Guilty conscience

Hmm I know I'll pass med school. I know I'll make a good doctor given time. But I dont feel confident enough to excel in my current exams. And if I dont, the one overwhelming feeling I would have is guilt towards my parents...then I'll hear my mummy say "Its alright you tried your best". Strange how this guilt far weighs any guilt I have towards my own inadequecies. Gotta get in my head that God controls everything that I'm merely riding a roller coaster. Arh.....Funny how though people all think I know my stuff....work!

Case - AMI & complications

Mr T, is a 64 year old gentlemen admitted to hospital 5 days ago with a cough and SOB on a b/g of a recent AMI 6 weeks ago and subsequent pleural effusion with a background history of DM.

HOPC

He first developed dry Cough and SOB 5 weeks ago. Day 1 after being discharged from hospital for his AMI. He also had fevers, sweating. No sputum production, chest pains, palpitations at that time. 4 days later he went to his GP. Had a CXR done which showed left-sided pleural effusion. Then admitted to hospital and started on oral doxycycline and amoxicillin and observed. He was subsequently discharged with the following medication. He was feeling unwell throughout. 6 days ago in the evening he suddenly developed chest pains that radiated on the left side from the front to the back. He was unable to tell whether it was of a similar nature to his previous AMI pain. There was associated coughing and SOB, no sputum production. no palpitations, nausea, vomiting or sweating. Relieved by panadeine fort and GTN. 2 days later the GP sent him to the hospital where he was managed both for his respiratory and cardiac problems. For his respiratory, had his antibiotics switched to IV ceftriaxone, U/S of the chest and CXR showed resolution of the effusion. In terms of his cardia problems, put on a holter monitor that showed a tachycardia and an abnormal rhythm. He had DC cardioversion last night and he reports feeling well and he noticed better perfusion of his fingers and better skin tone.

Had a recent AMI 6 weeks ago during the evening with symptoms of vomiting, pain to his right shoulder tip, cheeks, chest, sweating and general sense of unwell. No meleana or fresh blood, he vomited only his food contents. His pain was 4/10 chest, 6/10 left cheek and 5/10 in his right shoulder tip. It was described as a dull aching pain. No agg/reliefing factors at that time. Unable to lie in bed and had to sit in his chair and slept fitfully the rest of the night. The next day he went to the GP who sent him to the ER and was diagnosed with a AMI with raised cardiac enzymes and ECG changes. He was subsequently investigated with an angiogram and a echocardiogram. 5 days post-admission he developed a sharp pain that radiated from his shoulder to the face with no other associated symptoms. It was an 8/10 in severity. Came on suddenly and was constantly there. He was diagnosed with pericarditis. Treated with morphine and oxygen. This pain subsided 48hrs later and he was discharged.

Medical history
CVD RF: No HT, no chol, smoked a pack a week for 3 years during his university days, drinks socially, has DM.

His type II diabetes was diagnosed 5-6 years ago on routine blood screen. Currently managed on diet and exercise control. He avoids sugary food, takes low fat and lean meat. Walks his dog 4 times a week/ 30min each time. Has lost 30kg from 134-104kg. After his recent admission to hospital his blood sugars were not well controlled and was put on insulin. currently on 3 times novorapid and one evening bolus of glargine. His current average blood glucose is 6mmol/L on insulin. No macro/microvascular complications of DM.

Non-active medical conditions: gall bladder removal, recently diagnosed carpel tunnel, hayfever and asthma when he was a kid, appendicitis.

Medications:
Novorapid, glargine, ceftriaxone, fruesemide, atenolol, atorvastatin, perindopril, aspirin, clopidogrel.

FH:
Father lung cancer, 79. Mother, diabetic.

Social: Live/family, support, depresion, financial, depression, exercise/drinking/diet/smoking, insight.

Physical examination:

Peter is a well-looking man, orientated in time/place. Not in any pain or respiratory distress.
V/S: HR 60bpm, regular. RR18bpm. BP110/70. Oxygen sats on room air was 94%. On general inspection. He had no supplemental oxygen, a venous cathether in the dorsum of this right hand. Scars??

On cardiac examination:
No pale palmar creases, no manifestations of IE. On inspection of his face, no central cyanosis or jaundice. JVP was not elevated. Carotid pulse felt normal. Apex beat was not displaced. No palpable heaves or thrills. Dual heart sounds with no murmers.

