Questions & Answers
Source is in blue, just click on it to get to the original article.
Anticoagulation Cases Q & A
Combining IVC filter and Coumadin
75 yo AAF with a PMH of DVT and PE, was treated with Coumadin, and had a GI bleeding due to diverticulosis. After that, Coumadin was stopped and an IVC filter was placed one year ago. Now she is admitted with a new DVT. Should you restart oral anticoagulation?
Yes. After evaluating the bleeding risk for this particular patient, oral anticoagulation is likely to provide additional benefits to the IVC filter al. Two years after placement, IVC filters do not decrease the PE risk, and actually increase the risk for new DVT. Coumadin use is recommended in these patients with IVC filters, although there are no RCTs to support it. The level of evidence is experts' opinion.
Inferior vena caval filters - UpToDate (paid subscription required)
Venous Thromboembolism Therapy - Cleveland Clinic MedEd.com
Anticoagulation before and after an invasive procedure
48 yo CF, a smoker with recurrent DVTs is anticoagulated with heparin IV drip during hospital stay. She has a lung nodule on CXR and a bronchoscopy is recommended. How may hours before the procedure you should stop the heparin, and when should you restart it?
For surgeries, heparin should be stopped 6 hours before, and restarted 12 hours after the surgery (if there is no evidence for bleeding).
For procedures, this time can probably be shortened to stopping heparin 2-4 hrs before the procedure, and restarting it 2-6 hrs post procedure. For all patients, Coumadin can be restarted at the normal dose on the night of the procedure.
Management of anticoagulation before and after elective surgery - UpToDate
Colonoscopy - American Society of Colon and Rectal Surgeons
Anticoagulation after surgery
67 yo CM had a back surgery 4 days ago for spinal osteomyelitis. Today he is a diagnosed with LLE DVT. Can you anticoagualate him?
Most spine surgeons will feel very uncomfortable putting the patient on full-dose anticoagulation with Lovenox/Coumadin so soon after surgery. The solution is to call vascular medicine and interventional radiology and to arrange for a temporary IVC filter. Anticoagulation can be started 2 weeks later.
62 yo AAF with ESRD on HD has anemia of chronic disease with Hgb 8.2 and ferritin 650. She receives EPO during HD on M/W/F. Is she a candidate for iron replacement?
Yes. According to K/DOQI guidelines, iron should not be given to dialysis patients if ferritin is >800 ng/ml, because it may cause iron overload (hemochromatosis). However, an increased serum ferritin is not necessarily a sign of iron overload.
What about if the ferritin is 1000?
In the previously reported cases of haemochromatosis among dialysis patients, the ferritin levels were well above 2000 ng/ml, usually in the 3000–10 000 ng/ml range.
According to a recent study, K/DOQI guidelines may not be appropriate and may deprive these possibly inflamed but not iron-overloaded patients of required iron. The study authors suggest a new cut-off point (>2000) above which supplemental iron should not be given.
Source: Nephrol Dial Transplant. 2004, Semin Dial. 2004
What is the frequency of lung metastases in prostate cancer?
35% of patients with prostate cancer have metastases at autopsy; 46% of them to the lungs.
In order of frequency: bone (90%), lung (46%), liver (25%), pleura (21%), and adrenals (13%).
Source: Hum Pathol. 2000
50 yo AAF with PMH of breast CA is having bone pain. What is the best test to diagnose bone metastases?
The most commonly used test is bone scan, the best test is PET scan.
Bone scan - sensitivity 75-85%, specificity 95%
PET scan - sensitivity 91%, specificity 96%
X-rays - good for characterezing the lesions but not for initial diagnosis although very often this is the first test to be ordered.
CT scan - low sensitivity (similar to X-rays)
MRI - sensitivity 82-91%, specificity 62-92%
Compared with bone scan, MRI costs 2-3 times as much, and FDG PET, 8 times as much.
Comparison of whole-body FDG-PET to bone scan for detection of bone metastases - Lung Cancer. 2004 Jun;44(3):317-25
70 yo AAM with BPH has an acute urinary obstruction which is relieved with a Foley, and now he is having postobstructive polyuria. What is the mechanism behind the polyuria?
There are several mechanisms:
-PGE-mediated increase in medullary blood flow
-tubular damage with decreased Na+ reabsorption and impaired concentrating ability
-activation of natriuretic factors following ECF volume expansion
The resulting loss of fluid and electrolytes represents a major hazard.
56 yo CM with LDL 145 is asking if he needs drug therapy. He was recently admitted to the hospital with CP and the catheterization showed "trivial CAD". What do you think?
You need to calculate his risk for CAD, and then to base the decision whether to treat or not on the calclulated risk.
A great starting point is the Quick Desk Reference based on ATP III from the NIH.
Detection, Evaluation, and Treatment of High Blood Cholesterol in Adults (Adult Treatment Panel III - ATP) - NIH - includes online calculators and PDA downloads
Patient with ESRD on HD is having atypical CP. The troponin is 2. Did he have an MI?
We cannot be sure. You need a second troponin level in 6-8 hours.
Elevations in troponins are commonly observed in patients with CRI (or ESRD on HD) in the absence of acute myocardial ischemia.
Troponin T (TnT) is elevated in 68% of stable ESRD patients on routine HD. TnI and CK-MB levels are elevated in 3.5% and 9%, respectively, that is why TnT is much more specific for myocardial damage than TnI. Dialysis does not affect troponin levels.
