Clinical Questions

Is the PPD obsolete?

May 1, 2007
Is the PPD obsolete?

In February of this year the New York City Department of Health released a new policy paper indicating that they will no longer use the PPD as a screening tool for tuberculosis in their clinics.They have switched to the QuantiFERON-TB Gold, (QFT-G), a blood test. This test is an ELISA, which measures interferon-gamma secretion by t-lymphocytes in response to tuberculosis specific antigens. The test requires heparinized whole blood and must be processed within 12 hours of the blood draw.

The test exposes the patients t-lymphocytes…

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Morning Report-How Do You Approach a Patient with a Significant Transaminitis?

March 23, 2007
Morning Report-How Do You Approach a Patient with a Significant Transaminitis?

Consultant: Robert Raicht, MD Professor of Medicine, Chief Division of Gastroenterology

Clinical Vignette:
The patient is a 50 year old male with a past medical history notable for type II diabetes, hypertension and recently treated right foot cellulitis and c.difficile colitis who presented to the emergency room with the complaint of fevers and malaise for 1 week. His labs were notable for a significant transaminitis (AST 1997, ALT 1620, alkaline phosphatase 365, total bilirubin 3.1), INR wnl. An abdominal ultrasound was ordered with outpatient follow-up…

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Will my breast cancer patient need adjuvant chemotherapy? Gene Micro array technology may help answer this question��

March 20, 2007
Will my breast cancer patient need adjuvant chemotherapy?  Gene Micro array technology may help answer this question��

Commentary By Sandra D’Angelo, PGY-3

Breast cancer is the most common cancer diagnosed in women, second only to lung cancer as a leading cause of death from cancer. Experts state that approximately 210, 000 women will be diagnosed in 2006 and about 40,000 will die from the disease.1 According to data compiled by the Surveillance, Epidemiology, and End Results (SEER) Program of the National Cancer Institute, 61% of breast cancer cases are diagnosed while the cancer is still confined to the primary site (localized stage);…

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When Should You Order a Serum Fructosamine Level for a Diabetic Patient?

March 14, 2007
When Should You Order a Serum Fructosamine Level for a Diabetic Patient?

Commentary By: Christopher Johnson, MSIV and Glenn Matfin, MD Clinical Associate Professor of Medicine, Divsion of Endocrinology

When was the last time you had a diabetic patient in clinic whose hemoglobin A1C was elevated, prompting you to modify their diabetic regimen? You may have scheduled a repeat hemoglobin A1C in 3 months, since you know A1C measures glycemic control over a 3 month period. A serum fructosamine may help give you a snapshot of more recent control.

What is fructosamine?
Fructosamine is…

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Does the Overuse of Macrolides Lead to Antibiotic Resistance?

March 12, 2007
Does the Overuse of Macrolides Lead to Antibiotic Resistance?

Commentary By: Danise Schiliro, PGY-3

Although intuitively we always worry about creating drug resistance when using antibiotics, there is a surprising lack of well done studies that show a clear causal effect of antibiotic use on the development of subsequent drug resistance. A recent study in Lancet may however lead us to re-evaluate our use of macrolides in everyday practice.

Azithromycin and clarithromycin are two of the most commonly used macrolides for treating respiratory infections. Azithromycin has a long half-life, making it convenient for once…

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How Do You Approach A Patient with a Non-Ischemic Cardiomyopathy

March 7, 2007
How Do You Approach A Patient with a Non-Ischemic Cardiomyopathy

A 26 year old woman developed uncontrolled hypertension peripartum 5 years prior to this presentation After diagnosis she was intermittently compliant with her medication although remained asymptomatic. She now presents with new onset congestive heart failure. On admission, she was in mild respiratory distress. Her physical exam was notable for tachycardia with a blood pressure ranging from 160/100-200/110. She had a jugular-venous pressure of 8cm, +S4, crackles were present bilaterally 1/2 way up, but no peripheral edema. Labs were notable only for renal insufficiency…

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Safety of Long-Acting Beta-Agonists in the Treatment of Asthma: Should they be used?

