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BREAST LUMP/MASS
Breast Lump/Mass - Differential Diagnosis, Workup. Differential diagnosis for breast lump (other than carcinoma): **depends on age, pre- vs post- menopausal. 1) Fibrocystic condition: painful, often multiple, usually bilateral masses in the breast. Rapid Fluctuation in the size is common. Frequently, pain occurs or worsens and sizeincreases
THROMBOPHILIA WORKUP Thrombophilia Workup - Indications. This is a controversial subject! Times to consider workup for inherited thrombophilia: Unprovoked DVT with young age, family history of VTE, recurrent thrombosis, unusual location (e.g. cerebral sinus thrombosis), or massive presentation (i.e. massive unprovoked PE). Factor V Leiden (Active protein Cresistance)
ALTERED MENTAL STATUS Altered Mental Status - DDx & Management. Can break it down into large categories: Primary neurologic (Stroke, Seizure, Bleed) Systemic Disease: Cardiovascular (Hypotension, low cardiac output), Pulmonary (Hypoxia), Renal (Uremia, Hypo/Hypernatremia, Hypercalcemia), Liver (Hepatic encephalopathy), Endocrine (hypoglycemia, thyroid dysfunctionCHEST WALL MASSES
B. Malignant - below are the most common malignant tumors. 1. Chondrosarcoma – most common malignant chest wall tumor, located on anterior chest wall. Presents with slowly growing, painful mass with hard,fixed chest wall lesion. 10% have lung mets at presentation. 2. Askin tumor – part of the Ewing sarcoma/PNET spectrum ofneuroendocrine
BETA BLOCKER OVERDOSE Beta Blocker Overdose. Clinical Manifestations: Mainly hypotension and bradycardia. On EKG, can see PR prolongation leading ot AV block, and sometimes QRS prolongation (with certain beta blockers like sotalol). Can also see mild hyperkalemia and hypoglycemia. Ddx includes overdose of calcium channel blockers, digoxin, and cholinergic agents. METHOTREXATE TOXICITY Common: GI symptoms (mucositis, nausea, dyspepsia, diarrhea), Skin (macular rash), Neurotoxicity, Macrocytosis. More serious: - Hepatotoxicity. - Pulmonary toxicity – both acute reactions and chronic pulmonary toxicity. - Renal toxicity – usually with high dose MTX – due to precipitation of MTX crystals and tubular injury.RIGHT HEART CATH
With a right heart cath (or swan), you can directly measure pressures in the RA, RV, PA, and wedge. Keep in mind for the Fick that O2 consumption is typically estimated based on the patient's weight, as well as age, sex, height, so the main weakness of this method is in patients who have an abnormal level of O2 consumption (like criticallyill
ANTIBIOTICS REVIEW
4. Aztreonam – high rates of resistance at most institutions, so use only if PCN-allergic, and empirically double-cover. 5. Fluoroquinolones - Ciprofloxacin (~70% coverage) > Levofloxacin (~65%), NOT Moxifloxacin (0%) - usually used as double coverage, notfor
SKIN CONTAMINATION AND BLOOD CULTURES There are really only four bugs that are commonly contaminants when blood cultures are positive: Coag negative staph (gram positive cocci); Corynebacterium (gram positive rods); Propionibacterium acnes (anaerobic gram positive rods); Bacillus species (anaerobic gram positive rods) ; While these are commonly contaminants, be careful to rule out true infection in the following settings: APPROACH TO FEVER IN HOSPITALIZED PATIENTS Malignancy (Tumor fever) – usually a diagnosis of exclusion. Vasculitis. Intraabdominal processes – i.e. pancreatitis, acalculous cholecystitis (fairly common and potentially devastating in critically ill patients) With this differential in mind, you can approach your physical exam accordingly i.e. in addition to the standard heart lungsBREAST LUMP/MASS
Breast Lump/Mass - Differential Diagnosis, Workup. Differential diagnosis for breast lump (other than carcinoma): **depends on age, pre- vs post- menopausal. 1) Fibrocystic condition: painful, often multiple, usually bilateral masses in the breast. Rapid Fluctuation in the size is common. Frequently, pain occurs or worsens and sizeincreases
