Today Nicole presented an interesting case with multiple turns which started out with pre-septal cellulitis and evolved into a-fib with RVR complicated by likely pulmonary edema as well as clinical concern foTolvaptanr a septic arthritis of the knee joint with current cultures pending. Amidst his hospital course the patient developed what appeared to be euvolemic hyponatremia with urine/serum osm studies suggest of SIADH. His SIADH was relatively treatment refractory, not responding well to fluid restriction, urea, or hypertonic saline while in the MICU. Ultimately, it did improve with escalating doses of tolvaptan.
Today Dr. Govert presented an interesting case of recurrent pneumothorax with CT findings suggestive of bullous emphysema/cystic lung disease. Biopsy ultimately demonstrated lymphangioleiomyomatosis (LAM), shout out to Anmol for the mic drop diagnosis upon entering the room. Ken Lyles would have been proud. Anyways, we briefly discussed the use of sirolimus for LAM. I’ve attached the NEJM RCT comparing sirolimus v placebo in 89 women with LAM. In short, those treated with sirolimus had less decline in FEV1 compared to placebo. They also had lower levels of VEGF-D and improved scores on a quality of life and functional performance survey. During a 12 month observational period of withholding sirolimus (after those randomized to sirolimus were treated), the decline in lung function resumed in the sirolimus group at a similar rate to those in the placebo group.
Nick presented an interesting case of RUL adenocarcinoma of the lung that presented without pulmonary symptoms, but instead with LLQ pain, back pain, anorexia, 25 lb weight loss, and nystagmus/dizziness. Imaging ultimately left adrenal mass and cerebellar mass. We discussed what would likely be first line treatment option, and assuming NGS testing was negative for an actionable mutation (such as EGFR), he would likely be a candidate for chemo + pembrolizumab. In the KEYNOTE-189 phase 3 trial, 616 patients with nonsquamous NSCLC were randomized to pemetrexed + platinum-based chemo plus pembrolizumab or placebo. There was superior OS at 12 months in the pembrolizumab containing arm (69.2% versus 49.4%), and improved PFS (8.8 months v. 4.9 months).
As a fun crossover, I also attached a case report in which a patient with LAM who developed metastatic adenocarcinoma of the lung was successfully treated with nivolumab.
See below YouTube video by Dr. Neil MacIntyre discussing ventilator management strategies in ARDS with considerations for COVID.
Notes from talk below:
Authors: Chris Ferreri, Akash Goyal, Matt McCulloch
Fatigue is a common and nonspecific symptom with a broad range of etiologies including acute or chronic medical conditions, psychological conditions, medication related effects, substance use.
- 1/3 of primary care visits are centered around fatigue
- First ask what your patient means by fatigue; here are some common responses:
- Anhedonia, abulia (lack of motivation)
- difficulty initiating activities
- subjective sense of weakness
- difficulty with concentration, memory
- problems with initiating or sustaining sleep
- dyspnea on exertion; decreased exercise tolerance
- UpToDate has a great table with causes of subacute and chronic fatigue: https://www.uptodate.com/contents/image?imageKey=PC%2F116315&topicKey=PC%2F2783&search=fatigue&rank=1~150&source=see_link
- Other questions to ask in history:
- ask how long has the patient has been feeling fatigued
- ask about functional limitations (e.g. are they able to carry out their tasks at work)
- ***Ask about what a typical day looks like*** (what time do you wake up, what are you doing during the day)
- screen for depression with PHQ2 -> if positive -> PHQ9
- screen for anxiety
- ask about sleep (what time do you go to bed, what do you do before going to bed, how long does it take to fall asleep, how often do you wake up at night, what time do you wake up?)
