Clinical Questions

How should you approach a pregnant patient with chronic kidney disease?

May 25, 2007

A 31 year old female with hypertension and proteinuria secondary to IgA nephropathy, currently treated with an ARB, presents to clinic stating that she would like to become pregnant.

What is the risk of fetal morbidity in the setting of ARBs/ACE-inhibitors? What antihypertensive medications are used during pregnancy? At what point would you switch a patient’s medications if she is trying to become pregnant? What is the natural course of IgA nephropathy during pregnancy?

-Minisha Sood MD, PGY-3

Pregnancy and Chronic Kidney…

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

March 14, 2007

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…

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

March 7, 2007

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…

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

February 21, 2007

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…

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

February 7, 2007

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…

When Should You Order a T Wave Alternans Test?

January 25, 2007

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…

How Aggressively Should You Treat a Patient with a Pulmonary Embolus?

January 17, 2007

An otherwise healthy 57 year old patient presents with shortness of breath and pleuritic chest pain. The patient is hemodynamically stable without evidence of shock. A chest CT reveals a pulmonary embolus.

Questions: 1. When should an echocardiogram to assess for right heart strain be performed in a patient with a pulmonary embolism? Should stable patients without evidence of shock have a routine echo once a diagnosis of pulmonary embolism is made?

2. If the echo shows signs of right…

To Lavage or Not to Lavage?

January 10, 2007

Case and Commentary by Minisha Sood PGY-3 and Ilseung Cho Fellow, Division of Gastroenterology

The patient is a 57 year-old man with a past history of hypetension, hyperlipidemia, hepatitis B/C cirrhosis and coronary artery disease status/post a non-st-elevation mi in August 2006, during which time he was on a heparin drip and developed an upper gastrointestinal bleed. Upper endoscopy at that time revealed non-bleeding esophageal varices and he was discharged on a beta blocker. He again presented to Tisch hospital in December 2006 with complaints…

Who Should Receive Prophylaxis for Gout?

December 26, 2006

A 70 year old male, former alcoholic, with a past history of gout diagnosed by joint aspiration, presents with his second episode of right 1st metatarsal erythema, swelling and severe pain in the last 6 months.

Commentary By Pamela Rosenthal, MD Assistant Professor of Medicine, Division of Rheumatology

Question 1. Is there any specific rule you follow when deciding to start someone on colchicine prophylaxis? e.g. >x # episodes…

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. …

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…

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?…

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Clinical Correlations