Dropping TAGs

To drop TAG below 1.7 use

1. very low fat diet
2. diet of 6-12 capsules of fish oil
3. diabetic control (esp if bad)
4. meds: fibrates/fenofibrates/nicotinic acid

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.