- screen for OSA with STOP-BANG (https://www.mdcalc.com/stop-bang-score-obstructive-sleep-apnea)
- Screen for drug and alcohol use (e.g. AUDIT-C or Binge drinking screening question)
- Supplements (e.g. St. John’s wart)
After a careful physical exam (see UpToDate table above for key physical exam findings), here are some initial screening labs to consider:
- Vitamin D – can use supplementation as a placebo effect
- Vitamin B12 – B12 deficiency can be caused by metformin and PPI use; consider MMA if B12 in ~300 range, supplement if <200
- Appropriate cancer screening interventions based upon the patient’s age and sex should be updated as necessary to exclude common occult malignancies as a potential cause for fatigue.
Chronic fatigue syndrome (CFS)
- High prevalence with depression, trauma, fibromyalgia, POTS
- Underlying pathophysiology is unclear but may be associated with epigenetic changes caused by trauma; high risk of chronic medical conditions in patients with early childhood trauma
- Diagnosis of exclusion; diagnostic criteria from Institute of Medicine of the National Academies. Beyond Myalgic Encephalomyelitis/Chronic Fatigue Syndrome: Redefining an illness. Report Brief, February 2015:
CFS Diagnosis requires that the patient have the following three symptoms:
- A substantial reduction or impairment in the ability to engage in pre-illness levels of occupational, educational, social, or personal activities that persists for more than six months and is accompanied by fatigue, which is often profound, is of new or definite onset (not lifelong), is not the result of ongoing excessive exertion, and is not substantially alleviated by rest.
- Post-exertional malaise – Worsening of a patient’s symptoms and function after exposure to physical or cognitive stressors that were normally tolerated before disease onset.
- Unrefreshing sleep.
At least one of the two following manifestations is also required:
- Cognitive impairment – Problems with thinking or executive function exacerbated by exertion, effort, or stress or time pressure.
- Orthostatic intolerance – Worsening of symptoms upon assuming and maintaining upright posture. Symptoms are improved, although not necessarily abolished, by lying back down or elevating the feet.
- Counseling: Tell patients that fatigue is rarely one thing. Usually combination of multiple factors – anxiety, sleep, anemia, etc.
- Counseling on substance use:
- Focus on the long-term consequences (e.g. “While alcohol may help you sleep at night, over time, use of substances will not get you quality sleep.”)
- It may take > 1 month off substance until patient notices a difference.
- do not have to go to the gym and work out 1-2 hours in order to get exercise
- goal is increase physical activity
- Set a smart goal
- Ask what is a realistic amount of time you can walk each day? E.g. start 5 min, add 1 min a week, by end of a year, will be working out 60 min
- A trial of antidepressant drugs should be offered to patients with depressive symptoms:
- Fluoxetine – most stimulating; most weight neutral; starting dose 10mg daily
- Generally, better to dose SSRIs in the morning to avoid causing insomnia
- Has more stimulating effect
- Can help with weight loss
- great for smoker with fatigue
- SR formulation is cheaper; BID dosing (don’t take 2nd dose at bedtime; better to take at breakfast and before dinner); start at 100 mg daily (150 mg approved for smoking cessation)
- XL is once a day dosing; has fewest side-effects; doses: 150, 300, 450mg
- Risk of seizures is relatively low, but still avoid in pt with seizure disorder
- Avoid in pt with eating disorder
- CBT may be useful in some patients with idiopathic chronic fatigue. It typically involves a series of one-hour sessions designed to alter beliefs and behaviors that may delay recovery. It is also offered online.
- Follow-up: Have the patient return to clinic within first 1-2 months to assess progress
Summarized by Dr. Eric Wei based on a presentation from Dr. Gregory Brown
Dermatology for the Internist
Lecture by Dr. Sarah Wolfe. Summarized by Dr. Eric Wei
- General Dermatology Order Sets!
- Type in “Gen Derm” into the order section and numerous order sets will come up to treat common conditions including acne, atopic dermatitis, urticaria, hidradenitis, psoriasis. This is a great place to start as it highlights first, second, and third line treatment options
The language of dermatology
- Macule: flat, < 1cm
- Papule: elevation of any type, < 1 cm
- Patch: flat, > 1 cm
- Plaque: elevated, > 1cm
- Nodule: like plague but dome shaped
- Hemorrhagic Crust (aka scab)
- Yellowing of the crust–> suggests superficial infection with staph/strep
- Erythematous, white, purple, brown, yellow, black, etc.
