We discussed a case about an older man with chronic HCV (treated ~2 years ago) and 10-pack-year smoking history, who presented with acute fevers, rigors, SOB, cough, and was admitted for acute hypoxic respiratory failure due to Legionella pneumonia (Legionnaires’ disease). Severity of CAP There are several severity scoring systems for CAP. Most common systems are the PSI / POST Score and CURB-65. The IDSA / ATS also has a criteria for defining severe CAP. Highlights about the clinical utility of MRSA nares screening to rule out MRSA pneumonia The high NPV (98.1%) of MRSA nares screening supp ..read more

We discussed a case of an immunocompetent middle-aged man with HTN, HLD, history of diverticulitis, who presented with subacute diarrhea, LLQ to diffuse abdominal pain, nausea + vomiting, decreased PO intake, found to have diverticulitis and CMV colitis. When should a patient be admitted and treated for diverticulitis? Risk factors for diverticulitis A diet low in fiber, high in fat, and high in red meat Physical inactivity Obesity Other medical problems eg Ehler-Danlos, Marfan’s, Williams-Beuren syndromes, HIV, patients undergoing chemotherapy Current smokers One topic that is brought up ..read more

We discussed a case of a younger man with HIV, who presented with subacute fevers, B symptoms, fatigue, progressively worsening SOB with dry cough, found to have diffuse bilateral GGO on CT chest and diagnosed with AIDS and hypoxemic respiratory failure due to Pneumocystis pneumonia. We reviewed the CD4 count thresholds for antibiotic prophylaxis against a few significant opportunistic infections (OI) in patients with HIV: One recent update to antibiotic prophylaxis guidelines is for MAC. Primary prophylaxis against MAC is NOT recommended for patients with HIV who immediately initiate ART. Oth ..read more

We discussed a case of a middle-aged man with uncontrolled diabetes, who presented with acute-subacute fevers, headache, L neck pain, L retroauricular pain, and was found to have L ophthalmoplegia, acute L eye swelling due to MRSA bacteremia, left skull base MRSA osteomyelitis, and septic cavernous sinus thrombosis. We reviewed various frameworks for secondary headache. Thunderclap headache = Abrupt onset and reaches its max intensity within 1 minute or less of onset Cerebral venous thrombosis is a rare (1%) cause of strokes. It usually affects younger patients (20-50 y/o) with a female > ..read more

We discussed a case about an older man with smoking history, who presented with acute exertional dizziness + fatigue + diaphoresis + nausea + presyncope, found to have symptomatic bradycardia due to 3rd degree heart block. SYNCOPE FRAMEWORK ACLS ADULT BRADYCARDIA ALGORITHM In 2020, there was an update that recommended the 1st dose of Atropine given be 1mg (instead of 0.5mg) q3-5 min for a max of 3 mg. AHA ACLS 2020 pocket cardsDownload PERMANENT PACEMAKER PLACEMENT INDICATIONS FIRST, RULE OUT ALL REVERSIBLE CAUSES! Symptomatic bradycardia due to sinus node dysfunction Permanent afib & ..read more

Today we discussed a case about an older woman who presented after subacute painless jaundice and chronic weight loss + fatigue + nausea, found to have new onset DM, mixed cholestatic and hepatocellular liver injury, and a large pancreatic head mass. She was diagnosed with pancreatic adenocarcinoma. JAUNDICE FRAMEWORK LIVER INJURY The R factor (or R value) could be useful in helping distinguish cholestatic vs hepatocellular liver injury. PANCREATIC ADENOCARCINOMA Definitely be concerned in patients presenting with painless jaundice. But patients with pancreatic cancer can also present wit ..read more

We presented an an elderly male presenting after recent travel and new medication exposure with ill-defined coalescing plaques with dusky centers as well as diffuse erythema over trunk, scrotum, UE/LE with areas of skin sloughing associated with pain and fever, + Nikolsky sign diagnosed with TEN. SJS and TEN are a spectrum of disease, TEN being more severe and SJS less severe. TEN covers >30% of total body surface area and SJS covers <10%. If between 10 and 30 percent of TBSA is covered by the rash, it is termed SJS/TEN overlap syndrome. sure SJS/TEN is provoked by exposur ..read more

Elderly female with history of uncontrolled DM presenting with DKA and found to have a cavitary lung lesion found to have biopsy proving broad, aseptate, ribbon like hyphae consistent with mucormycosis. Mucormycosis is a invasive fungal infection (common species include Rhizopus, Mucor species); can cause necrosis of host tissue from invading vasculature. The main risk factor for developing mucormycosis: DM with DKA, steroids, underlying malignancy, AIDS and malnutrition. Most commo presentation of Mucor is rhino-orbital-cerebral mucor and pulmonary mucor. Treatment for our patient included lo ..read more

We discussed an interesting case of a middle aged female with high risk sexual behavior, active smoker with alcohol use disorder who presents with 3 weeks of globus sensation and odynophagia likely a presentation of acute pharyngitis. Remember to always take a sexual history in an adult with acute pharyngitis. On physical exam, make sure to look for signs of muffled voice, drooling, stridor, tripod positioning, crepitus and trismus when evaluating an adult with acute pharyngitis. Patient received a biopsy of her tonsil that resulted in IHC stain positive for Treponema Pallidum; RPR 1:65; Syphi ..read more

We discussed a middle aged female with uncontrolled diabetes that presents with profound subacute (5 week history) development of proximal over distal weakness and associated muscle pain. Other symptoms included 1 week of dysphagia to solid>liquid food. Overall, she presented with proximal muscle weakness with absent Babinski sign and 2+ reflexes bilaterally. Her medication included Simvastatin 20qhs. EMG shows myopathic process; ANA 1:160; HMGcoAR Antibody negative, Anti-SRP negative; biopsy showing fibrocellular variation with necrotic fibers within clusters of inflammation most consisten ..read more