CPS Bingo!April 13, 2010

Presenter: Erin Snyder, MD

B5Today’s speaker has no conflict of interest to disclose.

The University of Alabama School of Medicine is accredited by the Accreditation Council for Continuing

Medical Education to provide continuing medical education for physicians.

UAB School of Medicine designates this educational activity for a maximum of 1 AMA PRA Category 1

Credit (s) Physicians should only claim credit commensurate with the extent of their participation in the

activity.

Case 1

58 year old African American Male presents to VA ER with AMS

Alternately agitated and somnolent

C/O pain all over when he is awake enough to respond to questions

Followed at VA in Tuscaloosa, Remote Data is “down”

Family not present

Physical Exam

Vitals: 98.2, 185/90, 95

Somnolent, slow to respond, sitting in bed, eyes closed, no acute distress

Eyes: PERRLA, EOMI

Neck: no JVD, no lymphadenopathy/thyromegaly

Chest: clear bilaterally, diffuse chest wall TTP

CV: RRR without murmur

Abd: soft nontender

Extremities: no edema, no clubbing, +2 pulses

Data

141 102 28

4.3 29 1.6

8.411.4

32.8176

CK: 146, MB: 2, troponin 0.188

EKG: +LVH, Q waves in II, III, AVF, no acute ST changes

UDS: negativeAmmonia: 20TSH: 1.80RPR: negativeHIV: negative

184Ca: 14.6Mg: 2.1PO4: 4.4

LFTs: Normal

UA: trace protein, 4+ glucose, 1+ blood, 6 RBC, <1 WBC

More Data

PTH: 7.3 (15-65)PTHrP: 16 (14-27)

SPEP: normalSerum IFE: not done

UPEP: 2 bands c/w paraproteinUrine IFE: + free Kappa Light Chains

Bone Marrow Biopsy: monoclonal plasma cell population c/w multiple myeloma

CT Chest/Abdomen/Pelvis: innumerable lytic lesions

throughout vertebral column, sternum, and medial iliac bones

Hypercalcemia: Differential Diagnosis

Hyperparathyroidism Often chronic, asymptomatic, normal physical

exam

Malignancy PTHrP: squamous cell carcinomas, renal,

bladder, breast, ovarian, lymphomas, leukemias

Osteolytic metastases: multiple myeloma, breast, lymphoma

Ectopic PTH: Ovarian, lung, pancreatic

Granulomatous Disease: TB, sarcoid

Vitamin D intoxication

Medications: Thiazides, lithium, theophylline

Etc: Hyperthyroidism, Adrenal Insufficiency, pheochromocytoma, milk alkali syndrome, immobilization, TPN

Hypercalcemia: Differential Diagnosis

Hypercalcemia: evaluation

Check PTH

Elevated or

High NormalLow

Primary

Hyperparathyroidism

Familial

Hypocalciuric

Hypercalcemia

Low PTH

PTHrP Vitamin DSPEP/UPEP

IFETSH

1,25 OH

Vitamin D high:

Granulomatous

Disease

25 OH

Vitamin D high

ingestion

Hypercalcemia: evaluation

Multiple Myeloma

Approximately 1% of cancers in US

Men>Women (1.4:1), Blacks>Whites>Asian

Median age at diagnosis 66

Proliferation of a clone of plasma cells producing a monoclonal immunoglobin

Present with: anemia, hypercalcemia, bone pain, protein gap, acute renal failure

Multiple Myeloma: diagnosis

SPEP/UPEP detects monoclonal band, IFE determines type Sensitivity of SPEP= 82%

add IFE = 93%

add UPEP and urine IFE= 97%

Urinalysis: Myeloma casts, negative protein

Peripheral Smear: rouleaux, leukopenia, thrombocytopenia

Bone marrow biopsy: usually >10% plasma cells

Skeletal survey: Chest, CTL spine, Pelvis, Skull, humeri, femora, any symptomatic areas 80% have lytic lesions, diffuse osteopenia, or fractures

