neumeister - alaskathieves' market dysuria, frequency, hematuria or flank pain lives ... lp wbc...
TRANSCRIPT
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Alaska Thieves’ MarketMay 2013
J. Scott Neumeister MD, FACP
Associate Professor, Internal Medicine
The Nebraska Medical Center
Disorientation
A 25 year old female is brought in by her fatherin February due to confusion and fevers. Her temperature at home has ranged between 99 and 102 degrees F.
When you talk to her it seems like she is oriented,however she is cradling her pillows and will tell you it’s her baby
She notes a headache that starts in the back ofher neck and wraps around to the front of her head with electric shocks for the past 3 days.
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NO photophobia, syncope, trauma, vision changes,seizures, other neurologic complaints, cough,or travel
She notes generalized abdominal pain and is worried about her “kidney stone”
No dysuria, frequency, hematuria or flank pain
Lives with her father. Single. One child.Owns a dog. Denies any alcohol, tobacco, or drug use
Dad (50’s) has CADMom has a “connective tissue disorder”
PMH
Transient liver failure (Tylenol OD 2 months ago)Acute kidney injury (last dialysis was 10 days ago)
Chronic abdominal painExploratory LaparotomyAppendectomyFibromyalgiaKidney stoneVaginal delivery
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Allergies: Cephalexin, Clindamycin
Meds: Prevacid 30 mgNorvasc 10 mgLopressor 50 mg bidRenagel 800 mg tidProcrit 10,000 units with dialysisDisalcid 500 mg bidDilaudid 2 mg tid
NO supplements or OTC drugs
Looks restless. Cradling her “baby”Oriented
38 140 resp 22 133/85Cr. N normal. Reflexes, strength, gait normalKernig, Brudzinski sign negativeTachycardic. Dialysis Catheter looks normal.CTAMild diffuse abdominal painHeme negativeNeck trigger points out of proportion to others No edema
Head CT normal
7.46/25/89 Sats 97% glucose 111
10.59.5 252 S80 L15 Bands 2
30
Coags normal
EKG Sinus Tachycardia
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LP WBC 1RBC 1765Protein, glucose normalcryptococcal ag negativegram stain negative
Very restless. She had been given Haloperidol for agitation. Her father states she had been agitated with previous hospitalizations. Haloperidol had helped previously.
Blood Cultures, CXR, UA, Influenza andmono spot ‐ all negative.
Drug screen + for opiates (on opiates)
143 106 13 9.9 mg, P04 normal3.5 17 1.4 111 ck, trop normal
AST 96 Alb 4.5 TSH normalALT 52 Pro 8.9AP 184 Amylase, lipase normalBili 0.8 Ammonia normal
143 106 13 7.46/25/893.5 17 1.4
gap 20
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Lactic acidTylenolKetonesETOHOSMc 295OSMm 298Glucose 111Bun 13Cr. 1.4
All normal
Wide Anion Gap with a Respiratory Alkalosis
PrevacidNorvascLopressorRenagelProcritAdvilDisalcid (Salsalate)Dilaudid
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Is the data good?
[H+] = 24 X PCo2/HCo3 = 24x25/17 = 34
[H+] 100 = 7.080 = 7.164 = 7.2 ‘rule of 80%’52 = 7.340 = 7.432 = 7.5
106 7.46/25/89 17
143
The data is good. Next calculate the anion gap.143 – 106 – 17 = 20. Wide anion gap acidosis
Next compare the change in the gap and the changein the HCo3. Normal gap is 12, normal HCo3 is 24
delta gap = 8 (20‐12), delta HCo3 is 7 (24‐17)
In acid base 8 = 7 (close enough is good enough)therefore there is NOT a second metabolic process asthe change in the bicarb equals the change in the anion gap.
7.45/25/89 143 10617
The final step is to look for compensationIn a metabolic acidosis the PCo2 = 1.5(HCo3) + 8
PCo2 = 1.5(17) + 8 = 33.5. The patients PCo2 is 25 which is lower than expected therefore she hasa respiratory alkalosis.
7.46/25/89 143 10617
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Salicylate Toxicity
• 10 – 30 gm fatal in adults
• Intoxication with levels above 40 mg/dl
• Activates respiratory center
• Interferes with cellular metabolism (accumulate organic acids)
• Stimulates chemoreceptor trigger zone (nausea and vomiting)
Salicylate Toxicity
• 90% protein bound
• With overdose hepatic detoxification is overwhelmed – half life of ASA changes from 3 hours to 30
• Tinnitis, N/V/F/D, vertigo, MS changes
• If respiratory acidosis – look for additional ingestant
Salicylate Toxicity
• Alkalinization traps salicylate anion in renal tubule and prevents reabsorption.
• GI lavage/charcoal
• Rx hypokalemia. If K+ low, H+ exchanged which makes alkalinization difficult.
• Altered mental status mandates hemodialysis.
• CNS glycopenia – give 50 – 100 gm glucose.
• If intubate – hyperventilate.