THROMBOPHILIA WORKUP Thrombophilia Workup - Indications. This is a controversial subject! Times to consider workup for inherited thrombophilia: Unprovoked DVT with young age, family history of VTE, recurrent thrombosis, unusual location (e.g. cerebral sinus thrombosis), or massive presentation (i.e. massive unprovoked PE). Factor V Leiden (Active protein Cresistance)
ALTERED MENTAL STATUS Altered Mental Status - DDx & Management. Can break it down into large categories: Primary neurologic (Stroke, Seizure, Bleed) Systemic Disease: Cardiovascular (Hypotension, low cardiac output), Pulmonary (Hypoxia), Renal (Uremia, Hypo/Hypernatremia, Hypercalcemia), Liver (Hepatic encephalopathy), Endocrine (hypoglycemia, thyroid dysfunctionCHEST WALL MASSES
B. Malignant - below are the most common malignant tumors. 1. Chondrosarcoma – most common malignant chest wall tumor, located on anterior chest wall. Presents with slowly growing, painful mass with hard,fixed chest wall lesion. 10% have lung mets at presentation. 2. Askin tumor – part of the Ewing sarcoma/PNET spectrum ofneuroendocrine
BETA BLOCKER OVERDOSE Beta Blocker Overdose. Clinical Manifestations: Mainly hypotension and bradycardia. On EKG, can see PR prolongation leading ot AV block, and sometimes QRS prolongation (with certain beta blockers like sotalol). Can also see mild hyperkalemia and hypoglycemia. Ddx includes overdose of calcium channel blockers, digoxin, and cholinergic agents. METHOTREXATE TOXICITY Common: GI symptoms (mucositis, nausea, dyspepsia, diarrhea), Skin (macular rash), Neurotoxicity, Macrocytosis. More serious: - Hepatotoxicity. - Pulmonary toxicity – both acute reactions and chronic pulmonary toxicity. - Renal toxicity – usually with high dose MTX – due to precipitation of MTX crystals and tubular injury.RIGHT HEART CATH
With a right heart cath (or swan), you can directly measure pressures in the RA, RV, PA, and wedge. Keep in mind for the Fick that O2 consumption is typically estimated based on the patient's weight, as well as age, sex, height, so the main weakness of this method is in patients who have an abnormal level of O2 consumption (like criticallyill
ANTIBIOTICS REVIEW
4. Aztreonam – high rates of resistance at most institutions, so use only if PCN-allergic, and empirically double-cover. 5. Fluoroquinolones - Ciprofloxacin (~70% coverage) > Levofloxacin (~65%), NOT Moxifloxacin (0%) - usually used as double coverage, notfor
SKIN CONTAMINATION AND BLOOD CULTURES There are really only four bugs that are commonly contaminants when blood cultures are positive: Coag negative staph (gram positive cocci); Corynebacterium (gram positive rods); Propionibacterium acnes (anaerobic gram positive rods); Bacillus species (anaerobic gram positive rods) ; While these are commonly contaminants, be careful to rule out true infection in the following settings: APPROACH TO FEVER IN HOSPITALIZED PATIENTS Malignancy (Tumor fever) – usually a diagnosis of exclusion. Vasculitis. Intraabdominal processes – i.e. pancreatitis, acalculous cholecystitis (fairly common and potentially devastating in critically ill patients) With this differential in mind, you can approach your physical exam accordingly i.e. in addition to the standard heart lungsRIGHT HEART CATH
With a right heart cath (or swan), you can directly measure pressures in the RA, RV, PA, and wedge. Keep in mind for the Fick that O2 consumption is typically estimated based on the patient's weight, as well as age, sex, height, so the main weakness of this method is in patients who have an abnormal level of O2 consumption (like criticallyill