On respiratory examination:
No deviation of the trachea, No palpable LN. Chest expansion was equal and normal. Stony dullness to percussion on mid to lower region on his left side. On asculation, there was decreased breath sounds and decrease vocal resonance.

In summary, Mr T is a 64 y.o gentlemen who was admitted to hosptal 5 days ago with cough and SOB on a b/g of a recent AMI. The SOB began 3 weeks ago and was treated with IV ceftriaxone. His current physical examination findings are consistent with a left sided pleural effusion. His issues are.

1. managment of his pleural effusion - which requires organized follow up with the GPs + continued Antibiotics. CXR to monitor the current pleural effusion.

2. Managment of his MI - start him on ACS medication and continue to watch for SE. and monitor complications. Optimise the control of his risk factor particularly his diabetes.

Watery diarrhoea cryptosporidium

Peter is a 47 y.o man who presents with a 4 week history of watery diarrhoea on a b/g of renal transplantation for PCKD.

HOPC:
4 weeks ago, Mr P developed a sudden episode of watery diarrhoea that has not resolved over. He has 4 diarrhoeas 8-12 times a day. No blood, mucous seen in the stool. Volume of the fecal material is high. His normal bowel motion is 1/day. He also developed fevers, chills and rigors &abdominal cramps during day 1 and 2 but has not have any of this symptoms since then.

Other relevant negatives (considering he is immunocompromised)

• No LOW, night sweats, lack of appetite.
• No cough, sputum, SOB.
• No chest pain, palpitations.
• No symptoms of UTI but has noticed a low volume of urine output (10-15mL). Claims to be dehydrated.
• No fainting, dizziness, blackouts.
• No Neurological signs.

He presented to the GP on day 2 and was subsequently admitted to hospital last week and treated.

• I- flu vaccination is up to date
• Contact - works with children (prone to norovirus, adenovirus, rotovirus diarrhoea). Last worked? No other sick contacts.
• Travel - No travel. Any dubious food? Any stream water or tank water?
• O - irrelevant
• A- lives with a cat
• D- imunnosuppressive drugs + cardiac drugs.
• Sex - never ask.

Med Hx.

1. PCKD diagnosed during the 80's. Currently on 3rd transplant. First transplant lasted 4 days. His last transplant was in 94'. On immunosupressive drugs for it. Has 1 URT infection/ 2mths. and also occasional diarrhoea. Attributed to him working with children. Hospital admissions for complications?
2. Cardiac disease with triple bypass done? any symptoms? PND, orthopnea, pillows used, exercise tol?

Medication?

Family history?

Social history?

• Live with? Family, children?
• DALYs?
• Support?
• Finanacially stable?
• depressed?
• Smokes, drink?
• exercise
• diet

Osteomyelitis

Most common bug is SA treat with flucoxicllin.
Randomly, in radical prostectomy, most commonly by pseudomonas (10-20% ciprofluxacillin resistant).

Septic arthritis

Septic arthritis - acutely inflammed joint and may destroy within 24hrs. Treat empirically with antibiotics.

Signs/symptoms

• Swollen, red joint
• associated fevers, chills and rigors, consider localised symptoms.

DDX - OA, gout, haemarthrosis, less likely psoriatic arthritis, reactive arthritis.

Ix-

1. Imaging - x-rays may be normal, consider CT, U/S, MRI.
2. FBE, ESR, CRP - raised WCC, inflammation.
3. U&E and LFT for baseline.
4. Joint aspiriate - appearance: turbid,yellow, low viscosity, microscopy: raised WCC, neutrophils. Culture& sensitivty: for the organism + sensitivity. also for polarized light microscopy: crystals (negatively bifringement crystals for gout)

Mx-

1. Analgesia
2. Empirical antibiotics until culture is known. Flucloxacillin (as most common organism is SA. consider benzylpenicillin + gentamicin)
3. Consult microbiologist
4. Consider joint wash-out especially in prosthetic knee.
5. Seek/ treat underlying cause - immunosupression? focus of infection?

