6/15/18 Intern Morning Report – Confusion, Shortness of Breath, Respiratory Alkalosis, Metabolic Acidosis, Aspirin Toxicity

CC: Confusion, shortness of breath, gait instability

HPI: This is a 72 yo female with past history of DM, HTN, chronic pain due to osteoarthritis and MI s/p DES in 2003 and 2017, who presents with 1 week of progressive confusion and 1 month of shortness of breath, cough, polyuria/polydipsia and gait instability. Patient has significant history of tobacco use but no alcohol or drug use. Patient is adherent to medication regimen, including Aspirin 81mg PRN pain, no recent changes in meds. Vitals significant for tachypnea to the high 20s, satting low 90’s on room air. Physical exam is otherwise unremarkable with no focal neurologic deficits. Labs are significant for bicarb of 9, Cr 1.21 and anion gap of 18. CT head and CXR do not show significant findings and urine studies suggest prerenal AKI with an FeUrea of 33%. An ABG revealed pH 7.36, PCO2 21, PaO2 62 (on RA) and HCO₃12. Serum osmolar gap was normal and volatile panel was negative. Salicylate level was positive to 39.4 (critical high >29.9).

Morning Report Pearls:

Work up of any acid base disturbance should include an ABG to determine the primary disturbance and compensation.
- This patient’s ABG was consistent with a primary metabolic acidosis and the expected compensated PCO2 would be 24 (Using the calculation for chronic metabolic acidosis, compensated PCO2 = 15 + Bicarb). However this patient’s PCO2 was lower than the expected value, which suggests a concomitant respiratory alkalosis.
- In the setting of any anion gap (AG), a delta ratio (ΔAG/ΔHCO₃) should be calculated. In an uncomplicated high AG metabolic acidosis, expect the delta ratio to be around 1-2. A delta ratio of <1 suggests a coexisting normal AG metabolic acidosis and a delta ratio >2 suggests a coexisting metabolic alkalosis. This patient’s delta ratio was <1 which indicates a concomitant normal and high AG metabolic acidosis.

Salicylate poisoning
- Early signs include tinnitus, vertigo and GI symptoms. More severe intoxication can present with encephalopathy, fevers, non-cardiac pulmonary edema. Tinnitus is a common sign, and can occur even at therapeutic range. Chronic toxicity presents similarly however signs may be more subtle.
- Acid base disturbances: Salicylates stimulate the respiratory center and cause tachypnea and hyperventilation, causing an respiratory alkalosis initially. Salicylates also uncouple oxidative phosphorylation causing a rise in ketoacids and lactic acid, resulting in a high AG metabolic acidosis. Generally patients present with a mixed primary respiratory alkalosis and primary metabolic acidosis. Several cases of patients with normal AG metabolic acidosis have also been reported, which are believed to be due to falsely elevated Cl due to salicylate ions competing with Cl ions for albumin binding. The falsely elevated Cl causes a narrowed AG.
- Management includes serum and urine alkalinization with IV sodium bicarbonate and IVF to replace insensible losses. Indications for hemodialysis include altered mental status, pulmonary or cerebral edema, renal insufficiency and impaired salicylate elimination, pH<7.2, significantly elevated salicylate level, or failure of medical management.

5/4/18 Intern Morning Report – Shortness of Breath, Cough, Unintentional Weight Loss, Bloody Pleural Effusion, Asbestosis, Malginancy

CC: Shortness of breath and cough for 2 weeks

HPI: This is a 65-year old female with no past medical history presenting with two weeks of shortness of breath and cough as well as three weeks of generalized malaise. She received a five day course of azithromycin prescribed by her primary care physician with no improvement in symptoms. She is from Northeastern China and moved to Los Angeles in the 1990s. She works at and owns a pencil manufacturing factory for ten years . She denies any smoking or alcohol use. Review of systems is pertinent for unintentional weight loss of 10 lbs over the last month. Physical exam shows the patient to be afebrile, heart rate in the 130s, tachypneic to 22, and sat’ing 96% on room air. Her rhythm is regular and pulmonary exam demonstrates evidence of a pleural effusion (decreased breath sounds in left lung base, dullness to percussion in the left lung field with decreased tactile fremitus).

Labs/Diagnostics:

CT Chest: Bilateral calcified pleural plaques are present with left pleural thickening.