BETA BLOCKER OVERDOSE Beta Blocker Overdose. Clinical Manifestations: Mainly hypotension and bradycardia. On EKG, can see PR prolongation leading ot AV block, and sometimes QRS prolongation (with certain beta blockers like sotalol). Can also see mild hyperkalemia and hypoglycemia. Ddx includes overdose of calcium channel blockers, digoxin, and cholinergic agents. SKIN CONTAMINATION AND BLOOD CULTURES There are really only four bugs that are commonly contaminants when blood cultures are positive: Coag negative staph (gram positive cocci); Corynebacterium (gram positive rods); Propionibacterium acnes (anaerobic gram positive rods); Bacillus species (anaerobic gram positive rods) ; While these are commonly contaminants, be careful to rule out true infection in the following settings:BLOODY DIARRHEA
Clinical features: · Nonbloody diarrhea that becomes bloody after 1–3 days. · No fever on initial presentation to medical care. · Tender abdomen. · More than 5 stools in the past 24 hours. · Pain is worse on defecation. · No, few, or moderate fecal leukocytes. · Diarrhea, and especially bloody diarrhea, persists during first 8hours in
BONE MARROW TRANSPLANTATION 101 Bone Marrow Transplantation 101. Two main types of BMT: Auto vs Allo. Basic idea is you receive high dose chemo and XRT to destroy cancer cells and progenitor cells, then reintroduce stem cells, either from your own stored stems cells (Auto) or a donor (Allo). 1) Autologous HSCT – harvest patient’s own stem cells before chemo/XRT, freezeCHOLEDOCHOLITHIASIS
High probability of choledocholithiasis has been defined as: 1. CBD stone on U/S or CT or. 2. At least 3 of the following: dilated CBD on US (>7 mm), fever, bilirubin >2 mg/dL, elevated alkaline phosphatase, or serum alanine aminotransferase (ALT) >twice normal. See Harrison's Table 305-3 for a summary of diagnostic studies for CBD stones. BULLOUS HEMORRHAGIC CELLULITIS Bullous Hemorrhagic Cellulitis. 1) Ddx for bullous hemorrhagic lesions in this case: Fairly broad, but basically broken down into: a) Infectious - Bullous cellulitis, Necrotizing fasciitis, Bullous impetigo, Echthyma gangrenosum, menigococcemia (late stage), Staph Scalded Skin, Herpes, Zoster, Gas gangrene. b) Autoimmune - bullouspemphigoid vs
VENTRICULAR TACHYCARDIA 1) Definitions of Ventricular Tachycardia. Nonsustained VT (NSVT) = at least 3 beats of VT that lasts < 30 seconds (if less than 3 beats, those are just PVCs) Sustained VT = 30 seconds. Accelerated idioventricular rhythm - basically like VT but with rate < 100. Monomorphic VT - all QRS complexes have same height and morphology(can be sustained
POSTERIOR REVERSIBLE ENCEPHALOPATHY SYNDROME Known as Posterior Reversible Encephalopathy Syndrome (PRES), Reversible Posterior Leukoencephalopathy Syndrome (RPLS) and other names. Syndrome that results from acute hypertension and endothelial damage in the brain, leading to vasogenic edema most commonly involving the white matter in the posterior brain (hence, PRES). INDICATIONS FOR ALBUMIN AFTER PARACENTESIS 2009 AASLD Guidelines recommend albumin replacement after large volume paracenteses if > 4-5 L are removed; 6-8 g/L of albumin (25% concentration) should be given.. So, for example, if 10 liters are removed, you would give 60-80 grams of 25% albumin. Although no trial has demonstrated any survival benefit from albumin replacement after large volume tap, it does help prevent asymptomatic ALTERED MENTAL STATUS Altered Mental Status - DDx & Management. Can break it down into large categories: Primary neurologic (Stroke, Seizure, Bleed) Systemic Disease: Cardiovascular (Hypotension, low cardiac output), Pulmonary (Hypoxia), Renal (Uremia, Hypo/Hypernatremia, Hypercalcemia), Liver (Hepatic encephalopathy), Endocrine (hypoglycemia, thyroid dysfunction THROMBOPHILIA WORKUP Thrombophilia Workup - Indications. This is a controversial subject! Times to consider workup for inherited thrombophilia: Unprovoked DVT with young age, family history of VTE, recurrent thrombosis, unusual location (e.g. cerebral sinus thrombosis), or massive presentation (i.e. massive unprovoked PE). Factor V Leiden (Active protein Cresistance)