February 21, 2007
Safety of Long-Acting Beta-Agonists in the Treatment of Asthma: Should they be used?

Commentary By: Sarah Huen, PGY-3 and David Chong, Director of Critical Care, Bellevue Hospital, Associate NYU Internal Medicine Residency Program Director

The role of long-acting b-agonists (LABAs) in the treatment of asthma continues to be controversial. Growing evidence that LABAs may cause an increased risk of asthma exacerbations and asthma-related deaths prompted the U.S. Food and Drug Administration (FDA) to approve “black box” safety warning labels for Serevent Diskus (salmeterol xinafoate), Advair Diskus (fluticasone propionate; salmeterol xinafoate), and Foradil (formoterol fumarate). Concern about…

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How Should You Approach A Patient with an Incidental Finding of a Portal Vein Thrombosis?

February 7, 2007
How Should You Approach A Patient with an Incidental Finding of a Portal Vein Thrombosis?

A  70 year old man  with a history of prostate cancer, status post radiation treatment in August 2003, a history of abdominal surgery for unknown reasons, and a history of heavy alcohol use was seen at the VA.   The patient was referred for a complaint of bright red blood per rectum and was incidentally noted to have elevated liver enzymes. 

Colonoscopy revealed blood in the rectosigmoid, dilated vessels in the rectum and angioectasia, thought to be secondary to the radiation…

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Ethics 101-How Do You Approach a Jehovah’s Witness Patient Who Needs a Transfusion?

February 5, 2007
Ethics 101-How Do You Approach a Jehovah’s Witness Patient Who Needs a Transfusion?

A 76 year old man with a history of coronary artery disease, diabetes and hypertension was brought in by his wife with two days of lethargy, slurred speech and right arm weakness. On presentation, the patient was awake and intermittently involved in conversation.  He was afebrile, with a pulse of 90 and blood pressure of 166/98  His exam was remarkable for dysarthria, orientation only to person, pinpoint pupils, left sided tongue deviation, 3/5 motor strength in the right upper extremity, 4/5 motor strength in…

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Bedside Rounds #1: Why is a pulsus paradoxus not a paradox?

February 1, 2007
Bedside Rounds #1: Why is a pulsus paradoxus not a paradox?

Welcome to our inaugural Bedside Rounds a new regular feature of Clinical Correlations.  Here you will learn not only practical physical diagnosis pearls, but also the historical context in which these findings were discovered.

Commentary By: Judith Brenner MD, Associate Program Director, NYU Internal Medicine Residency Program

When you take a deep breath in, what happens? Because of an increase in the negative intrathoracic pressure, blood is sucked into the right side of the heart. Temporarily, a filled right ventricle can bulge…

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How Should You Treat Agitation in Patients with Dementia?

January 29, 2007
How Should You Treat Agitation in Patients with Dementia?

Case: A 74 year old male with a history of hyperthyroidism, now treated and euthyroid, and with longstanding slowly progressive Alzheimer’s, has now become increasingly agitated at home, pacing the floors and not sleeping. In light of side effects and the recent warning against the use of atypical antipsychotics and the side effects of the older medications, what kind of stepwise approach to medications would you recommend to use to treat his agitation?

Commentary By Brian Bronson, MD Clinical Assistant Professor of Psychiatry,

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When Should You Order a T Wave Alternans Test?

January 25, 2007
When Should You Order a T Wave Alternans Test?

A 58 year old male is admitted for "presyncope".  He has not had chest  pain and his baseline ECG is unchanged.  The patient has an ischemic cardiomyopathy with an ejection fraction of 39% with mild reversible changes on a stress echo that was done 5 months prior to admission.  On telemetry, the patient has frequent  polymorphic premature ventricular contractions. The cardiology consult recommends a T wave alternans test.  What is the reason for this test?

Commentary By: Neil

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