Monday AM report 11-23-09

1. Monday AM report 11-23-09

2. CC: Weakness, myalgias, arthralgias and fever

3. Bring it on! HPI ROS Meds/Allergies FH/SH PE I PE II Problem list Chemistry LFTs Coags Heme Urinalysis Endocrine Immunology Microbiology Molecular Microbiology Toxicology Pathology US Chest X-ray Abdomen X-ray Extremities X-ray CT head CT chest CT abdomen CT extrem/bone MRI head MRI chest MRI abdomen MRI extrem/bone EKG TTE TEE PVL Lecture

4. HPI HPI: This is a 54 yo caucasian male who was transferred from Maria Parham ED for a several day history of generalized weakness, muscle aches with associated subjective fevers (101 F) that started 5 days ago with a sore throat. He was in his usual state of health who reports that approximately 3 weeks ago he hurt his back while lifting a heavy television. As a result of this injury, he began to experience sharp pains that would go down his left leg. He was seen in the Maria Parham ED, who obtained a MRI spine that revealed a "pinched nerve" from a possible slipped disc. He was referred to an orthopedist in Raleigh, who prescribed cyclobenzaprine and physical therapy with good response. After that he developed a fever 5 days ago followed closely by myalgias, nausea/vomiting, headaches that converted to migraines, and general weakness. He presented to Maria Parham again, who diagnosed him with the flu, gave fluid resuscitation, and sent him home. However, his symptoms continued to a point where he could no longer walk, and re-presented at Maria Parham ED for evaluation. At that time, he was noted by the physician there to have bilateral lower extremity weakness and diminished reflexes. Out of concern for possible acute inflammatory demyelinating polyneuropathy (Guillian-Barre syndrome) he was transferred to UNC. He also developed swelling and tenderness of the right knee on Sunday. He developed a red patchy rash on his elbows 3 weeks ago. He also developed purple papules on palms and soles that have worsened over the course of the day. Back

5. ROS GENERAL: +appetite loss, +chills, no nightsweats, mild weight loss due to appetite loss HEENT: +HA, +Nausea/vomiting, + sore throat, no vision changes CHEST: no chest pain LUNGS: no SOB, no cough, no hemoptysis ABDOMEN: no abdominal pain, no diarrhea, no blood in stools GU: no urinary symptoms, no discharge MSK: generalized myalgias and arthralgias, back pain SKIN: + jaundice, bilateral elbows with red patchy rash with a few pustules, petechial rash on right chest medial to mid axillary line, purple pustules present on soles of hands and feet. Neuro/Psych: 3xoriented, anxious, general weakness Back

6. PMH - Meds/allergies - FH/SH PMH: HTN HLD Gilbert's Syndrome Osteoarthritis in Neck Low back pain since 3 weeks with radicular, pinched nerve at L3-L4 from lifting injury PSH:Appendectomy at age 12 Kidney stones lithotripsy x 5 L inguinal hernia repair 2005 Crown lengthening procedure about 1 month to 6 weeks ago and a root canal a few weeks prior to that CURRENT MEDS: HCTZ 25mg daily Simvastatin 40 mg daily Skelaxin (metaxalone) 400mg bid (muscle relaxant)ASA 81 mg Etodolac 400mg BID Vitamins E and C  Allergies: NKDA SH No tobacco, No ETOH, No history of IV drug use, No history of sexually transmitted disease. Currently working as support analyst at Lab Core in Burlington. Lives in Henderson with wife. 2 Children FH 3. Cousin had toe fungus (JUST kidding!). Noncontributory! Back

7. PE PE T 98.7 RR 22 HR 115 BP 116/68 Sa O2 96 % on RA General: Pt. in acute distress, diaphoretic HEENT: Mouth dry, no palatal petechia or aphtae, yellow sclera, no JVD Heme: no LADCV: S1, S2, rapid regular, no murmur, no rub, no gallopLungs: CTAB, no wheezes Abdomen: soft, nontender, nondistended, +hemorrhoidsSkin: Purpule pustules present on soles of hands and feet, petechial rash on right chest medial to mid axillary line, + jaundice, bilateral elbows with red patchy rash with a few pustules. GU: no discharge MSK: Decreased strength due to pain.Extremities: R knee effusion, no erythema, no warmth, pulses 2+ throughout Neuro: AAOx 3, no focal, DTRs 2+ bilaterally, sensation intact, Babinski negative, CNs 2-12 grossly intact Back

8. Skin lesions I Next

9. Skin lesions II Next

10. Skin lesions III Back

11. Problem list Weakness Myalgias Arthralgias (+ right knee swelling) Subjective fevers Tachycardia Low O2 sats Jaundice Headaches Nausea/vomiting Dehydration Pain Skin lesions (elbow, palms, soles, petechia on chest) Back

12. Chemistry Sodium 140 Potassium 3.9 Chloride 104 CO2 30 BUN 39 Creatinine 1.54 (GFR 45) Stage 3 Glucose 115 Calcium 8 Magnesium 1.8 Phosphorus 4 CK 134 CK-MB 3.6 Troponin 0.48 !!! Protein 5.3 Albumin 2.7 LD 687 Back