Other medication to consider

1. MSSA - 1st/2nd gen cephalosporin - cephazolin/cephalexin.
2. Gp D streptococci - (like GP A but affects immunocompromised patients). Ideal medication would be penicillin as you would prefer a narrow spectrum medication to avoid antibiotic resistance (unnecessay killing of gram negative) but ceftriazone for convinience - as it is once a day dose and lower risk of PICC line occlusion.
3. infected prosthetics - combination therapy with flucoxicillin + ciprofluoxacin or rifampicin. better chance of killing organism due to presence of biofilm. options: surgery to remove joint then IV antibiotics until aseptic then joint replacement takes 9 months or lifelong prophalaxis.
4. ???Culture negative - cipro, rifampicin(treat myco), fusedic acid.

PUO: investigations

PUO is defined as a temperature of >38.3 degrees for more than 3 weeks.

DDX think broadly from top to down.

1. Infection - abscesses
2. CTD/autoimmune
3. Malignancy
4. Drugs
5. Others; hypothalamic lesion, factitious fevers.

Ix:

1. FBC - raised WCC
2. U&E - ARF, pyelonephritis, baseline for antibiotic treatment
3. LFT - liver damage especially abscess
4. Haemolytic anemia - anemia, raised weiyong is smelly bilurubin, raised urobilinogen, raised LDH, reticulocytosis, direct antiglobulin test. Considering drug reaction?
5. Myeloma screen - serum plasma electrophoresis (paraprotein & monoclonal band), urine plasma electrophoresis (Bence Jones protein). beta2 microglobulin, Ig G, M, A levels
   
6. autoimmune - Rf, ANA, dsDNA, ENA, complement activity (C3, C4), ESR, CRP, GBM, ANCA(C & P), liver/kidney microsomal antibodies.
7. peripheral blood flow cytology
8. copper, ceruloplasmin.
9. ACE
10. septic workup. consider TB.
    
11. viral serology - HIV, HAV, Hbs Ag, HCV, others:flavivirs, mycoplasma, CMV, EBV, Q fever. CD4.
12. Imaging: CT brain, body, sinuses.
    

PUO- endocarditis

Intro:
Peter is a 80 y.o gentlemen who came to the hospital via ambulance due to an episode of uncontrollable rigors and SOB. This is in the setting of a previous pacemaker infection in October 2008.

HOPC

6 days ago, he had an episode of rigors that lasted about 20min. He was at home at that time and he started shaking uncontrollably with involved all of his limbs there was associated SOB, increase RR and feeling cold. No chest pains, palpitations. There was no associated neurological deficits- muscle weakness, numbness, visual changes. There was no LOC. During this episode he called the ambulance and was sent to the hospital. He recovered in the ambulance and was feeling tired but otherwise not confused. Prior to this episode he had two similar episodes while at home and while in hospital he developed a similar episode. The total number of attacks is 4.

Patient has no recent

· Fevers ( spiking (malaria), high swinging( abscesses), constant ( gen. bacterial/ neoplasia/CTD), intermittant fever (viral especially in paediatrics) ( (has chills and rigors)
· Fatigue, LOW(despite eating a lot), night sweats.
· Localised symptoms:
1. Cough, sputum(blood? Colour? Amt?), (SOB)
2. Chest pain, palpitations, PND, orthopnea, pillows used, peripheral odema (if HF)
3. urinary – freq, urgency, nocturia, dysuria, and incontinence
4. diarrhoea, constipation, abdominal pain, blood in stools
5. Neck stiffness, photophobia, Head ache
6. Arthralgia (backpain – epidural abscess), myalgia and skin rashes.
7. ear pain, face pain (sinusitis).
8. wounds/bites.

· Dentition
· Immunization – was up to date with both his pneumococcal and flu vaccine
· Contact – no contact with anyone that’s sick recently or anyone with TB
· Travel – gone to alice springs and NT but nothing too adventurous like swimming in rivers
· Occupation – purchasing manager
· Animals – No
· Drugs – later
· Sex- Nil.

Medical conditions

· Heart failure with AF was diagnosed in 2002. He presented with APO and was unable to sleep at night his wife had to send him in ED. A pace maker was then inserted in December 2002. Since then he does not complain of PND, orthopnea, uses 1 pillow, has occasional leg swelling well controlled by diuretics. His exercise tolerance is about 50m.
· October last year he noticed a rash on his skin overlying the pacemaker. Prior to this he developed a boil on his head when he bumped his head on the shower. His GP sent him to the hospital for further investigations and he was treated for a pacemaker infection with 1/12 of antibiotic treatment and the infection was presumed cleared.
· He had no other admissions for exacerbations for HF. His current HF meds are carvedilol, spironolactone, lasix.

