1st Quarter 2016-17 Volume 1:

Author:  Anthony Ea, DO

A 49 year old women is evaluated in the ED, 90 minutes after the sudden onset of right sided weakness and slurred speech. Her PMHx is notable for dyslipidemia and HTN. Her medications are simvastatin, 81 mg ASA, and hydrochlorothiazide.

Vitals are afebrile, BP 160/88 mmHg, pulse 78, RR 12, O2 99 on RA. Cardiac exam demonstrates regular rate and rhythm, and no carotid bruits. Neurologic exam demonstrates dysarthria, R facial weakness, R pronator drift, loss of sensation to L touch on R arm and face. R leg strength is normal. NIHSS = 7 (moderate). EKG shows sinus rhythm without ST deviations or T wave changes. Non-contrast CT head is normal.

Which of the following is the most appropriate next step in treatment?

a. Rectal ASA and High Dose statin

b. IV Labetalol

c. IV Heparin

d. IV rTPA

She receives IV rTPA within 60 mins of arrival to the ED. Three hours following completion of rTPA infusion, her BP is noted to be 188/110 mmHg and pulse is 68. The remainder of her exam is unchanged.

Which of the following is the most appropriate treatment?

a. IV nicardipine

b. Rectal ASA

c. Subcutaneous heparin

d. Sublingual Nitroglycerin

She is monitored in the ICU and eventually discharged without further complications. She comes to your continuity clinic 1 month later following her admission. Her deficits are improving and she states compliance with all of her medications. She monitors her BP and reports systolic BP ~ 130 mmHg and diastolic ~ 70. She would like to know if there is anything else she can do to prevent another stroke.

Which of the following is the most appropriate treatment?

a. Add clopidogrel

b. Add dipyridamole

c. Substitute ticlopidine for Aspirin

d. Substitute warfarin for Aspirin

Chief Resident Update

  • TALK to and LISTEN to the NURSES.  Do NOT be afraid to partner with them.  They are your eyes and ears at the bedside √Working closely together can provide safe quality patient care.

  • Communication with consultants is very important √Patients’ pain management and overall satisfaction must be kept in mind while on the floors, including consult services. 

  • ATTENDANCE and Punctuality with Didactics 

Committee Updates

  • Severe Sepsis ‘presentation time’ determined by:  2 SIRS criteria + organ dysfunction + documentation of suspected/possible clinical infection. Septic Shock ‘presentation time’ determined by documentation sepsis present + Hypotension persists in the hour after 30cc/kg of crystalloid fluid administration

Upcoming Reminders

  • Continuity Clinic begins 8/1/16.
  • Evaluations need to be completed for each rotation
  • Committee  listings/meetings.
  • M&M (7/29/16)

Scholarly Activity/Questions (S. Burke, DO)

A 60 year old male with a history of COPD and HTN presents to the ED with altered mental status, temp of 102 and neck stiffness.

What is the best empiric treatment regimen?

A. Vancomycin and ceftriaxone
B. Vancomycin, ceftriaxone, ampicillin
C. Vancomycin, ceftriaxone, ampicillin, rifampin 
D. Vancomycin, ceftriaxone, doxycycline


After receiving ceftriaxone the patient develops rash and shortness of breath and refuses to receive the medication again. What is the next best approach to treatment?

A. After explaining the risks of not receiving the medication, comply with their wishes and do not give it.
B. Administer chloramphenicol instead of ceftriaxone
C. Administer cefepime instead of ceftriaxone, this is a minor reaction and will not likely occur with cefepime.

D. Administer doxycycline instead of ceftriaxone


Your institution does not have chloramphenicol on formulary. It will take 2 days to get this medication. Which is an alternative agent?

A. Aztreonam
B. Tobramycin
C. Tygecycline
D. Moxifloxacin

3rd Quarter 2015-16 Volume 1:2

Author:  Islam Badawy, DO

A 42-year-old man presents with subjective fever, night sweats, malaise, headaches, abdominal pain, chest discomfort, and LE edema. Several months ago he had similar symptoms.  He notes that these symptoms last a week or two, and then appear to resolve, but then recur after a few weeks. He tried taking antibiotics given by an urgent care clinic for a week for one of the episodes, but noted no major difference/improvement. He has no prior medical problems though he thinks he was told that he had a heart murmur noted during childhood (he doesn’t remember any definitive diagnosis), grew up on a cattle ranch, and reveals no family history. He recently returned from Iraq, where he was doing work as a defense contractor. Examination is notable for a temperature of 38.3°C (100.9°F), pulse rate of 114 beats per minute, and question of a soft, difficult to characterize murmur at the base of the heart. The laboratory studies are notable for moderate serum transaminases. Blood cultures are negative at 48 hours.

