Random Pearls from Inpatient Rounds

Things I Learned During Rounds
fluoroquinolones can make elderly delirious.
asthmatic kids need EITHER inh OR po steroids, but not both
– Xopenex (levalbuterol) is not superior to albuterol
– diabetic pts who are NPO should be given 1/2 their usual insulin dose

– do not load warfarin!
ciprofloxacin covers Staph but not strep, so we don’t use it in the lung.
– albumin after paracentesis: 6-8g per L removed (only if >5L)

Fomites (fom-eh-tees) is plural for fomes.

The clavicle is the first bone in the fetus to calcify.

The first manifestation of GBS septic arthritis in the newborn can be refusal to move the shoulder, without systemic signs.  GBS prefers the shoulder to the hip.

All septic hips have to be drained surgically because of the tenuous blood supply to the head of the femur, which can cause avascular necrosis and Legg-Calve-Perthes disease.

Early onset GBS is < 72h from mom (type 1-2), late-onset GBS > 1 wk is community-acquired (type 3).

Early-onset –> GBS pneumonia – if symptomatic in delivery room, mortality rate 95%!

15% of hemophilia is spontaneous mutation – take a family history before a circumcision.

Risk of serious infection with circumcision = 1:50,000 (risk of dying in an MVA this year 1:5000).  Yet, chloramphenicol was taken off the market because of 1:50,000 adverse reactions.

Asthma natural hx on CXR:  causes nodules, infiltrates and bronchial thickening
– There is a relationship between PTH and EPO
– cold agglutinins:  6 drops whole blood in blue tube  (heparin) in ice water 5″ then shake 30 sec and roll slowly and watch for flocculation.
– erythema migrans – associated w Mycoplasma

PPDs:  negative in never-exposed pts, and negative for first 12 wks after exposure before immunity develops.  Also becomes negative during re-activation of TB, fever, HIV, etc.  Negative PPD does not rule out active TB.  AFB (x3) samples do (but still not a guarantee– culture results are the gold standard!)

–  Levofloxacin does have some anti-TB activity, but is never used as a single agent.

– Control tests are worthless.  Don’t do them.

Quantiferon is usually positive is active disease, but is occasionally negative.

– 1 bronch specimen is equal to 1 (not 3) AFB sputum sample.

– For r/o TB, it’s AIRBORNE, not droplet precautions.

Medication lists can be very useful in deducing medical history.

Zosyn can worsen coagulopathy – it kills all of your vitamin K producing bacteria.

FFP has an INR of 1.3 (roughly).

Only 30-40% of patients with aspiration develop a BACTERIAL pneumonia – usually, it’s a chemical pneumonitis.

Hydrocortisone stress dose:  100mg q 8 hrs or 50mg q 6 hrs x 7 days (no taper, unless on steroids before)
– doesn’t improve mortality, but does improve reversal of shock

Colloids and crystalloids
– Mix it up.
– Give 5% albumin if you’re looking for volume
– Australian study:  two groups, one with high-chloride crystalloids, one with low-choride crystalloids – and the low Cl folks did better.

Tend to get more hyperK with LR vs NS, but otherwise no real difference.

If you’ve got a liver patient in shock and they’re not swelling up, you’re not doing a good job.

False positive for amphetamines on Utox:  1st gen antipsychotics > 2nd gen; OTC decongestants.

Some babies with CSF and disseminated HSV do NOT have skin lesions – they just look sick.

Our urine tox does not distinguish between methamphetamine and amphetamine.

Difficid – new novel abx for C diff

Causes of pericardial effusions: malignant, uremia (ESRD), post-MI, infection (viral),
autoimmune, hypothyroidism (as many as 25% of patients with hypothyroid though
overall 2-5% of people with pericardial effusion), radiation, meds, trauma

HINTS for vertigo evaluation-more sensitive than MRI for brainstem stroke

Zosyn wipes out gut flora so you don’t produce Vitamin K, thus increases INR

Mutter Museum-megacolon on display with plushie toy

Converting from iv dilt drip to po dilt

HCAP (health care associated pneumonia): pneumonia caused by pseudomonas

ESBL gram negatives: E coli, Klebisella pneumoniae, Klebsiella oxytoca, others

Things that cover enterococcus: vanc, ampicillin, linezolid

R heart strain: Paradoxical split S2 and Loud S2 (pulmonic valve)

Rifaximin is a poorly absorbed antibiotic that is thought to reduce ammonia production

by eliminating ammonia-producing colonic bacteria (that normally take urea and convert
it to ammonia.) Normally the bacteria produce ammonia and other nitrogenous
compounds that are then absorbed.

Sokal Score in CML for 5y prognosis

ABCD2 score for risk of stroke after TIA

REALLY High WBC (over 100) can impair gas exchange (cause hypoxia) and can cause

kidney injury through micro-infarction.

Increased echogenicity of kidneys indicates CHRONIC renal disease.

When Dr. Whiteford is one service, all of a sudden all the patients are on lactulose and

floranex (probiotic).

Sgarbossa Criteria-For identifying MI within a LBBB

Hyponatremia– See May 15, 2004 AAFP article. Many other learning points. Find time to sit

down with chief for more details.

Prozac after stroke can improve functional performance—evidence-based!

