The StethoSCOOP - University of Cincinnati

The StethoSCOOP
UCMC
INTERNAL
MEDICINE
RESIDENCY
V O L U M E
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I S S U E
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J U N E
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2 0 1 6
Weekly Calendar
SPECIAL
POINTS OF
INTEREST:
 Last minute room
fixes
 The farewells
6/13: Noon Report: Blue Team
6/14: Noon Report: Green Team
6/15: Grand Rounds: Ahsan Zafar, MD: “From Idea to
Outcomes: Improving Care Delivery for COPD Patients”
begin
6/16: nothing
6/17: Noon Report: GI Team
INSIDE
THIS ISSUE:
Infection
Prevention
2
Old to new
2
Rheum
emergencies
3
New door handle
4
Resident Research
4
Upcoming Events
4
Board Review
5
Resident Awards
5
Weekend to-do
6
Medical Trivia
6
Shoutouts
6
End of a noon report era. Start
of a brilliant new HD epoch.
Anonymous Feedback
Our website has a section for anonymous feedback. Think of this like an electronic suggestion box that
you can use at any time. The message will be sent directly to Dr. Warm, and is completely anonymous. If
you have constructive feedback that you would like to share, please use this tool. The link is: http://
intmed.uc.edu/education/residency/feedback.aspx
VOLUME
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ISSUE
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Infection
Prevention
Prevention of hospital-acquired infection
is the responsibility of all who care for
patients. You will see this data in the
newsletter routinely in the future. Please
take note of the trend, remember to use
interventions such as the nurse-driven
Foley protocol, and join the teams
working to improve quality care of our
patients.
See Renee Hebbeler-Clark to join a team!
PAGE
UCMC Days Since Last:
CAUTI
CLABSI
C-Diff
MRSA
(Bloodstream)
SSI
VAP
LAST INFECTION 5/7/16
31 days (NSICU)
LAST INFECTION 5/29/16
9 days (SICU)
LAST INFECTION 6/2/16
5 days (MSD)
LAST INFECTION 5/17/16
21 days (CVICU)
LAST INFECTION 5/13/16
25 days
LAST INFECTION 5/27/16
11days (MICU)
Note :
VAP contains ICU data only.
MRSA/C. diff as per HA NHSN defined
Interns! AME 6/13-6/17 Osteoporosis – find in your Dropbox folder or in Medhub
Long Blockers! Special AAP 6/15 MIGRAINES Part I MSB 6254
This week’s Pearl – Cleveland Clinic Journal of Medicine
Clarifies the Pneumococcal vaccine confusion! Download the
quick read as a PDF from CCF!
Clinic Corner
Come Monday, there will be new kids
on the block. Onward and upward.
THE
STETHOSCOOP
2
VOLUME
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PAGE
3
Rheumatologic Emergencies
Vignette
Diagnosis
Positive History of longstanding
Rheumatoid Arthritis, develops
Cervical Myelopathy
cervical pain with radiation to occiput,
2/2 cervical
+/- both upper and motor neuron
subluxation: C1-C2
signs; +/- unsteady gait and
decreased proprioception
Pearls
Propensity of RA to involve C-spine: synovitis with
erosions that destroy the ligaments anchoring C1C2; definitive diagnosis via Cervical MRI; **screen
RA patients preoperatively with plain films if
undergoing general anesthesia**
Suspect in patients: - with unexplained thrombotic
events (arterial, unusual organ involvement) Young female patient of child-bearing
Antiphospholipid
unexplained adverse pregnancy outcomes (fetal
age p/w livedo reticularis,
Antibody Syndrome --> loss, recurrent miscarriage) - unexplained
thrombocytopenia, elevated INR,
Catastrophic
thrombocytopenia - unexplained prolonged PTT;
