Patient: RG DOB: NKDA
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2 Patient: RG DOB: NKDA RG presented to the ED complaining of new onset generalized weakness Difficulty walking, fatigued with exertion, feeling off balance, dry mouth, and dysphasia
3 HPI: approximately two days PMH: Chronic back pain, remote heroin addiction (possible current addiction based on patient exam), positive for Hepatitis B and C FH: unavailable SurH: Cataract surgery SH: Admits to 10 cigarettes per day, denies alcohol use, and denies current illicit drug use
4 Home Medications Dolophine (methadone) Bactrim DS (sulfamethoxazole/trimethoprim) Vibratab (doxycycline) Hospital Medications Review of Systems
5 Vitals BMP Renal Function CBC Electrolytes LFT s Miscellaneous Cultures Radiology Neuro Labs AchR Antibody MuSK Antibody EMG Physical Exam
6 Myasthenia Gravis (MG) Pulmonary Embolism (PE) Aspiration Pneumonia Acute Respiratory Distress Syndrome (ARDS) Wound Abscesses
7 Myasthenia Gravis Generalized weakness spreading in an ascending fashion Per review of neurologist, noted classic signs of MG RG quickly progressed to a proposed myasthenic crisis (involving respiratory failure) Goals: Confirm diagnosis with tests Begin therapy for MG based on severity of symptoms Manage further complications, if needed
8 Myasthenia Gravis Pyridostigmine 90mg q6h Plasmapheresis Monitor for improvement of symptoms Potential adverse effects DUMBBELSS
9 Pulmonary Embolism (PE) Despite prophylaxis, RG developed a PE Possibly too low of a dose Goals Increase anticoagulation (possible filter insertion) Consider warfarin therapy upon discharge Monitor for signs of recurrent PE SOB Swollen lower extremity
10 Pulmonary Embolism (PE) Enoxaparin 60mg q12h (60kg patient) Monitor for signs of bleeding RG developed bleeding from an unknown source. Counsel on use of filter (patient denied use) Continue heparin Ambulate RG as soon as clinically safe
11 Aspiration Pneumonia Developed secondary to barium swallow Most likely due to dysphasia Goals Manage with broad spectrum antibiotics Especially anaerobes Reduce risk of progressing infection
12 Aspiration Pneumonia Vancomycin 1250mg IV QD Pipercillin/tazobactam 4.5g IV q8h Therapy changed to ampicillin/sulbactam 3g IV q6h Monitor for adverse reactions and symptom improvement
13 Acute Respiratory Distress Syndrome (ARDS) RG quickly developed ARDS Can exacerbate already proposed MG crisis Goals Increase oxygenation Reduce inflammation Provide respiratory support (intubation)
14 Acute Respiratory Distress Syndrome (ARDS) RG should be placed in a pronator bed Sedate patient with midazolam (1-2mg PRN) and fentanyl (4mg QD) Paralytics are inappropriate Corticosteroids are inappropriate during MG crisis Maintain pronation until symptoms improve
15 Wound Abscesses Significant on the inner right and left thighs Possibly secondary to heroin injections Home regimen of antibiotics did not improve Goals Begin empiric antibiotic therapy Obtain wound cultures Narrow antibiotics when appropriate
16 Wound Abscesses Vancomycin 1250mg IV QD Pipercillin/tazobactam 4.5g IV q8h Metronidazole 500mg IV q8h was started after vancomycin was discontinued Therapy changed to ampicillin/sulbactam 3g IV q6h (targeted therapy) Negative for botulinin toxin Not indicative of absence of disease
17 Summary RG was discharged to the general medicine floor After a few days, he developed suspected HCAP Transferred back to the ICU for treatment Antibiotic therapy was changed Tobramycin 420 mf QD Pipercillin/tazobactam 4.5g q8h
18 Introduction Autoimmune Presentation Broad range of symptoms Epidemiology Prevalence Gender Age
19 Risk Factors Family History Female Exacerbating disorders Etiology Three mechanisms of receptor destruction Accelerated turnover Blockade Damage Thymus involvement
20 Signs and Symptoms Weakness Fatigability Ocular issues Ptosis Diplopia Cranial Issues No sensory impairment
21 Diagnostic Procedures Acetylcholinesterase Test Electrodiagnostic test (EMG) Pulmonary Function Test MuSK Antibody Test Acetylcholine Receptor Antibody Test
22 Treatment Acetylcholinesterase Inhibitors Cholinergic agents may be inappropiate Thymectomy Immunosuppression Plasmapheresis Management of crisis
23 Follow-Up Monitoring Signs and Symptoms Number of receptors Prognosis
24
25 Chaudhuri A and Behan PO. Myasthenic Crisis. Q J Med. 2009; 102: Drachman Daniel B, "Chapter 381. Myasthenia Gravis and Other Diseases of the Neuromuscular Junction" (Chapter). Fauci AS, Braunwald E, Kasper DL, Hauser SL, Longo DL, Jameson JL, Loscalzo J: Harrison's Principles of Internal Medicine, 17e: Jamal BT and Herb K. Perioperative Management of Patients with Myasthenia Gravis: Prevention, Recognition, and Treatment. OOOE. 2009; 107 (5): Lexi-Comp Online Taylor Palmer, "Chapter 10. Anticholinesterase Agents" (Chapter). Brunton LL, Chabner BA, Knollmann BC: Goodman & Gilman's The Pharmacological Basis of Therapeutics, 12e: Witoonpanich R, et al. Electrophysiological and Immunological Study in Myasthenia Gravis: Diagnostic Sensitivity and Correlation. Clin Neurophysiol. 2011; Epub ahead of print.
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DRUG AND TREATMENT Intubation Phase Notify Therapy for STAT intubation Medications SUB Rapid Sequence Induction (SUB)* ***Reminder: Order SUB Rapid Sequence Induction (SUB) on a separate form*** lidocaine
Melanoma Immunotherapy. Nursing Perspective on Immune-Related Adverse Events: Patient education, Monitoring & Management
Melanoma Immunotherapy Nursing Perspective on Immune-Related Adverse Events: Patient education, Monitoring & Management Mike Buljan, NP UCSF Medical Center Melanoma Oncology Disclosures None Only FDA-approved
Dr. Steve Ligertwood Dr. Roderick Tukker Dr. David Wilton
Dr. Steve Ligertwood Hospitalist Royal Columbian Hospital Regional Department Head-Hospitalist for Fraser Health Authority Project Lead BC Hospitalist VTE Collaborative Clinical Instructor, UBC School
M0BCore Safety Profile
M0BCore Safety Profile Active substance: Clostridium botulinum neurotoxin type A haemagglutinin complex Pharmaceutical form(s)/strength: powder for solution for injection, 300 unit and 500 unit P-RMS:
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