tag:blogger.com,1999:blog-63820563756681401522011-10-05T17:37:28.923-04:00Case Reports from my residency. This information is not intended for patient care without your own professional and critical interpretation.tclhttp://www.blogger.com/profile/13413333074656762877noreply@blogger.comBlogger1901100tag:blogger.com,1999:blog-6382056375668140152.post-46533682281661708362010-09-06T20:03:00.001-04:002010-09-06T20:03:39.846-04:00

The simplified PESI is useful to select patients at low risk of death from PE who could probably be treated as outpatients (see archives int medicine article linked above).  A score of zero has a negative predictive value of 99% in both derivation and validation cohorts.

tclhttp://www.blogger.com/profile/13413333074656762877noreply@blogger.com0tag:blogger.com,1999:blog-6382056375668140152.post-39938808560875165492009-06-18T10:24:00.004-04:002009-06-18T10:52:21.984-04:00

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,

tclhttp://www.blogger.com/profile/13413333074656762877noreply@blogger.com0tag:blogger.com,1999:blog-6382056375668140152.post-22769065499794185772009-06-16T11:40:00.001-04:002009-06-16T11:44:39.835-04:00

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

tclhttp://www.blogger.com/profile/13413333074656762877noreply@blogger.com0tag:blogger.com,1999:blog-6382056375668140152.post-6449569880656021532009-06-15T09:12:00.003-04:002009-06-15T09:33:45.234-04:00

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

tclhttp://www.blogger.com/profile/13413333074656762877noreply@blogger.com0tag:blogger.com,1999:blog-6382056375668140152.post-39153017142438506742009-06-12T18:00:00.000-04:002009-06-14T18:14:46.710-04:00

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

tclhttp://www.blogger.com/profile/13413333074656762877noreply@blogger.com0tag:blogger.com,1999:blog-6382056375668140152.post-12150854076105493692009-06-11T17:53:00.000-04:002009-06-14T18:00:25.367-04:00

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.

tclhttp://www.blogger.com/profile/13413333074656762877noreply@blogger.com0tag:blogger.com,1999:blog-6382056375668140152.post-46383670554033324832009-06-10T09:03:00.002-04:002009-06-10T09:34:51.373-04:00

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.

tclhttp://www.blogger.com/profile/13413333074656762877noreply@blogger.com0tag:blogger.com,1999:blog-6382056375668140152.post-9496811860075400742009-06-08T10:31:00.001-04:002009-06-08T10:44:24.778-04:00

I've previously blogged and referenced hyponatremia here

tclhttp://www.blogger.com/profile/13413333074656762877noreply@blogger.com0tag:blogger.com,1999:blog-6382056375668140152.post-53932730207024647312009-06-05T08:51:00.012-04:002009-06-05T11:43:33.477-04:00

Today we heard about a patient with a diagnosis of Henock Schonlein Purpura (Henock left, Schonlein, right). A similar case is presented in the NEJM here.They presented with a prodromal URTI (more common in patients younger than 30) and then:Lower extremity purpuric rash (picture here)Abdominal pain with or without gastrointestinal bleeding (GI manefestations reviewed here)Symetrical arthritis

tclhttp://www.blogger.com/profile/13413333074656762877noreply@blogger.com0tag:blogger.com,1999:blog-6382056375668140152.post-1444507704257337662009-06-04T09:28:00.003-04:002009-06-04T09:58:57.060-04:00

Today we discussed a patient with fever of unknown origin (previous blogs here including links to the articles I mentioned)I erred when I said that abdominal imaging was required prior to making the diagnosis -- however, given the ease at which we can get said imaging I would say that it probably *should* be required before labeling as FUO. Certainly, it should be the first test performed in the

tclhttp://www.blogger.com/profile/13413333074656762877noreply@blogger.com0tag:blogger.com,1999:blog-6382056375668140152.post-10183888754566623532009-06-03T08:59:00.007-04:002009-06-03T11:36:50.794-04:00

Today we had a patient present with weight gain, facial changes, abdominal obesity, psychosis and hypertension with hypokalemia.The most common cause of Cushing Syndrome is Cushing's Disease (ACTH producing pituitary adenoma 68%). Ectopic ACTH production and adrenal ademomas are the second most common causes at approx 10% each.The clinical symptoms and physical signs are wonderfully illustrated

tclhttp://www.blogger.com/profile/13413333074656762877noreply@blogger.com0tag:blogger.com,1999:blog-6382056375668140152.post-32409211485666725382009-06-02T09:15:00.002-04:002009-06-02T09:51:46.263-04:00

Today we heard a case of a patient post ETOH binging who presented with acute anuric renal failure. We briefly discussed hepatorenal syndrome and then abandoned this diagnosis.We discussed an approach to renal failure.We then discussed the possibility of interstitial nephritis, and the role (or lack therof) of testing for urine eosinophils which I have blogged about here.Some speculations

tclhttp://www.blogger.com/profile/13413333074656762877noreply@blogger.com0tag:blogger.com,1999:blog-6382056375668140152.post-2394208227187044852009-06-01T09:58:00.002-04:002009-06-01T10:25:05.941-04:00

Today we presented a case of a patient with hepatitis C presenting with a presumed non-antibody mediated hemolytic anemia with renal failure and hematuria. We have discussed the vascular and renal complications of Hepatitis C, including cryoglobulinemia and membranoproliferative glomerulonephritis previously. Another good review of crytoglobulinemia and hepatitis C is available here.Note that

tclhttp://www.blogger.com/profile/13413333074656762877noreply@blogger.com0tag:blogger.com,1999:blog-6382056375668140152.post-50548179564813774192009-05-29T14:51:00.003-04:002009-05-29T15:02:59.405-04:00

See approach to massive transaminitis here.There is a nice NEJM review on autoimmune hepatitis here. The table below is linked from there. Labs:In general, ANA is positive more than 1:80, anti-smooth muscle antibody 1:80, there is an elevated IgG, pANCA may be positiveTreatment:Prednisone 20-60mg per day with AZATHIOPRINE 50-100mg per dayMaintentance with AZATHIOPRINE (or other)Goal is

tclhttp://www.blogger.com/profile/13413333074656762877noreply@blogger.com0tag:blogger.com,1999:blog-6382056375668140152.post-51565757947543602772009-05-28T14:34:00.000-04:002009-05-29T14:51:34.460-04:00

This patient presented with stroke. This article reviews stroke in IE. This related article reviews the neurologic manifestations of IE.An original article by Osler on IE!Some key points:Mitral Valve IE ~ 10% stroke rateMortality is high -- 35% in hospital 52% at one yearEarly antibiotic therapy reduces neurologic complicationsI have previously blogged about infective endocarditis (see here)

tclhttp://www.blogger.com/profile/13413333074656762877noreply@blogger.com0tag:blogger.com,1999:blog-6382056375668140152.post-2001818007159862972009-05-27T09:07:00.007-04:002009-05-27T09:52:17.947-04:00