prolonged aPTT, clinical concern for
antiphospholipid
order antiphospholipid antibodies: 1. Lupus
concomitant venous and arterial
antibody syndrome anticoagulant 2. Anticardiolipin Ab 3. Anti-Beta-2
thromboembolism
glycoprotein; tx = anticoagulation, high-dose
steroids, plasmapheresis
Pt with systemic sclerosis, recent
exposure to glucocorticoids, +/- HA,
new-onset/worsening HTN; lab
evidence of MAHA, AKI, bland UA
with non-nephrotic range proteinuria
SLE pt p/w LE edema, hematuria, lab
evidence of active lupus and AKI
SLE patient hypoxemia, new
pulmonary infiltrates on chest
radiograph, and decreasing
hematocrit, +/- hemoptysis
Acute monoarticular arthritis; +/elderly, history of joint trauma,
alcoholism, DMII,
immunosuppression, IVDU
THE
STETHOSCOOP
Scleroderma Renal
Crisis
Pathophysiology theory: insult/injury to endothelial
cells > intimal thickening, proliferation, and an
absence of inflammatory cells within the renal
vasculature; narrowed afferent renal arterioles >
glomerular ischemia and hyperplasia of the
juxtaglomerular apparatus and subsequent renin
release (hyperreninemia); ~10% of patients present
with normotension; TX = ACEi (CAPTOPRIL)
Lupus Nephritis
6 types- require renal biopsy to diagnose. Most
common = type IV: Diffuse proliferative LN (>50%
glomeruli involved); all may be with segmental or
global involvement (active; active and chronic;
chronic) Most severe kidney involvement with active
urine sediment, HTN, heavy proteinuria (often
nephrotic range); and often reduced GFR; serology
very active; active lesions require treatment: highdose steroids, cyclophosphamide
Diffuse Alveolar
Hemorrhage
Bronchoscopy with bronchoalveolar lavage (BAL)
and biopsy is the most appropriate diagnostic
test to perform next in this patient with
suspected diffuse alveolar hemorrhage (DAH), 50%
of patients have hemoptysis. DAH occurs in the
setting of active SLE, and up to 90% of patients
have evidence of nephritis; - Mechanical ventilation
and aggressive immunosuppression are
generally required:
• Methylprednisolone 1g daily
• Cyclophosphamide
• Transfusion support as indicated
Bacterial Arthritis
Synovial fluid analysis = paramount; WBC
>50,000 most likely infectious in etiology. Can
coexist with deposition disease (gout/pseudogout).
Empiric antibiotic coverage ASAP.
VOLUME
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PAGE
4
The work room
door is fixed!
Thank you for your patience through
this challenging and dangerous time.
Special shout out to Steve Amatangelo
for rigging up an emergency escape
solution. Shout out to Leslie Applegate
for her impressive grip strength.
Resident Research Symposium
Job well done to all of
the presenters today.
Kudos to your
scholarship!
Upcoming Residency Events
GRIT & Finding Meaning in Medicine
Last meeting of the year with reflection on the
initiative thus far and planning for the year ahead.
Finding Meaning in Medicine will follow. Come for
one, stay for both! FMM Topic: Gratitude.
Time: 5:30 June 15th (Wednesday) (FMM ~6:30)
Location: Elise’s house (ask Rachel or Elise for
address)
THE
STETHOSCOOP
Vulnerable Populations
Dinner
We will be reflecting on the year
past and planning for the year
ahead. PLEASE come and be a
part of the pathway’s future!
Time: 5:30 June 13th (Monday)
Location: UH 7104 (NRR)
VOLUME
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PAGE
5
B
OAR D R EVI EW WITH T HE C HI E FS :
DUST OFF THOSE STETHOSCOPES, FOLKS. IT’S BOARDS STUDYING TIME!