If you want to rule out MI, the best approach is serial measurements of TnI. A sequential rise in TnI rules in MI in patients with CRI in the appropriate clinical settings. If TnI is elevated but does not change over time of the hospitalization, this is less consistent with a new MI.
Source: J Am Coll Cardiol, eMedicine, Clin Nephrol, UpToDate
77 yo AAF is admitted with suspected small bowel obstruction (SBO). Abdominal X-rays are inconclusive. She is NPO. Should we do a noncontrast CT scan of the abdomen?
Yes. The sensitivity of plain X-rays for SBO is only 45-70%. Avoid barium studies in patients with suspected perforations or complete SBO.
CT of the abdomen has a sensitivity and specificity of 90-100% in SBO. Intraluminal administration of contrast may not be necessary because the fluid and gas in the bowel provide sufficient contrast. National Guideline Clearinghouse rates the usefulness of imaging studies in acute abdomen on 1-9 scale (1 = least appropriate, 9= most appropriate). CT with oral and IV contrast rates 8 vs. CT without oral or IV contrast - 6.
Source: Guideline.gov, VH.org - Univ Iowa, Radiographics J, eMedicine, Postgrad Med,
Patient is having acute DVT. Heparin is started. Can I order protein C, S, and other tests to rule out hypercoagulability now?
No. It is never a good time to do hypercoagulability tetsts when the patient is in the hospital with acute DVT. Both protein S and protein C may be low in acute thrombosis and illness. AT-III can be low in acute thrombosis and rarely with heparin therapy. Heparin does not alter plasma protein C and S levels.
Normal protein C, S and AT-III levels drawn acute DVT rule this out deficiency as a cause of a hypercoagulable state. Protein C and protein S are vitamin K dependent proteins their levels will be reduced by warfarin therapy. The optimal time for performing these tests is 6 months after the DVT, when a decision should be made about continuing anticoagulant therapy.
Patiens has been on Coumadin for one year after 2 episodes of DVT. Can I check for protein S, C and other deficiencies now?
Yes, stop Coumadin for 2 weeks (cover the patient with Lovenox during this time), and then order the tests. Protein S is a vitamin K-dependent clotting factor and the diagnosis of its deficiency is difficult in anticoagulated patients. Protein C level is decreased 35 to 50% by Coumadin. Two methods are used to make the diagnosis of protein S deficiency in patients on Coumadin:
-compare levels with those of another vitamin K-dependent factor such as factor X
-use normal ranges for patients taking warfarin
The normal range for free protein S in stably anticoagulated patients is 0.27 to 0.79 (0.64-1.30 in patients not on Coumadin).
The approach is similar when assessing protein C. Some labs use protein C activity assays in conjunction with measurements of factor VII, a vitamin K-dependent factor with a similar plasma half-life to protein C.
Source: eMedicine, NEJM, Blood J 3/00
76 yo lady presents with a 5.5 cm asymptomatic AAA. Should I recommend surgery?
The answer is to consult a surgeon; she may need to have the AAA repaired.
AAA rupture has 80% mortality. Elective repair has an operative mortality of 4 to 6 percent.
Abdominal U/S has a sensitivity and a specificity of nearly 100 percent for AAA.
Elective surgical repair is indicated when an asymptomatic AAA is greater than 5.5 cm in diameter. The size for elective repair of thoracic aorta aneurysm is bigger, more than 6 cm.
The USPTF recommends U/S screening for male smokers older than 65 (less clear for women).
Source: Click here to see how the AAA looks on U/S, CT and aortogram (AFP 2002)
AFP 1, 2, NEJM, BMJ 1, 2, Oxford Bandolier
67 yo CF with end-stage pancreatic cancer feels depressed (depression at the end of life). What antidepressant should we choose?
Ritalin (methylphenidate). Stimulnats are used when a rapid response (within 24 to 48 hours) is desired. They are most effective in patients with psychomotor retardation. Stimulants should be avoided in agitated patients and in those who are confused or delirious. SSRIs and TCAs have a much slower onset of action (within 3-4 weeks).
Source: AFP, J Clin Onc, Ann Int Med
Can we use Lasix in rhabdomyolysis-induced acute renal failure? What about mannitol?
Diuretics (loop or others) should not be used because they do not improve, and may actually worsen, the final renal outcome. The use of mannitol remains controversial. It is mostly supported by animal studies.
Source: AFP 2002
Can hypocalcemia cause rhabdomyolysis?
Hypocalcemia is listed among the causes of rhabdomyolysis but in most cases, it is a consequence rather than the cause of rhabdomyolysis. Hypocalcemia occurs in rhabdomyolysis and is most likely related to calcium deposition in injured tissues. Elevation in 1,25(OH)2 D plays an important role in the hypercalcemia during the diuretic phase of patients with rhabdomyolysis-induced acute renal failure. The usual sequence is hypoCa++ --> hyperCa++.
Source: NEJM 1981, Journal of Clinical Endocrinology & Metabolism 1986
Can ischemia cause a long QT-interval?
Certainly, although more common causes are medications and electrolyte disturbances.
Source: ECG Library, Univ of Florida, FP Notebook, Ann Int Med 1995
How often do patients with seizures have urinary incontinence?
No specific number is reported but the literature reviews show that incontinence occurs commonly in seizures and is uncommon in syncope.
Is there a "30-seconds rule" in syncope and what does it mean?
Yes, there is. Syncope is loss of consciousness from temporary disruption of cerebral oxygenation. This is typically due to the interruption of blood flow to the brain, and the loss of consciousness usually lasts for less than 30 seconds.