Today we discussed a patient with polyarticular gout presenting with fever and multiple swollen joints.Precipitants:Drugs: HCTZ, other diuretics, ASA, pyrazinamine, allopurinol, cyclosporin, otherFoods: Alcohol (red wine), Red Meat, CheesesDiseases: Myeloproliferative disorders, hematologic malignancies, renal failureDiagnosis (how to do an arthrocentesis):Synovial fluid cell count usually in

tclhttp://www.blogger.com/profile/13413333074656762877noreply@blogger.com0tag:blogger.com,1999:blog-6382056375668140152.post-43294105850242095152009-05-26T09:04:00.006-04:002010-01-27T10:58:25.329-05:00

A great case today -- and some good topics were covered by the discussant.1) Hypercalcemia (previously blogged here)2) Hepatitis C and its complications including:* Mixed cryoglobulinemia (image) which can cause a vasculitis* Membranoproliferative glomerulonephritis (review here)* Porphyria Cutanea Tarda* HCV Associated Lymphoma3) Sarcoidosis (from review)"sarcoidosis is established on the basis

tclhttp://www.blogger.com/profile/13413333074656762877noreply@blogger.com0tag:blogger.com,1999:blog-6382056375668140152.post-59281799678175199542009-05-25T09:11:00.004-04:002009-05-26T17:09:10.670-04:00

From the JAMA series:History:Jaw Claudication LR + 4.2 LR - 0.72Diplopia LR + 3.9 LR - 1Other historical features not helpful to rule in or out. Most sensitive sign is headache (~70%) other signs and symptoms have sensitivity less that 50%Physical:Beaded temporal artery LR + 4.6 LR - 0.9Prominant Temporal Artery LR + 4.3 LR - 0.7Tender Temporal Artery LR+ 2.6 LR - 0.8Other physical exam findings

tclhttp://www.blogger.com/profile/13413333074656762877noreply@blogger.com0tag:blogger.com,1999:blog-6382056375668140152.post-67245331885803285502009-05-22T09:30:00.002-04:002009-05-22T09:50:12.586-04:00

Today we heard a case of a patient with undelying Wegner's Granulomatosis who presented with several days of fever and cough. Her chest xray showed no infiltrate. The majority of patients with influenza will present with cough (90%) and fever (~70%). Headache, myalgias, arthralgias, fatigue are also common but seen in only 50-60%. There is a rational clinical exam on influenza here.The

tclhttp://www.blogger.com/profile/13413333074656762877noreply@blogger.com0tag:blogger.com,1999:blog-6382056375668140152.post-47492122175954479372009-05-21T14:14:00.003-04:002009-05-21T14:28:55.963-04:00

Today we discussed a great case of SEPSIS (focus of infection unclear) with associated DIC.SIRS Criteria:Fever or hypothermiaWBC >12,000 or less than 4,000HR >90RR >20Sepsis = 2 or more SIRS criteria of presumed infective etiologySevere sepsis includes sepsis with end organ dysfunction or lactate >4Septic shock includes severe sepsis with refractory hypotension requiring inopressorsI have

tclhttp://www.blogger.com/profile/13413333074656762877noreply@blogger.com0tag:blogger.com,1999:blog-6382056375668140152.post-9492515843085314172009-05-20T09:14:00.004-04:002009-05-20T10:00:11.521-04:00

Very complex case facilitated by an expert discussant. The key focus, other than on the case at hand was a demonstration of clinical reasoning and Bayes theorem. We highlighted the importance of Occam's Razor -- but stressed the importance of recognizing Hickam's dictum.I have previously blogged about pulmonary eosinophilia here (with references). In my mind, an important consideration in this

tclhttp://www.blogger.com/profile/13413333074656762877noreply@blogger.com0tag:blogger.com,1999:blog-6382056375668140152.post-22753421812857587002009-05-19T09:16:00.006-04:002009-05-19T09:48:09.577-04:00

Today we heard a case of a patient presenting with symptomatic anemia and thrombocytopenia (with co-incidental leukopenia).I have blogged about my approach to isolated anemia and thrombocytopenia. The combination of the two suggests a number of processes:Decreased Production:Bone Marrow Problem: Leukemia, Lymphoma, Myeloma, Myelodysplastic Syndromes, Myelofibrosis, Myelopthysis, Aplastic

tclhttp://www.blogger.com/profile/13413333074656762877noreply@blogger.com0tag:blogger.com,1999:blog-6382056375668140152.post-59482535556020126612009-05-15T14:59:00.000-04:002009-05-16T15:08:36.804-04:00

Today we heard a case of a patient with alcoholic cirrhosis who developed a significant anemia in hospital without overt blood loss. In this case, it turned out to be a large buttock/thigh hematoma which was not detected because the patient was quadraplegic. It mimicked haemolytic anemia because of the massive resorption.I have previously blogged about anemia here (including hemolytic anemias

tclhttp://www.blogger.com/profile/13413333074656762877noreply@blogger.com0tag:blogger.com,1999:blog-6382056375668140152.post-34463587633170166762009-05-14T14:40:00.000-04:002009-05-16T14:58:52.114-04:00

Today we heard the case of a patient who presented with diplopia, ataxia and vertigo in association with severe hypertension. The CT Scan was normal.We discussed the differential diagnosis including hypertensive encephalopathy, PRES (posterior reversible encephalopathy syndrome, first described in NEJM here with two good reviews here and here), and a pontine infarction. We highlighted the

tclhttp://www.blogger.com/profile/13413333074656762877noreply@blogger.com0tag:blogger.com,1999:blog-6382056375668140152.post-27989239855335976032009-05-13T11:01:00.002-04:002009-05-13T11:43:57.749-04:00

Today we discussed a case of a patient with jaundice from decompensated cirrhosis with encephalopathy, hepatorenal syndrome, and likely spontaneous bacterial peritonitis, who had a decreased level of consciousness. The presumed etiology was ETOH cirrhosis with possible co-morbid hemochromotosis (NEJM review and recent study). Hemochromotosis is suggested when the transferrin saturation is above

tclhttp://www.blogger.com/profile/13413333074656762877noreply@blogger.com0tag:blogger.com,1999:blog-6382056375668140152.post-69480932282432542182009-05-12T09:17:00.003-04:002009-05-12T09:51:53.186-04:00

We discussed a great case of tuberculosis causing pleural effusion today. I have previously blogged about this before.Previous blogs on pleural effusion here and here (including discussion of Light's Criteria and parapneumonic effusions/empyema).Modified Light's Criteria (see review here):Change LDH pleural fluid 0.45 ULN (increases sensitivity but reduces specificity)Alternative tests:LDH (

tclhttp://www.blogger.com/profile/13413333074656762877noreply@blogger.com0tag:blogger.com,1999:blog-6382056375668140152.post-46260456986504079052009-05-11T09:21:00.008-04:002009-05-11T10:04:06.370-04:00