Respiratory Failure Quick Hit Thoughts:
Benefits of NIPPV in patients with acute
hypoxemic respiratory failure due to heart failure
1. Decreased need for mechanical ventilation 2. Improves respiratory
parameters 3. Potential decrease in mortality
Tidal volume and plateau pressure limits to
prevent ventilator-induced lung injury
Tidal volume <6mL/kg of ideal body weight and plateau pressure <30cm
H2O
Vent mode for initial mechanical ventilation for
acutely ill, hemodynamically unstable patients
Volume-controlled continuous mandatory ventilation
Indication for hypoxia altitude simulation testing
before air travel
Lung disease and sea-level O2 saturation between 92% and 95%
Management of respiratory failure due to
progressive idiopathic pulmonary fibrosis
Palliative care
Patient positioning that increases survival in acute
respiratory distress syndrome
Prone positioning
3 criteria of spontaneous breathing trial that
predict successful extubation
1. Tolerate 30 minute weaning trial 2. RR <35 3. SaO2 >/= 90% without
arrhythmias, change in vital signs, or signs of respiratory distress
Congratulations to our very
deserving resident award winners!
Department of Internal Medicine Outstanding
Medical Student Graduate: Ashley Cattran
Herbert C. Flessa Physician’s Physician Award:
Andrew Petersen
Jerome Herman
Award for Excellence
in Patient Care:
Katie Donnelly
Resident Teacher
award: Robbie Bach
THE
STETHOSCOOP
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Weekend to-do!
Friday:
Cincinnati Fringe Festival, through Saturday. Held at various venues in Over-the-Rhine. Local,
regional, national and international artists present 12 days of artistic celebration. www.cincyfringe.com.
BalloonFest: Bands, BBQ and Beer, 4-10 p.m. Friday, noon-10 p.m. Saturday, Rising Star Casino &
Resort, 777 Rising Star Drive, Rising Sun; www.risingstarcasino.com.
Saturday: NamasDEY, 10 a.m., Paul Brown Stadium, Downtown. Yoga on the field led by instructors from The
Yoga Bar and all levels are welcome.www.bengals.com/yoga.
Northside Second Saturdays, noon-midnight, Hamilton Avenue, Northside. Art openings, later retail
hours, food and drink specials, live music, interactive events and more. Free.
FC Cincinnati Soccer, 7 p.m., Nippert Stadium, University of Cincinnati, University Heights. vs.
Montreal. www.fccincinnati.com.
Sunday: Concours d’Elegance, 10:30 a.m.-4 p.m., Ault Park, 3600 Observatory Ave., Mount Lookout. More
than 200 collector vehicles; www.ohioconcours.com.
Clam Bake in the Park, noon-9 p.m., Washington Park, 1230 Elm St., Over-the-Rhine;
www.washingtonplatform.com
TRIVIA
This statue is meant
to depict the battle of
Man vs. Disease. It is
part of a monument
to what historical
titan of pathology?
First correct
answer wins a $5
Starbucks gift card
Congrats to Joanna
Marco for
identifying
Curschmann’s
spirals in asthma.
SHOUT OUTS!!!
-to Geoff Motz for taking the time to help a patient through a difficult situation.
“Had a Jehovah's Witness patient w/ hgb of 5.5 at admission, newly dx cirrhotic
w/ UGIB. Looked up on JW website to find a rationale for her to agree to a
transfusion...and getting scoped.” Some Jehovah’s Witnesses may agree with
alternative teaching that "fractions of blood are up to the beliefs of the person"
versus whole blood.
-to the long block residents covering for graduation: Avanti Jakatdar, John Murithii, Rita Schlanger,
Javier Baez, Tim Reed, Mike Sabbah, Cameron Ditty, Kantha Medepalli. It means a great deal to
know we support each other for events like this!
-to the rising chiefs Danielle Weber, Caitlin Richter, Nabeela Siddiqi, Thomas Getreu, and Owen
Baldwin who are kicking it in gear to plan an awesome residency year 2016-2017. If anyone knows how
much work there is behind the scenes, we do, and you are doing a fantastic job already. Good luck!
THE
STETHOSCOOP