Source: eMedicine 1, 2, NEJM
Do people with ICD feel the shock? Can they have a silent shock that is revealed only during the ICD interrogation?
When the ICD delivers pacing therapy, patients may not feel anything. Some people feel a fluttering in their chest. Cardioversion is stronger than a pacing pulse. It feels like being thumped in the chest. The defibrillator shock is the strongest treatment. Many people say it feels like being kicked in the chest. It usually comes suddenly and lasts only a second.
Source: Familydoctor - AAFP 2/00, Texas Heart Institute
Can we use prolactin level to diagnose a seizure?
Yes. Prolactin level, if done within 10-20 minutes of a seizure, is elevated 5-30 times above the baseline. It is a useful diagnostic tool to exclude pseudoseizures. A positive test result is highly predictive of a seizure, however a negative test result does not exclude a seizure. Prolactin should be measured in patients presenting to the ER within an hour of a syncope. Prolactin may also be elevated after pseudo-epileptic seizures.
Source: eMedicine, Emerg Med J 2004; 21:e3
What is the driving restriction for an epileptic patient in Ohio?
The physician decides if the patient can drive or not. He or she needs a reevaluation every year until seizure-free or off medication and seizure-free for 1 year, and the physician may be liable for the driving recommendation. Doctors are not required by law to report epilepsy.
Source: Neurology 2001;57:1780-1785, epilepsy.com
Can you give antibiotics to treat a UTI in a DNR-CC patient?
Yes, if the UTI is causing symptoms. The difference between DNR-CCA and DNR-CC is the goal. In DNR-CC the goal is to treat the disease symptoms, in DNR-CCA the goal is to cure the disease.
Comfort care definition:
(1) "Nutrition when administered to diminish the pain or discomfort of a principal, but not to postpone death; (2) Hydration when administered to diminish the pain or discomfort of a principal, but not to postpone death; or (3) Any other medical or nursing procedure, treatment, intervention, or other measure that is taken to diminish the pain or discomfort of a principal, but not to postpone death." Ohio Revised Code § 1337.11(C)
A publication of the Ohio Legal Rights Service (OLRS) - Ohio.gov
CCF Implementation of the New Ohio "DNR Comfort Care" Rules and Regulations - CCF
How sensitive is the physical exam for DVT? Is it like a toss-up, 50% only?
Sensitivity of the clinical examination for DVT ranges from 60% to 96%. Tenderness occurs in 75% of patients, edema in 97%.
Source: JAMA, eMedicine, Pubmed 1, 2, J Fam Practice
What is the CK level in PMR? What about fibromyalgia?
PMR: ESR greater than 50 mm/h, normal CK level
Fibromyalgia: mean ESR is 15 mm/h, normal CK level
Source: AFP, Merck, eMedicine - PMR, eMedicine - Fibromyalgia
Is jaundice one of the causes of sinus bradycardia?
No. Although jaundice is listed among the causes of sinus bradycardia in some sources this is not confirmed by studies. Jaundice is not among the causes of bradycardia in UpToDate or eMedicine.
What is a more comon cause of hemoptysis - TB or PE?
TB. DDx of Hemoptysis : CA (28%), chronic bronchitis (19.8%), bronchiectasis (14.5%), pneumonia or lung abscess (11.5%), idiopathic (8%), and TB and its sequelae (5.7%), cardiac diseases (1.5%) and PE (2.3%).
Source: Pubmed, Merck manual
How specific are night sweats for TB?
Difficult to evaluate. Night sweats are seen in 33% of adults and 13% of elderly with TB.
What is the mechanism of contraction alkalosis when diuretics are used?
Dehydration concentrates the body electrolytes. Contraction alkalosis occurs when there is loss of relatively large volumes of bicarbonate-free fluid. The plasma bicarbonate concentration rises in this setting because there is contraction of the extracellular volume around a relatively constant quantity of extracellular bicarbonate. Administration of a loop diuretic to induce rapid fluid removal in a markedly edematous patient is the most common cause of a contraction alkalosis.
Source: eMedicine, UpToDate, First described in 1965 in Ann of IM, click to see a diagram
Can PE present with asthma-like diffuse wheezing? Is it true that PE causes only localized wheezing?
"All that wheezes is not asthma" (Chevallier Jackson) and also PE is known as "the great masquerader". PE may appear as asthma when diffuse wheezing results from the release of vasoactive and bronchoactive mediators. Just 10-20% of PE patients present with wheezing.
Source: eMedicine, Pubmed 1, 2, 3, 4, 5
How to recognize MI if the patient is having an old LBBB?
The answer is in the Feb 1996 edition of NEJM. The 3 EKG criteria for diagnosing AMI in patients with LBBB are ST-segment elevation of >= 1 mm concordant with (in the same direction as) the QRS complex; ST-segment depression >= 1 mm in lead V1, V2, or V3; and ST-segment elevation >= 5 mm discordant with (in the opposite direction from) the QRS complex. A scoring system (0 to 5) was developed, which allowed a highly specific diagnosis of AMI to be made.
Source: NEJM, see the flowchart, editorial
Patient is having a new-onset AFib. Can we start Coumadin at the same time as Heparin?
Yes. Warfarin-induced skin necrosis is an uncommon complication - it occurs in only 0.01-0.1% of patients (85% of reported patients are females). Full heparinization should be achieved before starting warfarin.
Source: eMedicine, Medscape, AFP, CCF
Should we start Coumadin at a dose of 5 or 10 mg?