13. LFTs Bilirubin 4.2 (direct 1.2) AST 234 ALT 435 AP 113 GGT 65 Back

14. Coags INR 1.5 PTT 33.2 Back

15. Heme CBC 9.7 (peak 4days later 17.2) Platelets 73 H&H 12.1/34.5 Back

16. Urinalysis Urine sodium <5 FeNa 0! UA: WBC 6 LE+ Prot 1+ RBC 17 Back

17. Endocrine TSH 3.53 Cortisol normal Back

18. Immunology CRP >45 HIV negative Hepatitis B,C negative ANA negative ANCA negative RF negative Glomerular basement membrane -Ab negative Back

19. Microbiology BC (3/3): MRSA (community acquired) Took 3 days to clear BCs UC (MRSA) Vitrous fluid negative 2+PMN Knee + L3/4 disk negative (50000 cells 95% neutrophils) Back

20. Molecular Microbiology Toxoplasma negative EBV negative CMV negative VZV negative HSV negative Chlamydia negative GC negative Back

21. Toxicology Back

22. Pathology Diagnosis:Synovium, right knee, biopsy - Acute and chronic synovitis. Back

23. EKG Sinustachycardia Back

24. TTE EF 55% No vegetations Back

25. TEE No vegetations Back

26. Renal US No hydronephrosis or nephrolithiasis. Back

27. PVL No DVT Back

28. Chest x-ray 1. Diffuse patchy opacities identified bilaterally consistent with mild pulmonary edema versus infection. 2. Question small bilateral pleural effusions versus overlying soft tissue. Back

29. CT head No acute intracranial abnormality is identified. Back

30. MRI spine Cervical spine: IMPRESSION: Multilevel degenerative disk disease. No abnormal cord signal or enhancement.  Thoracic spine: IMPRESSION: Unremarkable pre-and postcontrast MRI of the thoracic spine.  Lumbar spine: IMPRESSION: Increased STIR signal and enhancement involving theposterior elements from L3 through L5 as well as the dorsalepidural space at this region. This could be related to inflammatory changes from recent lumbar puncture versus aninfectious process. No drainable fluid collections or masseffect in the spinal canal is present. Back

31. MRI head Next

32. MRI head Back

33. CT chest/abdomen/pelvis IMPRESSION: 1. Distal position of right PICC line as above. 2. Splenic and renal hypodensities are indeterminant given size. 3. Trace pelvic fluid. Gas within bladder may be secondary to Foley placement. 4. Mild splenomegaly. Back

34. Endocarditis • Infectious Endocarditis (IE): an infection of the heart’s endocardial surface • Classified into four groups: • Native Valve IE • Prosthetic Valve IE • Intravenous drug abuse (IVDA) IE • Nosocomial IE

35. Further Classification • Acute • Affects normal heart valves • Rapidly destructive • Metastatic foci • If not treated, usually fatal within 6 weeks • Organisms: • Staphylococcus aureus, • Streptococcus pyogenes, • Streptococcus pneumoniae • Subacute • Often affects damaged heart valves • Indolent nature • If not treated, usually fatal by one year • Organisms: • Streptococcus viridans • Enterococcus

36. Infective Endocarditis • Gram negative organisms • P. aeruginosa most common • HACEK - slow growing, fastidious organisms that may need 3 weeks to grow out of culture • Haemophilus sp. • Actinobacillus • Cardiobacterium • Eikenella • Kingella

37. Infective Endocarditis • Case rate may vary between 2-3 cases /100,000 to as high as 15-30/100,000 depending on incidence of i.v. drug abuse and age of the population • 55-75% of patients with native valve endocarditis (NVE) have underlying valve abnormalities • MVP • Rheumatic • Congenital • ASH or: • i.v. drug abuse

38. Infective Endocarditis • Adult population • Rheumatic Heart Disease • 20 – 25% of cases of IE in 1970’s & 80’s • 7 – 18% of cases in recent reported series • Mitral site more common in women • Aortic site more common in men • Congenital Heart Disease • 10 – 20% of cases in young adults • 8% of cases in older adults • PDA, VSD, bicuspid aortic valve (esp. in men>60)

39. Infective Endocarditis • Intravenous Drug Abuse • Risk is 2 – 5% per pt./year • Tendency to involve right-sided valves • Distribution in clinical series • 46 – 78% tricuspid • 24 – 32% mitral • 8 – 19% aortic • Underlying valve normal in 75 – 93% • S. aureus predominant organism (>50%, 60-70% of tricuspid cases)

40. Clinical Features I • Interval between index bacteremia & onset of sx’s usually < 2 weeks • May be substantially longer in early PVE • Fever most common sign • May be absent in elderly/debilitated pt. • Murmur present in 80 – 85% • Generally indication of underlying lesion • Frequently absent in tricuspid IE • Changing murmur

41. Clinical Features II • Acute • High grade fever and chills • SOB • Arthralgias/ myalgias • Abdominal pain • Pleuritic chest pain • Back pain • Subacute • Low grade fever • Anorexia • Weight loss • Fatigue • Arthralgias/ myalgias • Abdominal pain • N/V

42. Petechiae • Nonspecific • Often located on extremities • or mucous membranes

43. Janeway Lesions

44. Janeway Lesions • More specific • Erythematous, blanching macules • Nonpainful • Located on palms and soles

46. Splinter Hemorrhage

47. Splinter Hemorrhages • Nonspecific • Nonblanching • Linear reddish-brown lesions found under the nail bed • Usually do NOT extend the entire length of the nail

48. Osler’s Nodes • More specific • Painful and erythematous nodules • Located on pulp of fingers and toes • More common in subacute IE

50. Subconjunctival Hemorrhages