Morning Report Thursday, April 9, 2015 Danielle Eggie
It s finally here!
Chief complaint: 18 year old male with vomiting and aches
H: E: A: D: D: S: S: Lives in LSU dorms during school, and at home with parents when out of school, good relationship with family Freshman at LSU, plans to go to nursing school, doing well, attending classes. No extracurricular activities, no job Denies drug use, occasional alcohol use, new tattoo 1/1/15 Denies depressive symptoms +sexually active, +intermittent condom use, only female partners, 1 partner in last 6 months, no history of STDs Denies suicidal thoughts or history of past SI/SA
HPI: Chief complaint: vomiting and body aches 18 year old male with non-bloody, non-bilious emesis with body aches for the past 3 days. No associated abdominal pain. Also complains of a mild sore throat and mild intermittent headache for the past 4 days. ROS: no chest pain, no dyspnea, +dec appetite, +fatigue, no cough/congestion, no diarrhea
HPI: PMHx: DM Type I on Humalog/Humalin PSHx: None Meds: Humalog/Humalin Shots: UTD, +flu shot this year
What is your differential diagnosis?
Differential Diagnosis Infectious Acute gastroenteritis Viral (influenza, rotavirus, norovirus, adeno virus) Bacterial (Campylobacter, C.diff, E.coli, Salmonella) Parasitic (Cryptosporidium, Giardia) GI/Kidneys Cholecystitis Hepatitis Pancreatitis Kidney stones Obstruction/gastric outlet ob. Functional GI disorders IBS CNS Migraines Increased ICP tumor/infarct Pseudotumor cerebri Endo DKA Uremia Hyper/hypoparathyroidism Addison s disease Cardiac CHF Pericarditis / Endocarditis Medications NSAIDs, Aspirin, antibiotic use
Let s examine the patient
Physical Exam VS: T 100.6, HR 85, RR 20, BP 109/58, GEN: HEENT: NECK: SKIN: Pox 100% on RA, Wt 65kg, BMI 20.5 Asleep, but arousable, NAD Dry mucus membranes, slightly erythematous tonsils without exudate Supple, no palpable lymphadenopathy No rashes. Normal skin turgor.
Physical Exam CV: RESP: ABD: EXT: Neuro: RRR, soft murmur at left sternal border, 2+pulses in all 4 extremities, CR <3 seconds. CTA bilaterally, no increased WOB soft, thin, non-distended, non-tender with normoactive bowel sounds, no rebound, no guarding, no HSM warm and well perfused, no cyanosis or edema, PIV to LUE no focal deficits on exam
What would you like to order?
LABS VBG: 7.34 / 44 / 28 / 23.7 / -2.2 137 100 17 < 212 Ca 8.4 AST 41 / ALT 71 4.4 24 1.4 HbA1C: 8.3% UA: (-)LE/nit, (-)protein, (-)blood, 3+ ketones, 5-10 wbc
LABS 4.4 14.7 157 44 S36 B47 L9 M5 E3 CRP: 0.4 (0-1) Amylase: 58 (25-180) Lipase: 357 (48-176) Bcx: pending Ucx: pending RVP: (-) Strep: (-) Rapid flu: (-)
What is your assessment at this point? 18 y/o male with DMT1 here with fever, dehydration secondary to emesis, and hyperglycemia without acidosis
Are you going to admit this patient?
Management: Dehydration NS Bolus, then 1.5 MIVF until PO improved Emesis Resolved upon admission. Likely secondary to AGE. Hyperglycemia Resumed home insulin regimen. New onset murmur Cardiology consulted. Echo and EKG normal.
Management: Bandemia Repeated CBC 1.91 14.2 Elevated Lipase S48 B19 L29 M4 Discussed with GI. Not due to pancreatitis. Plan to repeat in 1 week. Ultimately, discharged home with diagnosis of viral illness and to follow up in 1 week with PCP. 40 103
1 week later, the patient returns to the ER with rash and sore throat Now what do you want to know?
