The Interstitial Lung Diseases (ILDs) confuse the heck of me. There's a billion different types of ILD and it just becomes a cryptococcal-silcosis-COP/BOOP mix of gobbledy-gook.
We had a patient who presented with 2 weeks of dyspnea and was found to have ground glass opacities on CT with interseptal thickening. We called a pulm consult, and the fellow was kind enough to give a simplified breakdown of the chronic ILDs.
2 main types of chronic ILD:
1) UIP (Usual interstitial pneumonitis) - the BAD one
- more scarring seen on chest CT
- not steroid responsive
- usually fatal within 2 years unless lung transplant
2) NSIP/COP (Nonspecific interstitial pneumonia/crytogenic organizing pneumonia)
- more ground glass opacities seen on chest CT
- steroid responsive
- better outcome
Distinguishing the two requires a VATS for tissue biopsy. Alteratively, start a trial of prednisone (1 mg/kg) for 4 weeks, with a max of 60 mg/day, tapered to 40 mg per day for the next 2 weeks. Don't forget about PCP prophylaxis, with 1 DS Bactrim MWF.
Saturday, June 25, 2011
Differential diagnosis of elevated LFTs
I'm sorry to go all medicalese but this blog in part serves as a repository for stuff I learn in the hospital. I'm on my medicine subI this month (hooray and oh my gosh I'm already a fourth year?!), and we got a fine chalk talk by a liver fellow about how to think about elevated liver function tests (LFTs).
The case is as follows: A 30M, previously healthy, arrives at the hospital with these abnormal findings on LFTs: ALT 1500, AST 750, AP 120, and TB 30. What pattern of liver disease does he have and what's the differential and workup?
The LFT panel consists of the ALT, AST, Alk phos, and total bili.
Surprisingly, this patient does NOT have a mixed pattern, for the definition of cholestatic disease is an elevated AP (ULM is ~100, but with ALTs and ASTs that high, 120 isn't considered cholestatic).
Here's the way to categorize:
The patterns of liver disease are:
1. Hepatocellular (> 5)
2. Cholestatic (< 2) 3. Mixed (2-5) Calculate this ratio: (# x ALT > ULN)/(# x AP > ULN)
*ULN = upper limit of normal
If it's > 5 then, it's hepatocellular, if < 2, then cholestatic, and mixed is somewhere in between. Kind of a simplified rule of thumb. Of course, there are measures of liver FUNCTION, namely: 1) INR: an indirect measure of the vitamin K dependent clotting factors (II, VII, IX, X, Protein C, S) in the extrinsic pathway 2) Albumin 3) Platelets: liver produces thrombopoeitin which stimulates platelet production in the bone marrow The differential diagnosis for ALT > 1000 is actually quite limited:
1) Toxins: Tylenol, Tylenol, Tylenol. If you suspect this, order a 5 panel tox screen and give N-acetylcysteine right away
2) Ischemia
- shock liver
- portal vein thrombosis
- hepatic artery thrombosis
Get a lactate, a ultrasound WITH doppler and/or a CTA/V
3) Viral
- HepA (test the IgM for acute infection)
- HepB (core IgM for acute infection)
- HebC (Ab or RNA)
- HepD and E
- EBV
- CMV
- HSV
4) Autoimmune
- test anti-smooth muscle Ab
- we'll often get an ANA and see elevated IgG from increased circulating immunoglobulins
5) Other (i.e Metabolic)
- Reye's syndrome, which is why you shouldn't give aspirin to kids!
- Acute fatty liver disease
- Wilson's acute crisis
Make sure you ask about a history of drugs, including IV drug use, tattoos, sexual history, travel, and history of autoimmune diseases.
Call the liver team when you suspect fulminant hepatic failure, as may be evidenced by encephalopathy. Test for asterixis and use tests of concentration. The "A cross-out test" is supposed to be a great way to track progress in encephalopathy. It's basically having the patient cross out every "A" she sees on a page with a few sentences of text. We actually used in a woman with alcoholic hepatic encephalopathy: on day 1, she missed nearly every 5th A. After several days of treatment, she got most of them. If the patient is encephalopathic, do NOT give agents that will alter mental status - benzos, opiates, Benadryl, NSAIDS - the drugs will muddy the etiology of the encephalopathy.
