We are re-booting the UTMCK Internal Medicine Blogspot at a time for increased stress and social distancing

We will get into cases - but let's start with some resources for your wellness...

The meditation app - "Headspace" is free for medical providers during this time.
https://www.headspace.com/health-covid-19

Radio Garden is a free app (works on desktop too) that allows you to plug into 8,000 radio stations around the world.
https://www.npr.org/sections/goatsandsoda/2016/12/16/505829305/radio-garden-lets-you-tune-into-a-world-of-global-broadcasts

Do you have a favorite song or playlist?  One stress reliever for my family is making me a playlist!
Dr. Lubas showed me how to make this into a hand washing poster which really made my family feel like they were helping me!  https://washyourlyrics.com/  Her preferred song is from Trolls "Can't Stop the Feeling" by Justin Timberlake.

Feel free to submit a song (or an app) that gets you through the day.

Dr, Norwood -  I think I will start with Kung Fu Fighting by Carl Douglas
https://www.youtube.com/watch?v=jhUkGIsKvn0

Interesting article from JAMA Internal Medicine.  Not surprisingly, physicians that own CT scans or radiation therapy machines are more likely to deploy these services on their patients, even when the clinical utility of these high cost modalities is in doubt.

Full text here

MR wrap-up from week of Aug 8

Interesting case of Werneckie's encephalopathy - there is an images in clinical medicine from a few years back that demonstrates the characteristic lesions of this disease, which were noted on the patient discussed in morning report.  Keep in mind the clinical triad of Werneckies - encephalopathy, ataxia, and oculomotor dysfunction.

The cost of intravenous vitamins and folate for prevention of Werneckies is excessive - $100 per "banana bag" vs a few cents for oral vitamin supplementation.  Treatment of established Werneckies is more complicated, and there is some literature that full course intravenous repletion in symptomatic cases may be cost saving in the long run due to concerns of patient compliance with oral thiamine replacement after discharge.

Another case this week was a patient with acute monocular vision loss - in this case suspected to be optic neuritis.  Great NEJM review on the topic here.




Also - for this week's ECG of the week, from a diabetic presenting with subacute dyspnea, shows inferior Q waves consistent with prior MI, which in this case was "silent" and came to clinical attention after the heart failure admission.  Up to 20% of MI's resulting in Q waves on ECG may be silent, and up to 8% of a high risk population can have myocardial scars from previous MIs without clinical or ECG evidence.

Evaluation of mixed LFT abnormalities

Todays case presented a patient with mixed LFT abnormalities and painless jaundice without evidence of extrahepatic biliary obstruction.  AST/ALT elevated >400, AlkPhos >500, bili >18.

Differentials discussed included drug induced liver disease, ? recent antibiotic exposure,

This page from NIH has a good breakdown of the varying patterns of drug induced liver disease, including the predominantly cholestatic pattern and the  mixed pattern.

The clinical/pathological syndrome of "granulomatous hepatitis" - expanded upon in this presentation - was also discussed, though does not usually lead to the degree of bilirubin elevations noted in this case.  The linked presentation walks through a good differential of this condition based on pathological or epidemiological risk factors present in the case.

Lastly, acute hepatitis C is a possibility to be considered.  Interestingly - a robust immune response is generally required to trigger symptomatic disease and jaundice, and this subset of patients (presenting with jaundice) have a lower rate of development of chronic hepatitis C infection.

And from noon conference - the noon conference on Sjogren's syndrom brought to mind this image from NEJM, which made an appearance in a prior Quiz Bowl and is likely to make an appearance at a future showing,

Sep 30 Update

Batch of updates today - MR back on schedule after month of CPC, inservice, etc.

Today's topic:  gastrointestinal hemorrhage in an anticoagulated patient.

First:  guidelines for management of peptic ulcer bleeds from the American College of Gastroenterology:  Their 30 key recommendations available here, also has link to full text of their guideline for additional reading.

Contrast those recommendations with the ones provided for management of variceal hemorrhage. Key differences in variceal hemorrhage:
 - Octreotide and prophylactic antibiotics indicated for variceal bleed
 - All variceal bleeds require ICU admission, whereas only the high risk subset of ulcer bleeds even require hospitalization.

As for reversal of anticoagulants, this handy pocket card from the American Society of Hematology covers dosing as well as reversal of multiple anticoagulant and antiplatelet medications.  Their guidelines are available as an app as well.

Cardiogenic Shock 

Also from noon conference - make sure you know your mechanical complications of acute myocardial infarction well.  This topic is all over the boards and in training examinations.

Also, remember that right ventricular infarction is something of a unique clinical syndrome.  Nitrates can do great harm, and large amounts of volume resuscitation are often required to overcome RV dysfunction,  Diagnosis in the setting of IWMI requires a R sided ECG, with lead V4r being the highest yield lead for diagnosis.

August 29 WeeklyUpdate

Not as much content this week due to quiz bowl and ethics case rounds, but the following articles are very good reading:

From Monday's noon conference on endocarditis, I recommend this condensed article from NEJM that covers what you need to know about endocarditis for board purposes.

Friday morning report covered management of acute ischemic stroke, as well as measures to prevent recurrences.  Good articles covering the topic are below:

Acute Ischemic Stroke (NEJM Clinical Practice)

Secondary Prevention After Ischemic Stroke (NEJM Clinical Practice)

On a related note, the question often arises - should we heparin bridge A-fib patients on warfarin therapy when their medication is held for surgical procedures.  The answer, according to a study in this week's NEJM, is no.  Stroke events are not reduced, and bleeding is increased if heparin is used during the time warfarin is held.  Always pay attention to exclusion criteria, as this trial excluded anyone who had experienced stroke or TIA symptoms within 12 weeks.

Resuscitated

After a long hiatus, the IM blog is back in action.  I will make weekly posts with links for additional reading to follow up discussions form conferences.

On the topic of resuscitation:  The AHA has specific guidelines for resuscitation in certain unique situations, such as severe asthma, pregnancy, etc.  I will develop a simulation center scenario for one of these for use in a future SimMan session.  The material in this article goes far beyond the material covered in standard ACLS provider courses, and should be reviewed before taking on code team leader responsibilities.  There are separate articles that describe ACLS in the setting of recent cardiac surgery.  These are not currently part of official AHA ACLS guidelines but have been adopted by some institutions.

On the topic of appropriate use of the thrombophilia panel - the BJH has a nice summary of the topic.  In general, these workups are most appropriate for the outpatient follow up setting in select cases only.  Their utility in guiding the inpatient management of most patients is questionable.