Systems

How do you approach a patient with Pneumomediastinum?

December 19, 2006

BH Morning Report Fast Facts

29 year old male presents with anuria, vomiting, and pneumomediastinum. 1 month prior to admission the patient traveled to South America and developed an upper respiratory infection. He returned to the US after traveling for two weeks feeling well. The patient used ecstasy and marijuana four days prior to presentation. The next day he developed vomiting including one episode of hemetemesis. For the next three days he had intermittent vomiting, no diarrhea. On admission his BUN/CR was 68/7.5. …

Does Circumcision Decrease the Transmission of HIV?

December 18, 2006

Recently, two large clinical trials in Kenya and Uganda that examined the role of circumcision in men to prevent the spread of HIV were halted on the grounds that not offering circumcision to men taking part in the trial would be unethical. The trials involved nearly 3,000 heterosexual men in Kenya and nearly 5,000 men in Uganda, none of whom were infected with HIV prior to starting the trial. In the Kenayn trial, men who were circumcised had a 53% relative risk reduction…

When Can You Safely Anticoagulate a Patient after an Intracranial Hemorrhage?

December 15, 2006

55 year old white male falls down a flight of stairs and sustains a subdural hemorrhage and a subarachnoid hemorhage with significant neurological changes. Hospital course was notable for 1 episode of chest pain without ekg changes and negative cardiac enzymes. The patient was seen several months later in medicine clinic with resolution of his neurologic findings but now with multiple episodes of chest pain. He was sent for a stress test which showed a mild reversible anterior wall defect, with normal left ventricle and…

Epogen and Anemia-Less is More (Part 2)

December 14, 2006

Commentary By David Goldfarb, M.D. Professor of Medicine, NYU Medical Center, Chief Nephrology Section VA New York Harbor

2 weeks ago we reported on 2 lead articles in the New England journal that suggested that our targets for hemoglobin values when treating with erythropoietin were too high.

Last week, the New York Times reported that based on those NEJM articles (CHOIR and CREATE), the National…

Mystery Quiz-Radiology

December 13, 2006

Posted By Robert Smith, MD Associate Professor of Medicine, Division Pulmonary and Critical Care Medicine

62 year old male smoker with past medical history notable for hypertension, copd, comes to clinic complaining of chronic cough x 6 months with minimal sputum, no wheezing. Lung exam shows decreased breath sounds throughout. Pt had the following CXR performed:

Click on Thumbnail to Enlarge

What's your diagnosis and the next step in his evaluation? Please submit your answers by clicking on the "comments" link below this post. …

What Is Sezary Syndrome?

December 11, 2006

Morning Report-Tisch Hospital

Case Presentation: 83 year old with a past medical history of hypertension noted erytematous plaques with scale about 1 year ago. The rash was associated with diffuse pruritis at that time. The patient subsequently underwent several inconclusive biopsies. She was eventially diagnosed with mycosis fungoides and treated with UV therapy. Her rash progressed to a diffuse pruritic erythema covering the vast majority of her body, including palms and soles. (erythroderma). She was noted to have Sezary cells on peripheral smear…

How do you approach a patient with asymptomatic primary hyperparathyroidism?

December 6, 2006

56 year old Hispanic female with a history of hypertension, type 2 diabetes on oral medications, hyperlipidemia and normal renal function. Over the past 2 years she has been noted to have mild hypercalcemia (11.0-11.5) on several basic metabolic panels. On her last visit, intact PTH was checked and was elevated at 66 (normal range 7-57). In patients such as this, with apparent asymptomatic primary hyperparathyroidism, what further diagnostic tests should be done and in whom is surgery indicated?…

Pfizer Shutting Lights on ILLUMINATE Study

December 4, 2006

Low HDL is a well known independent risk factor for atherosclerotic disease. As a result, there have been several attempts to develop medications to raise HDL. Specific targets include the inhibition of cholesteryl ester transfer protein, which plays an essential role in HDL metabolism by facilitating the transfer of cholesterol esters from HDL cholesterol to apolipoprotein B-containing lipoproteins.

Pfizer created just that drug. Known as Torcetrapib, it was seen as a promising therapeutic to increase HDL and potentially…

Fast Facts-Rheumatology

November 30, 2006

Bellevue Morning Report Teaching Points 11/27

CC: Left knee swelling and pain x 1 week

54 yo male without past medical history in his usual state of health until 5 weeks prior when he had painful ejaculation and intermittent dysuria, denies penile discharge. Treated for a urinary tract infection with unknown antibiotic. 3 weeks later develops recurrent symptoms and again treated with another course of unknown abx by outside physician. However he develops left knee pain and swelling and is unable to…

Should You Recommend Surgery or Conservative Care for Disc Herniation?

November 29, 2006

In the November 22nd issue of JAMA, the results of two studies from the Spine Patient Outcomes Research Trial (SPORT) on lumbar disk surgery for persistent radicular pain are reported. Both these studies sought to assess the efficacy of surgery for lumbar disk herniation as compared to nonoperative treatment, including counseling, anti-inflammatory medications, injections, and physical therapy. It is important to note that specific inclusion criteria were radicular pain as well as imaging showing disk herniation. Because a large number of study participants declined…

Diagnostic Dilemma #2 How Should You Approach a Low Titer +RPR?

November 28, 2006

45 year old male with history of Hep B ( Hep B Surf Ag + but Hep E Ab+ and E Ag – and DNA viral load was not sent) and syphilis treated in the past. He has RPRs in the past that were 1:1 for years and then negative x 2 a year apart, the last being over two years ago. He had labs drawn last week and had an RPR of 1:4. He does report high-risk unsafe sexual activity (with female prostitutes)…

Fast Facts-Critical Care

November 22, 2006

VA MICU Conference 11/22/06

56 y.o. male with PMH ETOH abuse and COPD presented with a LUL PNA and BCx positive for penicillin-resistant pneumococcus.

Early Goal-Directed Therapy in Severe Sepsis and Septic Shock

Early broad spectrum antibiotics. Goal directed hemodynamic resuscitation with IV fluids pressors PRBCs (for Hct <30) inotropes To maintain: Central Venous Pressure 8-12 mm Hg Arterial Pressure: MAP >65 mm Hg but <90 mm Hg Central Venous Oxygen Saturation >70% Consider cosyntropin stimulation to evaluate for relative adrenal insufficiency. Consider

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