Pearls & Pitfalls

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Pearls & Pitfalls. 63 y/o man with long standing HTN, hyperlipidemia arrives in office Friday afternoon with chest pain 80 pack-year smoker 1 year ago: cardiac cath: 3v CAD, not amenable to CABG/PCI – medical management (beta blocker, ASA, statin) Severe pain centrally, to left arm and back. - PowerPoint PPT Presentation

Text of Pearls & Pitfalls

  • Pearls & Pitfalls

  • 63 y/o man with long standing HTN, hyperlipidemia arrives in office Friday afternoon with chest pain80 pack-year smoker1 year ago: cardiac cath: 3v CAD, not amenable to CABG/PCI medical management (beta blocker, ASA, statin)Severe pain centrally, to left arm and back

  • BP 180/110, pulse 90, resp 14, afebrileNo CHF, new AI murmurOtherwise unremarkable exam

  • EKG

  • You start ASA, give a dose of metoprololCall Cardiology

  • What is your next step (diagnostic/therapeutic?)

  • Aortic dissectionh/o HTN, tearing pain, radiation to backCan dissect into renal / mesenteric / carotid / coronary arteries (presents as acute MI, as in this case)New AI murmur from aortic dilatationPITFALL: no thrombolytics/anticoagulation if dissection suspectedDiagnosis confirmed with ECHO, CT, MRICall CT surgery

  • Objective: recognize the clinical presentation of aortic dissection

  • 27 year old man is admitted with chest pain after a rear-end motor vehicle accident 6 days agobelted, 10 mphHistory of HIVOccasional thrush, no other opportunistic infections

  • How do you manage this patient?

  • Tube thoracostomy2.Bactrim for presumed PCPObjective: recognize PCP as a cause of spontaneous pneumothorax in patients with HIV

  • 50 year old man is admitted with chest pain

    Becomes confused, clammyBp 90/58, pulse 106, rr 22Which ABG below would most likely fit the clinical picture?a) 7.40/40/100c) 7.32/52/82b) 7.52/26/90d) 7.30/28/88

    Objective: identify the blood gas findings in a patient with acute MI / cardiogenic shock

  • You evaluate a 47 year old woman with chronic kidney disease for hypertension. She has no history of diabetes, no cardiac problems, and other medical problems. She has followed a low sodium diet. She does not smoke or drink alcohol.

    She is 5 8 tall and weighs 230 lbs. BMI is 35.

    Blood pressure is 158/92, pulse 70. The exam is unremarkable. She appears well hydrated.

    Creatinine is 3.2, glucose 90, and the remainder of the metabolic panel is normal.

    Urinalysis shows 2+ proteinuria.

  • Which of the following interventions is most likely to reduce this patients risk of requiring dialysis in the future?

    a) implementing a low protein dietb) starting hydrochlorothiazidec) starting an ACE inhibitord) starting amlodipinee) weight reduction until BMI is 30

  • Which of the following interventions is most likely to reduce this patients risk of requiring dialysis in the future?

    a) implementing a low protein dietb) starting hydrochlorothiazidec) starting an ACE inhibitord) starting amlodipinee) weight reduction until BMI is 30

  • ACE inhibitors and kidney diseaseClearly reduce progression to ESRD in diabetic patients (especially with proteinuria micro or macro)Nondiabetic patients have similar benefit:MDRD trialBenazapril trialREIN trialREIN 2 trialAASK trialEven patients with creatinines up to 5.0 mg/dL had reductions in progression to ESRDBe sure the patient is well hydrated, evaluate diuretic use.AARBs similar antiproteinuric effect, but outcome trials lackingObjective: Rx to limit progression renal disease in a 47 y/o woman w/chronic renal insufficiency

  • 64 year old woman with DM II for 20 years, gout, HTN seen in the officeNo S3, no displacement of PMI, no increased JVD, no ralesHistory of blood clot, very high cholesterol (TC 320)Findings below on BOTH legs:

    Most likely cause of the exam finding?CHFNephrotic syndromeDVTGoute)An overly aggressive GT3 examObjective: identify cause of edema in patients with diabetic nephropathy

  • 35 year old woman with malaise, abdominal pain, diarrhea, nausea/vomitingRecently visited here

    What are you likely to find on stool gram stain?a) normal florab) large parasites with few eggs, many RBCc) gram positive rods which are germ tube positived) gram positive cocci in grape-like clusterse) the lost colony of Atlantis

    Objective: understand the most common cause of travelers diarrhea and how to identify it

  • You see a 32 year old man in the emergency department for fever, stiff neck and malaise. He has a petechial rash on his ankle. Gram stain of his CSF shows the following:

  • What therapy is warranted for the household family members of this patient?

    a) no therapy, watchful waiting is appropriateb) Penicillin V-K, 500 mg orally three times daily x 7 daysc) Ciprofloxacin, 500 mg x1 (adults), oral rifampin x 2 days (children)d) meningococcal vaccine, post-exposure dosee) respiratory isolation, culture anterior nares, no therapy

  • What therapy is warranted for the household family members of this patient?

    a) no therapy, watchful waiting is appropriateb) Penicillin V-K, 500 mg orally three times daily x 7 daysc) Ciprofloxacin, 500 mg x1 (adults), oral rifampin x 2 days (children)d) meningococcal vaccine, post-exposure dosee) respiratory isolation, culture anterior nares, no therapyObjective: recognize drug treatment for the family of a patient with meningococcal meningitis.

