Patient: RG DOB: 09.26.1959 NKDA RG presented to the ED complaining of new onset generalized weakness Difficulty walking, fatigued with exertion, feeling off balance, dry mouth, and dysphasia
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
Home Medications Dolophine (methadone) Bactrim DS (sulfamethoxazole/trimethoprim) Vibratab (doxycycline) Hospital Medications Review of Systems
Vitals BMP Renal Function CBC Electrolytes LFT s Miscellaneous Cultures Radiology Neuro Labs AchR Antibody MuSK Antibody EMG Physical Exam
Myasthenia Gravis (MG) Pulmonary Embolism (PE) Aspiration Pneumonia Acute Respiratory Distress Syndrome (ARDS) Wound Abscesses
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
Myasthenia Gravis Pyridostigmine 90mg q6h Plasmapheresis Monitor for improvement of symptoms Potential adverse effects DUMBBELSS
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
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
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
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
Acute Respiratory Distress Syndrome (ARDS) RG quickly developed ARDS Can exacerbate already proposed MG crisis Goals Increase oxygenation Reduce inflammation Provide respiratory support (intubation)
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
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
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
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
Introduction Autoimmune Presentation Broad range of symptoms Epidemiology Prevalence Gender Age
Risk Factors Family History Female Exacerbating disorders Etiology Three mechanisms of receptor destruction Accelerated turnover Blockade Damage Thymus involvement
Signs and Symptoms Weakness Fatigability Ocular issues Ptosis Diplopia Cranial Issues No sensory impairment
Diagnostic Procedures Acetylcholinesterase Test Electrodiagnostic test (EMG) Pulmonary Function Test MuSK Antibody Test Acetylcholine Receptor Antibody Test
Treatment Acetylcholinesterase Inhibitors Cholinergic agents may be inappropiate Thymectomy Immunosuppression Plasmapheresis Management of crisis
Follow-Up Monitoring Signs and Symptoms Number of receptors Prognosis
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