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Dyspnea
A 72 year old female presents with dyspnea for 2weeks. She states that she is SOB in the morningand it improves later in the day however at bedtimeshe feels SOB again.
Dyspnea
She notes that her SOB is worse with exertion but denies any chest pain, palpitations, orthopnea or PND. No cough or hemoptysis. She has not noted any blood loss, does not get lightheaded. No new medications and no recent travel history. Pt did have a recent cold and bronchitis that has resolved. She had an ENT eval for her sinusitis and took a course of Vantin (Cefpodoxime) and Clarithromycin that has resolved her sinus symptoms.
Dyspnea
PMH Hodgkin’s lymphoma 1973. C4 subluxation. Osteoporosis. Back surgery 1995. Cataracts. GERD.Sinusitis
NKMA
MEDSPrilosec. Vit E. Calcium with Vit D.Annual Zoledronic acid infusions.Flexeril prn.
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Dyspnea
SOC Married with 3 children. Lives in Atlantic,Iowa. No tob/etoh/drugs
FAM Mom with stroke. Dad with MI, polycystickidney disease, and colon cancer.
Dyspnea
130/80 90 22 37 C
Non toxic. AO x3. HEENT normal. No LN or TMRRR. Lungs with faint wheezing posteriorly in the upper lung fields. Abdomen normal with well healedsplenectomy scar (Hodgkin’s therapy). Liver normalto percussion. No edema. Ambulates without difficulty. No focal neurologic findings.
What would you do next/What is wrong?
Data
O2 sat 95 % on room air
CBC, CMP, TSHD‐dimer, CPKTroponin, CHF peptide, EKG,CXR‐ All normal
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The patient also states that she was evaluated byher home town physician and walked on a treadmillwith normal EKG before and after walking.
The patient was placed on steroids (40 mg a day)with an inhaler for ‘post viral bronchitis’ and reassured. With phone follow up 3 days laterpt was unable to talk. Her husband put her on thephone and she could only gasp for air.
Pt was sent immediately to her local ER. Her O2 sats were normal. Upon arrival to UNMC (6 hourslater due to ambulance issues) the patient was asymptomatic.
The patient does not appear in any distress upon arrival to UNMC. She states that she actually feelsfine, now. With further questioning the patient statesthat this is typical – she is SOB in the morning whenshe gets up with resolution as the day progressesbut when she goes to bed she gets SOB again. Withfurther clarification the patient feels SOB mainlywhen she is recumbent. She states is seems like there is something in ‘here’ as she grabs her neck.
What do you think is wrong/What next?
expiration
inspiration
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trachea
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Tracheal Sarcoma
• 2% of head and neck tumors
• Risk factors include Chemo, radiation, HIV, HHV 8, Genetic, and chronic irritation
• Mixoid Chondrosarcoma survival 45% at 5 years
• Chemotherapy generally not helpful
• ? benefit from radiation
Tracheal stenosis Tracheomalacia Tracheomalaciaintubation Vocal cord paralysis TumorsWegener’s Vocal cord polyps Adenopathy
Tracheal tumor RelapsingForeign body polychondritis
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Headache
A 22 year old patient 15 weeks pregnant presents with a throbbing headache for 1 week. She has a history of seizures, but has not had a seizure ortaken any medications for 4 years.
HeadacheThe patient takes Tylenol on a regular basis. It usually helps her headaches. She has had thesetypes of headaches since she was a child, just in a more mild manner. They occur in the left frontal orright occipital area. They occur shortly after waking up (they do not wake her up at night). Throbbing.She notes photophobia and prefers the lie quietly ina dark room. The headaches will get better in a few days. She has headaches 13 days out of each of thelast few months and getting more frequent. No fevers,nausea, visual complaints or neurologic symptoms.
HeadachePrior C‐section, Seizure d/o
Dad with HTN,DM
No alcohol, tobacco, illicit drugs
No meds, No allergies
112/71 68 36.3 18 4’9’’ 130lbsNormal neurologic exam Fundoscopic normalMental status normal
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Dad has similarfreckling
Freckling moreevident aroundher neck; othersun exposed areas devoid of freckles
What data do you want??
suprasellarsoft tissuefullness
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BHcg appropriate for 15 weeks gestationCBC normalCMP normalCortisol 3.2Prolactin 41 (a little high)TSH normalFree T4 normal
time 0 30 min 60 minCosyntropin stim test 6.2 13.1 13.7
Repeat random cortisol 26.4
She got pregnant – “pituitary function is okay”
Other unidentified bright objects
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HIV negativeSyphyllis IgG negative
CSF WBC 1RBC 52 (clears)Pro normalGlucose normalNo oligoclonal bandsACE normalViral panel negative
What do you think is wrong??
There were similarlesions on her backand legs
What other specificexam findings do you want??