Today we discussed a case of a patient with known HIV disease (CD4 300-500, not on therapy) who presented with fever, diffuse adenopathy, and splenomegaly. The presumed cause is lymphoma.The differential diagnosis would include:Infections:HIV with high level viremiaMononucleosis syndromes (EBV, CMV, acute toxoplasmosis)SyphilisDisseminated TBIn the more immunosuppressed host:Mycobacterium Avium

tclhttp://www.blogger.com/profile/13413333074656762877noreply@blogger.com0tag:blogger.com,1999:blog-6382056375668140152.post-46849047912220543682009-05-08T13:21:00.004-04:002009-05-08T14:02:20.172-04:00

What to do with symptomatic patients? (ACC Guidelines on ablation, ACC Guidelines on the management of supraventricular tachycardia)AVRT is the most common arrythmia seen in WPW.If you've had sudden death -- you need an ablation.If your refractory period is short (less than 240ms) you should consider an ablation to prevent sudden death.Risk of cardiac death is about 0.25% per year or 3-4% over

tclhttp://www.blogger.com/profile/13413333074656762877noreply@blogger.com0tag:blogger.com,1999:blog-6382056375668140152.post-62021291812960777822009-05-07T09:54:00.005-04:002009-05-08T14:04:26.349-04:00

Today we discussed the case of a patient with the classic presentation of paroxysms of hypertension, headache (80%), palpitations (60%), and diophoresis (70%). This is a rare diagnosis occuring in approximately 1-2 per 100,000. Approximately 10% will be extra-adrenal. About 10% of sporatic pheo will be malignant. Approximately 10% will have metastasis.25% of patients may have a genetic

tclhttp://www.blogger.com/profile/13413333074656762877noreply@blogger.com0tag:blogger.com,1999:blog-6382056375668140152.post-15249594841778303042009-05-05T09:12:00.003-04:002009-05-05T09:37:36.300-04:00

Great case. I have previously blogged about the diagnosis of endocarditis here and here.Patient with multiple prosthetic valves develops sepsis in the context of an enterococcal bacteremia. Highly suspicious though non diagnostic echo for PVIE. Treated with VANCOMYCIN ("penicillin allergy" is a pet peeve of mine) and GENTAMICIN (for synergy). The evidence for synergy is not totally supported by

tclhttp://www.blogger.com/profile/13413333074656762877noreply@blogger.com0tag:blogger.com,1999:blog-6382056375668140152.post-81426657722254457582009-05-01T14:08:00.003-04:002009-05-04T19:25:35.752-04:00

We discussed a case of pulmonary and extrapulmonary tuberculosis which presented on TNF-alpha antagonist therapy.Addendum: TB Immune Reconstitution Reviewed Recently here.We also discussed paradoxical worsening of TB post-discontinuation of immunosuppression. The case report I was talking about is available here.

tclhttp://www.blogger.com/profile/13413333074656762877noreply@blogger.com0tag:blogger.com,1999:blog-6382056375668140152.post-11618903840183309642009-04-28T09:45:00.003-04:002009-04-28T09:49:13.017-04:00

Today we discussedETOH dependency and withdrawlAlcohol and tylenol co-ingestionCirrhosis, and the management of cirrhotic complication

tclhttp://www.blogger.com/profile/13413333074656762877noreply@blogger.com0tag:blogger.com,1999:blog-6382056375668140152.post-21772579361971526492009-04-27T10:17:00.004-04:002009-04-27T15:12:24.398-04:00

Today we discussed a few issues:The developing influenza outbreak (see previous blogs on influenza). A review of the neurologic manifestations of influenza infection is available here.A case of meningoencephalitis (see TWH blog), presumably due to mumps (though I have my reservations as the parotid enlargement classically predates the encephalitis and the IgM is still pending!)TB Meningitis was

tclhttp://www.blogger.com/profile/13413333074656762877noreply@blogger.com0tag:blogger.com,1999:blog-6382056375668140152.post-90946375800216373182009-04-24T13:29:00.000-04:002009-04-26T13:37:34.423-04:00

Today we talked about a patient with decreased level of consciousness from hypernatremia.This a great review of the topic.The key in management is to provide free water at a rate that allows the serum sodium to decrease 10mmol/L/24h. This is usually accomplished after treating any severe ECF volume contraction with normal saline.

tclhttp://www.blogger.com/profile/13413333074656762877noreply@blogger.com0tag:blogger.com,1999:blog-6382056375668140152.post-27977292332088833262009-04-23T13:03:00.000-04:002009-04-26T13:29:32.108-04:00

Today we discussed a case of a patient with chronic hepatitis B who presented with massive elevations of his liver enzymes. The cause was felt to be a flare of his underlying hepatitis B.

tclhttp://www.blogger.com/profile/13413333074656762877noreply@blogger.com0tag:blogger.com,1999:blog-6382056375668140152.post-20598756909698207442009-04-22T12:41:00.009-04:002009-04-22T15:00:00.668-04:00

Today we heard about a patient with massive splenomegaly who presented with symptoms anorexia and weight loss.We discussed the physical diagnosis of splenomegaly. We also talked about differentiating the spleen from an enlarged kidney or stomach based.SpleenHas notchCannot palpate aboveDescends with inspirationCannot ballotSplenic rubKidneyNo notchCan ballotMay be able to palpate aboveNo change

tclhttp://www.blogger.com/profile/13413333074656762877noreply@blogger.com0tag:blogger.com,1999:blog-6382056375668140152.post-30826638419676747292009-04-15T09:26:00.007-04:002009-04-15T10:03:12.525-04:00

Today was great! We talked about the approach to acute confusion. Then we talked about alcohol withdrawl and the treatment thereof. An approach that seems "easy" to remember is to use CIWA-A hourly giving 15mg for CIWA-A 8 to 15 and 30mg for scores above 15. Diazepam or lorazepam can be substituted. Disorientation and hallucinosis can be treated with small doses of haloperidol (i.e. 2.5-5mg)

tclhttp://www.blogger.com/profile/13413333074656762877noreply@blogger.com0tag:blogger.com,1999:blog-6382056375668140152.post-22416817613077849982009-04-14T09:08:00.004-04:002009-04-14T09:35:18.664-04:00

The patient (not the man in the picture!!) today had alcohol induced cirrhosis -- cirrhosis, its complications, and treatment thereof previously blogged (here, here, and here) with hepatic encephalopathy, massive ascites, and jaundice and possible hepatorenal syndrome.We also later learned that the patient initially underreported their alcohol consumption. I couldn't find any literature on this

tclhttp://www.blogger.com/profile/13413333074656762877noreply@blogger.com0tag:blogger.com,1999:blog-6382056375668140152.post-39097639359186746492009-04-13T11:16:00.004-04:002009-04-13T14:06:39.347-04:00