Case 2

49 year old African American Female

Chief complaint: Hematuria

Intermittent x2 days

Painless

No dysuria

Never happened before

Past Medical History

Frequent urinary tract infections

Hospitalization for urosepsis 2006

Hypertension: on HCTZ since 2006

Pulmonary Thromboembolism 2002

“one time, the ER told me I had a kidney stone”

Incidental finding when she was there for headache

CT angio of chest showed renal stones, urine was infected

Family History

Both parents died with CAD in their 70s

Sister alive with HTN

No family with renal disease or kidney stones

No sickle cell disease or sickle trait

Social History

Patient works as PCT at UAB

has one daughter, healthy.

Drinks a few times a year

Never smoked, no illicit drug use

More History

Review of Symptoms

No fever, chills, weight changes

No nasal congestion, pharyngitis, rhinorrhea

No abdominal pain, nausea, vomiting, diarrhea, rectal bleeding

Post-menopausal: No period in a year, intermittent hot flashes, not worse

No change in exercise/activity level

Physical Exam

142/85, 79, temperature 97.3, weight 151.

General, HEENT, CV, Lungs all benign

Abdomen: soft, non tender, NABS, no hepatomegaly

No CVA or suprapubic tenderness

GU: Adenexa non-palpable, non-tender, Uterus small, firm, non-tender

Data

141 104 9

3.6 29 0.8110

5.7

13.6

42

318PTT 30PT 14, INR 1.07

UA: red, pH 6.0, specific gravity 1.0173+ blood, 1+ ketones, 2+ LE, +nitrite, 3+ protein, - Glucose>25 RBC, 6-10 WBC, Many bacteriaNo casts

Renal US: Normal size kidneys, Right renal calculi with moderate right hydronephrosis

CT Abdomen: Moderately severe right hydroureteronephrosis, multiple stones in the right lower pole collecting system. Delay in contrast excretion into the right collecting systemA small amount of the air in the right collecting system.

Resolution

Urology referral

Cystoscopy normal

Renal scan with mild delay, consistent with UPJ obstruction

OR Laparoscopy, ureteral stent placement, stone removal

26 Calcium Oxalate stones removed from collecting system

Red Urine

Examine Urine

Sediment

- Red Cells + Red Cells

GlomerularExtra-

glomerularHemoglobinuria/

Myoglobinuria

Gross Hematuria:Differential Diagnosis

Extraglomerular Glomerular

Renal Mass Post streptococcal glomerulonephritis

Vascular: AVM, renal artery/vein thrombosis

IG A Nephropathy

Loin-pain hematuria syndrome Thin basement membrane disease

Polycystic Kidney Disease Inherited disease: Alport syndrome, Fabrydisease, sickle cell nephropathy

Nephrolithiasis Analgesic nephropathy

Bladder disease: schistosomiasis, bladder mass, cystitis

Prostate disease

Urethritis

Extraglomerular Hematuria: Evaluation

Urine Cytology

Sensitivity 40-76% for bladder cancer

Imaging

CT urography: pre and post contrast imaging

Less sensitive: IVP, US, MRI

Cystoscopy

If negative

Low risk patients (young, transient hematuria): consider periodic urine cytology

High risk (>50 yo, persistent hematuria): q6-12 month imaging (US), urine cytology, possibly repeat cystoscopy at 1 year

Stone prevention

Increase fluid intake: increases urine flow rate and decreases urine solute

Decrease animal protein, increase fruit/vegetable intake: decreases urine calcium, uric acid and increases urine citrate

Limit dietary oxalate: spinach, rhubarb, peanuts, cashews, almonds

Low Sodium diet: increases calcium reabsorption in proximal tubule

Normal calcium intake:

Less calcium absorbed from intestine increased oxalate absorption and excretion = enhanced stone formation

