8/21/2012

1

AMBULATORY CHIEFS , CYCLE 2 !

AUGUST 21 , 2012

Two slides, two minutes, two questions!

Case #1

� 49yo F w/ DD fell and hit her head, no LOC, 2wks prior to admission. Seen in ED cleared of bleed.

Sutured scalp lac.

� Now with HA, probs with numbers, fatigue, transient blurriness, trouble sleeping

� Taking lots of Vicoden for HA pain

� DDx?

Post Concussive Syndrome

� Classic Sx: HA, dizziness, cognitive impairment, neuropsych Sx � Don’t have to have LOC

� Prognosis: � Sx worst 7-10d

� most recovered @ 3mo

� 10-15% still Sx @ 1 year

� Tx for HA: � amitriptyline

� stop analgesia overuse

� +/- occipital nerve block

• 52F presents for well-woman exam and rash on leg

• HPI: L>R LE edema, Non-healing ulcer, puritis and pain

• PMH: Total hysterectomy 10 yrs ago in LA. No PCP visit in at least 5 yrs

• SHx: From El Salvador, grown children, no partner, works at MacDonalds

2. What is wrong with her leg? What tx?

1. What HCM does she need? Pap smear?

Cervical Cancer

Surveillance• 89-99% detection of

recurrence by 5y

• In women w/o symptoms– 0-16% detected by pap

– 20-47% detected by CXR

• ACOG recommends:– Visits 2-3x per year up to 5

years

– Annual pap smear

– Annual CXR up to 5y

• >90% with distant recurrence die within 5 yrs

Stasis

Dermatitis

1. Yes, pap smear! (FIT, mammo, Tdap)

• Complications:

– Autosensitization

– Contact sensitization

– Superinfection

• Treat Different Aspects Differently:

– Venous stasis

– Skin

– Superinfection

– Ulcers

2. TEDs, triamcinolone, +/-abx, wound care

43M: h/o TB lymphadenitis (3 weeks of RIPE) and HIV/AIDS (1 week of Atripla) presents with fever, chills, nausea, and enlarging neck mass

ghorayeb.com

Anna Chollet, MD

8/21/2012

2

Immune Reconstitution Inflammatory Syndrome (IRIS)

� Inflammatory reaction to OI by rapidly recovering immune system

� Paradoxical worsening of symptoms or unmasking of previously unidentified infection

sciencedirect.com

CD4 count of 10 � 10 days of ART

(Meintjes et al 2012)

TWO SLIDES

DOS MINUTOS

DEUX QUESTIONS

Bekka Zak

MS4

CASE STUDY� 45 y/o F with PMH of recently diagnosed HTN presents to

clinic c/o rash.

� Painful, burning, mildly pruritic

� No systemic symptoms

� No recent travel travel, change in detergent/soap, sick contacts

� Has patient ever had a similar episode? YES! Immediately

following d/c from the hospital in April, where she was

started on Lisinopril and HCTZ.

� When did this new rash start? One week ago, after her HCTZ dose

was increased

� Physical exam shows dry, erythematous, macular lesions

with fine scales on the chest and arms. No lesions anywhere

else on the body.

� What do these locations have in common?

DRUG

PHOTOSENSITIVITY

� Phototoxic

� Most common

� Caused by absorption of UVA by the causative drug, which releases energy and damages cells

� Presents as exaggerated sunburn, often with blisters

� Most common causative agents: NSAIDS, quinolones, tetracyclines, amiodarone, phenothiazines

� Photoallergic

� Lymphocyte-mediated reaction.

� Absorbed UVA by drug �immunologically active compound � presented to lymphocytes by Langerhans cells �widespread eczema

� Most common causative agents: topical agents, phenothiazines, chlorpromazine, sulfa products, NSAIDS

Two basic types of photoeruptions:

http://0-www.uptodate.com./contents/drug-eruptions?source=search_result&search=drug+photosensitivity

• Would you get imaging in this child?

• What are the indications for imaging?

CT/MRI

• Chronic Progressive

• Neuro findings

• Neurocutaneous syndrome

• Thunderclap, Worst HA of life

• Indications for LP…

8/21/2012

3

3 yo F with a funny looking rash for the past year

•Asymptomatic, but sometimes itchy•Linear, with streaks that follow lines of Blaschko•Small, flat topped pink/skin colored/tan papule that becomes hypopigmented•Sometimes involves digits and results in nail dystrophy (onycholysis)

LICHEN STRIATUS

Differential Diagnosis:

ILVEN Linear lichen planus Linear psoriasis(inflammatory linear verrucous epidermal nevus)

Why?

To build rapport with

the patient.

To build rapport with the patient.

To establish a clinical

baseline.