Today we heard the case of a young man with a history of constitutional symptoms (sweats, weight loss) in association with a non-productive cough and a cavitary right upper lobe infiltrate.I have previously blogged about the differential of cavitary lung lesionsBased on the presentation I favor an infectious etiology, most likely tuberculosis. The absence of AFB on the bronchoscopy does *not*

tclhttp://www.blogger.com/profile/13413333074656762877noreply@blogger.com0tag:blogger.com,1999:blog-6382056375668140152.post-83624728944585497842009-04-08T10:31:00.005-04:002009-04-08T10:43:54.344-04:00

Great case of haemolytic anemia presenting as shortness of breath. I have previously blogged about AIHA and linked to good articles here. The approach to anemia is discussed in this blog, and the approach to microangiopathic haemolytic anemia (and TTP).We also discussed the approach to dyspnea as a presenting illness which is easily remembered by the pneumonic FIT-RCMPFitness (i.e. out of shape

tclhttp://www.blogger.com/profile/13413333074656762877noreply@blogger.com0tag:blogger.com,1999:blog-6382056375668140152.post-83124327925519966132009-04-03T13:48:00.003-04:002009-04-03T13:56:33.243-04:00

A good review of severe asthma is available here. The ACLS guidelines are available here.The ACLS guidelines for the hypothermic patient.

tclhttp://www.blogger.com/profile/13413333074656762877noreply@blogger.com0tag:blogger.com,1999:blog-6382056375668140152.post-38871430852848624282009-04-03T13:16:00.002-04:002009-04-03T13:41:04.616-04:00

Today we heard a very complicated case of a man with an extensive cardiac and vascular history who presented with decreased level of consciouness and paresis which was felt to be due to a seizure (Todd's paresis)The underlying cause for the seizure was presumed to be multiple old and subacute infarcts, the etiology of which was unclear -- but suspicious for embolism given his recent large

tclhttp://www.blogger.com/profile/13413333074656762877noreply@blogger.com0tag:blogger.com,1999:blog-6382056375668140152.post-80914578292353649062009-04-02T23:06:00.003-04:002009-04-02T23:24:17.707-04:00

Today we discussed a case of a patient with multiple immunological deficiencies (a review of primary immunodeficiencies is available here)Multiple myeloma with dysgammaglobulinemia predisposing to infections with encapsulated organisms like streptococcus pneumoniae and other bacterial infections like staphylococci.High dose prednisone leading to relative deficiencies with cell mediated immunity

tclhttp://www.blogger.com/profile/13413333074656762877noreply@blogger.com0tag:blogger.com,1999:blog-6382056375668140152.post-53421801294850687032009-04-01T16:07:00.002-04:002009-04-01T16:26:24.196-04:00

Today we discussed a case of a patient from a marginalized social status with severe hypertension, decreased level of consciousness and seizure.The issue of possible cocaine intoxication came up. A review of the cardiovascular consequences of cocaine use is presented here.The management of hypertensive emergencies also was discussed. In general, with the exception of aortic dissection, the goal

tclhttp://www.blogger.com/profile/13413333074656762877noreply@blogger.com0tag:blogger.com,1999:blog-6382056375668140152.post-91248414553740434732009-03-31T09:05:00.007-04:002009-03-31T09:51:53.097-04:00

Today we discussed a patient with sickle cell anemia (previous blogs) who presented with acute onset chest pain, bilateral chest xray infiltrates and profound hypoxemia.This patient had a compound heterozygote of sickle and beta-thalassemia. A review of the various compound heterozygotes is available here.This patient may have had chest crisis. We did not see the initial xray. The definition of

tclhttp://www.blogger.com/profile/13413333074656762877noreply@blogger.com0tag:blogger.com,1999:blog-6382056375668140152.post-381656812806575762009-03-30T08:08:00.003-04:002009-03-30T08:29:15.909-04:00

Today we discussed a patient with previously resected lung cancer who presents with new onset worsening of hemoptysis. We've previously discussed haemoptysis here .This case subsequently turned out to be a pulmonary hemmorhage syndrome (Churg Strauss) with glomerulonephritis. There is a good case report in the NEJM here. There is another case in NEJM here as well.The original case description

tclhttp://www.blogger.com/profile/13413333074656762877noreply@blogger.com0tag:blogger.com,1999:blog-6382056375668140152.post-76859618339485771182009-03-26T09:57:00.002-04:002009-03-26T10:04:53.199-04:00

Today we heard about a case of a man who presented with acute hepatic encephalopathy of multiple possible etiologies including substance withdrawal and probable GI bleeding. We reviewed the complications of nasogastric tube insertion.I have blogged extensively on cirrhosis and its complications (and treatment thereof) previously (here, here, here, and here)Previous blogs on upper GI bleed here

tclhttp://www.blogger.com/profile/13413333074656762877noreply@blogger.com0tag:blogger.com,1999:blog-6382056375668140152.post-46054887302459143752009-03-25T09:29:00.002-04:002009-03-25T09:35:49.122-04:00

Today we heard a case of a young man with headache and diplopia who rapidly went on to develop ischemic brain lesions and progressive deficits.I have blogged about diplopia here.The final diagnosis was meningovascular syphilis. The discussant also described the natural history (or stages) of syphilis as I have covered here.

tclhttp://www.blogger.com/profile/13413333074656762877noreply@blogger.com0tag:blogger.com,1999:blog-6382056375668140152.post-61818042832712303802009-03-24T10:04:00.001-04:002009-03-24T10:52:49.105-04:00

Today we heard the story of a young woman with fever, headache, photophobia, and confusion/drowsiness with a normal CT and an LP with a lymphocytic pleocytosis with elevated protein. The presumed diagnosis was viral meningoencephalitis and she was treated with IV acyclovir.Despite excellent data on bioavailability, there are only case reports of substituting oral valacyclovir for IV acyclovir in

tclhttp://www.blogger.com/profile/13413333074656762877noreply@blogger.com0tag:blogger.com,1999:blog-6382056375668140152.post-41401107249616919462009-03-23T09:22:00.005-04:002009-03-23T09:59:25.188-04:00

I have previously blogged about the approach to pleural effusion here.We reviewed some general causes of:Exudate:MalignancyInfectionParapneumonicEmpyemaTBSubdiaphragmatic abscessInflammatorySLE/RA/FMFPulmonary EmbolismHemothorax/ChylothoraxTransudates:CHFCirrhosis (including sympathetic)Nephrotic SyndromeMalnutritionHypothyroidismI have previously discussed congestive heart failure here (link to

tclhttp://www.blogger.com/profile/13413333074656762877noreply@blogger.com0tag:blogger.com,1999:blog-6382056375668140152.post-52879314918227529942009-03-20T12:30:00.000-04:002009-03-20T12:30:00.625-04:00