The case is as follows: A 30M, previously healthy, arrives at the hospital with these abnormal findings on LFTs: ALT 1500, AST 750, AP 120, and TB 30. What pattern of liver disease does he have and what's the differential and workup?
The LFT panel consists of the ALT, AST, Alk phos, and total bili.
Surprisingly, this patient does NOT have a mixed pattern, for the definition of cholestatic disease is an elevated AP (ULM is ~100, but with ALTs and ASTs that high, 120 isn't considered cholestatic).
Here's the way to categorize:
The patterns of liver disease are:
1. Hepatocellular (> 5)
2. Cholestatic (< 2) 3. Mixed (2-5) Calculate this ratio: (# x ALT > ULN)/(# x AP > ULN)
*ULN = upper limit of normal
If it's > 5 then, it's hepatocellular, if < 2, then cholestatic, and mixed is somewhere in between. Kind of a simplified rule of thumb. Of course, there are measures of liver FUNCTION, namely: 1) INR: an indirect measure of the vitamin K dependent clotting factors (II, VII, IX, X, Protein C, S) in the extrinsic pathway 2) Albumin 3) Platelets: liver produces thrombopoeitin which stimulates platelet production in the bone marrow The differential diagnosis for ALT > 1000 is actually quite limited:
1) Toxins: Tylenol, Tylenol, Tylenol. If you suspect this, order a 5 panel tox screen and give N-acetylcysteine right away
2) Ischemia
- shock liver
- portal vein thrombosis
- hepatic artery thrombosis
Get a lactate, a ultrasound WITH doppler and/or a CTA/V
3) Viral
- HepA (test the IgM for acute infection)
- HepB (core IgM for acute infection)
- HebC (Ab or RNA)
- HepD and E
- EBV
- CMV
- HSV
4) Autoimmune
- test anti-smooth muscle Ab
- we'll often get an ANA and see elevated IgG from increased circulating immunoglobulins
5) Other (i.e Metabolic)
- Reye's syndrome, which is why you shouldn't give aspirin to kids!
- Acute fatty liver disease
- Wilson's acute crisis
Make sure you ask about a history of drugs, including IV drug use, tattoos, sexual history, travel, and history of autoimmune diseases.
Call the liver team when you suspect fulminant hepatic failure, as may be evidenced by encephalopathy. Test for asterixis and use tests of concentration. The "A cross-out test" is supposed to be a great way to track progress in encephalopathy. It's basically having the patient cross out every "A" she sees on a page with a few sentences of text. We actually used in a woman with alcoholic hepatic encephalopathy: on day 1, she missed nearly every 5th A. After several days of treatment, she got most of them. If the patient is encephalopathic, do NOT give agents that will alter mental status - benzos, opiates, Benadryl, NSAIDS - the drugs will muddy the etiology of the encephalopathy.
Thursday, June 23, 2011
Heard in the hospital today
I'm getting the hell outta here!! 91 yo little old lady on stretcher to rehab.
Wednesday, June 22, 2011
Medication Noncompliance
We have a patient who had severe, New York Heart Classification III heart failure. He didn't take his medications. Not because he couldn't figure them out or couldn't afford them, but because he didn't think they would help. He was an educated guy, didn't think these Western medications would help. Instead, he went on a purification diet, felt better, and relapsed on his diet/alcohol and of course, went into florid decompensated heart failure. Over the course of his hospitalization, we tried to negotiate - his cardiology, our attending, our social worker, chaplain, family members, and now outpatient primary care doctors (2!) tried to explain the seriousness of his disease. We said hey, it's up to you, taking these medications; you're not to appease us but we've explained the risk/benefits and want you to make an informed choice. The guy has an EF < 20% for goodness sakes! He has a big clot in his left ventricle! We discharged him feeling better and he has been seen a few times by the primary care center. He is still noncompliant.
