Toxicology Website (has nomograms)

http://www.ncemi.org/

Documentation for DC Dictations when Someone Dies/ Doing Death Certificates

A discharge summary done when someone passes should be done with the same criteria as any discharge summary - within 48 hours or less (stat), diagnosis list including primary and secondary causes of death, list of significant procedures, history/physical exam, hospital course with major highlights. Documentation of code discussions, family discussions, and mode of passing/code/events should be included. Instead of "discharge planning" a discussion of counseling done and ancillary staff (chaplaincy called) should also be included.

By TN law, a licensed physician should be completing the death certificate within 48 hours but the TN Office of Vital Records acknowledges the difficulty of this. Death certificates which are signed later than 4 days are reviewedby the state. Therefore, it is important for residents and faculty to discuss the appropriate listing of the cause of death and that it is consistent between the death summary and death certificate. Cardiopulmonary arrest, for instance, is a mode of death but not the cause. Myocardial infarction is a cause of death. This can be due to 1 or more factors (coronary artery disease, for example). The death certificate asks for approximate amount of time of the diagnosis prior to death (days, weeks, months, years can be listed generally). The death certificate also asks for contributing diagnosis or significant diagnosis that may not have been direct cause of death (diabetes, prostate cancer, etc). It would be beneficial to include this level of detail in the dictation.

An online module providing education about death certificates and deciding on the cause of death is available through UT Memphis for free: http://www.uthsc.edu/cme/TN_death_certificate/index.php

11 March - CML presenting as priapism

Forgot to include this one last week.  The case was a young male who presented to hospital with priapism.  He had significant leukocytosis on evaluation and was ultimately determined to have CML.  This is an uncommon but not rare clinical presentation in adults with leukemia.  CML treatment has been revolutionized by the introduction of imatinib, a specific inhibitor tyrosine kinase.

Review this disease for boards - everything from the blood smear to the BCR-ABL tyrosine kinase to the Philadelphia chromosome.

For a good reference on blood smears that you can use in teaching, see the American Society of Hematology Image Bank.  Easily searchable database of pretty much any blood smear you could ever want.

For student teaching, they also have these interactive teaching cases designed for medical students.

12 March - New Onset CHF

Today's case was an interesting presentation of a 51 year old Korean male presenting with new onset congestive heart failure.  In this case, dialted cardiomyopathy was diagnosed and untreated hypertension was felt to be the most likely cause.  The significant elevation in liver enzymes in this case was striking, somewhat above what would be expected with congestive hepatopathy.  This Cleveland Clinic Journal review article has a nice summary of the differential and workup of this disease. 

An interesting historical footnote is an outbreak of cardiomyopathy in Canada and the US Midwest associated with cobalt containing beer.  Cobalt had been added to certain brands of beer as a foam stabilizer and was felt to be non-toxic.  Apparently they did not consider the "volume" consumed by certain Canucks and Midwesterners, especially during hockey season...  This was favorite challenge bowl fodder where I trained.

As for heart failure management in general, the ACP In the Clinic series has an excellent review of the topic linked here.  The In The Clinic site also have slide sets of their topics that you can use for teaching interns / students / etc.  Make use of it!

10 March - Obstructive Jaundice

This morning's case was a brief discussion of a patient that presented with painless jaundice.  In this case the workup eventually led to ERCP with with biopsy specimen positive for adenocarcinoma at the ampulla.  Importantly, a recent CT scan did not reveal a mass in this case, which is often the case with cholangiocardinoma.  MRCP/ERCP is essential to diagnose these lesions.  The first step in the differential is to determine whether the bilirubin is primarily unconjugated or conjugated.  Unconjugated suggests diseases such as Gilbert's or hemolysis, whereas conjugated suggests hepatocyte dysfunction or obstruction. 

Read this NEJM case discussion for a nice breakdown of how to evaluate painless jaundice in a systematic way.  Had this one in my file from when I was an R2.... If you want to learn diagnostic medicine and refine your illness scripts and differential diagnoses you should be reading the Case Records of the Massachusetts General Hospital every week!

8 March - Abnormal CXR Teaching Rounds

Densities in the lung fields seen on CXR can be lumped into 4 broad categories - mnemonic AVID: Alveolar, Vascular, Interstitial, and Damage.  Vascular markings are self explanatory.  Damage = anything that causes cavities / abscesses and has its own differential (Clinical Microbiology Reviews, April 2008).  Alveolar infiltrates can be pus, fluid, protein, or cells.  One CXR to remember the appearance of is bronchoalveolar cell carcinoma.  It can present as pulmonary infiltrates that mimic pneumonia.  As for the alphabet soup of ILD - a nice review can be found here. (MD Consult login or on campus access required).

One thing that is new on my radar - eosinophilic pneumonia and chronic pneumonitis induced by daptomycin therapy.  This was reported in the 1 March 2010 issue of Clinical Infectious Diseases and cases have been previously reported elsewhere, but this is the first time I have noticed it.

3 Mar - Febrile Illness in Dialysis Patient

Always respect febrile illnesses in dialysis patients and poorly controlled diabetics.  Signs of significant pathology are often muted in these populations and clinical suspicion is key (isn't it always...)

One study showed hemodialysis access and chills to be strong predictors of S aureus bacteremia, a finding that has been described by other clinicians. 

In this case the gallbladder was felt to be the likely source.  Diabetic patients are at risk for empysematous cholecystitis, a rapidly progressive and often fatal infection.  Clostridium perfringens accounts for a significant number of these infections.  Surgical or percutaneous drainage is essential.

Regarding the atriall fibrillation portion of the case - patients with Afib/RVR that are in shock or are experiencing ischemic chest pain should be promptly cardioverted (synchronized shock, 100J).  If still awake enough to feel it, see if anesthesia can get there quickly and give some sort of conscious sedation beforehand.  If the BP is marginal and they are not in shock, try digoxin for rate control.  0.5mg IV bolus often has prompt effects on the AV node and can slow the rate within minutes.  As you do not see digoxin used much these days, it would be useful to review this article covering the contemporary use of digoxin.

2 March - Cards board review

Posted verbatim - Dr Yarbrough's clarification of murmur maneuvers.  Anyone still confused??

Reminders based on today’s board review:


In general: rIght sided murmurs are louder during Inspiration
lEft sided murmurs are louder during Expiration
a – wave: atrial pressure during atrial contraction
c – wave: increased pressure from tricuspid valve bulge into the RV during isovolumetric ventricular contraction
x –descent: results from downward movement of ventricle during ventricular contraction and atrial relaxation
v – wave: atrial filling
y – descent: decreased pressure from opening of the TV

we usually don’t worry about h and z or a more simplistic view

Standing and Valsalva decrease right and left cardiac filling and lead to decrease murmur intensity except for MVP and HCM

Squatting and Supine position increase ventricular filling and lead to increase murmur intensity except for MVP and HCM

In short: MVP and HCM are increased by standing and valsalva and decreased by squatting and supine position

To differentiate between AS, MVP and HCM use sustained hand grip: this will increase MVP; decrease HCM and AS

1 March - Quiz Bowl Follow Up

No MR today or Friday, but I did want to post a link to an article mentioned in quiz bowl Friday.  This one looked at an EMR that flagged orders that deviated from guidelines, and allowed the ordering doc to indicate whether the deviation was appropriate or not.  All in all, the deviations were correct  94% of the time.  Something to consider as the hospital implements expert system support once order entry goes online.