  • Meningococcal prophylaixsIndicated for high risk exposure:household contacts>4 hours spent with patient for 5 of 7 days priordorms, barrack roommates, day caremouth-to-mouthProphylaxis regimens:rifampin (600mg q 12h x 4) there is resistance to rifampin in some areascipro 500-750 mg x 1ceftriaxone 250 mg IM x 1

  • 35 year old man with this finding on tuberculin skin testing:

    He begins treatment. Which of the following will help prevent symptomatic side effects of therapy?a) Vitamin B12, 1000mcg monthlyb) Vitamin B3, 1 mg dailyc) Vitamin B6, 50 mg dailyd) folic acid, 1 mg dailye) Jack Daniels, nightly

    Objective: recall the management of side effects of anti-TB medications

  • You are consulted to see a 72 year old man whose urine output has diminished 48 hours after aortofemoral bypass grafting. He has Type II diabetes and hypertension, and has had claudication for 1 year, which was angiographically confirmed the morning of surgery.

    He appears well hydrated. Blood pressure is 148/84; otherwise vital signs are normal. There is an S4 on exam, but no other abnormalities. Distal pulses are 1+ and symmetric.

    Serum creatinine is 2.5 (baseline 1.2).

  • What is the most likely cause of the renal failure?

    a) contrast-induced nephropathyb) surgical errorc) renal artery thrombosisd) atheroembolism to the renal arterye) post-op MI with congestive heart failure

  • What is the most likely cause of the renal failure?

    a) contrast-induced nephropathyb) surgical errorc) renal artery thrombosisd) atheroembolism to the renal arterye) post-op MI with congestive heart failureObjective: recognize contrast nephropathy.

  • You are called to admit a 50 year old man from the emergency department for obtundation. The family states he has been complaining of fatigue for nine months, and two weeks of vomiting. He has also lost approximately 20 lbs. over the previous two months.He has no other past medical history, and takes no medications.Vital signs:BP 96/60 P 88 R 20 T 38.4 COn exam, the patient is obtunded but responds to painful and loud verbal stimuli. He grimaces when you palpate his abdomen. You notice dark coloration of his palmar creases.

  • What is the best initial management for this patient?

    a) Broad spectrum antibioticsb) Vasopressorsc) Glucocorticoidsd) L-thyroxinee) Thiamine

  • What is the best initial management for this patient?

    a) Broad spectrum antibioticsb) Vasopressorsc) Glucocorticoidsd) L-thyroxinee) ThiamineObjective: Understand initial treatment for a 50 y/o man w/fatigability/vomiting/wt loss/obtunded/brown palmar creases.

  • You see a 65 year old woman with Type II Diabetes who complains of exertional pain in the chest for the past three weeks. The episodes last a few minutes, are not associated with nausea or dyspnea, and resolve either with rest or spontaneously. She has no history of cardiac or pulmonary disease. She now presents with a similar episode of chest pain which has lasted about 35 minutes.

    Her exam is normal.EKG is completely normal.

  • What is the best initial management for this patient?

    a) Admission, cardiac enzymes, medical therapy for acute coronary syndromeb) Reassurance, prescribe GI cocktailc) Begin aspirin, schedule outpatient stress testd) Send for CT of the chest with PE protocole) Immediate cardiac catheterization

  • What is the best initial management for this patient?

    a) Admission, cardiac enzymes, medical therapy for acute coronary syndromeb) Reassurance, prescribe GI cocktailc) Begin aspirin, schedule outpatient stress testd) Send for CT of the chest with PE protocole) Immediate cardiac catheterization

  • EKG in Acute Coronary SyndromeInitial ECG is often not diagnostic in patients with an ACSIn two series,not diagnostic in 45 percentnormal in 20 percent of patients subsequently shown to have an acute MI Patients with history suggestive of ischemia / ACS should be managed as such despite a normal or non-diagnostic EKGObjective: Manage a 64 yo woman w/type 2 DM with 3 weeks of exertional chest pressure and a normal ECG.

  • A 62 year old man with a history of chronic bronchitis is admitted to the hospital with lobar pneumonia. He presented to his physician after one day of cough and shortness of breath. He has no other chronic medical conditions. Baseline arterial blood gas is as follows:pH 7.34 pCO2 68 pO2 60Vital signs on admission:BP 130/80 P 100 R 24 afebrilePulse oximetry shows an SAO2 of 84% on room air.

    He is begun on cefuro