic at LLSB

Handgrip Post MI with new murmur

ASD SEM at LSB Fixed split S2.O-Primum: LAD, RBBBO-Secundum: RAD, RBBB

BBB, no prophylaxis Abx for ostium secundum.Look for AV block with primum

From P. Vidwan’s 2008 Cards Presentation

Q 117: 42 y/o male with non-pruritic, non-painful spreading rashBeen outdoors and getting tanOTC corticosteroid cream ineffective On simvastatin for hyperlipidemia onlyLabs: Cholesterol level: 190 with LDL=110Direct microscopy of skin: Large, blunt hyphae and thick-walled budding

spores in a “spaghetti and meatballs” pattern. LFTs are normal. Which of the following is the most appropriate treatment?a) Oral terbinafineb) Oral itraconazolec) Topical triamcinoloned) Topical ketoconazolee) Oral griseofulvin

Ketoconazole for tinea versicolor: two weeks and continuation of therapy at least one week after resolution of symptoms

Griseofulvin, terbinafine, or itraconazole can be used with tinea barbae: monitor liver function in patients with hepatic impairment or with prolonged therapy

Treat oncychomycosis in patients with PVD or diabetes to prevent development of cellulitis

• 30 yr man

• Lifelong epistaxis + easy bruising

• Tooth extraction – bleeding for several days

• Adopted

• Hbg 13.0; MCV 78; plts. 250,000

• BT 13.5 min; PT 12 sec; aPTT 40 sec; TCT

normal

• Platelet aggregation study normal

1% of the population Bruising and mucosal bleeding (after

extractions) • Dx: von Willebrand factor activity

factor VIII bleeding time, PFA100 von Willebrand factor multimers