Either can be used. Some authors recommend starting at 5 mg because of a slightly increased risk of skin necrosis if the first Coumadin dose is >= 10 mg.
Source: CCF, Annals, NEJM
65 yo male with DVT is started on Lovenox. Two days later he is having several bloody BM. VS and H/H are stable. Colonoscopy done 2 weeks ago showed diverticulosis. What to do?
Give protamine. No agent, including FFP and vit. K, is effective for complete reversal of supratherapeutic anticoagulation with LMWH. Reversal of LMWH with protamine sulfate may be incomplete, with neutralization of 60 to 75% at most.
67 yo male with new onset AFib needs anticoagulation. Can we use Lovenox?
Probably yes. Lovenox is not FDA approved yet for anticoagulation in AFib. Lovenox may be approved in the future though because a recent study (2004) showed that Lovenox was noninferior to UFH + phenprocoumon for prevention of ischemic and embolic events in TEE-guided cardioversion of atrial fibrillation.
How effective is chemical cardioversion in AFib?
What is the risk of stroke in AFib? How much does Coumadin cut the risk?
5-8% without anticoagulation. Coumadin decreases the stroke risk to 1.7%.
(Rate of stroke per year in %)
How often is Hep. C acute?
Infection due to HCV accounts for 20% of all cases of acute hepatitis. Acute infection is usually asymptomatic, 20% of patients develop jaundice, 75% of those infected develop chronic disease with chronically elevated ALT, and 20% of patients eventually develop cirrhosis.
Source: eMedicine, FPH
How to diagnose acute Hep. C infection?
RNA-HCV will be positive after 1-2 weeks of the initial contact with HCV. Antibodies against HCV are detected later (after 7-8 weeks on average), and are not useful in distinguishing acute infection from chronic infection.
Can HIV cause hepatitis?
Yes. Elevated LFT have been reported in 21 % of patients with symptomatic primary HIV, and an acute-hepatitis–like picture has been described.
What is the sensitivity and specificity of lipase in acute pancreatitis (AP)?
When the cutt-off levels of amylase were set at the upper normal level or up to 5-fold as high, the sensitivity decreased from 92% to 74%, the specificity increased from 85% to 99%. Lipase sensitivity is similar but the specificity is lower. Although once considered to be specific for AP, nonspecific elevations of lipase have been reported in almost as many disorders as amylase, thus decreasing its specificity. Simultaneous estimation of amylase and lipase does not improve the accuracy.
Approach to elevated amylase -UpToDate
Source: Pubmed 1, 2, AFP
62 yo lady with metastatic pancreatic adenoCA is having recurrent DVT despite being on Coumadin and INR 2.9. What to do?
LMWH (not Coumadin) is the treatment of choice. In Trousseau's syndrome, a condition in which recurrent, migratory thromboembolism is found in patients with adenoCAt was found that 19% of patients benefited from warfarin while 65% benefited from heparin. CA patients treated with warfarin for their first venous thromboembolism had a recurrence rate of 22% within 3 months in contrast to those treated with heparin (standard or LMWH) who had a recurrence rate of 7%.
Source: The Oncologist, Cancer 1997
62 yo lady smoker with COPD is c/o increased cough and SOB. On physical exam there is decreased air entry (B) but no wheezing. Is it COPD exacerbation?
Yes. You don't need to have wheezing to define COPD exacerbation.
Definition of COPD exacerbation:
One or more of the following: increase in sputum purulence, increase in sputum volume, and worsening of dyspnea.
Type I (severe) has all 3 symptoms, type II (moderate) has 2, and type III (mild) has 1 symptom plus at least 1 of the following: URTI, fever, increased wheezing, increased cough, or increase in RR or HR by 20% above baseline.
Source: Chest 1, 2; NEJM; PMJ
What is the sensitivity of elevated LDH in PCP?
Sensitivity and specificity are 0.94 and 0.78 at a cutoff point of LDH greater than 220 IU/L.
Source: Pubmed, eMedicine
Can hypernatremia cause central pontine myelinolysis?
Yes. Although central pontine myelinolysis is observed more commonly with rapid correction of hyponatremia (low Na) it can also occur with the correction of the hypernatremia (high Na).
Source: Pubmed, eMedicine
We know that ASA and beta-blockers are good for AMI but how good are they? What is the absolute risk reduction (ARR)?
ASA: ARR 2.4%, NNT 42 for vascular death; ARR 1.2%, NNT 84 for non-fatal reinfarction.
Beta-blockers: ARR 0.4%
Source: Clinical Evidence-BMJ
Should we use ASA for primary prevention?
ASA role in primary prevention is uncertain.
Source: Clinical Evidence-BMJ (create your password starting from our front page link)
Should we use Plavix for stroke prevention (secondary prevention)?
No. ASA is good enough. There is no good evidence that Plavix is superior to ASA for secondary prevention of stroke. There is no significant difference between Plavix and aspirin - ARR 1.1% for both.
Source: Clinical Evidence-BMJ
What are the guidelines for using ASA and Plavix for primary and secondary prevention of CAD and stroke?
According to the Clinical Evidence:
Primary prevention: no data, trials are underway.
Secondary prevention of CAD: either ASA or Plavix (CAPRIE trial, which showed that Plavix was slightly better, barely reached significance with P 0.043). The situation is different when patients need PCI, then Plavix + ASA combination is indicated (PCI-CURE trial).
Secondary prevention of stroke: ASA or Plavix.