Examples of ECGs of the 4 stages of pericarditis are here.Stage 1: Diffuse concave ST elevation with PR depressionStage 2: PR depression only with pseudonormalizationStage 3: T wave inversionStage 4: NormalizationGood review in NEJM here. A further review on the use of colchicine in the treatment of acute and recurrant pericarditis is available here.

tclhttp://www.blogger.com/profile/13413333074656762877noreply@blogger.com0tag:blogger.com,1999:blog-6382056375668140152.post-78912562337407380962009-03-20T10:00:00.002-04:002009-03-20T10:15:35.426-04:00

Idiopathic pulmonary fibrosis:Older, but still relevant NEJM review. There are few treatment options aside from lung transplantation, which actually substitutes one chronic disease for another. A review is available here. We discussed the concept of "acute exacerbation" of IPF -- a review of this condition and the treatment is here. The mortality is approximately 60-70% at 3 months. Like many

tclhttp://www.blogger.com/profile/13413333074656762877noreply@blogger.com0tag:blogger.com,1999:blog-6382056375668140152.post-6978723075288147842009-03-19T09:27:00.003-04:002009-03-20T09:58:14.012-04:00

Today we heard a case of a patient with a known history of injection drug use who presented with multiple swollen joints, in the context of a persistant staphylococcal bacteremia. The patient also had a history of previous endocarditis and on exam had evidence of moderate-severe tricuspid regurgitation.I have reviewed the diagnostic criteria for endocarditis here.I have previously blogged about

tclhttp://www.blogger.com/profile/13413333074656762877noreply@blogger.com0tag:blogger.com,1999:blog-6382056375668140152.post-5841661242763478912009-03-18T13:23:00.004-04:002009-03-18T13:52:30.892-04:00

Today we heard a case of a patient who presented with an acute, cold/blue, painful leg. The cause of this was identified as a mixture of a large DVT on a background of peripheral vascular disease.In phledmasia cerulea dolens (see right, from NEJM) the DVT, usually very large, causes venous outflow obstruction which, in turn, leads to elevated tissue pressures which can significantly reduce

tclhttp://www.blogger.com/profile/13413333074656762877noreply@blogger.com0tag:blogger.com,1999:blog-6382056375668140152.post-19973264531697838102009-03-17T13:16:00.000-04:002009-03-18T13:23:48.793-04:00

Today was a special session on safe signover practices. Signover/Signout/Handover of care between physicians (particularly at teaching hospitals) is one of the most dangerous times. By paying attention to the process, we can improve the quality of signover and hopefully provide safer and more efficient cross-coverage.The presenters referenced these articles:ANTICipate - A model for generating a

tclhttp://www.blogger.com/profile/13413333074656762877noreply@blogger.com0tag:blogger.com,1999:blog-6382056375668140152.post-7921764618878997612009-03-16T11:48:00.002-04:002009-03-16T11:51:45.933-04:00

Today we heard the case of a patient with severe thrombocytopenia, presumed ITP (bone marrow biopsy pending)I have previously blogged about thrombocytopenia here.

tclhttp://www.blogger.com/profile/13413333074656762877noreply@blogger.com0tag:blogger.com,1999:blog-6382056375668140152.post-66663089370418156922009-03-12T11:51:00.001-04:002009-06-18T10:52:56.940-04:00

Today we talked about a case of a patient with organizing pneumonia in the context of advanced rheumatoid arthritis on penicillamine.The discussant reviewed the respiratory complications from RA:Pulmonary nodulesPleural effusionPulmonary FibrosisBronchiolitis ObliteransOrganizing pneumoniaCavitary disease -- with pneumoconiaosis (Caplan's syndrome)Related to immunosuppression (i.e. methotrexate

tclhttp://www.blogger.com/profile/13413333074656762877noreply@blogger.com0tag:blogger.com,1999:blog-6382056375668140152.post-10154729528122031852009-03-11T09:16:00.002-04:002009-03-11T09:25:49.088-04:00

I have discussed PE/DVT before here (diagnosis, management)There is a good taxonomy of the myeloproliferative disorders and leukemias here. Another (less detailed but more readable) review is available here.A specific review of thrombocytosis and its management (which this patient has) is available here.The NEJM has an article on the initial treatment of CML (which I suspect this patient has).

tclhttp://www.blogger.com/profile/13413333074656762877noreply@blogger.com0tag:blogger.com,1999:blog-6382056375668140152.post-65223258832140188192009-03-10T09:28:00.003-04:002009-03-10T09:47:56.979-04:00

We've previously discussed atrial fibrillation and the urgent management thereof here.This patient was on digoxin, and was not toxic. I've discussed digoxin toxicity and the use of digoxin in CHF here.I have discussed CHF here and some of the causes of cardiomyopathy here. An article on cardiomyopathy taxonomy is available here.

tclhttp://www.blogger.com/profile/13413333074656762877noreply@blogger.com0tag:blogger.com,1999:blog-6382056375668140152.post-80590766117557474012009-03-09T09:07:00.003-04:002009-03-09T09:36:41.585-04:00

The approach to syncope involves an attempt to determine the etiology on the basis of the history, physical exam, and investigations. A guideline is available here.Approximately 20% of the population, at any age, will have syncope.Cardiogenic Cause (Highest 1yr mortality)Structural - AS, HOCM, Severe MS, Myxoma, OtherArrythmogenic -Tachyarrythmia: Atrial fibrillation, VT/VF, otherBradyarrythmia

tclhttp://www.blogger.com/profile/13413333074656762877noreply@blogger.com0tag:blogger.com,1999:blog-6382056375668140152.post-1095320141335394002009-03-06T11:34:00.001-05:002009-03-06T11:34:26.833-05:00

See here.

tclhttp://www.blogger.com/profile/13413333074656762877noreply@blogger.com0tag:blogger.com,1999:blog-6382056375668140152.post-5545034386730105382009-03-06T09:59:00.002-05:002009-03-06T10:26:09.054-05:00

Today we discussed a case of severe Clostridium difficile associated diarrhea. I have previously blogged about the differential of colitis here.There is a general review of C. difficile available from last week's JAMA. I prefer these two (#1 and #2) editorials by John Bartlett. A full suppliment to the journal Clinical Infectious Diseases was devoted to C. difficile in January 2008 and it is

tclhttp://www.blogger.com/profile/13413333074656762877noreply@blogger.com0tag:blogger.com,1999:blog-6382056375668140152.post-74641144799224101282009-03-05T17:10:00.002-05:002009-03-05T17:16:01.395-05:00

Today we discussed a case of presumed cirrhosis and pancytopenia from chronic ETOH over-use.I have previously blogged about cirrhosis (including management of complications, approach to ascites/SBP) here and here. The Physical Exam for ascites is reviewed here. How-to paracentesis here.I have also blogged about the approach to macrocytic anemia here.