CHEST WALL MASSES
B. Malignant - below are the most common malignant tumors. 1. Chondrosarcoma – most common malignant chest wall tumor, located on anterior chest wall. Presents with slowly growing, painful mass with hard,fixed chest wall lesion. 10% have lung mets at presentation. 2. Askin tumor – part of the Ewing sarcoma/PNET spectrum ofneuroendocrine
TOXIC SHOCK SYNDROME Two varieties – Staphylococcal TSS and Streptococcal TSS. Both are essentially syndromes of acute multi-organ failure caused by toxins that act as superantigens, activating the immune system and causing a massive cytokine cascade that leads to capillary leak, tissue damage, shock, and multiorgan failure.ANTIBIOTICS REVIEW
4. Aztreonam – high rates of resistance at most institutions, so use only if PCN-allergic, and empirically double-cover. 5. Fluoroquinolones - Ciprofloxacin (~70% coverage) > Levofloxacin (~65%), NOT Moxifloxacin (0%) - usually used as double coverage, notfor
INDICATIONS FOR SBP PROPHYLAXIS Indications for SBP Prophylaxis. 1. Active GI bleed in a cirrhotic patient – treat with abxs (good choices are Ceftriaxone, Cipro, or Norfloxacin) for a 7 day course.. 2. Prior episode of SBP – treat with long-term prophylaxis.Good choices are PO norfloxacin, Cipro (weekly or daily), and Bactrim.SPEP/UPEP OVERVIEW
SPEP/UPEP Overview. Overview of SPEP/UPEP and Immunofixation for Monoclonal Proteins. 1) SPEP – screening test to look for M-protein, but sometimes get false positives where M-protein is actually a polyclonal increase in Ig. Benefit is cheap, easy, and also gives a quantitative estimate of the concentration of the M-protein. 2) Serum BETA BLOCKER OVERDOSE Beta Blocker Overdose. Clinical Manifestations: Mainly hypotension and bradycardia. On EKG, can see PR prolongation leading ot AV block, and sometimes QRS prolongation (with certain beta blockers like sotalol). Can also see mild hyperkalemia and hypoglycemia. Ddx includes overdose of calcium channel blockers, digoxin, and cholinergic agents. METHOTREXATE TOXICITY Common: GI symptoms (mucositis, nausea, dyspepsia, diarrhea), Skin (macular rash), Neurotoxicity, Macrocytosis. More serious: - Hepatotoxicity. - Pulmonary toxicity – both acute reactions and chronic pulmonary toxicity. - Renal toxicity – usually with high dose MTX – due to precipitation of MTX crystals and tubular injury. HEPATORENAL SYNDROME Presents as oliguria and worsening renal function associated with severe liver disease (usually cirrhosis, but can occur with alcoholic hepatitis), with a benign urine sediment and very low urine sodium – essentially the “ultimate prerenal state.” ALTERED MENTAL STATUS Altered Mental Status - DDx & Management. Can break it down into large categories: Primary neurologic (Stroke, Seizure, Bleed) Systemic Disease: Cardiovascular (Hypotension, low cardiac output), Pulmonary (Hypoxia), Renal (Uremia, Hypo/Hypernatremia, Hypercalcemia), Liver (Hepatic encephalopathy), Endocrine (hypoglycemia, thyroid dysfunction THROMBOPHILIA WORKUP Thrombophilia Workup - Indications. This is a controversial subject! Times to consider workup for inherited thrombophilia: Unprovoked DVT with young age, family history of VTE, recurrent thrombosis, unusual location (e.g. cerebral sinus thrombosis), or massive presentation (i.e. massive unprovoked PE). Factor V Leiden (Active protein Cresistance)
CHEST WALL MASSES
B. Malignant - below are the most common malignant tumors. 1. Chondrosarcoma – most common malignant chest wall tumor, located on anterior chest wall. Presents with slowly growing, painful mass with hard,fixed chest wall lesion. 10% have lung mets at presentation. 2. Askin tumor – part of the Ewing sarcoma/PNET spectrum ofneuroendocrine
