August 4, 2011 - Today we had "rapid fire" post-call morning report and reviewed several cases from last night. Here are some synopses:
Case 1. 57M mucosal bleeding. PMHx: APLA, ITP with splenectomy. Meds: Prednisone 15mg daily, no warfarin. O/E: petechiae, ecchymosis, cushingoid.
What do you think is causing his bleeding?
Investigations: Plt 285, INR 1.0, PTT 25.7, bleeding time >15s, U/A 2+ blood, creat 78
Does this change your differential diagnosis?
Remember the components of coagulation:
- factors, inhibitors (check via INR, PTT)
- Plt fxn (uremia, antiplt)
- fibrinogen
- vWF/factor 8 deficiency
Disorders of primary hemostasis:
- Acquired: antiplatelet agents (ASA, Plavix), thrombocytopenias (ITP, HIT, TTP), primary bone marrow diseases (myeloproliferative disorders, MDS, plasma cell dyscrasias), severe renal failure (so called "uremic platelets")
- Congenital: vWD, some platelet dysfunction disorders
Disorders of coagulation/fibrinolysis:
- Acquired: liver failure, Vit K deficiency, anticoagulant meds, factor inhibitors, scurvy
- Congenital: coagulation factor deficiencies (hemophilias), antiplasmin deficiency
Initial lab tests:
- CBC, liver enzymes, ABO blood group
- INR, aPTT, if abnormal: consider 1:1 mixing studies
- fibrinogen
- vWF antigen, ristocetin cofactor, factor VIII
- platelet aggregation test
- standardize bleeding time
***
Case 2. 58F 6-weeks post-THR (PMHx: JRA). Recent C. Diff treated with Flagyl, returning with worsening diarrhea, abdo pain.
C. diff recurrence - Definition: complete abatement of C. diff infection symptoms while on appropriate therapy, followed by subsequent reappearance of diarrhea and other symptoms after treatment has been stopped; must distinguish from persistent diarrhea without resolution during initial therapy.
Treatment of C. diff:
Initial episode: Flagyl 500 mg PO TID x 10 to 14 days
Alternative ($$$): Vanco 125 mg PO QID x 10 to 14 days
First relapse: repeat treatment as in initial episode (Flagyl)
Second relapse: tapering course of PO Vanco, +/- probiotics (Saccharomyces boulardii 500 mg orally twice daily).
***
Case 3. 78M from ICU post hypercapneic resp failure due to severe COPD
NB: The traditional teaching of supplemental oxygen decreasing the "drive to breathe" in CO2-retaining COPDers, is incorrect. The current thinking is that therapy with supplemental oxygen alters hypoxic pulmonary vasoconstriction and modulates the Haldane effect (decreased carriage of CO2 by oxyhemoglobin when compared with reduced hemoglobin), resulting in changes in physiologic deadspace and worsening hypercarbia.
Published in:
Hanson, C William III et al. Causes of hypercarbia with oxygen therapy in patients with chronic obstructive pulmonary disease. Crit Care Med 1996; 24(1): 23-28.
***
Case 4. 50F 6-week abdo pain, diarrhea. CT abdo shows: Terminal ileitis.
What is your differential diagnosis?
DDx terminal ileitis:
- Crohns (#1, 2, 3!)
- infectious (especially Yersinia, TB)
- spondyloarthropathies
- vasculitides
- ischemia
- neoplasm
- medication-induced (especially NSAIDS)
- eosinophilic enteritis