According to one of our neurologists, Dr. Hachwi, the choice is as follows:
Primary prevention - no data, trials are underway.
Secondary prevention of CAD: ASA + Plavix (CURE trial).
Secondary prevention of stroke: Plavix alone, if patient cannot afford it for financial reasons, then ASA alone. The combo ASA + Plavix increases the bleeding risk and this offsets any benefits.
Source: AFP 3/03, the Clinical evidence 1, 2, 3, CAPRIE trial in Lancet 1996, GP Notebook
Clinical Evidence-BMJ (create your password starting from our front page link)
Should we use dobutamine for decompensated end-stage CHF?
No. Positive inotropes (other than digoxin) are likely to be ineffective or harmful. One non-systematic review (6 RCTs, 8006 people) of RCTs found that non-digitalis inotropes increased mortality compared with placebo.
Source: Clinical Evidence-BMJ
Patient had a left carotid endarterectomy (CEA) 5 years ago. Do I need to monitor for restenosis by carotid Duplex?
No. The incidence of recurrent stenosis 70% or greater is 0.5% during a 6-year follow-up after a CEA. On the other hand there is often a progression in the stenosis of the contralateral artery which did not have a CEA. Bottom line: there is no established policy for post-CEA monitoring.
Remember that the carotid angioplasty and stenting (CAS) and CEA may be equally effective and safe.
39 yo lady smoker is having bilateral toe pain and weak pulses. Can it be Buerger's disease?
Yes. Though Buerger disease is more common in males (male-to-female ratio, 3:1), incidence is believed to be increasing among women, and this trend is postulated to be due to the increased prevalence of smoking among women. Most patients with Buerger disease are aged 20-45 years.
Does Raynaud's disease affect lower extremities?
Yes. In one study of of 474 females with primary Raynaud's Syndrome, 54·6% exhibited attacks in the fingers only, 42·7% in the fingers and toes, and less than 1% in the toes only.
Source: eMedicine, Podiatry college
How sensitive is elevated ESR in connective tissue diseases?
An elevated ESR value has a sensitivity of approximately 80 percent for polymyalgia rheumatica and greater than 95 percent for temporal arteritis. But normal ESR values do not rule out these conditions.
The sensitivity of an elevated ESR value is approximately 50 percent in patients with signs of rheumatoid arthritis. However, the specificity of an elevated ESR is quite low, limiting its use as a diagnostic test.
An extremely elevated ESR (>100 mm/hr) will usually have an apparent cause--most commonly infection, malignancy or temporal arteritis.
Source: AFP 1999, AFP 2002, FP Handbook
Patient is having a sickle cell trait (not the disease). Is it possible that she may have veno-occlusive crises?
Yes, although this is very rare. Patients with sickle trait have RBCs that contain only 30-40% HbS and have a benign clinical course. Sickling does not occur under physiologic conditions. Rarely, patients may experience hypoxia or shock when flying at high altitudes in an unpressurized aircraft, causing vaso-occlusive phenomena. Spontaneous hematuria, usually from the left kidney, also can occur. Dehydration may precipitate a crisis in people with sickle cell trait.
Source: eMedicine 1, 2
What is the iron profile of a person with sickle cell disease?
Iron profile typically shows iron overload. It is recommended to check ferritin or serum iron and TIBC at least once per year.
65 yo male with DM2 wants a prescription for Viagra. Does he need a stress test?
Yes. Pre-Viagra treadmill tests to assess for stress-induced ischemia in patients with overt and covert CAD can guide the physician relative to the risk of cardiac ischemia during sexual intercourse. If the patient can achieve 5 to 6 METS on an ETT without demonstrating ischemia, the risk of ischemia during coitus is probably low and Viagra can be prescribed. In one study none of the men with a negative stress test had an MI during intercourse.
Source: ACC/AHA Expert Consensus Document - 1999
Erectile Dysfunction - NEJM 2000, Sexual Activity in Patients With Angina - JAMA 2003
What is the incidence of primary sclerosing cholangititis (PSC)?
Incidence in men is 1.25 per 100,000 person-years compared with 0.54 per 100,000 person-years in women. Prevalence of PSC is 20.9 per 100,000 men and only 6.3 per 100,000 women (95% CI, 0.1 to 12.5). Seventy-three percent of cases have IBD, the majority with UC.
How often do we see pyoderma gangrenosum (PG) in IBD?
0.6% incidence. PG appeared 6.5 years on average after diagnosis of IBD in all patients. PG is a rare extra-intestinal manifestation of IBD that coincides with the exacerbation of the IBD but does not always respond to treatment of the bowel disease.
Erythema nodosum is seen in up to 3% of patients.
Additional info: PowerPoint file on PG
Can the primary chancre in syphilis be painful?
Yes. In fact oral primary syphilis lesions are often painful. Genital primary chancre is classically not painful unless there is a superimposed bacterial infection but a reported literature review of 23 textbooks challenged this statement.
Bottom line: Don't rule out syphilis if a genital ulcer is painful.
Source: Pubmed, AFP, eMedicine, BDJ
Can the lesions of primary and secondary syphilis occur at the same time?
Yes, although typically the rash of secondary syphilis develops 4-8 weeks after the chancre heals. 30% of patients with secondary syphilis have evidence of a healed chancre.
Source: FP Handbook, Cecil Textbook of Medicine
Can TB cause a scrotal ulcer?
Yes, although this is rare and it is a consequence of chronic epididymitis or epididymoorchitis.