To build rapport with the patient. To establish

goals of

care.

To remind you of the

person the patient

used to be...and still

wants to be.

What do you do for fun?

RECURRENT OTITIS MEDIA

� 9 month old boy with h/o acute otitis media (AOM)

presents with 1 day of ear tugging and fussiness.

� History includes

� 4 mos: Bilateral otitis media – Treated with amoxicillin x 7days

� 7 mos: Bilateral otitis media – Treated with amoxicillin x 10 days

� 8.5 mos: Bilateral otitis media – Treated with Azithromycin x 5 days

� 9 mos: Erythematous right TM – Antipyrine/benzocaine ear drops

+/- amoxicillin

� Recurrent otitis media

� ≥3 distinct, well-documented episodes of AOM within 6 mos

OR ≥4 episodes within 12 months

TYMPANOSTOMY

� Mean absolute decrease in the incidence of AOM

was 1.75 episodes per child-year1

� Lower threshold for tympanostomy tube

placement may be beneficial if <6 mos old at first

AOM episode.2

� Prompt insertion of tympanostomy tubes does not

measurably improve developmental outcomes at

4 years of age.3

References: 1. Rosenfeld RM. Surgical prevention of otitis media. Vaccine 2000; 19 Suppl 1:S134.2. Higgins TS et al: Medical decision analysis: indications for tympanostomy tubes in RAOM by age at first episode.

Otolaryngol Head Neck Surg 2008;138:50.3. Paradise, J. et al. Otitis Media and Tympanostomy Tube Insertion During the First Three Years of Life:

Developmental Outcomes at the Age of Four Years. Pediatrics Vol. 112 No. 2 August 1, 2003.pp. 265 -277

65yo woman with daily

migraines• On nadalol, 80mg in the morning,

40mg in the evening

• Depakote 250mg TID

• Magnesium 250mg daily

• Sumatriptan 50mg TID prn, no

more than 3 days/wk

8/21/2012

4

Medication overuse headache? (aka

analgesic rebound headache)

• When HA disorder begins or markedly worsens during medication overuse

• Typically preceded by an episodic HA disorder (most often migraine or tension) treated with frequent and excessive acute symptomatic meds

• NSAIDS<triptans<ASA/caffeine/acetaminophen=opioids<butalbital

• How frequent is too frequent?

� 47 y/o Ugandan F, glucose intolerance, HTN, knee pain, eczema

� No notable FH, SH

� Meds: Atenolol; NKDA

� Episodic, tingling, burning, numbness and “feeling that I am walking on stones” lasting 2-3 weeks, waking from sleep, completely resolves. Some associated joint pain

� No visual symptoms, weakness, rash

� Differential: peripheral neuropathy (B12, DM, folate, HIV, Thyroid); paraneoplastic syn, MS, sarcoid, SLE, Sjogren

� MRI C-spine: neg. MRI brain: periventricular & cerebral white matter T2 hyperintensities

Demyelinating Disease Workup

� MRI brain & C-spine

� Protein, glucose, cell count, cytology, oligoclonal bands, CSF SPEP, paraneoplastic panel

� MS: McDonald Criteria: dissemination of CNS lesions in both space and time (>/= 2)

� What now?

55 yo M with a 12 hrs of “second gout

attack” of 1st MTJ. Has HTN, red joint

What do you do first?

1. Tap the joint since this is an acute

monoarthritis?

2. Get an X-ray of the toe because tapping the

joint will alter the film if done later

3. Rx the same medications that worked before

and draw cbc and uric acid on the way out?

4. Send to ED stat to get labs prior to tapping

Pre-tap Gout PredictionJanssens et al , Arch Int Med/ vol 170 (No. 13) July 12, 2010 p.1126

Score

• Male sex 2.0 pts

• Previous pt-reported arthritic

attack 2.0 pts

• Onset within a day 0.5 pts

• Joint redness 1.0 pts

• Involvement of 1st MPJ 2.5

pts

• Hypertension or a vascular

syndrome 1.5 pts

• Serum uric acid > 5.88 3.5 pts

Actions

• > 8 treat

• > 4-8 tap

• < 4 think of something else

8/21/2012

5

Case #2

� Twins born @ 36+0 for cholestasis

� 36wks = late preterm (34-

37wks)

� Both low birth weight

(<2500g)

� Exclusively breast fed

� Need Fe supplementation 1st

year of life to prevent anemia of prematurity

Anemia of Prematurity

� Prevention: Fe Supplementation:

� 2-4mg/kg/day if exclusively BF

� If preterm or low birth weight

� Causes:

� * �production (� Epo)

� �labs

� �RBC lifespan (60-80d)

� Fe depletion (�utilization, �stores)