The StethoSCOOP - University of Cincinnati
Transcription
The StethoSCOOP - University of Cincinnati
The StethoSCOOP UCMC INTERNAL MEDICINE RESIDENCY V O L U M E 3 , I S S U E 5 0 J U N E 1 0 , 2 0 1 6 Weekly Calendar SPECIAL POINTS OF INTEREST: Last minute room fixes The farewells 6/13: Noon Report: Blue Team 6/14: Noon Report: Green Team 6/15: Grand Rounds: Ahsan Zafar, MD: “From Idea to Outcomes: Improving Care Delivery for COPD Patients” begin 6/16: nothing 6/17: Noon Report: GI Team INSIDE THIS ISSUE: Infection Prevention 2 Old to new 2 Rheum emergencies 3 New door handle 4 Resident Research 4 Upcoming Events 4 Board Review 5 Resident Awards 5 Weekend to-do 6 Medical Trivia 6 Shoutouts 6 End of a noon report era. Start of a brilliant new HD epoch. Anonymous Feedback Our website has a section for anonymous feedback. Think of this like an electronic suggestion box that you can use at any time. The message will be sent directly to Dr. Warm, and is completely anonymous. If you have constructive feedback that you would like to share, please use this tool. The link is: http:// intmed.uc.edu/education/residency/feedback.aspx VOLUME 3, ISSUE 50 Infection Prevention Prevention of hospital-acquired infection is the responsibility of all who care for patients. You will see this data in the newsletter routinely in the future. Please take note of the trend, remember to use interventions such as the nurse-driven Foley protocol, and join the teams working to improve quality care of our patients. See Renee Hebbeler-Clark to join a team! PAGE UCMC Days Since Last: CAUTI CLABSI C-Diff MRSA (Bloodstream) SSI VAP LAST INFECTION 5/7/16 31 days (NSICU) LAST INFECTION 5/29/16 9 days (SICU) LAST INFECTION 6/2/16 5 days (MSD) LAST INFECTION 5/17/16 21 days (CVICU) LAST INFECTION 5/13/16 25 days LAST INFECTION 5/27/16 11days (MICU) Note : VAP contains ICU data only. MRSA/C. diff as per HA NHSN defined Interns! AME 6/13-6/17 Osteoporosis – find in your Dropbox folder or in Medhub Long Blockers! Special AAP 6/15 MIGRAINES Part I MSB 6254 This week’s Pearl – Cleveland Clinic Journal of Medicine Clarifies the Pneumococcal vaccine confusion! Download the quick read as a PDF from CCF! Clinic Corner Come Monday, there will be new kids on the block. Onward and upward. THE STETHOSCOOP 2 VOLUME 3, ISSUE 50 PAGE 3 Rheumatologic Emergencies Vignette Diagnosis Positive History of longstanding Rheumatoid Arthritis, develops Cervical Myelopathy cervical pain with radiation to occiput, 2/2 cervical +/- both upper and motor neuron subluxation: C1-C2 signs; +/- unsteady gait and decreased proprioception Pearls Propensity of RA to involve C-spine: synovitis with erosions that destroy the ligaments anchoring C1C2; definitive diagnosis via Cervical MRI; **screen RA patients preoperatively with plain films if undergoing general anesthesia** Suspect in patients: - with unexplained thrombotic events (arterial, unusual organ involvement) Young female patient of child-bearing Antiphospholipid unexplained adverse pregnancy outcomes (fetal age p/w livedo reticularis, Antibody Syndrome --> loss, recurrent miscarriage) - unexplained thrombocytopenia, elevated INR, Catastrophic thrombocytopenia - unexplained prolonged PTT; prolonged aPTT, clinical concern for antiphospholipid order antiphospholipid antibodies: 1. Lupus concomitant venous and arterial antibody syndrome anticoagulant 2. Anticardiolipin Ab 3. Anti-Beta-2 thromboembolism glycoprotein; tx = anticoagulation, high-dose steroids, plasmapheresis Pt with systemic sclerosis, recent exposure to glucocorticoids, +/- HA, new-onset/worsening HTN; lab evidence of MAHA, AKI, bland UA with non-nephrotic range proteinuria SLE pt p/w LE edema, hematuria, lab evidence of active lupus and AKI SLE patient hypoxemia, new pulmonary infiltrates on chest radiograph, and decreasing hematocrit, +/- hemoptysis Acute monoarticular arthritis; +/elderly, history of joint trauma, alcoholism, DMII, immunosuppression, IVDU THE STETHOSCOOP Scleroderma Renal Crisis Pathophysiology theory: insult/injury to endothelial cells > intimal thickening, proliferation, and an absence of inflammatory cells within the renal vasculature; narrowed afferent renal arterioles > glomerular ischemia and hyperplasia of the juxtaglomerular apparatus and subsequent renin release (hyperreninemia); ~10% of patients present with normotension; TX = ACEi (CAPTOPRIL) Lupus Nephritis 6 types- require renal biopsy to diagnose. Most common = type IV: Diffuse proliferative LN (>50% glomeruli involved); all may be with segmental or global involvement (active; active and chronic; chronic) Most severe kidney involvement with active urine sediment, HTN, heavy proteinuria (often nephrotic range); and often reduced GFR; serology very active; active lesions require treatment: highdose steroids, cyclophosphamide Diffuse Alveolar Hemorrhage Bronchoscopy with bronchoalveolar lavage (BAL) and biopsy is the most appropriate diagnostic test to perform next in this patient with suspected diffuse alveolar hemorrhage (DAH), 50% of patients have hemoptysis. DAH occurs in the setting of active SLE, and up to 90% of patients have evidence of nephritis; - Mechanical ventilation and aggressive