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Yellow/brownmacules in theIris
Neurofibromatosis type 1
• 6 or more Café au lait spots
• Freckling in areas of skin apposition
• 2 or more neurofibromas
• Optic Glioma
• 2 or more Lisch nodules (Iris hamartoma)
• 1st degree relative with NF1
Neurofibromatosis
• Autosomal dominant
• Variable expression
• Lisch nodules develop by adulthood
• 25% of the normal population has CALS
• Unidentified bright objects (UBO’s) in 60 to 70% of NF1
• Seizures in 4%
• Hypertension in adults common
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Optic Glioma
• If NF1 Optic Glioma present 15‐40%
• If Optic Glioma 10‐38% have NF1
• Bilateral Optic Glioma = NF1
• No good therapy – high rates of visual loss with therapy
• Slow growing
• Rare to metastasize
Hypertension
A 27 year old Sudanese male is seen for his highblood pressure. He has been treated for the past6 years with escalating medications. He currentlyis taking Hydrochlorothiazide/Triamterene (25/37.5), Hydralazine 50mg 3 times a day, Metoprolol50 mg 2 times a day, and Felodipine 10 mg a day.
Hypertension
He is otherwise feeling well. No headaches, chestpain, breathing problems, palpitations, weight loss,tremor, flushing, or abdominal pain. No skin or hairchanges. No illicit drug use or herbal products.
He was taken away from his family at age 13.
No tobacco or alcohol use. He does data entry.
NKMA
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Hypertension
149/93 57 Afebrile 74kg 5’10”Thyroid normalNo bruittNo murmurPulses normalAbdomen normalDry skinNo tremorNeurologic exam normal
142 99 21 98 LFT’s normal Chol 1823.1 33 1.2 9.1 CBC normal TSH 1.9
UA normal
Now what would you do?
Aldosterone 32 (4-31) MetoprololRenin 3.4 (0.7 – 3.3) DyazideEpinephrine 10 (<25) PlendilNorepinephine 48 (<100) HydralazineDopamine 444 (<440)Cortisol 19.35HIAA normalVMA 4.1 (<7.0)Metanephrine 233 (30-350)Normatenephrine 586 (50-650)
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His Dyazide was stopped and his potassium supplemented.
Aldosterone 4Renin <1.0
Now what?
Renal US
“Parvus et Tardus wave forms and lowresistance indices in the renal vasculature.”
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normalrenalvasculature
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What do you think of this?
prominentintercostalvessels
Now whatwould youdo?
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Coarctation of the Aorta
• 6 – 8% of all congenital heart disease
• More common in males
• Associated with Bicuspid AV, PDA, AS, MS, and intracranial aneurysms
• Acquired secondary to Takayasu arteritis or rarely atherosclerosis
• Typically distal to the subclavian artery
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Coarctation of the Aorta
• Hypoperfusion leads to increased Renin
• If PDA is present, this minimizes sx in childhood
• Hypertension UE > LE, delayed femoral pulses
• Claudication
• Follow up BP 110/70 only on metoprolol
Tachycardia
A 66 year old female is noted to have a heart rateof 190 during a routine physician visit.
She has occasional palpitations. No pain, fevers,or dizziness. No flushing or weight change.
She drinks 1 pot of coffee a day plusnumerous glasses of tea. No herbal products.
Tachycardia
PMH HTN, DM, Migraine HA, Cataracts,Partial Hysterectomy
MEDS Metformin, Amitriptyline, HCTZ,Butalbital, Tylenol
SOC Tecumseh, NE. 1pk/day tobaccoNO ETOH/drugs. Unemployed.
FM Mom with DM/HTN. Aunt with a goiter. GF with lung cancer.
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Tachycardia
146/90 190 36.4 18HEENT normalNo lymphadenopathyThyroid normalIrregular heart ratelungs clearABD/Ext normalSkin no rashesReflexes brisk, No focal findings
EKG with a supraventricular tachycardia(resolves spontaneously)
NORMALCBCCMPUATox screen
TSH undetectable Now what?FT4 elevatedFT3 elevated
She was started on a beta blocker
RAIU revealed bilateral uptake, normal sizedthyroid with multiple nodules.
She was started on Methimazole
She elected for a thyroidectomy.
On follow up (weeks later) her TSH wasundetectable, FT4 and FT3 was elevated….
Now what would you do?
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Thyrotoxic?
Patient denies taking any thyroid hormone or herbals.
Her pharmacy denies giving her any thyroid pills.
She denies eating any non – store bought meat.
US shows no detectable thyroid tissue.
Whole body RAIU shows only scant uptake at her thyroid bed…..
Now what would you do?
Thyrotoxic!
Repeat FT4 elevated and confirmed by dialysisequilibrium (TSH still undetectable)
Thyroglobulin levels markedly elevatedThyroglobulin Antibody negative
Now what would you do?
RAIU following low iodine diet - pelvis scan
Now what?
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What is the diagnosis?
Struma Ovarii
• Presence of thyroid tissue
• Typically a Teratoma (12% of ovarian tumors)
• 1% of Teratomas contain thyroid tissue
• 60 year old females
• Resection then Ablation if any Mets
• Graves/Toxic multinodular goiter association rare but reported (no %)