I have very mixed feelings about this but this patient makes me angry. Yes, that's right, angry. It is not an emotion that I often feel when I'm practicing medicine and I feel incredibly guilty about being angry at a patient. It is not in the ethos of medicine and sets up a terrible "us vs. you" mentality. I dislike patient conflict but also feel obligated to confront patients about their choices because 1) it affects their overall well-being and 2) it affects the well-being of the health care system. His prognosis is not good, especially without taking his cardiac meds like Lasix, an ACE inhibitor, spirinolactone, Coumadin, and will likely need an implanted cardiac defibrillator (ICD) in the future because of increased risk of sudden cardiac death. The next step after that is cardiac transplant. I mean, what's the ethics of giving people like this an ICD or transplant when they will not adhere to physician instructions? Yes, it is ultimately his choice, but we are paying for this every time he bounces back to the hospital in decompensated heart failure. I suppose this is a slippery slope argument but where's the line draw, say when in a few years, he becomes NY heart classification 4 and wants a donor heart?
I have very mixed feelings about this but this patient makes me angry. Yes, that's right, angry. It is not an emotion that I often feel when I'm practicing medicine and I feel incredibly guilty about being angry at a patient. It is not in the ethos of medicine and sets up a terrible "us vs. you" mentality. I dislike patient conflict but also feel obligated to confront patients about their choices because 1) it affects their overall well-being and 2) it affects the well-being of the health care system. His prognosis is not good, especially without taking his cardiac meds like Lasix, an ACE inhibitor, spirinolactone, Coumadin, and will likely need an implanted cardiac defibrillator (ICD) in the future because of increased risk of sudden cardiac death. The next step after that is cardiac transplant. I mean, what's the ethics of giving people like this an ICD or transplant when they will not adhere to physician instructions? Yes, it is ultimately his choice, but we are paying for this every time he bounces back to the hospital in decompensated heart failure. I suppose this is a slippery slope argument but where's the line draw, say when in a few years, he becomes NY heart classification 4 and wants a donor heart?
Saturday, June 18, 2011
Blah and I'm going crazy
Oh drat...I think I am coming down with something. I actually ended up sleeping nearly four hours in the call room post-call because I was so tired and fuzzy-headed that I didn't think I could go home straight away. When I woke up, I noticed a sore throat that I hoped was just dehydration. Now I feel headachy and my throat hurts more. Rats. Boo sleep deprivation, bad immune system and hospital bugs. Hope it's not S. pyogenes --> rheumatic fever --> mitral/aortic valve insufficiency --> mechanical valve --> Coumadin --> cranial bleed. But wait, I have no tonsillar exudates nor cervical adenopathy nor fever. Crisis averted. Can you tell I'm still delirious?
AMA
Done with another call day! I can't believe I have only one more call left. We had a packed night yesterday. 4 admissions total, which is a lot for our service, which is capped at 13. My co-subI and I each admitted 2 patients each.
My first admission turned out be very straightforward - small bowel obstruction and aspiration pneumonia. The second, however, was craaazy! Our patient tried to leave AMA (against medical advice) on us. Perhaps "tried" is an understatement. The nurse literally put her foot in the elevator door as the patient was storming downstairs to take out her IV, which the patient threatened to self-remove. Our sweet attending, who is the most even, soft-spoken, kind person I have ever met, remained so collected throughout the episode (and it was quite an episode, involving multiple nurses and security guards). Our patient apparently went out for a smoke and wanted to return to the emergency room to get admitted to another floor. Apparently, once the patient got to the emergency room and realized how insane it, the patient returned to the ward within 30 minutes. Yikes. Goes to show how you've just got to be prepared for any kind of patient behavior. At least it wasn't physically violent. I'm leaving out much of the backstory, but I think our patient was just at the end of his/her rope and completely frustrated with system. Our attending, bless her heart, made a teaching point out of it and actually debriefed during our hectic night.
