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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.
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
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
slide11
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)
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
slide19
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
slide20
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

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
slide35
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?
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