What is the Incidence of Seizures after Head Trauma?
It depends on the severity of the injury.
The risk of posttraumatic seizures after severe injury is 7.1% within 1 year and 11.5% in 5 years, after moderate injury the risk is 0.7 and 1.6%, and after mild injury the risk is 0.1 and 0.6%. The incidence of seizures after mild head injuries is not significantly greater than in the general population.
Source: Neurology, Vol 30, Issue 7 683-689
Does eating peanuts increase cholesterol?
No. Actually peanuts are good for you. Eating peanuts decreases LDL by 14%. In general nuts consumption leads to 30-40% reduction in CAD risk. Don't go nuts for nuts though - there is a catch. Nuts are high in fat. In order to avoid gaining weight you should decrease the intake of other fats if you planning to increase your nuts consumption. In this case peanuts decrease even DM risk.
Source: Curr Atheroscler, Am J Clin Nutr, JAMA
Shrimp is high in cholesterol. Does eating shrimp increase serum LDL levels?
Yes, LDL is increased by 7% but at the same HDL is increased by 12% and TG are decreased. Study conclusion was that shrimp may be included in the "heart healthy" diet.
Source: Medline 1, 2
Does Troponin Increase in PE? How high can it go?
Yes. In a small case series, troponin concentrations were raised in patients with massive PE because of the dilatation of RV. The range in this case series was about 0.01-0.18 but in another study they mentioned levels as high as 2.5.
What is the definition of heavy alcohol use? What is a "drink"?
NIAAA definition for "heavy" alcohol use is
Men: Over 5-6 drinks per day
Women: Over 3-4 drinks per day
A drink is 12 grams of alcohol, e.g.
Can of 4.5% Beer (12 oz)
Glass of 12.9% Wine (5 oz)
Glass of 40% or 80-proof Liquor (1.5 oz)
Source: Family practice notebook
What is the risk of alcoholics to develop liver damage?
10-15 % of heavy alcoholics will develop liver damage
How does Gout present?
90 percent of first attacks are monoarticular. In more than 50% the first MTP joint is the initial joint involved, a condition known as podagra. Joint involvement (in decreasing frequency) includes the MTP, the instep/forefoot, the ankle, the knee, the wrist and the fingers. In chronic gout polyarticular involvement becomes more common over time and can often mimic other forms of arthritis.
What is the most common age for migrane headache onset?
The first attack often is in childhood, and incidence increases in adolescence. More than 80% of patients who develop migraines will have a first attack by age 30. They may begin or occur at any age but are less likely to begin after age 50.
What are the causes of aseptic meningitis?
1-Viruses - most common - Enteroviruses 50-80% , Arboviruses , HIV, HSV, Lymphocytic choriomeningitis virus, Mumps
2-Mycobacteria, 3-Listeria, 4-Syphilis, 5-Leptospira, 6-Toxoplasma, 7-Fungi - Cryptococcus, 8-Meningeal carcinomatosis, 9-Meningeal reaction to nearby inflammation, destructive process or medications
Source: Univ of North Carolina
Is liver failure one of the causes of high AG metabolic acidosis?
No. Liver failure can cause nonanion gap metabolic acidosis because of the failure to execrate ammonium. Just remember the mnemonic MUD PILES for causes of high AG metabolic acidosis.
Source: Harrison's, Family Practice Notebook
What is the earliest time to see an ischemic stroke on CT brain?
12-18 h. The sensitivity of the brain CT scan in the first 24h for brain infarction is 58% only.
Patient with cirrhosis is having fever. Can I use Tylenol ?
Yes. In patients with chronic liver disease who have pain, acetaminophen can be used safely in a dosage of no more than 2 g per day. NSAIDs can cause idiosyncratic liver toxicity. Fatalities associated with NSAID use have been reported. Because of the unpredictable hepatotoxicity of NSAIDs, patients who have chronic liver disease should not use these medications.
Are the neurofibrillary tangles and plaques specific for Alzheimer's dementia?
No. it can can happen in various other clinical diseases.
Is the multi infarct dementia region specific?
No. Any region infarction can be a high risk for dementia. However one study mentioned increased risk in lacunar infarcts and with hippocampal involvement (the memory area).
Source: Harrison's Textbook
Is Digoxin indicated in Cor Pulmonale?
No, except in cases of coexisting left sided CHF
What are the EKG changes in Cor Pulmonale?
Right axis deviation, Increased P wave amplitude in lead II, Incomplete or complete RBBB
What is the evidence behind the use of surgery in COPD?
Not very good.
There was a RCT Comparing Lung-VolumeReduction Surgery with Medical Therapy for Severe Emphysema published in NEJM in 5/2003.
Lung-volumereduction surgery increases the chance of improved exercise capacity but does not confer a survival advantage over medical therapy. It does yield a survival advantage for patients with both predominantly upper-lobe emphysema and low base-line exercise capacity. Patients previously reported to be at high risk and those with nonupper-lobe emphysema and high base-line exercise capacity are poor candidates for lung-volumereduction surgery, because of increased mortality and negligible functional gain.
What is the incidence of asthma in the elderly?
What are the causes of hypoglycemia in nondiabetic patients?