My first admission turned out be very straightforward - small bowel obstruction and aspiration pneumonia. The second, however, was craaazy! Our patient tried to leave AMA (against medical advice) on us. Perhaps "tried" is an understatement. The nurse literally put her foot in the elevator door as the patient was storming downstairs to take out her IV, which the patient threatened to self-remove. Our sweet attending, who is the most even, soft-spoken, kind person I have ever met, remained so collected throughout the episode (and it was quite an episode, involving multiple nurses and security guards). Our patient apparently went out for a smoke and wanted to return to the emergency room to get admitted to another floor. Apparently, once the patient got to the emergency room and realized how insane it, the patient returned to the ward within 30 minutes. Yikes. Goes to show how you've just got to be prepared for any kind of patient behavior. At least it wasn't physically violent. I'm leaving out much of the backstory, but I think our patient was just at the end of his/her rope and completely frustrated with system. Our attending, bless her heart, made a teaching point out of it and actually debriefed during our hectic night.
Tuesday, June 14, 2011
Subinternship and Q4 call
As I mentioned earlier, I'm on my medicine subinternship this month. I am having a blast. I lucked out and got assigned to a pretty unique service that's very supportive. The attendings, nurses and staff have been great teachers and very kind, and I'm with an awesome co-subI. Internal medicine is where I swim.
For those not entrenched in the medical field, the subinternship or "subI" as most medical people call it, is essentially a dress rehearsal for intern year. I know it can't quite compare to the real chaos and demands of internship, but it's a month where we are supposed to think and act like interns. At my hospital, 2 subIs replace one intern, although I'm on a unique service with no residents and only attendings, so the situation is a bit different! On the subI, we take increased responsibility for our patients, place orders (cosigned by an MD of course), and really act as the point person for that patient. At night, my cosub-I, and I split the patient roster and carry 5-7 patients each. Essentially, it's a trial run for the real deal.
Speaking of nights, I'm back to a q4 call schedule. But it's a luxurious q4 call! On call days, we don't have to arrive until noon and then are usually finished by 1 pm (or mid-afternoon if we have post-call class - boo) the next day.
What exactly is q4 call? It's a confusing concept that friends and relatives often struggle to understand. q4 call means we stay overnight on a 24 hour shift every fourth night(q is shorthand for "every" in medicalese - it's Latin, maybe?). Take this example: Say I start work on Monday and I know that my "call day" begins on Wednesday. On Monday and Tuesday, I work normal hours (7 am - 7 pm). On Wed (Day 1 of the cycle), I work from 12 noon to 12 noon on Thursday. On Thursday (Day 2), I'm "post-call" and go home at noon, having spent the prior 24 hours in hospital. On Friday (Day 3), it's a regular 7 am - 7 pm day. Saturday (Day 4) is off. Sunday (back to Day 1) is my call day, so I'm back in the hospital on a 24 hour shift (although this is complicated by the fact that there's usually no additional help on weekends, so we come in at a regular 7 am). Confused yet? Yeah, me too. It works out to be technically less that 80 hours a week, but in reality, I get in by 6:30 am each day to preround and typically don't leave until 7:30 pm at the earliest after signout (where we relay or "sign out" the day's patients to the person staying overnight). On call days, it's 11:30 am to ~1:30 pm the next day after noon conference or class.
The hours are actually way better here than third year at my other hospitals, where call days started at regular times (6:30 am or 7 am) and finished the next day at 1 pm - a true 30 hour shift. How can you be awake that long?? At least during third year, my interns were usually really nice (or maybe I was really annoying!) and sent me to bed as soon as I'd admitted the requisite 1-2 patients. But here, we're really first stop for middle of the night pages (with ample supervision by a night float) so we're up for most of the night. Luckily, each night I've managed to get at least an hour or two of sleep and that helps a lot, but I'll be the first to say that around 2 or 3 am, I am really feeling the lack of sleep. The whole work hour limitations and medical-safety-when-young-doctors-are-sleep-deprived is a whole other debate, perhaps for another post.
In any case, we've been witness to new intern orientation for the last couple days. It's so exciting! A lot of our recent grads are at my current hospital, and it's so exciting to see the new bunch and a bit terrifying to think that's soon to be me. Now just remember not to get sick this month - just kidding :) The interns are really good and there's a lot of support, especially in the July/Aug/Sept when everybody is getting used to their new roles.