TOXIC SHOCK SYNDROME Two varieties – Staphylococcal TSS and Streptococcal TSS. Both are essentially syndromes of acute multi-organ failure caused by toxins that act as superantigens, activating the immune system and causing a massive cytokine cascade that leads to capillary leak, tissue damage, shock, and multiorgan failure.ANTIBIOTICS REVIEW
4. Aztreonam – high rates of resistance at most institutions, so use only if PCN-allergic, and empirically double-cover. 5. Fluoroquinolones - Ciprofloxacin (~70% coverage) > Levofloxacin (~65%), NOT Moxifloxacin (0%) - usually used as double coverage, notfor
INDICATIONS FOR SBP PROPHYLAXIS Indications for SBP Prophylaxis. 1. Active GI bleed in a cirrhotic patient – treat with abxs (good choices are Ceftriaxone, Cipro, or Norfloxacin) for a 7 day course.. 2. Prior episode of SBP – treat with long-term prophylaxis.Good choices are PO norfloxacin, Cipro (weekly or daily), and Bactrim.SPEP/UPEP OVERVIEW
SPEP/UPEP Overview. Overview of SPEP/UPEP and Immunofixation for Monoclonal Proteins. 1) SPEP – screening test to look for M-protein, but sometimes get false positives where M-protein is actually a polyclonal increase in Ig. Benefit is cheap, easy, and also gives a quantitative estimate of the concentration of the M-protein. 2) Serum BETA BLOCKER OVERDOSE Beta Blocker Overdose. Clinical Manifestations: Mainly hypotension and bradycardia. On EKG, can see PR prolongation leading ot AV block, and sometimes QRS prolongation (with certain beta blockers like sotalol). Can also see mild hyperkalemia and hypoglycemia. Ddx includes overdose of calcium channel blockers, digoxin, and cholinergic agents. METHOTREXATE TOXICITY Common: GI symptoms (mucositis, nausea, dyspepsia, diarrhea), Skin (macular rash), Neurotoxicity, Macrocytosis. More serious: - Hepatotoxicity. - Pulmonary toxicity – both acute reactions and chronic pulmonary toxicity. - Renal toxicity – usually with high dose MTX – due to precipitation of MTX crystals and tubular injury. HEPATORENAL SYNDROME Presents as oliguria and worsening renal function associated with severe liver disease (usually cirrhosis, but can occur with alcoholic hepatitis), with a benign urine sediment and very low urine sodium – essentially the “ultimate prerenal state.” TOXIC SHOCK SYNDROME Two varieties – Staphylococcal TSS and Streptococcal TSS. Both are essentially syndromes of acute multi-organ failure caused by toxins that act as superantigens, activating the immune system and causing a massive cytokine cascade that leads to capillary leak, tissue damage, shock, and multiorgan failure. HEPATORENAL SYNDROME Presents as oliguria and worsening renal function associated with severe liver disease (usually cirrhosis, but can occur with alcoholic hepatitis), with a benign urine sediment and very low urine sodium – essentially the “ultimate prerenal state.”SPEP/UPEP OVERVIEW
SPEP/UPEP Overview. Overview of SPEP/UPEP and Immunofixation for Monoclonal Proteins. 1) SPEP – screening test to look for M-protein, but sometimes get false positives where M-protein is actually a polyclonal increase in Ig. Benefit is cheap, easy, and also gives a quantitative estimate of the concentration of the M-protein. 2) Serum BETA BLOCKER OVERDOSE Beta Blocker Overdose. Clinical Manifestations: Mainly hypotension and bradycardia. On EKG, can see PR prolongation leading ot AV block, and sometimes QRS prolongation (with certain beta blockers like sotalol). Can also see mild hyperkalemia and hypoglycemia. Ddx includes overdose of calcium channel blockers, digoxin, and cholinergic agents.BLOODY DIARRHEA
Clinical features: · Nonbloody diarrhea that becomes bloody after 1–3 days. · No fever on initial presentation to medical care. · Tender abdomen. · More than 5 stools in the past 24 hours. · Pain is worse on defecation. · No, few, or moderate fecal leukocytes. · Diarrhea, and especially bloody diarrhea, persists during first 8hours in