HPI: Chief complaint: rash and sore throat Was well for 1 day following discharge, then developed red rash that began on his wrists and spread to his entire body. Rash has been itchy, but not painful. Sore throat returned and is worse now. ROS: no fevers, +dec PO intake, no vomiting/nausea, +inc voiding
Now what are you concerned about?
Differential Diagnosis Mononucleosis (EBV/CMV) Toxoplasmosis Rubella Syphilis Viral hepatitis Disseminated gonococcal infection New onset autoimmune disease (SLE) HIV Strep Rocky Mountain Spotted Fever
Physical Exam VS: T 97.8, HR 96, RR 18, BP 105/71, GEN: HEENT: NECK: SKIN: Pox 98% on RA, Wt 57.8kg Awake, alert, NAD erythema with some ulcers and plaques to soft palate and bilateral tonsils Supple, some swelling/fullness at the angle of the mandible confluent, flat, erythematous rash to entire body
Physical Exam CV: RRR, no murmur, 2+pulses in all 4 extremities, CR <3 seconds. RESP: ABD: EXT: Neuro: CTA bilaterally, no increased WOB soft, thin, non-distended, non-tender with normoactive bowel sounds warm and well perfused, no cyanosis or edema, PIV to LUE no focal deficits on exam
What labs would you order?
LABS CBG: 7.30 / 40 / 52 / 19.7 / -6.3 132 96 36 < 670 Ca 10.2 AST 29 / ALT 42 6.1 24 1.8 HbA1C: 8.3% UA: (-)LE/nit, (-)protein, (-)blood, 1+ketones, 3+ glucose, no wbc
LABS 5.7 15.7 45.9 261 S61 B16 L7 M13 AL3 CRP: 0.4 (0-1) Amylase: 71 (25-180) Lipase: 625 (48-176) Mono spot: (-) RPR: NR HIV PCR: (+)
Acute Retroviral Syndrome
Acute Retroviral Syndrome AKA, Acute HIV infection The effect of the immune response to a primary infection of HIV-1 or HIV-2 following dissemination of HIV.
Acute Retroviral Syndrome 40-90% of acute HIV infections are symptomatic. The usual time from HIV exposure to onset of symptoms is 2-4 weeks. Symptoms can last from days to weeks. Acute phase lasts for as long as the immune response takes to control viral replication
Clinical Manifestations Most common complaints Fever Fatigue Myalgia Suggestive of HIV diagnosis: mucocutaneous ulcers and. prolonged duration of symptoms
Clinical Manifestations Constitutional symptoms Fever, fatigue and myalgias Adenopathy Nontender axillary, cervical, and occipital nodes Develops during the second week of illness Oropharyngeal findings Sore throat with pharyngeal edema and hyperemia, without tonsillar enlargement or exudate Ulcerations can be found on oral mucosa, as well as anus and penis
Clinical Manifestations Rash Generalized maculopapular rash, non-pruritic Occurs 48-72 hours after onset of fever Persists 5-8 days GI symptoms Nausea, diarrhea, anorexia, and weight loss (~5kg) Neurologic symptoms Headache described as retro-orbital pain that worsens with eye movement Aseptic meningitis
Rash
Rash
Opportunistic Infections Rare in the acute phase Most common opportunistic infection seen in this phase is. oral and esophageal candidiasis Esophageal ulceration provides local environment that promotes growth of Candida Administration of empiric antibiotics for symptoms of acute HIV can alter normal oropharyngeal flora
Labs Viral RNA level very high (>100,000 copies/ml) and CD4 cell count can drop transiently Period of rapid viral replication and infection of CD4 T cells Negative HIV antibody Leukopenia Elevations of liver enzymes Mild anemia Thrombocytopenia
Stages based on lab testing
Time to positivity
Back to our patient
LABS HIV viral load: 2,900,000 Genotype: HIV-1, no resistance CD4: 350 CD8: 250 CD4:CD8 ratio: 1.41 RPR NR; GC/CT neg; HSV neg HepA AB: positive Baseline Vitamin D, TFTs, and lipid panel
The End! Noon conference: Dr. Jeyakumar Noisy Airway Across the street