The causes of hypoglycemia in nondiabetic patients can be divided into 2 categories:
1. Reactive hypoglycemia which happens after meals and is most commonly seen:
-after gastric surgery
-rare enzyme deficiency disorders like fructose intolerance
2. Fasting hypoglycemia which can be caused by:
-Medications: oral hypoglycemics, aspirin, Quinine, sulfa and pentamidine
-Critical illnesses like sepsis with multiple organ failure, cirrhosis or kidney failure
-Hormonal deficiency: low glucagone, low cortisole, low GH, Low epinephrine or hypopituitarism
-Tumors like insulinoma
How do we grade pitting edema? What is 2+ or 3+ ?
• 1+ - mild pitting, slight indentation
• 2+ - moderate pitting edema, indentation subsides rapidly
• 3+ - deep pitting - indentation remains for a short time, leg looks swollen
• 4+ - deep pitting, leg is very swollen
Source: college website but I think I've seen it in Bates' physical exam book.
Medscape is a better source:
Pitting" is the term used to describe the indentation caused when pressure is applied to the skin, forcing fluids into the underlying tissue. It occurs when there is an increased amount of low protein fluid in the interstitial space and is associated with disorders caused by high capillary filtration (DVT, chronic venous insufficiency, or venous obstruction) or hypoalbuminemia. Pitting is a subjective assessment using the grading scale of 1+ for mild and up to 4+ for deep pitting. Given the subjective nature of this assessment, continuity of provider is ideal when making successive assessments.
Yale SH, Mazza JJ. Approach to diagnosing lower extremity edema. Compr Ther, 2001, 27;242-252
Patient is having CRI, should I start ACEi ? What if Cr is 3? What if Cr increases from 2 to 4 with ACEi?
In patients with renal insufficiency, no creatinine level is an absolute contraindication to ACE inhibitor therapy. ACE inhibitors are not nephrotoxic. Baseline serum creatinine levels of up to 3.0 mg per dL (27 µmol per L) are generally considered safe. The manufacturers make recommendations for initiating treatment and suggest titrating the dosage slowly. An increase of 20 percent in the serum creatinine level is not uncommon and is not a cause for discontinuing the medication. For any higher increase, the family physician should consider a nephrologist. During the first four weeks of treatment, serum potassium and creatinine levels should be monitored closely.
AFP, CCF 1, 2
Is the CRI anemia a part of the anemia of chronic disease?
(CRI - Chronic Renal Insufficiency)
Anemia of chronic disease is associated with a wide variety of chronic disorders, including inflammatory conditions, infections, neoplasms and various systemic diseases. The diagnosis of anemia of chronic disease is NOT USUALLY applied to the anemias associated with renal, hepatic or endocrine disorders.
What is the MCV in CRI anemia? Normal or Low?
The anemia is usually normocytic but may be microcytic.
How accurate is the cocaine urine test?
Over 95% accurate
How long does cocaine and other drugs stay in the urine?
Cannabinoids (THC,Marijuana) 20-90 days
Cocaine (Crack) 3-5 days
Phencyclidine (PCP, Angel Dust) 1-30 days, Single (Use : 1-7 days, Regular Use : up to 30 days)
Opiates (heroin, Vicode, morphine, codeine) 2-7 days
When to D/C a patient with rhabdomyolysis? Is there a specific CK level which is safe for D/C?
Rhabdomyolysis is defined by a serum CK level of more than 1,000 U/L (more than fivefold that of normal).
High rates of IV fluid administration should be used at least until the CK level decreases to or below 1,000.
In a 1988 review, Ward suggested that predictors for the development of renal failure include peak CK more than 6000 IU/L, dehydration (hematocrit >50, serum sodium >150 mEq/L, orthostasis, pulmonary wedge pressure <5). href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=8198305">exercise-induced rhabdomyolysis without nephrotoxic cofactors than in other forms of rhabdomyolysis.
When to use bicarbonate in rhabdomyolysis?
Urinary alkalinization is recommended for patients with rhabdomyolysis and CK levels in excess of 1000 IU/L. The objectives are to alkalinize urine to a pH of greater than 6.5 (thereby decreasing the toxicity of myoglobin to the tubules) and to enhance the flushing of myoglobin casts from renal tubules by means of osmotic diuresis. However, these measures should not be employed if oliguria is established despite initial generous hydration with normal saline. Conclusion - NS first, then bicarb. No bicarb. if oliguric.
Once the blood pressure is stable and urine output is adequate, the hydration fluid can be switched to a solution such as one-half isotonic saline to which sodium bicarbonate has been added. The goal of bicarbonate therapy is to alkalinize the urine, while minimizing any alkalinization of the plasma, which can promote calcium phosphate deposition and worsen or induce the manifestations of hypocalcemia. Thus, monitoring the urine pH, which should rise above 6.5 for renal protection, is essential. This goal may not be achievable in patients who already have developed renal injury. Thus, bicarbonate administration should be stopped if the plasma bicarbonate concentration becomes elevated in the absence of an alkaline diuresis. UpToDate
Abnormal CK levels are common among critically injured patients, and a CK level greater than 5,000 U/L is associated with RF. BIC/MAN does not prevent RF, dialysis, or mortality in patients with creatine kinase levels greater than 5,000 U/L.
How often do we see rhabdomyolysis in cocaine users?
24% of the cocaine users have rhabdomyolysis The patients' mean creatine kinase level was 12,187 U per liter (range, 1756 to 85,000). Thirteen of the 39 patients (33 percent) had acute renal failure; 6 of them died.
Is AVN (avascular necrosis) more common in young adults or in the elderly?
AVN is more common in adults 30-60 yo rather than in the elderly. Source: eMedicine, Dr.Erfan
I hear a carotid bruit - how significant is that?