UNTITLED DOCUMENT
Click this link to go to our live event and ask questions!!! Views: Pikes Peak, Colorado Springs, CO by Errol Ozdalga. Subscribe to our mailing list * indicates requiredCHOLEDOCHOLITHIASIS
High probability of choledocholithiasis has been defined as: 1. CBD stone on U/S or CT or. 2. At least 3 of the following: dilated CBD on US (>7 mm), fever, bilirubin >2 mg/dL, elevated alkaline phosphatase, or serum alanine aminotransferase (ALT) >twice normal. See Harrison's Table 305-3 for a summary of diagnostic studies for CBD stones. VENTRICULAR TACHYCARDIA 1) Definitions of Ventricular Tachycardia. Nonsustained VT (NSVT) = at least 3 beats of VT that lasts < 30 seconds (if less than 3 beats, those are just PVCs) Sustained VT = 30 seconds. Accelerated idioventricular rhythm - basically like VT but with rate < 100. Monomorphic VT - all QRS complexes have same height and morphology(can be sustained
ANTIBIOTIC DOSING
Stanford Antibiogram (2010) (Click to download FULL pdf) Obtained with permission from Stanford Microbiology Laboratory. Niaz Banaei MD. Nancy Watz, CLS. Diane Getsinger, CLS. Patricia Buchner, CLS. BULLOUS HEMORRHAGIC CELLULITIS Bullous Hemorrhagic Cellulitis. 1) Ddx for bullous hemorrhagic lesions in this case: Fairly broad, but basically broken down into: a) Infectious - Bullous cellulitis, Necrotizing fasciitis, Bullous impetigo, Echthyma gangrenosum, menigococcemia (late stage), Staph Scalded Skin, Herpes, Zoster, Gas gangrene. b) Autoimmune - bullouspemphigoid vs
ALTERED MENTAL STATUS Altered Mental Status - DDx & Management. Can break it down into large categories: Primary neurologic (Stroke, Seizure, Bleed) Systemic Disease: Cardiovascular (Hypotension, low cardiac output), Pulmonary (Hypoxia), Renal (Uremia, Hypo/Hypernatremia, Hypercalcemia), Liver (Hepatic encephalopathy), Endocrine (hypoglycemia, thyroid dysfunction THROMBOPHILIA WORKUP Thrombophilia Workup - Indications. This is a controversial subject! Times to consider workup for inherited thrombophilia: Unprovoked DVT with young age, family history of VTE, recurrent thrombosis, unusual location (e.g. cerebral sinus thrombosis), or massive presentation (i.e. massive unprovoked PE). Factor V Leiden (Active protein Cresistance)
CHEST WALL MASSES
B. Malignant - below are the most common malignant tumors. 1. Chondrosarcoma – most common malignant chest wall tumor, located on anterior chest wall. Presents with slowly growing, painful mass with hard,fixed chest wall lesion. 10% have lung mets at presentation. 2. Askin tumor – part of the Ewing sarcoma/PNET spectrum ofneuroendocrine
TOXIC SHOCK SYNDROME Two varieties – Staphylococcal TSS and Streptococcal TSS. Both are essentially syndromes of acute multi-organ failure caused by toxins that act as superantigens, activating the immune system and causing a massive cytokine cascade that leads to capillary leak, tissue damage, shock, and multiorgan failure.ANTIBIOTICS REVIEW
4. Aztreonam – high rates of resistance at most institutions, so use only if PCN-allergic, and empirically double-cover. 5. Fluoroquinolones - Ciprofloxacin (~70% coverage) > Levofloxacin (~65%), NOT Moxifloxacin (0%) - usually used as double coverage, notfor
INDICATIONS FOR SBP PROPHYLAXIS Indications for SBP Prophylaxis. 1. Active GI bleed in a cirrhotic patient – treat with abxs (good choices are Ceftriaxone, Cipro, or Norfloxacin) for a 7 day course.. 2. Prior episode of SBP – treat with long-term prophylaxis.Good choices are PO norfloxacin, Cipro (weekly or daily), and Bactrim.SPEP/UPEP OVERVIEW