- atopic dermatitis commonly distributed where shoe rubs feet
- candida likes pannus, chest, moist areas
- Psoriasis – interdigital and plantar surfaces of the toes; well-demarcated plague with a thick silvery scale
Please see the Stanford 25 website which has an excellent introduction to the language of dermatology with great photos and videos: https://stanfordmedicine25.stanford.edu/the25/dermatology.html
Tinea Pedis (Athlete’s Foot) & other Tinea conditions (corporis, cruris, etc.)
- Clinical Patterns:
- Interdigital – flaking epidermis between toes
- Maceration can occur between the toes. Shows up first between the fourth and fifth toes.
- Moccasin – Forms a rim around the bottom of the foot
- Vesicobullous – blister forming
- Interdigital – flaking epidermis between toes
- First line:
- Clotrimazole cream BID x 4 weeks (can buy OTC as Lotrimin)
- Terbinafine Cream (e.g. Lamasil)
- First line:
- Things to avoid!
- Do not treat something that may be fungal with a topical steroid –> this will cause the rash to increase in size. If you are unsure if it is inflammatory or fungal, opt to treat for 4 weeks with OTC anti-fungals and instruct patient to use a topical steroid if this first line therapy is ineffective
- Key findings: subungual debris and nail discoloration
- What tests should be ordered?
- Fungal culture of subungual debris (textbook answer, although this is not always done clinically)
- First line: Oral terbinafine x 3 months
- After treatment, the nail will take roughly 1 year to “grow out” before it may return to normal.
- Treatment failure rate: 50%
- Terbinafine risks: low risk of hepatotoxicity; check baseline LFTs
- Ciclopirox nail lacquer
- This is a toenail polish. Must be used daily for 1 year. Treatment success rate is only 11%
- Second Line
- Pulse dosing for 3 months: 200mg BID x 7 days during the first week of every month.
- You must watch out for interactions with other medications: e.g. statins
- If there is concern for co-infection with mold, it can be useful
- First line: Oral terbinafine x 3 months
Tinea versicolor (pityrosporum yeast)
- May be hypo or hyperpigmented
- Ketoconazole shampoo – 5 days
- Selenium sulfide (Selsun Blue)
- rash that results from 3rd spaced fluid; due to hemosiderin spilled from RBCs
- Tx: Triamcinolone; avoid skin, face, groin, armpits
- Compression wraps “unna boot” -> transition to compression stockings (20-30 mmHg)
- Candida will involve scrotum; dermatophytes usually doesn’t involve scrotum.
- Treatment: clotrimazole, nystatin, ketoconazole (not great for dermatophytes)
Excellent visual recap on insomnia by Dr. Wei. Adapted from a lecture by Dr. Spector
-bioprosthetic valves usually last ~15 years so we tend not to use those in younger patients as they’ll need a replacement
-symptomatic HF and valvular dysfunction-left sided IE c/b fungal infections or high resistant organisms-complications like annular or aortic abscess, penetrating lesions, or significant heart block-persistent bacteremia or fevers >5-7d despite appropriate abx therapy-also considered if pt has recurrent emboli and large (>10mm) left sided vegetation
Another excellent infographic by Dr. Eric Wei, adapted from morning report by Dr. Metz.
Excellent Infographic by Dr. Eric Wei. Created from talk by Dr. Lynn Bowlby.
In Intern Report this week, we discussed Peut-Helger Anomaly. One of the key features of this is decreased lobulation as seen in the bilobed nucleus below connected by a thin strand.
This is in contrast to neutrophils with increased lobulation (or hypersegmentation, ie greater than five lobes) suggesting a megaloblastic process or (rarely!) iron deficiency anemia.
We also distinguished between easily confused MDS and MPNs. MDS leads to dysplastic cells. MPNs cause proliferation of cell lines, but these cell are often normal appearing.