Commentary by Albert B. Knapp MD, NYU Clinical Professor of Medicine (Gastroenterology)
THE CASE:
WS, a 49 yo year old Caucasian male with a known 35 year history of alcohol abuse, now presents with jaundice, tense ascites and a left shoulder fracture following a bar room brawl last night. He is admitted to the orthopedic service for elective pinning but is presently in great pain. You are consulted in regards to pain management….
THE QUESTION:
How should you approach…
Commentary by Howard Leaf, M.D. Assistant Professor, Division of Infectious Diseases and Immunology
Pressure continues to build for healthcare facilities to act to decrease hospital-acquired infections, particularly those associated with MRSA. This is partly data-driven, with one study reporting that 25% of patients acquiring MRSA colonization during a hospitalization subsequently become infected . The call to act is also partly a political response to concerns in the lay press about “superbugs” wreaking havoc both in hospitals and in the community. Seven states have…
Commentary by Daniel Frenkel, MD PGY-2 and Aleksandar Adzic, MD PGY-2 (in consultation with Greg Mints, MD Attending Physician, General Internal Medicine)
Case #1: A 47 year old man with no significant medical history, nonsmoker, and no family history of CAD. Blood pressure 124/72 Cholesterol 202, LDL 129, HDL 35, Triglycerides 190.
Case #2: A 36 year old man history of hypertension controlled with hydrochlorothiazide, smoker, with no family history of CAD. Blood pressure 134/72 Cholesterol 168, LDL 91, HDL 46, Triglycerides 155.
Would you…
Commentary by Fritz Francois, MD, MS, NYU Division of Gastroenterology
Humans are essentially the only reservoir for Helicobacter pylori, which is estimated to colonize the stomach of about half the world’s population (1). Although the bacteria generally do not invade the mucosa, attachment to the epithelium leads to an inflammatory reaction with neutrophils, lymphocytes, plasma cells, and macrophages. Over time, the persistent inflammation leads to changes in the gastric mucosa that may predispose to the development of dysplasia(2).
Commentary by Bani Chander MD, PGY-2
Esophageal varices are a common complication of cirrhosis and approximately one-third of all cirrhotic patients with varices will develop a variceal bleed . Each episode of variceal hemorrhage is associated with a 15 to 20 percent risk of mortality in patients with severe liver dysfunction. The risk of bleeding is related to the location, size, and appearance of the varix, presence of red wale markings, variceal pressure, prior history of variceal bleeding, as well as the severity…
Commentary by Cathy Cruise, M.D. Director Department of Veterans Affairs Care Coordinator, Chair Rehabilitation Council
Case: A 25 year old woman with no significant past medical history presents to walk-in clinic complaining of several days of right heel pain. She notes that the pain is quite sharp and worst when walking. It is so severe that she has skipped her morning run for three consecutive days. She has tried taking acetaminophen which has provided minimal symptom relief. Physical exam reveals mild swelling and…
Commentary by Sean Cavanaugh MD, Associate Editor, Clinical Correlations
A 51-year-old man with a history of DVT diagnosed seven months ago presents to your clinic for follow up. He has no family history of blood clots. He has been on coumadin since his DVT was diagnosed. No testing for thrombophilia has been done. How do you proceed?
Recently, The Annals of Internal Medicine released an excellent statement about the treatment of venous thrombosis (see prior post). Unfortunately, it does not address the more interesting questions…
Should patients with Hepatitis C (HCV) with no evidence of cirrhosis undergo screening for hepatocellular carcinoma (HCC)? Is there any reason to check for HCC when the liver associated enzymes (LAEs) are normal?
-Sandeep Mangalmurti, PGY-2
Commentary by Mike Poles MD, Associate Editor Clinical Correlations and Assistant Professor, Division of Gastroenterology
HCC continues to be one of the most common solid malignancies worldwide. Further, almost all cases of HCC occur in the background of a histologically-abnormal liver; approximately 90% of cases…
An 80 year old male with atrial fibrillation, hypertension, hypokalemia is diagnosed with hyperaldosteronism with an aldosterone to renin ratio of 34.5/0.15=230 . CT scan reveals a right adrenal 1 cm presumed adenoma
Questions:
1. How do you accurately diagnose primary hyperaldosteronism?
2. Do medications which the patient is taking influence the work-up?
3. Can you have primary hyperaldosteronism in the absence of hypokalemia?
4. Can the adrenal mass be incidental? Should the patient have additional testing?
-Anna Dvorak PGY-3…
-Commentary by Susan Morey, PharmD. Pharmacy Practice Resident
A true allergy to penicillin is known to occur in less than 10% of patients exposed to penicillin. 1, 2 The cross-reactivity to cephalosporins has been reported to be approximately 8% to 18% in patients with a documented penicillin allergy. True allergic, type I reactions are IgE mediated, with a spectrum of presentation ranging from urticaria to severe anaphylactic shock.1, 2
The beta-lactam ring has been implicated as the structure responsible for cross-reactivity…
Commentary by Sarah Berry MD, PGY-3 and Joseph Weisstuch, MD Clinical Assistant Professor of Medicine, Divsion of Nephrology
Case: Mr. K is a 59 year old gentleman with a past medical history of hypertension, non-insulin dependent diabetes mellitus, dyslipidemia and worsening chronic kidney disease (CKD) over the last six years, despite compliance with his medications and optimized glucose and blood pressure control. His current medication regimen includes metoprolol, hydrochlorothiazide, aspirin, simvastatin, glyburide, and monopril. Mr. K’s most recent lab work indicates that…
A 48 year old male is diagnosed with type 2 Diabetes Mellitus after presenting to the emergency room with symptoms of hyperglycemia. He was immediately started on insulin and has been very compliant with his regimen. His initial Hemoglobin A1C at the time of diagnosis was 15. However, over the past few months, due to hypoglycemia, his insulin dosage has been titrated down. He is currently on low doses of NPH and aspart, with an A1C of 6.6. Would it be possible to…