Pleural fluid is grossly bloody with the following studies:

Glucose 72
LDH 1100
Protein 5.3
Color: Red
Markedly bloody
902 nucleated cells
84% segmented neutrophils
16% lymphocytes
Pathology did not show malignant cells

Body Fluid Comparison

Glucose 90
LDH 161
Protein 6.6

Initial cytology is negative, so the favored diagnosis at the time is BAPE. However repeat cytology done, showing atypical cells most consistent with Invasive Ductal Carcinoma primary site likely breast. Patient is eventually diagnosed with breast cancer that is ER+/PR+/HER2 negative.

Morning Report Pearls:

Grossly bloody pleural effusions can narrow your differential to: Malignancy, Trauma, Asbestos, Pulmonary infarct, and Infection

Hemothorax is when the Hct in the pleural fluid is >50% of serum. Important to know because chest tube placement would be indicated.

Benign Asbestos Pleural Effusion came up on this differential given the fluid being bloody, exudative and with a CT showing calcified pleural plaques. Just remember that BAPE is a diagnosis of exclusion! Malignancy should be ruled out first particularly given the elevated risk with asbestos exposure.

Risk Factors to know with regards to asbestos exposure include construction, automotive servicing, mining workers and shipbuilding industries. When exposed the shorter fibers are typically cleared from the lungs however the longer fibers are transported to the interstitium or to the lymphatics where they can reach the pleura. Most common finding in asbestos related pleural diseases is parietal plaques followed by pleural fibrosis and pleural effusion. Pleural fibrosis can cause a restrictive disease if diffuse. BAPE is almost always hemorrhagic as mentioned above and eosinophils can be elevated in 1/3. Mesothelioma is a potential cancer that can be difficult to exclude in cases suspicious for BAPE given the low sensitivity of cytology so pleuroscopy may be needed.

Lung cancer is the most common malignancy to cause a pleural effusion and asbestos exposure does increase the risk of lung cancer. Other cancers that can commonly lead to pleural effusion to consider are breast cancer and lymphoma.

4/24/18 Resident Morning Report – Shortness of breath, Dizziness, Cough, Anorexia, Fever, Transaminase Elevation, Thrombocytopenia, Relative Bradycardia, Murine Typhus

CC: Dizziness, Shortness of Breath

HPI: This is a 60 yo obese male with no past medical history presenting with one week of dizziness and shortness of breath. He states that he has been feeling dizzy with standing and short of breath when walking just in his apartment. He does not have any chest pain, nausea, vomiting, orthopnea, or paroxysmal nocturnal dyspnea but does have subjective fevers at home. On review of systems he reports truncal rash that started a day or two ago. Social history is pertinent for working at the Mission shelter in Downtown Los Angeles. On exam, he is febrile to 40.8 with a HR of 110. He is tachypneic, diaphoretic with dry mucous membranes. On repeated checks, patient has waxing and waning mental status. He has no murmurs, his lungs are clear, and his abdomen soft. The rash is macular and blanchable overlying his anterior chest with no palmar or sole involvement. Labs are pertinent for a Cr of 1.5 with FeNa 0.2%. UA does show some WBCs and RBCs but complements are normal and serologies negative. Transaminases are elevated: AST 175, ALT 133 with intact liver function. There is also a thrombocytopenia to 113. LP shows normal protein and glucose with 0 WBC. Blood cultures remain negative. Rickettsial serologies are pursued and R typhi IgG and IgM are positive with titers of 1:256 and patient is diagnosed with Murine Typhus.

Morning Report Pearls:
Relative bradycardia is a unique finding in certain infections, mainly intracellular organisms. Defining relative bradycardia requires a patient to have a fever of >102, be in sinus rhythm, and not be on beta blockers. If their heart rate does not correspond to the normal rate seen with the degree of fever then it can be termed a relative bradycardia.

T 102 should have a HR >110

T 103 should have a HR >120

T 104 should have a HR >130

T 105 should have a HR >140

T 106 should have a HR >150

Infectious Etiologies that have Relative Bradycardia:

Viral: Dengue fever, Yellow fever
Bacterial: Brucellosis, Legionella, Tularemia, Mycoplasma, Typhoid, Leptospirosis, RMSF, Typhus, Q fever, Psittacosis
Malaria

Non-infectious Etiologies that have Relative Bradycardia:

Central Fever
Drug Fever
Tumor fever
Factitious

Consider rickettsial diseases when a patient has high fevers, headache, transaminase elevation, thrombocytopenia, and rash. Because we reside in Los Angeles, always have to consider Murine Typhus specifically (only really seen in California and Texas).