SPEP/UPEP Overview. Overview of SPEP/UPEP and Immunofixation for Monoclonal Proteins. 1) SPEP – screening test to look for M-protein, but sometimes get false positives where M-protein is actually a polyclonal increase in Ig. Benefit is cheap, easy, and also gives a quantitative estimate of the concentration of the M-protein. 2) Serum BETA BLOCKER OVERDOSE Beta Blocker Overdose. Clinical Manifestations: Mainly hypotension and bradycardia. On EKG, can see PR prolongation leading ot AV block, and sometimes QRS prolongation (with certain beta blockers like sotalol). Can also see mild hyperkalemia and hypoglycemia. Ddx includes overdose of calcium channel blockers, digoxin, and cholinergic agents. METHOTREXATE TOXICITY Common: GI symptoms (mucositis, nausea, dyspepsia, diarrhea), Skin (macular rash), Neurotoxicity, Macrocytosis. More serious: - Hepatotoxicity. - Pulmonary toxicity – both acute reactions and chronic pulmonary toxicity. - Renal toxicity – usually with high dose MTX – due to precipitation of MTX crystals and tubular injury. HEPATORENAL SYNDROME Presents as oliguria and worsening renal function associated with severe liver disease (usually cirrhosis, but can occur with alcoholic hepatitis), with a benign urine sediment and very low urine sodium – essentially the “ultimate prerenal state.” ALTERED MENTAL STATUS Altered Mental Status - DDx & Management. Can break it down into large categories: Primary neurologic (Stroke, Seizure, Bleed) Systemic Disease: Cardiovascular (Hypotension, low cardiac output), Pulmonary (Hypoxia), Renal (Uremia, Hypo/Hypernatremia, Hypercalcemia), Liver (Hepatic encephalopathy), Endocrine (hypoglycemia, thyroid dysfunction THROMBOPHILIA WORKUP Thrombophilia Workup - Indications. This is a controversial subject! Times to consider workup for inherited thrombophilia: Unprovoked DVT with young age, family history of VTE, recurrent thrombosis, unusual location (e.g. cerebral sinus thrombosis), or massive presentation (i.e. massive unprovoked PE). Factor V Leiden (Active protein Cresistance)
CHEST WALL MASSES
B. Malignant - below are the most common malignant tumors. 1. Chondrosarcoma – most common malignant chest wall tumor, located on anterior chest wall. Presents with slowly growing, painful mass with hard,fixed chest wall lesion. 10% have lung mets at presentation. 2. Askin tumor – part of the Ewing sarcoma/PNET spectrum ofneuroendocrine
TOXIC SHOCK SYNDROME Two varieties – Staphylococcal TSS and Streptococcal TSS. Both are essentially syndromes of acute multi-organ failure caused by toxins that act as superantigens, activating the immune system and causing a massive cytokine cascade that leads to capillary leak, tissue damage, shock, and multiorgan failure.ANTIBIOTICS REVIEW
4. Aztreonam – high rates of resistance at most institutions, so use only if PCN-allergic, and empirically double-cover. 5. Fluoroquinolones - Ciprofloxacin (~70% coverage) > Levofloxacin (~65%), NOT Moxifloxacin (0%) - usually used as double coverage, notfor
INDICATIONS FOR SBP PROPHYLAXIS Indications for SBP Prophylaxis. 1. Active GI bleed in a cirrhotic patient – treat with abxs (good choices are Ceftriaxone, Cipro, or Norfloxacin) for a 7 day course.. 2. Prior episode of SBP – treat with long-term prophylaxis.Good choices are PO norfloxacin, Cipro (weekly or daily), and Bactrim.SPEP/UPEP OVERVIEW
SPEP/UPEP Overview. Overview of SPEP/UPEP and Immunofixation for Monoclonal Proteins. 1) SPEP – screening test to look for M-protein, but sometimes get false positives where M-protein is actually a polyclonal increase in Ig. Benefit is cheap, easy, and also gives a quantitative estimate of the concentration of the M-protein. 