Lateral Medullary Syndrome=Wallenberg Syndrome-posterior inferior cerebellar artery

-ipsilateral facial pain or reduced pain and temperature
-loss of pain and temperature on contralateral limbs and body
-nystagmus
-ipsilateral Horner’s (ptosis, anhydrosis, miosis)
-ispsilateral arm incoordination
-leaning and veering while sitting and walking with gait ataxia
Stress tests: Choose one from each category
Method of stress
Method of “imaging”
Reminders: no caffeine or beta-blockers before a stress test (order a cardiac diet which has
no caffeine automatically selected)
2 day Rest and Stress (with nuclear imaging)-recommended for patients weighing more
than 250 pounds or BMI >30 because of technical difficulty with the imaging (ie suboptimal
image quality resulting from relevant photon attenuation and a decreased signal-to-noise
ratio)

* See info below about how to actually order these things

Lexiscan-regadenoson, like adenosine dilates the coronary vessels and creates stress

through the concept of “steal” (blood will follow the path of least resistance). Preferred
over adenisone because it has fewer systemic side effects because it’s supposed to
selectively antagonize the adenosine subtype that is in the heart only. Caffeine inhibits its
vasodilatory effects. Reversal agent is aminophylline (like caffeine.) Contraindicated in
people with asthma.

Some Systems-Based Learning

Hospice-A patient enters hospice with 1 hospice diagnosis that portends a less than 6-

month prognosis. Hospice will not pay for life-sustaining treatment for that diagnosis,

HOWEVER, the patient can receive life-sustaining treatment for the non-Hospice diagnoses.

A patient does NOT have to be DNR to be in Hospice, but you do have to be DNR to stay at

the Hospice care center.
DNR is a physician order NOT a patient decision (though we often try to align our order
with our patient’s wishes.) This is NOT true at the VA where the patient/MDPOA must
agree with the physician order.
Palliative Care-symptom management, the inpatient team can also discuss goals of care
with patients
Hospice-if you know your patient wants Hospice, then you can just enter a Hospice
consultation AND a care management consultation for Hospice and the care managers will
contact Hospice

Things we learned about Epic

-How to order different stress tests:

“Stress test panel”

-How to find out what Coumadin clinic is doing (dosing and INR goal)-click on flowsheets

(specifically on “review flowsheets” which is the 2nd one down) on the left panel, select
anticoagulation

-How to get back into the “hospital encounter” once they’ve discharged. Go to patient’s
chart, under encounters tab, right click the hospital encounter and select “edit or addend”

-How to route discharge summaries: must be in the inpatient encounter, in the “notes”
section on the left, high the note to route, click the yellow route arrows up top and route to
“p hn smmg fm res triage RN”

Things our chief bugs us about:

-Always document supplemental O2 requirements in notes

-Updating the list obsessively: fluids, supplemental oxygen, CHF (EF), diabetes (A1c), home

O2, dates instead of “today”; because this is your primary patient safety tool for safe hand-
offs.
Metronidazole’s disulfiram reaction is milder than disulfiram itself, but is EtOH-dose dependent.
Heart Failure Classifications:
New York:  functional and symptoms – A, B, C, D.
ACC/AHA Stage:  presence of structural disease with/without HF:  I, II, III, IV
GFR cutoff for not using nitrofurantoin is 60. (It doesn’t concentrate enough to tx infection below 60.)
FDA has released new warnings about fluoroquinolones – side-effects and also that they should not be used for AECOPD, sinusitis or UTI. (Nov 2015)
Fusobacterium necrophorum – common cause of pharyngitis, a Gram-negative rod that does not grow on typical Strep agar.  Fortunately, treated by our common pharyngitis abx.  Cause of Lhermitte’s syndrome (septic thrombophlebitis of IJ or EJ).
Reticulocytes can be seen within 3-5 days in a person with anemia who has enough substrates (Fe, B12, etc.)
AML in the acute phase has a 70-80% mortality (intermediate risk).
Trial of albuterol in bronchiolitis: if severely ill and awaiting transfer; strong family or known personal hx of asthma in child.
Metformin is associated with B12 deficiency (as are PPIs).
Pre-eclampsia definition is now HTN after 20 wks gestation with: proteinuria OR severe features (i.e., proteinuria no longer required).
Jones fractures (proximal 5th metatarsal fractures near the metaphysis) in non-athletes can be treated with immobilization, non-weightbearing for 6 weeks.  Athletes should have surgical repair (quicker recovery).  The fx is in a vascular watershed area, which makes healing tenuous.
Avastin chemo causes coronary vasospasm.
Kayexelate – the sorbitol can accumulate and cause necrosis of the GI tract.
Statins for contrast-induced nephropathy: evidence that this works, probably by reducing inflammation.  Benefit in statin-naive patients, and the higher the dose of statin, the higher the benefit in general.
Gentamicin does not penetrate the CNS well unless there is active inflammation; cefotaxime is preferred for its better CNS penetration if treating for meningitis.
Insulin glargine titration protocol (“treat to target”):  if fasting glucose 150 – 200, increase by 4 U.  Check a few days later x 3 days, take average and decide again.  If 200+, increase by 8 U and do the same.
SMX/TMP can cause ATN in pts with AKI
Posterior penetrating peptic ulcer can cause pancreatitis.
 
Best imaging for pancreatitis is CT or MRCP.
Consider carvedilol for both HR control and BP management.
Use Allis clamp instead of tenaculum for IUD placement and other cervical procedures.
In patients with RA who are on immunosuppressive drugs, bridge with steroids if they have to go off their med.
Pregabalin onset for neuropathic pain is DAYS, vs gabapentin which can take up to 3 weeks to work.
Following amylase rather than lipase is better to see resolution of pancreatitis – amylase decreases faster than lipase.
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