Day #343 - Interstitial Lung Disease

This is likely to be my final blog of the academic term. It has been a great 'year in medicine'. I hope those of you who read this have gotten something out of it. It will be likely be resumed by the incoming chief resident(s) @ Mount Sinai and/or TGH in July. I will be continuing to blog about other cases as I progress through my Infectious Diseases fellowship. For anyone who cares to read, you will find that blog starting here in July.

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Today we presented a challenging case -- where Occam's Razor again met head to head with Hickam's dictum.

The discussant began by talking about the various rheumatoid manifestations in the lung.

We then honed in on interstitial lung disease (previous blog on IPF here), and discussed the phenomenon of acute exacerbation of ILD (other review on non-IPF related AE-ILD here) -- a relatively new concept in respirology.

We also talked about the possibility -- and confirmation -- of pulmonary embolism. Noting of course that PE would not explain the diffuse ground glass opacities.

We discussed the possibility of a superimposed community acquired pneumonia, or TNF-alpha associated granulomatous infection and the need for treatment of same.

Day #341 - Likely TB Pleural Effusion

I missed it today -- but seems eeerily similar to this post....

Day #340 - Occular Myasthenia

Today we discussed a patient who presented with bilateral ptosis. EMG revealed evidence of myasthenia gravis and the patient responded to treatment with an acetylcholine esterase inhibitor.




The JAMA rational clinical exam series addresses the physical diagnosis of MG here.



History:

"speech becoming unintelligible during prolonged speaking" LR 4.5

presence of the peek sign increase the likelihood of myasthenia gravis LR 30 (eyes "peek" open within 30 seconds of closure)

Bedside Tests:

• Ice test LR + 24 LR - 0.16
  (apply ice to the eyelids x 2 mins then evaluate response which should be immediate and short-lived)


• Response to an anticholinesterase medication LR+ 15 LR - 0.11
  (give tensilon, look for response within 30 seconds lasting less than 5 mins)


• Sleep test LR+ 53.0; LR - 0.16
  (have patient lie in a dark room resting the eyes for 30 mins, look for improvement of ptosis)

A review of autoimmune NMJ diseases is available here.

A discussion of myasthenia mimics is available here.

Day #337 - Cirrhosis (PBC)

Today we heard a case of a patient with decompensated cirrhosis (new diagnosis). The precipitant was likely a general anesthetic on the background of unrecognized cirrhosis.

Given the markedly elevated ALP with no bony symptoms and normal ducts on the ultrasound, we proposed a diagnosis of Primary Biliary Cirrhosis (see review here).

See the associated review/editorial on cholestatic liver diseases from a prominant Toronto hepatologist here.

I have also provided a link to a review article on Hepatitis C and HIV co-infection, since it was discussed and is relevant. There is some evidence that HAART may actually worsen the liver disease in these patients and that perhaps the HCV needs to be treated.

Day #336 - Terminal Illeitis and Abscess

Today we heard a case of presumed Crohn's disease (new diagnosis) with intrabdominal abscess. A NEJM review is available here. American practice guidelines are available here.

The NEJM article on the radiation risk of CT scan is available here.

Day # 335 - Severe Influenza

Today we discussed a case that I have talked about before of severe influenza. This case highlights several key issues -- the most important is pointing out just how sick young patients can get with influenza.

We have previously talked about influenza here and pneumonia here.

Day #333 - Hyponatremia

I've previously blogged and referenced hyponatremia here