tclhttp://www.blogger.com/profile/13413333074656762877noreply@blogger.com0tag:blogger.com,1999:blog-6382056375668140152.post-16418858515542799862009-03-04T09:45:00.006-05:002009-03-04T10:26:40.934-05:00

Hepatocellular carcinoma is a highly vascular primary cancer of the liver which often arises in the context of underlying cirrhosis and ongoing/chronic liver inflammation caused by viral hepatitis (B and C). In general the risk in cirrhosis is approximately 3% per year.The diagnosis is often made based on the radiographic appearance and clinical context. From uptodate: "If the lesion is

tclhttp://www.blogger.com/profile/13413333074656762877noreply@blogger.com0tag:blogger.com,1999:blog-6382056375668140152.post-76746135846623763302009-03-03T09:10:00.003-05:002009-03-03T09:14:46.424-05:00

I've previously blogged about PCP here.We discussed opportunistic infections in HIV here.A previous talk I've given on HIV is available here.

tclhttp://www.blogger.com/profile/13413333074656762877noreply@blogger.com0tag:blogger.com,1999:blog-6382056375668140152.post-51886639040475613062009-02-26T16:40:00.004-05:002009-02-26T16:56:05.444-05:00

Today we discussed an immunosuppressed patient with bilateral upper lobe cavitary lung lesions. The differential diagnosis for such lesions in the immunocompetent includes:Infection:TB or Atypical Mycobacterial DiseaseCavitary PneumoniaGram negatives (Klebsiella, E. Coli, Pseudomonas)Gram positives (Staphylococcus aureus (particularly CA-MRSA), group A streptococci)Anaerobes (Lung Abscess)Fungal

tclhttp://www.blogger.com/profile/13413333074656762877noreply@blogger.com0tag:blogger.com,1999:blog-6382056375668140152.post-83330570978452835022009-02-25T11:43:00.003-05:002010-10-07T09:56:49.167-04:00

Today we heard a case of a patient with 2 weeks of fever and cough with diffuse abnormal chest x-ray infiltrates and profound eosinophilia. This differential diagnosis of pulmonary eosinophilia is discussed here. Another good review is available here. Interestingly -- there are case reports of SSRI induced eosinophilic pneumonia and our patient in this case was on two different SSRIs. Update

tclhttp://www.blogger.com/profile/13413333074656762877noreply@blogger.com0tag:blogger.com,1999:blog-6382056375668140152.post-83542184986318076582009-02-24T11:17:00.000-05:002009-02-25T11:43:02.067-05:00

We heard a case today for which the diagnosis was unclear. The patient presented with a febrile illness with odynophagia and headache accompanied by hallucination which was ascribed to group A streptococcus. A review of the neurologic sequelae of GAS infection is available here. There has been a link between GAS infections and neuropsychiatric symptoms (primarily OCD and tic disorders) in

tclhttp://www.blogger.com/profile/13413333074656762877noreply@blogger.com0tag:blogger.com,1999:blog-6382056375668140152.post-70344197880426819692009-02-23T09:17:00.004-05:002009-02-23T11:10:04.607-05:00

Today we heard a great case of bilateral visual loss that was ultimately diagnosed as bilateral optic neuritis.Acute demylenating optic neuritis typically presents with progressive unilateral eye pain (usually with movement) and visual loss over hours to one week. The visual loss may be exacerbated in the shower (Uhtoff's phenomenon). Progressive worsening over more than one week is atypical as

tclhttp://www.blogger.com/profile/13413333074656762877noreply@blogger.com0tag:blogger.com,1999:blog-6382056375668140152.post-10328446841970107532009-02-12T19:21:00.003-05:002009-02-14T19:29:52.875-05:00

Today's case was highly suspicious of PMR with an elderly woman presenting with bilateral shoulder and hip girdle stiffness with associated proximal muscle weakness and pain. It was not suggestive of closely related Giant Cell Arteritis as there was no suggestion whatsoever of temporal arteritis.Polymyalgia rheumatica is reviewed in NEJM here.

tclhttp://www.blogger.com/profile/13413333074656762877noreply@blogger.com0tag:blogger.com,1999:blog-6382056375668140152.post-69919838556024698012009-02-11T08:59:00.008-05:002009-02-11T09:16:57.518-05:00

We talked about a case of a patient with an acute rise in creatinine to the 600's from a baseline of 50 in the context of adding new medications. The patient developed eosinophilia and white blood cell casts compatible with a diagnosis of interstitial nephritis.The types of interstitial nephritis are shown (above).A similar case is presented in the NEJM here with associated discussion. This was

tclhttp://www.blogger.com/profile/13413333074656762877noreply@blogger.com0tag:blogger.com,1999:blog-6382056375668140152.post-12386771017989254062009-02-10T09:16:00.004-05:002009-02-10T10:16:55.623-05:00

Classification of Lymphoma:A good review article here, from which I have shared with you some of the best figures. If you read this you realize that the classification of lymphoma is extremely complicated and depends on morphologic appearance, genetics and immunophenotype. Lymphomas can arise from B-cells, T-cells or Natural Killer (NK) cells.It is far easier to conceptualize non-Hodgkin's

tclhttp://www.blogger.com/profile/13413333074656762877noreply@blogger.com0tag:blogger.com,1999:blog-6382056375668140152.post-87052195557437892692009-02-09T09:08:00.004-05:002009-02-09T09:37:00.468-05:00

The discussant went over an approach to diplopia:Neurological -- i.e. ischemia/vasculitis, demyelination, tumour (including leptomenegeal), infection (TB, syphilis, listeria, lyme), toxic/metabolic (alcohol/wernike's)NMJ - mysesthenia and other myesthenic syndromesMuscular/Structural - Graves, masses in the muscles, muscular impingementOpthomologic -- monocular diplopia -- think corneal or lens

tclhttp://www.blogger.com/profile/13413333074656762877noreply@blogger.com0tag:blogger.com,1999:blog-6382056375668140152.post-12696757217691460962009-02-05T14:30:00.003-05:002009-02-05T14:37:27.702-05:00

A very complicated case today where we touched upon multiple issues.Here is a good case review of more than 1000 patients with Gaucher's disease.Here is a case review of malignancies in Gaucher's disease. Bottom line: The risk of lymphoma, melanoma, and pancreatic cancer is 2-3 fold that of age matched healthy controls.

tclhttp://www.blogger.com/profile/13413333074656762877noreply@blogger.com0tag:blogger.com,1999:blog-6382056375668140152.post-64134885473903947162009-02-04T08:54:00.004-05:002009-02-04T09:07:18.741-05:00