immunosuppression are generally required: • Methylprednisolone 1g daily • Cyclophosphamide • Transfusion support as indicated Bacterial Arthritis Synovial fluid analysis = paramount; WBC >50,000 most likely infectious in etiology. Can coexist with deposition disease (gout/pseudogout). Empiric antibiotic coverage ASAP. VOLUME 3, ISSUE 50 PAGE 4 The work room door is fixed! Thank you for your patience through this challenging and dangerous time. Special shout out to Steve Amatangelo for rigging up an emergency escape solution. Shout out to Leslie Applegate for her impressive grip strength. Resident Research Symposium Job well done to all of the presenters today. Kudos to your scholarship! Upcoming Residency Events GRIT & Finding Meaning in Medicine Last meeting of the year with reflection on the initiative thus far and planning for the year ahead. Finding Meaning in Medicine will follow. Come for one, stay for both! FMM Topic: Gratitude. Time: 5:30 June 15th (Wednesday) (FMM ~6:30) Location: Elise’s house (ask Rachel or Elise for address) THE STETHOSCOOP Vulnerable Populations Dinner We will be reflecting on the year past and planning for the year ahead. PLEASE come and be a part of the pathway’s future! Time: 5:30 June 13th (Monday) Location: UH 7104 (NRR) VOLUME 3, ISSUE 50 PAGE 5 B OAR D R EVI EW WITH T HE C HI E FS : DUST OFF THOSE STETHOSCOPES, FOLKS. IT’S BOARDS STUDYING TIME! Respiratory Failure Quick Hit Thoughts: Benefits of NIPPV in patients with acute hypoxemic respiratory failure due to heart failure 1. Decreased need for mechanical ventilation 2. Improves respiratory parameters 3. Potential decrease in mortality Tidal volume and plateau pressure limits to prevent ventilator-induced lung injury Tidal volume <6mL/kg of ideal body weight and plateau pressure <30cm H2O Vent mode for initial mechanical ventilation for acutely ill, hemodynamically unstable patients Volume-controlled continuous mandatory ventilation Indication for hypoxia altitude simulation testing before air travel Lung disease and sea-level O2 saturation between 92% and 95% Management of respiratory failure due to progressive idiopathic pulmonary fibrosis Palliative care Patient positioning that increases survival in acute respiratory distress syndrome Prone positioning 3 criteria of spontaneous breathing trial that predict successful extubation 1. Tolerate 30 minute weaning trial 2. RR <35 3. SaO2 >/= 90% without arrhythmias, change in vital signs, or signs of respiratory distress Congratulations to our very deserving resident award winners! Department of Internal Medicine Outstanding Medical Student Graduate: Ashley Cattran Herbert C. Flessa Physician’s Physician Award: Andrew Petersen Jerome Herman Award for Excellence in Patient Care: Katie Donnelly Resident Teacher award: Robbie Bach THE STETHOSCOOP VOLUME 3, ISSUE 50 PAGE 6 Weekend to-do! Friday: Cincinnati Fringe Festival, through Saturday. Held at various venues in Over-the-Rhine. Local, regional, national and international artists present 12 days of artistic celebration. www.cincyfringe.com. BalloonFest: Bands, BBQ and Beer, 4-10 p.m. Friday, noon-10 p.m. Saturday, Rising Star Casino & Resort, 777 Rising Star Drive, Rising Sun; www.risingstarcasino.com. Saturday: NamasDEY, 10 a.m., Paul Brown Stadium, Downtown. Yoga on the field led by instructors from The Yoga Bar and all levels are welcome.www.bengals.com/yoga. Northside Second Saturdays, noon-midnight, Hamilton Avenue, Northside. Art openings, later retail hours, food and drink specials, live music, interactive events and more. Free. FC Cincinnati Soccer, 7 p.m., Nippert Stadium, University of Cincinnati, University Heights. vs. Montreal. www.fccincinnati.com. Sunday: Concours d’Elegance, 10:30 a.m.-4 p.m., Ault Park, 3600 Observatory Ave., Mount Lookout. More than 200 collector vehicles; www.ohioconcours.com. Clam Bake in the Park, noon-9 p.m., Washington Park, 1230 Elm St., Over-the-Rhine; www.washingtonplatform.com TRIVIA This statue is meant to depict the battle of Man vs. Disease. It is part of a monument to what historical titan of pathology? First correct answer wins a $5 Starbucks gift card Congrats to Joanna Marco for identifying Curschmann’s spirals in asthma. SHOUT OUTS!!! -to Geoff Motz for taking the time to help a patient through a difficult situation. “Had a Jehovah's Witness patient w/ hgb of 5.5 at admission, newly dx cirrhotic w/ UGIB. Looked up on JW website to find a rationale for her to agree to a transfusion...and getting scoped.” Some Jehovah’s Witnesses may agree with alternative teaching that "fractions of blood are up to the beliefs of the person" versus whole blood. -to the long block residents covering for graduation: Avanti Jakatdar, John Murithii, Rita Schlanger, Javier Baez, Tim Reed, Mike Sabbah, Cameron Ditty, Kantha Medepalli. It means a great deal to know we support each other for events like this! -to the rising chiefs Danielle Weber, Caitlin Richter, Nabeela Siddiqi, Thomas Getreu, and Owen Baldwin who are kicking it in gear to plan an awesome residency year 2016-2017. If anyone knows how much work there is behind the scenes, we do, and you are doing a fantastic job already. Good luck! THE STETHOSCOOP