Inpatient small feedings
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Inpatient small feedings. Daniel J. Brotman, MD, FACP Director, Hospitalist Program, Johns Hopkins Hospital Associate Professor of Medicine. Financial disclosures. No relevant disclosures. Case #1.

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Inpatient small feedings

Inpatient small feedings

Daniel J. Brotman, MD, FACP

Director, Hospitalist Program,

Johns Hopkins Hospital

Associate Professor of Medicine


Financial disclosures

Financial disclosures

  • No relevant disclosures.


Case 1

Case #1

  • 34 y/o African American man, generally healthy. Fell of 3rd floor balcony during altercation and hurt R leg.


Right tib fib fracture confirmed

Right tib/fib fracture confirmed


Additional imaging body ct no evidence of internal bleeding went to or for repair

Additional imaging (body CT), no evidence of internal bleeding------ Went to OR for repair


Gen med consult post orif

Gen Med consult post-ORIF


Additional history

Additional history

  • No prior medical history.

  • Admits to occasional marijuana, inhaled cocaine. No IV drugs.

  • + incarceration 2 months prior; reportedly negative PPD at this time. Was told he had abnormal CXR, but no work-up done.

  • + occ dark sputum, attributed to smoking marijuana.

  • No fevers, weight loss, malaise


Inpatient small feedings

Labs

  • BUN/CR = 25/1.7

  • Albumin 3.9, Tot Pro 8.6

  • AlkP = 140; AST/ALT 27/26

  • WBC 13K, Hct 42, Plts 239


Differential diagnosis

Differential diagnosis

  • TB (no fever/wt loss; but + cough, recent incarceration)

  • Fungus (?marijuana-related vs endemic)

  • Cancer (eg, lymphoma, given spleen)

  • Sarcoid (black race, multi-system)


Would you isolate this patient to rule out tb

Would you isolate this patient to rule-out TB?


Diagnosis intentionally omitted from handout e mail dr brotman for full slide set brotman@jhmi edu

Diagnosis intentionally omitted from handout e-mail Dr. Brotman for full slide set: [email protected]


Case 2

Case #2:

  • 41 y/o African American woman presents to ED with malaise, jaundice, and loose stools.

  • 5 weeks prior, had undergone frontal craniotomy for a brain mass

    • Pathology showed adenocarcinoma

    • Additional imaging negative for primary


Additional history1

Additional history

  • Hepatitis C from prior IV drug use

  • + Tobacco use

  • Morbid obesity

  • Only med: Prophylactic phenytoin (300mg bid) started as seizure prophylaxis following brain surgery


Inpatient small feedings

Exam:

  • Fatigued appearing and anxious, but alert and appropriate

  • HR 120; Temp 99.1F; BP 90/60; RR 18; Sats 97% RA

  • HEENT: post-op changes; + icterus

  • No focal findings


Inpatient small feedings

Labs:

AST = 634

ALT = 510

124

26

87

AlkP = 382

113

23

3.7

0.9

Alb = 2.8

Tbili = 7.6 (conj = 6.1)

13.0

11.5

246

INR = 3.6

37.7

PTTr = 1.2

PMN = 52%, L = 18%, M = 7%, E = 23%


Fearing the worst

Fearing the worst…

  • Adenocarcinoma of unknown primary, now with jaundice

    • ? Pancreatic cancer

    • ? Cholangiocarcinoma

  • Phenytoin held


Ruq ultrasound

RUQ ultrasound

  • Liver appears normal

  • Possible 1.5cm mass in body of pancreas

  • 3mm common bile duct

  • Cholelithiasis, with mildly thickened GB wall (5mm), but no pericholecystic fluid


Abdominal mri hosp day 2

Abdominal MRI (hosp day 2)

  • Not suggestive of cholecystitis

  • No intrahepatic or extrahepatic ductal dilatation, and normal pancreatic ducts

  • Supposed pancreatic lesion seen on US was not visualized on MRI


Patient s status day 2

Patient’s status, day 2

  • Low-grade fever (38.1)