Today we heard an interesting case of a patient with post-prandial pain, early satiety and weight loss. The underlying cause was obstruction of the celiac and superior mesenteric arteries.There is a general review of SMA syndrome here.The relevant anatomy is reviewed below (images from wikimedia.org, click to enlarge)Celiac Artery:Superior Mesenteric Artery:Inferior Mesenteric Artery:

tclhttp://www.blogger.com/profile/13413333074656762877noreply@blogger.com0tag:blogger.com,1999:blog-6382056375668140152.post-37853746801130603282009-02-03T08:49:00.000-05:002009-02-04T08:54:21.770-05:00

We resurrected an old case today. I've previously blogged about cyrptococcal meningitis here and here. There are useful links to the HIV guidelines on those pages.Here is a link to a talk I once gave on "the basics" of HIV.

tclhttp://www.blogger.com/profile/13413333074656762877noreply@blogger.com0tag:blogger.com,1999:blog-6382056375668140152.post-20748501036849356492009-02-02T14:21:00.002-05:002009-02-02T14:42:16.153-05:00

We had a good discussion today looking at the approach to renal failure (previous blog here) in pregnancy.It is important to note that the correlation between flank pain in pregnancy and hydronephrosis is tenuous. In cases of obstruction, MRI can be useful in differentiating between physiologic and calculi obstruction with no radiation risk. In the absence of recurring infection, renal failure

tclhttp://www.blogger.com/profile/13413333074656762877noreply@blogger.com0tag:blogger.com,1999:blog-6382056375668140152.post-89124491221607470542009-01-28T13:51:00.000-05:002009-02-02T14:21:09.149-05:00

This was a case of a man from an endemic country with an encephalopathy of several weeks duration and a lumbar puncture with a lymphocytic pleocytosis, elevated protein, low glucose and no organisms on the LP. Viral PCR was also negative as were fungal studies. The presumed diagnosis on clinical grounds was TB meningitis.A modern era review article including a discussion on the role of nuclear

tclhttp://www.blogger.com/profile/13413333074656762877noreply@blogger.com0tag:blogger.com,1999:blog-6382056375668140152.post-16874916201057940432009-01-26T10:48:00.002-05:002009-01-26T10:56:55.958-05:00

Today we discussed a case of a patient with hemoptysis x months with associated weight loss. One of the episodes sounded like "massive hemoptysis"I have previously discussed hemoptysis here.We discussed the importance of differentiating hemoptysis from hematemesis and epistaxis. I have previously blogged about upper GI bleeding a few times (linked from here)In the end, we had a chest xray

tclhttp://www.blogger.com/profile/13413333074656762877noreply@blogger.com0tag:blogger.com,1999:blog-6382056375668140152.post-19433483017776837192009-01-22T08:25:00.004-05:002009-01-26T10:47:20.431-05:00

The blogs this month are short because I am on clinical service...We've previously discussed an approach to acute confusion here.Today we talked about a 83 year old woman with underlying cognitive impairment with acute confusion. When I hear this stem, I think "what have we, as doctors, done iatrogenically to cause this" because this is probably one of the most common causes.In this case the

tclhttp://www.blogger.com/profile/13413333074656762877noreply@blogger.com0tag:blogger.com,1999:blog-6382056375668140152.post-43918085127039554392009-01-20T16:09:00.002-05:002009-01-20T16:10:43.578-05:00

A link to an approach to stroke in the young is here.An article on PFO and stroke (and the treatment thereof) is here.

tclhttp://www.blogger.com/profile/13413333074656762877noreply@blogger.com0tag:blogger.com,1999:blog-6382056375668140152.post-61194998055636900882009-01-19T08:38:00.003-05:002009-01-19T08:48:56.838-05:00

Approach to hyponatremia, including references available here.The study, highlighted by the discussant, on marathon induced hyponatremia is available here.Remember -- the doctor may be the most dangerous factor in the treatment of hyponatremia. Overcorrection can lead to severe consequences.

tclhttp://www.blogger.com/profile/13413333074656762877noreply@blogger.com0tag:blogger.com,1999:blog-6382056375668140152.post-9354079796046043222009-01-13T22:04:00.004-05:002009-01-13T22:34:37.636-05:00

Today we discussed a case of intracranial hemorrhage presenting as a stroke like syndrome with confusion, aphasia and neglect.I have previously blogged about acute confusion and aphasia here.Intracerebral Hemorrhage:Second most common cause of stroke syndromeMortality -- ICH ScoreGCS 3-4 (=2 pts) 5-12 (=1 pt)ICH greater than 30cm2 = 1 ptIntraventricular extension (spills into ventricles) = 1

tclhttp://www.blogger.com/profile/13413333074656762877noreply@blogger.com0tag:blogger.com,1999:blog-6382056375668140152.post-86462358584823409832009-01-13T22:03:00.002-05:002009-01-13T22:04:20.325-05:00

I wasn't there (post-call) but I've blogged about this before and I encourage you to read that here.

tclhttp://www.blogger.com/profile/13413333074656762877noreply@blogger.com0tag:blogger.com,1999:blog-6382056375668140152.post-51704234695439300262009-01-09T17:25:00.002-05:002009-01-09T17:31:44.481-05:00

Previously presented this 'classic' case here. Dr. Allison McGeer, the director of infection control and an infectious diseases physician here at MSH has recently published an article discussing the use of empiric influenza treatment in hospitalized patients here.You can look up the current level of influenza across Canada here.

tclhttp://www.blogger.com/profile/13413333074656762877noreply@blogger.com0tag:blogger.com,1999:blog-6382056375668140152.post-74083857934734302632009-01-08T22:45:00.002-05:002009-01-08T23:44:45.883-05:00

I have previously blogged about hepatitis and tylenol overdose here and here.The article the discussant mentioned on alcohol and tylenol overdose is available here. There is a newer publication that looks retrospectively at 20 years of ingestion data and adjusts the classic Rumack-Matthew nomogram for chronic alcohol use (without simultaneous co-ingestion). A similar study proposes to predict

tclhttp://www.blogger.com/profile/13413333074656762877noreply@blogger.com0tag:blogger.com,1999:blog-6382056375668140152.post-39515874673343386832009-01-07T22:41:00.004-05:002009-01-10T18:42:55.702-05:00

Today was a case of pulmonary embolism in a patient with advanced malignancy.We didn't really talk about PE -- but the discussant talked about very relevant issues including end of life care, diagnostic reasoning and clinical decision making.For your information, I have previously blogged about DVT/PE here and thrombophilia here.Addendum: NEJM article from Jan 2009 on PE.

tclhttp://www.blogger.com/profile/13413333074656762877noreply@blogger.com0tag:blogger.com,1999:blog-6382056375668140152.post-50969520280404849802008-12-18T09:05:00.000-05:002008-12-17T23:02:46.422-05:00