Non-active medical conditions
· 2 hernia operations (1980)
· Right knee replacement (80’s)
· Backpain caused by lumber sacral spinal stenosis, which is getting worse recently. Still able to drive, no muscle weakness or numbness
· OSA(04’)- used to be on CPAP but doesn’t need to use it now.
· Bilateral varicose veins

CVD risk factors – HT, high cholesterol, No DM, smoked 16 pack/yrs and quit when he was 35.

Medications-
Carvedilol, spironolactome, lasix, lipitor, irbesatan, warfarin.
Was treated on ceftriaxone, flucoxicillin and vancomycin 3 days ago for empirical treatment of sepsis.

FH- NIL
Social – live, occupation, depression, financial, support, exercise, diet.

On physical examination

· Alert, well-orientated, no signs of fevers, rigors or sweats.
· V/S – 120/80 bp, 72 HR regular, sats 98%, temperature 37.7 at 0600hrs but previously afebrile.
· CVL in for 3 days – area of insetion not oedematous or red.
· Cannula on right arm.
· Pacemaker area not oedematous, no rash.

CVD exam – normal. Looking specifically for signs of IE – Janeway, oslers, splinter haemorrhage. Petechiae in the conjunctivae. Roth spots. Splenomegaly.

Resp- Normal

Abdomen – normal

Mx issues-
Identify source of infection – septic screen - sputum, stool, urine culture. CSF? CXR. Ideally 3 samples of bloods spaced at least 30min apart.
Empirical treatment for sepsis – antibiotics ( gentamycin+ ceftapine) + supportive therapy. This treatment does not cover for gram +ve -staphs aures, enterococci. [ use ampicillin or vancomysin], TB, PCP (co-trimaxazole, if allergic to sulphur meds use pentamidine), anaerobes(metronidazole). Consider fungal causes. If less sick ceftriaxone + stat dose of gentamycin is enough.

Treatment in type II diabetes.

1. Diet/weight/exercise control
2. Oral hypoglycemics - metformin is first line. Over time additional therapy is requried. add a 2nd drug, sulfonylureas. Beware thiazolidinediones ( especailly rosiglitazone - associated fluid retention. some studies show that it is associated with coronary artery disease)
3. Consider use of alpha-glucosidase inhibitors(acarbose), lipase inhibitors (orlistat) [ not good for weight loss but indicated for glycemic control], DPP-IV inhibitors (sitagliptan (Januvia)-oral [prevents incretin break down], GLP-1 receptor agonist(exenatide (byetta)-s/c [ increases incretin levels] This new class increases insulin secretion and decreases glucagon secretion. Lowers post-prandial sugar levels and keeps pre-prandial levels low.
4. once per day insulin is added to oral hypoglycemic therapy in patients with type 2 diabetes, either insulin NPH or detemir given at bedtime or insulin glargine given in the morning or at bedtime. Start low at 10 units and vary by 10-20% over 2-4 days.
5. Total daily dose of 1unit/BMI of insulin.
   
6. Consider pre-mixed insulin or NPH + a short acting. twice a day. Not recommended in type I diabetics.
7. More complex insulin regimens are recommended when needed. Similar to type I diabetes. (long-acting basal bolus in the night+ pre-meal short or rapid acting insulin)
8. Target of 4-6mmol pre-prandial and 4-7.7 post-prandial. HbA1C of 6-7% (reflects past 3 months glucose levels)
   

ALWAYS REMEMBER PATIENT EDUCATION! insulin injections, warnings on hypoglycemia - in relation to illnesses, missed doses, exercise, diet.