2) Serum BETA BLOCKER OVERDOSE Beta Blocker Overdose. Clinical Manifestations: Mainly hypotension and bradycardia. On EKG, can see PR prolongation leading ot AV block, and sometimes QRS prolongation (with certain beta blockers like sotalol). Can also see mild hyperkalemia and hypoglycemia. Ddx includes overdose of calcium channel blockers, digoxin, and cholinergic agents. METHOTREXATE TOXICITY Common: GI symptoms (mucositis, nausea, dyspepsia, diarrhea), Skin (macular rash), Neurotoxicity, Macrocytosis. More serious: - Hepatotoxicity. - Pulmonary toxicity – both acute reactions and chronic pulmonary toxicity. - Renal toxicity – usually with high dose MTX – due to precipitation of MTX crystals and tubular injury. HEPATORENAL SYNDROME Presents as oliguria and worsening renal function associated with severe liver disease (usually cirrhosis, but can occur with alcoholic hepatitis), with a benign urine sediment and very low urine sodium – essentially the “ultimate prerenal state.” TOXIC SHOCK SYNDROME Two varieties – Staphylococcal TSS and Streptococcal TSS. Both are essentially syndromes of acute multi-organ failure caused by toxins that act as superantigens, activating the immune system and causing a massive cytokine cascade that leads to capillary leak, tissue damage, shock, and multiorgan failure. HEPATORENAL SYNDROME Presents as oliguria and worsening renal function associated with severe liver disease (usually cirrhosis, but can occur with alcoholic hepatitis), with a benign urine sediment and very low urine sodium – essentially the “ultimate prerenal state.”SPEP/UPEP OVERVIEW
SPEP/UPEP Overview. Overview of SPEP/UPEP and Immunofixation for Monoclonal Proteins. 1) SPEP – screening test to look for M-protein, but sometimes get false positives where M-protein is actually a polyclonal increase in Ig. Benefit is cheap, easy, and also gives a quantitative estimate of the concentration of the M-protein. 2) Serum BETA BLOCKER OVERDOSE Beta Blocker Overdose. Clinical Manifestations: Mainly hypotension and bradycardia. On EKG, can see PR prolongation leading ot AV block, and sometimes QRS prolongation (with certain beta blockers like sotalol). Can also see mild hyperkalemia and hypoglycemia. Ddx includes overdose of calcium channel blockers, digoxin, and cholinergic agents.BLOODY DIARRHEA
Clinical features: · Nonbloody diarrhea that becomes bloody after 1–3 days. · No fever on initial presentation to medical care. · Tender abdomen. · More than 5 stools in the past 24 hours. · Pain is worse on defecation. · No, few, or moderate fecal leukocytes. · Diarrhea, and especially bloody diarrhea, persists during first 8hours in
UNTITLED DOCUMENT
Click this link to go to our live event and ask questions!!! Views: Pikes Peak, Colorado Springs, CO by Errol Ozdalga. Subscribe to our mailing list * indicates requiredCHOLEDOCHOLITHIASIS
High probability of choledocholithiasis has been defined as: 1. CBD stone on U/S or CT or. 2. At least 3 of the following: dilated CBD on US (>7 mm), fever, bilirubin >2 mg/dL, elevated alkaline phosphatase, or serum alanine aminotransferase (ALT) >twice normal. See Harrison's Table 305-3 for a summary of diagnostic studies for CBD stones. VENTRICULAR TACHYCARDIA 1) Definitions of Ventricular Tachycardia. Nonsustained VT (NSVT) = at least 3 beats of VT that lasts < 30 seconds (if less than 3 beats, those are just PVCs) Sustained VT = 30 seconds. Accelerated idioventricular rhythm - basically like VT but with rate < 100. Monomorphic VT - all QRS complexes have same height and morphology(can be sustained
ANTIBIOTIC DOSING
Stanford Antibiogram (2010) (Click to download FULL pdf) Obtained with permission from Stanford Microbiology Laboratory. Niaz Banaei MD. Nancy Watz, CLS. Diane Getsinger, CLS. Patricia Buchner, CLS. BULLOUS HEMORRHAGIC CELLULITIS Bullous Hemorrhagic Cellulitis. 1) Ddx for bullous hemorrhagic lesions in this case: Fairly broad, but basically broken down into: a) Infectious - Bullous cellulitis, Necrotizing fasciitis, Bullous impetigo, Echthyma gangrenosum, menigococcemia (late stage), Staph Scalded Skin, Herpes, Zoster, Gas gangrene. b) Autoimmune - bullouspemphigoid vs
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