The last morning report @ TGH. I move to MSH in January.Today we heard a case of auto-immune haemolytic anemia presenting as symptomatic anemia. The patient may have had a prodromal illness.This is a great article on AIHA. This one is good too.In reading these something interesting became clear -- in what appears to be AIHA with a negative DAT there are a few possibilities.Subthreshold

tclhttp://www.blogger.com/profile/13413333074656762877noreply@blogger.com0tag:blogger.com,1999:blog-6382056375668140152.post-31072486239576365682008-12-17T13:57:00.001-05:002008-12-17T13:58:36.732-05:00

I have previously blogged about acute hepatitis, and have linked to a great article on acetaminophen overdose. Please see here.

tclhttp://www.blogger.com/profile/13413333074656762877noreply@blogger.com0tag:blogger.com,1999:blog-6382056375668140152.post-50305329941254462082008-12-16T20:42:00.002-05:002008-12-16T20:44:15.662-05:00

Due to fun rounds time constraints -- will point you to my previous blogs on FUO -- here.

tclhttp://www.blogger.com/profile/13413333074656762877noreply@blogger.com0tag:blogger.com,1999:blog-6382056375668140152.post-24907560549194961062008-12-15T13:07:00.004-05:002008-12-15T13:50:57.416-05:00

Today we talked about a case of a patient with a presumed cardioembolic (atrial fibrillation mediated) TIA and evidence of old parieto-occipital stroke.We discussed the use of anticoagulants such as warfarin in atrial fibrillation and the CHADS2 score. This patient was "warfarin allergic". Often this is an allergy to the dye in the tablets, and one can use dye free tablets.In these patients

tclhttp://www.blogger.com/profile/13413333074656762877noreply@blogger.com0tag:blogger.com,1999:blog-6382056375668140152.post-5577697668494110512008-12-12T08:56:00.002-05:002008-12-12T09:04:25.417-05:00

Today we discussed a medically complex patient presenting with subacute anemia. We discussed an approach to anemia with reticulocytopenia. I have blogged about anemia a few times before (here and here (macrocytic anemia)).This article discusses the issue of pure red cell aplasia in the context of synthetic EPO.This Toronto study talks about the use of supplemental iron in dialysis patients.

tclhttp://www.blogger.com/profile/13413333074656762877noreply@blogger.com0tag:blogger.com,1999:blog-6382056375668140152.post-62707910299079963972008-12-11T21:24:00.003-05:002008-12-11T22:08:21.138-05:00

Today we discussed a case of severe hypothyroidism presenting with impaired cognition, bradycardia and hypothermia.We discussed the treatment of severe hypothyroidism/myxedema coma:Supportive careIV levothyroxine 200-500mcg then 100mcg q24h until improving then oral 1.6mcg/kgAfter obtaining ACTH, cortisol levels, strongly consider stress dose steroids until concommitant adrenal insufficiency is

tclhttp://www.blogger.com/profile/13413333074656762877noreply@blogger.com0tag:blogger.com,1999:blog-6382056375668140152.post-40303565265258161882008-12-10T11:38:00.003-05:002008-12-10T11:48:13.691-05:00

Today we heard a case of PCP pneumonia with a classic presentation. For those of you who will end up doing medical education -- you should start saving up cases during your residency that you can use as exemplars of diagnoses, management, or approaches -- especially if they have key teaching points or interesting imaging. This will also help you for when you are suddenly called upon to provide

tclhttp://www.blogger.com/profile/13413333074656762877noreply@blogger.com0tag:blogger.com,1999:blog-6382056375668140152.post-13970219870564594282008-12-09T23:18:00.002-05:002008-12-09T23:38:14.336-05:00

Today we talked about an interesting case of a patient with cirrhosis (presumably alcohol and hepatitis C related) who presented with ascites, confusion, and anemia. Cirrhosis (including approach to ascites and SBP) previously blogged here and hereUpper GI bleeding previously blogged here, here, and here.Anemia previously blogged here and here (macrocytic anemia).NB: One of the key teaching

tclhttp://www.blogger.com/profile/13413333074656762877noreply@blogger.com0tag:blogger.com,1999:blog-6382056375668140152.post-77203183817556475802008-12-03T12:45:00.003-05:002008-12-03T13:07:37.328-05:00

We talked about a case of stroke in a young patient. An approach to stroke in a young patient is outlined briefly here.The case turned out to be meningovascular syphilis. Here is an interesting article on the history of syphilis and another which talks about whether or not Shakespeare himself was infected.The second case was that of massive liver enzyme elevation with synthetic dysfunction. I

tclhttp://www.blogger.com/profile/13413333074656762877noreply@blogger.com0tag:blogger.com,1999:blog-6382056375668140152.post-6920013497168525972008-12-02T14:16:00.007-05:002008-12-02T21:52:49.996-05:00

Today we heard about a great case of pyogenic liver abscess. I wanted to clarify a few points of discussion.Pathogenesis (most common in blue):Ascention of pathogens up biliary treeAscention of pathogens through portal circulation. Often in the context of an intraabdominal nidus of infection like diverticulitis. May be in context of septic portal thrombophlebitisCyptogenicDirect innoculation

tclhttp://www.blogger.com/profile/13413333074656762877noreply@blogger.com0tag:blogger.com,1999:blog-6382056375668140152.post-78617629140967722452008-12-01T10:26:00.005-05:002008-12-01T10:51:13.186-05:00

Today we discussed a case of severe pulmonary hypertension presenting with shortness of breath and right heart failure.There is a great review article on pulmonary hypertension here.We initially discussed the physical exam findings in pulmonary hypertension:JVP - Often elevated, may have CV waves if has tricuspid regurgitation, may have kussmaul's sign or abnormal abdominojugular reflux if RV

tclhttp://www.blogger.com/profile/13413333074656762877noreply@blogger.com0tag:blogger.com,1999:blog-6382056375668140152.post-3660207261310588542008-11-27T10:22:00.000-05:002008-12-01T10:26:45.360-05:00

Today we talked about a case of a patient with symptomatic hypotension, that was not initially fluid responsive with a known history of intrabdominal malignancy and hyponatremia with hyperkalemia. The combination of these things led to the suspicion of adrenal insufficiency.This is a classic (now 12 year old) review of adrenal insufficiency from nejm.I have previously blogged about adrenal

tclhttp://www.blogger.com/profile/13413333074656762877noreply@blogger.com0tag:blogger.com,1999:blog-6382056375668140152.post-8964876145690635632008-11-26T09:22:00.003-05:002008-11-26T10:10:40.416-05:00

Today we talked about a case of rapid atrial fibrillation.The ACC guidelines for atrial fibrillation are here, and the ACLS tachycardia algorithm is here.Is the AF causing severe CHF, hypotension or angina? If so manage as unstable. Otherwise manage as stable.Unstable:DC CardioversionStable:Does the patient have pre-excitation or a grade III/IV LV?Amiodarone 150mg IV over 10 minutes, can repeat

tclhttp://www.blogger.com/profile/13413333074656762877noreply@blogger.com0