  • Complains of eye irritation and continued malaise/loose stools

  • Exam shows conjunctival injection and some new cutaneous erythema


Day 2 labs

Day 2 Labs:

AST = 483

ALT = 441

127

21

95

AlkP = 393

113

21

3.6

0.8

Tbili = 8.8

13.0

12.0

246

INR = 5.8

37.7

(No diff)

Hepatitis serologies pending


Diagnosis intentionally omitted from handout e mail dr brotman for full slide set brotman@jhmi edu1

Diagnosis intentionally omitted from handout e-mail Dr. Brotman for full slide set: [email protected]


Case 3

Case #3:

  • 53 y/o orthopedic surgeon from Florida presents for 2nd opinion for FUO

  • Previously extremely healthy (exercise nut)


6 weeks prior to presentation

6 weeks prior to presentation…

  • Headache

  • Dyspnea on exertion

  • Fevers to 103F with shaking chills, limiting his ability to operate

  • Aching all over (flu-like)

  • Presented to outside hospital


At outside hospital 6 weeks prior

At outside hospital (6 weeks prior)

  • WBC 37,000

  • Febrile

  • Diffuse achiness with musculoskeletal pain and abdominal pain

  • Received piperacillin/tazobactam, vancomycin, and cefepime

  • RUQ ultrasound showed some fluid

    • Laparoscopic cholecystectomy

    • Normal GB


Delirium ensued

Delirium ensued

  • LP showed >2000 WBCs, mainly PMNs; cultures and cytology negative

    • Acycolvir and doxycycline empirically added

    • MRI brain showed meningeal enhancement but no focal lesions

  • Near-intubation for pulmonary infiltrates thought due to ARDS

  • ESR > 100


Negative studies

HIV

Crypto serology

Toxo serology

West Nile

Zoonoses

Rickettsia

Borrelia

Coxiella

Ehrlichia

Leptospirosis

PPD negative

TA biopsy

Blood cultures

TEE

ANA, RF (trivially elevated RF)

No steroid trial done

Negative studies


Repeat lp 1 week after 1 st lp

Repeat LP 1 week after 1st LP:

  • 128 WBC, still with PMN predominance

  • Discharged feeling partially better (still fatigued and achy, but not delirious)

  • About a week later, symptoms returned so he came for 2nd opinion.


Upon presentation to jhh

Upon presentation to JHH…

  • Fatigued, achy, c/o weight loss of 14 lbs in 6 wks.

  • Meds PRN only (analgesics)

  • Temp 38.5

  • No rash or other focal findings on exam, but hurt to touch over many joints/muscles without obvious inflammation


Inpatient small feedings

Labs:

AST = 41

ALT = 66

130

18

94

AlkP = 120

135

27

4.2

1.0

Alb = 3.1

Tbili = 0.2

8.5

18.0

367

ESR = 122

26.0

PMN = 79%, L = 9%, M = 11%, E = 1%


Labs continued

Neg rheum serologies

HIV negative

RPR negative

Periph smear negative except for L shift with toxic granulation

Marrow biopsy: hypercellular, increased M:E ratio. No lymphoma

Ferritin 338

TIBC 191

Iron 10 (5% sat)

LDH = 134

Labs…continued


Pet ct

PET-CT:

  • Diffuse increased bone marrow uptake

  • Mild R hilar adenopathy

  • Significant adenopathy gastrohepatic ligament

  • Anterior abd wall inflammation


How likely is cancer

How likely is cancer?

  • Biopsy abdominal nodes?

  • Biopsy hilar nodes?


Diagnosis intentionally omitted from handout e mail dr brotman for full slide set brotman@jhmi edu2

Diagnosis intentionally omitted from handout e-mail Dr. Brotman for full slide set: [email protected]


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