Types of insulin

Ultra-short acting: insulin aspart(novorapid), insulin lispro
Onset:15min Peak: 1hr duration: 4hrs

Short-acting: actrapid, hypurin neutral
Onset:30min Peak: 4hrs duration:8hrs

Intermediate: Protaphane, Humulin NPH, Hypurin Isophane (bovine), Hypurin Isophane (porcine) via SAS.
Onset:1.5hrs Peak: 8 hrs duration: 16hrs

Long-acting: glargine(constant output), detimir
Onset: 2hrs Peak: No peak Duration: 24hrs (less for detimir)

Mixed insulin: mixtard 70/30. novomix 70/30
Both contain a short-acting(30%) and a long-acting (70%), given twice a day.

http://www.betterhealth.vic.gov.au/BHCV2/bhcarticles.nsf/pages/Diabetes_insulin_choices?OpenDocument

Managment of mucositis post chemotherapy

Mucositis

Grade I - sore but can eat/ erythamatous mucosa
Grade II - modified diet/ patchy ulceration
Grade III - unable to maintain adequete hydration/ confluent ulceration
Grade IV - cannot eat or drink/ tumor necrosis and bleeding

Mx:

1. Symptomatic topical lignocaine mixed with mylanta (use when in pain or 30 min before meal)
2. diligent mouth care for anaerobes (Na bicarbonate)
3. nystatin fungal drop - candidiasis
4. nutritional status (inflammation of mucosa) - consider nasogastric feeding or total parenteral nutrition.
   

Febrile neutropenia

Definition: neutrophil count less than 0.5x 10^9/L or >38 degrees fever associated with neutrophils less than 1x 10^9/L with predicted to further drop.

DDX:

1. Drugs- post chemo(typically 10-14 days after chemotherapy), cytotoxic agents, carbimazole,sulfonamides.
2. Infection- viral or severe sepsis
3. Autoimmine- neutrophil antibodies (SLE, haemolytic anemia.)
4. hypersplenism - leukemias, felty's syndrome
5. bone marrow failure - Myeloproliferative, mylelofibrosis, malignant infiltration(myeloma), aplastic anemia, leukemia, infection(TB), drugs.
   

Examination: Paying attention to respiratory, abdominal (neutropenia colitis [typhlitits]), cardiac, pelvic(urinary). Look at mouth for mucositis and skin for rashes.

Treatment:

1. Initiated even if patient is afebrile but appears toxic. Assume septicemia.
2. Choice depends on local susceptibility. Cover for pseudomonas due to high morbidity and mortality.
3. Treat with broad spectrum Antibiotics - ceftazidime/cefepine( 4th generation - good pseudomonas cover + gram -ve), + timentin(ticarcillin+calvulanate acid)[ for gram +ve plus pseudomonas cover]. Austin protocol is ceftapine + gentamycin for more sick people and ceftriaxone + stat gentamycin for not so sick people. Note this this does not provide cover for staph aures, enterococci, TB, PCP, anaerobes.
4. Consider vancomycin for hospital acquired MRSA (rising due to increase presence of venous lines), serious shock, intravascular devices(PICC LINES ESPICALLY IN ONCOLOGY PATIENTS). This could result in the death of gut commensals and overpopulation of gut VRE which could lead to sepsis.
5. Treat routinely with anti-fungals(nilstat drop) and mouth washes to control ulcers and fungal mouth infections. Anti-virals if reactivation of VZV or HSV.
6. Consider barrier nursing and postive pressure room.
7. septic work up - blood (3 sets), sputum, urine, stool cultures. Swab also from any peripheral or central line. CXR
8. FBC, U&E, LFT, ABG ( decide if person is in hypoxic drive or not)
9. Continue until afebrile or neutrophil count recovers.
10. Failure to respond after 96 hrs consider fungal infections - candida or aspergillosus.(tx- amphotericin B or fluconazole)
11. Consider PCP, TB.
12. Granolocyte CSF- seek expert advice.
13. Education- food prep, hand washing, trauma to skin, oral hygiene, no live vaccines. If temp > 38 degrees go to ED.

---------------------
Always be aware of shock. Circulatory failure resulting in inadequete organ pefusion. bp <90.>

1. Call for arrest team
2. ABC ( high flow oxygen, consider bagging)
3. Initial work up - sats, glucose level, ECG, CXR, U&E (ARF?), LFT, FBE, CRP, ESR.
4. Septic workup and commence antibiotics (above) if suspected septic shock.
5. Need to correct for hypotension to maintain adequete organ perfusion.
6. IV access with 2 large bore for cystalloid infusion.
7. Consider inotropes(dobutamine) or vasopressors (dopamine, noreadrenalin) via central venous line to maintain a bp of >90mmHg, CVP 8-12mmHg, MAP>65.
8. Achieve a urine output of >0.5mL/kg/hr.