Stone Prevention: medication

Check 24 hour urine for calcium, protein, creatinine, uric acid, oxalate, citric acid, pH

Hypercalciuria: thiazide

Hyperuricosuria: Allopurinol

Hypocitraturia or low pH: Potassium citrate

For calcium phospate/ calcium oxalate stones: check serum calcium and PTH

Case 3

30 year old White Female

Chief complaint: “Worst headache of my life”

Presentation: sudden onset 2 days ago

Quality: sharp pain

Severity: “Worst headache of my life”

Timing: Intermittent x2 days

Better with: dark room

Worse with: light, noise, activity

Associated findings: nausea, photophobia

Noted light-headed, dizzy, blurred vision with exercise recently

Past Medical History

Migraines

This HA is different

Usual migraine meds don’t help

Depression

Medications

OCPs

Prozac

Zolmatriptan prn

More History

Family History

No aneurysm

No Polycystic Kidney Disease

Social History

Single, two children

No tobacco, ETOH, illicits

Physical Exam

Vitals: AF, 144/90- improves to 120/90 in the room

HEENT: sharp optic disc, fundi normal, EOMI, CN intact

Neck: no meningismus, no lymphadenopathy

CV, lung, abd all normal

Neuro: 3+ symmetric DTRs, otherwise normal

Evaluation

CT head: L cerebellar infarct

MRI brain: Left vertebral artery dissection

Headache

Migraine

Cluster

Tension

Medication Overuse headache

Mass: pseudotumor, CNS tumor, meningeal tumor

Infection: meningitis, CNS abcess

Bleeding: Subarachnoid hemorrhage, Subdural hematoma, AVM, aneurysm/dissection

Migraine

Unilateral (60-70%) or bilateral

gradual onset, crescendo pain pattern

Throbbing pain

Worse with activity

Associated with nausea, aura, photophobia, phonophobia

Lasts 4-72 hrs

Cluster Headache

Always unilateral, usually around the eye

Begins quickly, quick rise to peak

Explosive, deep, continuous pain

Associated with lacrimation, eye redness, rhinorrhea/nasal congestion, sweating, sensitivity to alcohol

Lasts 30 minutes to 3 hrs, may recur at same time of day for several days/weeks at a time, then remit

Tension Headache

Usually bilateral

Pain waxes and wanes, described as tightness, stiffness

Duration variable, often at end of the day

Headache danger signs

Sudden onset, reaches maximal intensity in seconds/minutes

First or Worst Headache

Worsening headache pattern

Neurologic symptoms, other than aura

Mental status changes

Fever

Association with exercise, minor trauma

New headache in: <5 or >50, cancer, HIV, pregnancy, postpartum

Cervical artery dissection

Headache most common presenting sign 60-95% of carotid dissection

70% of vertebral dissection

Unilateral (same side as dissecting artery)

Often with neck pain, especially with carotid dissection

Associated signs: Horner’s syndrome, amarosus fugax, diplopia, TIA, pulsatile tinnitus

In absence of stroke, CT head not diagnostic MRI/MRA, CTA, ultrasound (need skilled operator)

References

Up To Date 17.3

Mazhari R, Kimmel PL. Hematuria: An algorithmic approach to finding the cause. Cleveland Clinic Journal Of Medicine. 2002; 69(11): 870-884

Portis AJ, Sundaram CP. Diagnosis and initial management of kidney stones. American Family Physician. 2001;63(7): 1329-1338

Kourambas J, et al. Role of stone analysis in metabolic evaluation and medical treatment of nephrolithiasis. J of endourology. 2001;15(2): 181-186

Debette S, Leyes D. Cervical-artery dissections: predisposing factors, diagnosis, and outcome. Lancet. 2009; 8: 668-678.

Tramontina, Gary. Alabama’s Bingo Halls. New York Times.http://www.nytimes.com/slideshow/2009/11/12/us/1112BINGO_index.html