Dx of Meningitis - CT before LP

25M college student p/w worst headache of his life, fevers, chills, painful & stiff neck. PMH epilepsy. Off meds. Hasn't had a seizure in 10 years. No other significant past medical. Tachy, febrile, tachypnic, normal O2 sat. Positive nuchal rigidity on exam. Oriented, follows commands, no motor or gaze palsy. WBCs 14. Does he need a head CT before LP?

Click here for a JAMA Rational Clinical Exam piece on bedside dx of acute meningitis (can you trust Kernig and Brudzinski?), the study that established the CT before LP rules, and some useful cards from ALiEM's PV series to enhance your bedside recall of these rules.

Ptosis, Erythema, and Vision Loss - Case

Check out this cool ophtho case in JAMA 2013. I think the answer to the What would you do next? segment is the most important learning point.

Then, do these questions and review the answers. (Not posted here so as to not spoil the case).

AAA Screening

Read this adapted from from UpToDate 2010 then answer the following questions from the AFP 2005:

M.G., a 70-year-old black man, requests refills for his medicines. His medications include lisinopril, atorvastatin, glipizide, and daily aspirin. He smoked heavily when he was younger but quit about 15 years ago. He also asks that you order “whatever tests should be done at my age.”

1. You review MG’s chart and find he is up to date on most age-appropriate immunizations and screening. You consider screening him for abdominal aortic aneurysm (AAA). Which of the following screening regimens reflects the U.S. Preventive Services Task Force (USPSTF) recommendations on screening for AAA?
A. Screen men and women aged 65 to 75 years.
B. Screen men yearly between the ages of 65 and 75 years.
C. Do not screen men who quit smoking more than 10 years ago.
D. Screen men aged 65 to 75 years who have ever smoked.
E. Screen women aged 75 to 85 years who have ever smoked.

2. Which one of the following statements about AAA is correct?
A. Blacks and patients with diabetes are at increased risk for AAA.
B. There is a low risk for surgical complications from AAA repair.
C. Operative mortality for open surgical repair of an AAA is less than 1 percent.
D. Men generally die from AAA rupture at an older age than women.
E. An age of 65 or older, male sex, and a history of smoking are the major risk factors for AAA.

3. After you discuss the risks and benefits of AAA screening with MG, he decides to proceed with screening. Which of the following statements about screening for AAA is/are are correct?
A. Ultrasonography is the screening test of choice.
B. An estimated 500 men aged 65 to 74 years who have ever smoked would need to be screened to prevent one AAA-related death over five years.
C. Screening and surgical repair of large AAAs in older men decreases all-cause mortality.
D. Abdominal palpation is an adequate screening alternative.

Answers

Gout Review

This one-pager on gout was adapted from this In The Clinic review from Annals 2010. Review the article and answer the MKSAP questions at the end.

Answers

Surgical Site Infections Prophylaxis

After reviewing this 2011 review article from the AFP, you should be able to answer the following questions:

1. What are the six Surgical Care Improvement Project (SCIP) performance measures?

2. In the recent study referenced in the article, approximately what percentage of surgical patients received prophylactic antibiotics within the appropriate time frame?

3. When should repeat antibiotic administration be done?

4. What is the go-to prophylactic antibiotic for most clean-contaminated surgeries?

5. When should vancomycin be used prophylactically?

6. When should metronidazole be added to the prophylactic regimen?

Answers

Cirrhosis Treatment Nuggets

Nuggets taken from AFP review paper on treatment in cirrhosis/chronic liver failure

Link to paper:  Liver Failure Treatment

1) In a patient with ascites, list the Grade A treatment recs.  (hint: 3 types)

2) What percentage of patients with ascites have cirrhosis as its etiology?

3) List causes of ascites that have SAAG <1.1 (hint: 1 malignant, 1 infectious, 1 endocrine/exocrine)

4) If propranolol is contraindicated for variceal bleeding prophylaxis, what's the next drug you can use?

Child-Pugh criteria mnemonic

HAPI BAbi

-hepatic encephalopathy
-ascites
-PT/INR

-Bili
-Albumin

Diagnostic Criteria for SLE

In keeping with our series on mnemonics for rheumatology diagnositic criteria: One on Lupus-

Article from AFP 2003 on Dx of SLE

How many criteria are there?
How many do you need?
What are the criteria?
Know a good mnemonic to remember?

Answers

Hair Loss

A frequently overlooked topic in general outpatient medicine, but should always be thoroughly evaluated and treated since it can be psychologically quite damaging to the patient and may be an indicator of underlying systemic disease.

A good article from the AFP, 2009 on the differential and treatments.

Name the diagnosis given the description and give a brief pathophysiological description of the diagnosis:

1. Focal, non-scarring, well-demarcated, normal scalp. Tip-off - exclamation point hairs.

2. Diffuse hair thinning in an elderly woman. Frontal hairline intact.

3. Focal hair loss with scaling scalp

4. Psych patient with patchy hair loss

5. Large amount of diffuse hair loss. 3 months ago the patient was in the ICU for a severe pneumonia.

Answers

Improving Outcomes in Acute Stroke

Two articles on management strategies in Acute Stroke and their affect on outcomes:

Processes in Acute Stroke, JAMA, 2010
Mannitol in Acute Stroke, Cochrane, 2009

After reading, should be able to answer the following questions:

What processes of care improve outcomes in acute stroke? (3)
Is mannitol indicated in the treatment of brain edema in the setting of acute stroke?


Bonus:

Read this:

Preventing VTE in Stroke, 2005

What may be the number one cause of mortality in the acute period post-stroke?


Answers

Rheumatoid Arthritis - Essentials

What are the diagnostic criteria for RA?
What's the most specific lab test for RA?
What is the treatment for RA? (3 parts)
What are the 4 DMARDs (1 is a group)?

Answers

Tuberculosis

Comprehensive review article on tuberculosis from NEJM by Zumla et al, 2013.

Related: An article from Journal of ID, Metcalfe, et al. 2011, re: the use of inteferon-gamma release assays in diagnosis of active pulmonary TB.

CME Questions for this article from the NEJM website:

1. Risk of developing active TB among pt's with latent infection?
2. Which is true re: diagnosis of latent or active TB?
1. TB skin test is as specific as interferon-gamma release assay but less sensitive in diagnosing latent TB. 
2. solid culture medium is the standard for diagnosis of active TB. 
3. interferon gamma release assays are useful in the diagnosis of active TB. 
4. the Xpert MTB/RIF assay test is more sensitive than smear microscopy. 
3. Which is true re: HIV & TB coinfection?
1. Early ART therapy has no effect on mortality. 
2. Early ART therapy improves outcomes in pts with TB meningitis. 
3. IRIS occurs in at least 10% of HIV-infected patients who start ART during TB treatment. 
4. The most common manifestation of IRIS is a maculopapular rash.