Wednesday Lectures, 9/9/2015

TTHM a3.3 PDR (9.9.15), TQM, TLLT

10a ~ PDR (Paolo) ~ HIV Emergencies & AIDS ~
Must know, despite uncommon emergencies now…
Pulmonary & CNS Disease greatest specific manifestations.
AIDS now fairly well controlled, better compliance.
Acute Retroviral Syndrome looks like Mono… Fever & Lymphadenopathy 2-6wks postexposure, common in IVDU with other IVDU complications (i.e. endocarditis)
Once it gets to lymph nodes pretty much chronic
Risk Stratify CD4 counts come back ~ LATE.
Last CD4 within 4-6wks pretty accurate. Ever had AIDS (<200) or had AIDS defining illness?
Candida Esophagitis? Cryptococcus? Many Fungal Dsxs… opportunistic infections…
Viral Load less important, but CD4 count go well with certain Dsxs <500, <200, <50…
CD4 Estimate = ALC2000 is low risk; ALC 1000-2000 indeterminate.
Physical Exam ~ Skin & Mouth matter! ~ Crackles in lungs not there bc no inflammation!
Dermatology & Neuro deficits! & meds have common rxns too!
Not all fever is sepsis! Rheumatology, Oncology, Pharmacology common too!
Sinusitis in HIV is BAD. MAC, Lymphoma, PCP/PCJ…
high rates of NMS in HIV! (Abacavir)
PNA the most common, despite PCP ppx… S.pneumo still most common! (Bactrim misses!)
HIV pts on ppx still get PCP PNA too! Pulse Ox gradient better indicator c walk desat… v A-a…
LDH not great for Dx in ED but ID docs may trend
PCP diffuse infiltrate on exam, but anything in real life!
Steroids not good in TB, but otherwise helpful c PNA with poor sats. TB has many coinfections. Treatment in ED, consider Rifampin?…
Toxoplasmosis associated c depression (3-10%), Cryptococcal meningitis (10%), Lymphoma, TB, other CNS manifestations… Toxo typical CD4 <400, fever, headaches, AMS, Sz, or WNL!!! Image ANY AIDS pt c ANY CNS-related Symptoms! Contrast usually no more helpful than NC-CT, & can always be added later. Never LP AIDS pt without CT! Ring enhancing ~ Abscess/Toxo v Lymphoma… Typical Acute Sepsis Abx still most important to cover common acute bugs first! Cryptococcus gets Ampho, prolonged fluconazole… Meningeal signs unreliable, less than usual. Crypto antigen in CSF > india ink… NonFocal CNS still needs head CT.

11a ~ PSQ (Rossettie) *Confidential
12p ~ RPL (Sheikh)

1230 ~ Journal Club (Kinariwala)
*REVERT trial showed Trendelenburg positioning with Valsalva Maneuver improved SVT conversion from ~17% to ~43% (~214 pts ea group), p<0.001, so probably relatively useful. *Kidney Stones given Tamsulosin or CCB(nifedipine) for follow up outcome improvement? …Not so much. Medical Expulsive Therapy has no role or not an established one at least. & Drugs not cheap. Tamsulosin can cause orthostatic hypotension in elderly… Paolo doesn’t want it. Get up slowly. 130 ~ Ultrasound Review (Nicholas) ~ Jeopardy 230 ~ TLLT & Clinical Controversy (Cohen) *Controversy of Abx for URI? …ok for specific indications like Strep Pharyngitis, AOM, but probably not even necessary… we likely overtreat & may do more harm than good despite current standards of care… More pharyngitis & even PNA is viral > bacterial etiology
EB Medicine Pharyngitis only recommends Abx c Strep. AOM with effusion or severe inflammation…
*Contraception in the ED ~ OCP complications, IUDs, vaginal bleeding & emergency contraception… Role of SANE vs ED physician? Most OCPs are combined vs progestin-only “mini-pills”…

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