 

What would be the next most reasonable step?

a.       Transthoracic Echocardiogram

b.      Start Antibiotic therapy without additional testing

c.       Cardiac CT

d.      Transesophageal Echocardiogram

e.       Start Lasix IV

Hepatitis serologies are negative. Abdominal ultrasonography reveals mild hepatomegaly, but is otherwise unremarkable. A tuberculin skin test is negative. The patient continues to be febrile. Computed tomography scanning of the chest, abdomen, and pelvis are unremarkable. The original blood cultures remain negative at 96 hours, as are repeat blood cultures. A TEE is performed, demonstrating two small, 1.5-2.0 mm vegetations on the aortic valve.

What would be the most likely organism causing this patients constitution of symptoms?

a.       Staphylococcus aureus

b.      Streptococcus Viridans

c.       Coxiella Burnetti

d.      Pseudamonas Aeruginosa

e.       Enterococcus faecalis

To confirm the diagnosis suspected in this patient what would be the indicated test of choice?

a.       Repeat Blood Culture now

b.      Follow up previously drawn Blood Culture in 2-3 months

c.       Electron Microscopy

d.      Immunofluorescence with polyclonal or monoclonal antibodies

e.       Culture from cardiac valves

What would be the best treatment for the suspected diagnosis?

a.       Vancomycin and Invanz for 6 weeks

b.      Doxycycline and hydroxychloroquine for 18 months

c.       Ampicillin and Gentamycin for 4 weeks

d.      Bactrim for 12 weeks

e.       Surgical Valve Replacement 

Chief Resident Update

  • Review ICU protocol carefully at the start of each month.
  • Plan ahead to make sure interviews/ activities do not conflict with Blue team/ ICU.
  • Patients’ pain management and overall satisfaction must be kept in mind while on the floors, including consult services.  Avoid giving missed messages, esp in terms of discharge.

Committee Updates

  • Code airway for ER help should be called for difficult airway.  ACLS review coming with with Dr. Lamonto.
  • Pain control and Infection control must be paid keen attention.

Upcoming Reminders

  • Inservice Exam: results to be discussed at quarterly meetings
  • Clinic 360 evals.
  • Committee meetings.
  • Apr 29 Grand Round
  • M&M (Dr. Scott)4/15

Scholarly Activity/Questions (N. Dsilva, DO)

A 40 yo AA woman with no pmhx presented with headaches, stating they have been increasing in frequency and intensity over the past few days. Reports taking OTC tylenol with minimal to no relief. On ROS, she denies everything except for intermittent joint pain, decreased urination with darker urine, and does mention that her fingers have been turning pale when she is outside in the coldor shopping in the frozen food section. Denies FamHx, stating she is adopted. No surgeries. NKDA. She was prescribed prednisone 20mg by her PCP for her joint pain and swelling 2 weeks ago. She does not take any other medications/ supplements. She works at a bank. Denies tob, ETOH or illicits.

T 98.6F, HR 82, BP 200/105, RR 14, SpO2 99% onRA; pain in head 9/10. On exam, she is AAOx3, mild distress due to headache, PERRLA, ophthalmic exam reveals cotton wool exudates, heart RRR, lungs clear, abdomen benign, trace ble edema. On exam of her nail fold beds, you note capillary cutoff. Plain CT head was unremarkable.

Na 135, K 4.7, Cl 110, CO2 22, BUN 45, Cr 2.5 (normal 0.9), WBC: 15.0, Hgb: 9.8, Plts: 110

ANA & anti-RNA polymerase III-positive

RF, CCP, Anti-SSA/SSB & dsDNA -negative

Given this patient’s clinical scenario, what is the first step in your treatment?

A. Start high dose IV corticosteroids

B. Continue oral prednisone, start labetalol drip

C. Plasmapheresis

D. Discontinue prednisone, give IV captopril

E. Emergent dialysis