For those not entrenched in the medical field, the subinternship or "subI" as most medical people call it, is essentially a dress rehearsal for intern year. I know it can't quite compare to the real chaos and demands of internship, but it's a month where we are supposed to think and act like interns. At my hospital, 2 subIs replace one intern, although I'm on a unique service with no residents and only attendings, so the situation is a bit different! On the subI, we take increased responsibility for our patients, place orders (cosigned by an MD of course), and really act as the point person for that patient. At night, my cosub-I, and I split the patient roster and carry 5-7 patients each. Essentially, it's a trial run for the real deal.
Speaking of nights, I'm back to a q4 call schedule. But it's a luxurious q4 call! On call days, we don't have to arrive until noon and then are usually finished by 1 pm (or mid-afternoon if we have post-call class - boo) the next day.
What exactly is q4 call? It's a confusing concept that friends and relatives often struggle to understand. q4 call means we stay overnight on a 24 hour shift every fourth night(q is shorthand for "every" in medicalese - it's Latin, maybe?). Take this example: Say I start work on Monday and I know that my "call day" begins on Wednesday. On Monday and Tuesday, I work normal hours (7 am - 7 pm). On Wed (Day 1 of the cycle), I work from 12 noon to 12 noon on Thursday. On Thursday (Day 2), I'm "post-call" and go home at noon, having spent the prior 24 hours in hospital. On Friday (Day 3), it's a regular 7 am - 7 pm day. Saturday (Day 4) is off. Sunday (back to Day 1) is my call day, so I'm back in the hospital on a 24 hour shift (although this is complicated by the fact that there's usually no additional help on weekends, so we come in at a regular 7 am). Confused yet? Yeah, me too. It works out to be technically less that 80 hours a week, but in reality, I get in by 6:30 am each day to preround and typically don't leave until 7:30 pm at the earliest after signout (where we relay or "sign out" the day's patients to the person staying overnight). On call days, it's 11:30 am to ~1:30 pm the next day after noon conference or class.
The hours are actually way better here than third year at my other hospitals, where call days started at regular times (6:30 am or 7 am) and finished the next day at 1 pm - a true 30 hour shift. How can you be awake that long?? At least during third year, my interns were usually really nice (or maybe I was really annoying!) and sent me to bed as soon as I'd admitted the requisite 1-2 patients. But here, we're really first stop for middle of the night pages (with ample supervision by a night float) so we're up for most of the night. Luckily, each night I've managed to get at least an hour or two of sleep and that helps a lot, but I'll be the first to say that around 2 or 3 am, I am really feeling the lack of sleep. The whole work hour limitations and medical-safety-when-young-doctors-are-sleep-deprived is a whole other debate, perhaps for another post.
In any case, we've been witness to new intern orientation for the last couple days. It's so exciting! A lot of our recent grads are at my current hospital, and it's so exciting to see the new bunch and a bit terrifying to think that's soon to be me. Now just remember not to get sick this month - just kidding :) The interns are really good and there's a lot of support, especially in the July/Aug/Sept when everybody is getting used to their new roles.
Saturday, June 11, 2011
Mobility in the hospital
The NYTimes's The New Old Age blog just posted a thoughtful piece about how the simple act of walking in the hospital (or "ambulating" in doctor-speak) can help maintain physical strength and ultimately long-term outcome.
From what I've observed in the hospital, the article is so accurate. So many times, I see elderly (and for that matter, young, previously healthy) folks walk into the hospital and then wither away during their stay. One of our attendings used to tell us that every week of bedrest meant at least a 10% decrease in muscle mass. It's a reminder that as a clinician, we can help prevent functional decline, or at least hasten recovery in the hospital, but encouraging patients and staff to "ambulate with assist."
From what I've observed in the hospital, the article is so accurate. So many times, I see elderly (and for that matter, young, previously healthy) folks walk into the hospital and then wither away during their stay. One of our attendings used to tell us that every week of bedrest meant at least a 10% decrease in muscle mass. It's a reminder that as a clinician, we can help prevent functional decline, or at least hasten recovery in the hospital, but encouraging patients and staff to "ambulate with assist."
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