Sensitivity and sensitivity of a carotid bruit for significant carotid stenosis (>70%) are in the 60s percentage wise.
Source: Best Practice of Medicine - Merck
Patient is having rhabdomyolysis, CK is 8,000 but the tropoinin I is 2.5. Is she having a heart attack? There are nonspecific changes on EKG and she is SOB.
There is no hard and fast answer. Troponin can be elevated in rhabdomyolysis. But this usualy happens when CK is more than 30,000 and high troponin was defined as more than 0.6 only. The patient in question should be treated as an AMI until ruled out for sure.
Source: Int J Cardiol
What is the dose of steroids in septic shock?
Hydrocortisone (a 50-mg intravenous bolus four times per day) and Fludrocortisone (50 mcg PO per day) for seven days.
Patient ingested unknown amount of Tylenol 3 hours ago. Tylenol level is 148. Should we start N-ACC?
Probably yes. Check the level 4 hours after the ingestion. If more than 150 the liver toxicity is likely and you should treat.
Source: Iowa University - VH, NEJM
Patient is on vent with AC. He is breating at 20/min and the vent rate is 14/min. Is the vent going to give him any breaths?
Sure. The vent with the AC setting will give him 14 breaths no matter what. In addition all his
spontaneous breaths will be "pumped in" with the preset vent volume. That's why you can probably try CPAP for some patients with an intact respiratory drive. Just don't forget the apnea backup.
Patient got Coumadin 7.5 mg yesterday and today's INR is 6.7. There is no bleeding. Should I give her Vit.K?
There are 2 approaches. First is simple - just hold Coumadin for a day or two and check INR in AM. Second - give a small dose of Vit.K like 0.5 mg PO x 1 in addition to holding Coumadin.Don't give Vit.K SQ or IV unless there is bleeding or INR >10.
Source: AFP, there is a nice flowchart.
Patient's IBW (ideal body weight) is 78 kg but his actual weight is just 52 kg. Which one should I take into account when I calculate his TV on the vent?
That's a difficult one. I think you pick a number somewhere in the middle between the IBW and the actual body weight (if the weight is below IBW) and you use it for the calculations - mainly TV (6-8 cc/kg).
Patient's body weight is 70 kg. How to estimate his required minute ventilation (MV) so that I can adjust TV and RR setting on the vent?
MV = 130 cc x Weight in kg (IBW)
You already know that his TV should be 6-8 cc/kg, don't you? Now that you know his MV you can calculate his vent. RR.
9100 (MV) / 490 (TV) = 18 (RR)
His vent. RR should be set at 18 / min. And of course you are going to check ABG.
What is the ratio suggestive of ARDS? What about ALI?
The ratio is PaO2 / FiO2. If the PaO2/FIO2 is less than 200 this is suggestive of ARDS, less 300 - of ALI.
Source: Critical Care Tutorials
Patient is having a Non-ST elevation AMI confirmed with positive troponins. Should she go to the cath. lab?
Yes. Contrary to the old belief that Non-ST AMI patients don't need cath. right away, the new studies show that PTCA reduces mortality as compared to the conservative strategy.
TACTICS-2001: In patients with unstable angina and myocardial infarction without ST-segment elevation who were treated with the glycoprotein IIb/IIIa inhibitor tirofiban, the use of an early invasive strategy significantly reduced the incidence of major cardiac events. These data support a policy involving broader use of the early inhibition of glycoprotein IIb/IIIa in combination with an early invasive strategy in such patients.
Yet according to the ultimate resource the Clinical Eidence the routine early invasive treatment has uknown effectiveness with contradictory trials (you need to register to view)
I think your best bet to solve the issue is to review the official guideline algorithm on Guideline.gov which recommeds urgent cath. when the patient is:
-Has ongoing chest pain
Recent trials (collectively FRISC II and TACTICS-TIMI) suggest an early aggressive/invasive approach (early diagnostic coronary angiography and appropriate PCI or CABG) within 48 hours of presentation, in non-STE ACS (with ST segment deviation, elevated cardiac markers or TIMI Risk Score greater than 3), significantly reduces the risk of major cardiac events.
Patient is having an asymptomatic thoracic aneurysm on CXR. CT chest confirms a size of 4.8 cm. Should he have a surgical repair?
No, thoracic aneurysms generally should be resected if >= 6 cm.
What about AAA? When should they be resected?
The natural history of AAAs is closely related to size. Rupture is uncommon if aneurysms are <> 6 cm. Thus, elective surgical repair is usually recommended for all aneurysms > 6 cm unless surgery is contraindicated. In patients who are good surgical risks, elective repair is generally recommended for aneurysms between 5 and 6 cm (mortality 2 to 5%).
Patient had an ischemic stroke and she is having a new onset Afib. She is already taking ASA and we started Coumadin. Does she really need both?
No, Coumadin alone is good enough. Actually for patients with Afib Coumadin is preferred over ASA for stroke prevention. There is no benefit form double treatment with ASA + Coumadin.
Source: AFP, Clinical Evidence (you need to register, it's free)
I have another patient with Afib with unknown duration. We started Heparin and did a TEE. There was no thrombus and he was converted to NSR.
Does he really need Coumadin?
Yes, he does. Coumadin for 3 weeks if NSR.
TEE has been used to exclude LA/LAA thrombus before elective cardioversion. In a multicenter observational study, however, 17 cases of thromboembolism in AF patients were reported after conversion to sinus rhythm even after TEE showed no LA/LAA thrombus.