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Файл:Ординатура / Хирургия / Библиотека им академика М.И. Перельмана / Книга_3063_Библиотеки_им_академика_М_И_Перельмана
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Chronic hepatitis C is the most common cause of cirrhosis and hepatoma in the United States. It
is transmitted via exposure to blood and blood products.
As of recently, there are effective drugs that provide >90% cure of chronic hepatitis C. FDA-
approved drugs include sofosbuvir (Sovaldi) and simeprevir (Olysio). When either of these
drugs is combined with peginterferon and ribavirin, hepatitis C can be cleared from the liver in
>90% of the most common form of the virus (genotype 1).
Acute hepatitis E is found mostly in Asia. It has the same acute presentation as acute hepatitis A
or B. Hepatitis E is particularly associated with increased severity in pregnant women.
Final Diagnosis
Chronic hepatitis B
Incubation period can be 1–6 mos—
First test to become abnormal is surface antigen, which becomes abnormal before the
development of symptoms or an increase in LFTs
—
Chronic hepatitis B is defined as the persistence of hepatitis B surface antigen for >6
mos.
—
If the PCR-RNA viral load is elevated, patients should be treated.
If there is fibrosis on the liver biopsy, treatment is even more urgent to prevent progression
to cirrhosis, which is irreversible.
71
Case 8
Chief Complaint
“I’ve had a pain in my leg for the last several weeks.”
History and Physical Examination
A 54-year-old man with a history of diabetes mellitus and peripheral vascular disease
comes to your office with an ulcer on his left leg below the knee for the last week. He has
been on aspirin alone as treatment for his peripheral vascular disease for several years
and has a stable pattern of leg claudication after he walks more than several blocks or a
few flights of stairs. He has had ulcerations of the skin on his legs intermittently for
several years, which have all resolved with local care. Generally, these ulcerations have
not been painful. The area at the site of the ulcer has been painful for the last 2 weeks.
Vital signs are T 37.4 C (99.3 F), BP 130/80 mm Hg, and pulse 72/min. He appears to be
pleasant and in no distress. Examination of the extremities shows a 3-cm ulceration on the
medial surface of proximal left tibia. The area is erythematous, mildly swollen, and tender
with a small sinus tract that drains a tiny amount of purulent material. The remainder of the
physical examination is normal.
Differential Diagnosis
Aseptic ulceration
1.
Osteomyelitis
2.
Cellulitis
3.
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Initial Management
Setting: outpatient; emergency department if symptoms are severe
Diagnostic/Therapeutic Plan
Test Results
CCS NOTE
The CCS values an orderly and sequential evaluation over a jump straight to a single
most accurate diagnostic test.
Assessment
Skin abscess4.
Plain x-rays of leg
ESR
CBC
X-rays of leg normal
ESR elevated at 90 mm/h (normal <20 mm/h)
CBC normal
When patient is short of breath, do chest x-ray before chest CT.
When patient has leg ulcer, do x-ray before bone scan or MRI, even if the x-ray
comes back negative.
73
This patient is at increased risk of infection because of the poor circulation from his peripheral
vascular disease. Diabetes gives a similar risk. Other risks for osteomyelitis also include
bacteremia from any source with seeding of the bone, although this is more common in
children, and the presence of a prosthetic device (e.g., total knee replacement).
An overlying ulceration and cellulitis can often be difficult to tell apart from an underlying
osteomyelitis. This patient’s symptoms are worse than usual with his ulcers in the past. In
addition, the area is tender with a draining sinus tract, which is more consistent with
osteomyelitis. The ESR is also quite elevated, which is consistent with osteomyelitis as well.
A normal x-ray of the bone does not rule out osteomyelitis; it can take many weeks for it to
become abnormal because >50% of the bone must become demineralized first. A technetium
bone scan is more sensitive, and will detect an osteomyelitis after several days. However, an
overlying infection can obscure the definitive diagnosis, and CT or MRI is superior for
localizing the infection to the bone itself. CT or MRI is also superior for identifying the precise
amount of bony destruction. MRI is superior to CT in terms of sensitivity. The MRI becomes
abnormal within 2 days after the onset of osteomyelitis. This is equal in sensitivity to bone scan
but with far greater specificity. MRI is excellent at distinguishing bone involvement from
overlying soft tissue infection. Bone biopsy prior to starting antibiotics is mandatory to identify
a specific organism.
CCS NOTE
The status of your patient can come up spontaneously as a “nurse’s note,” telling you
how the patient is doing. You can’t predict when this will happen. These notes come up
spontaneously as the clock is moved forward.
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Further Diagnostic Plan Results
MRI scan of the leg Mild bony destruction of the proximal tibia
Biopsy of the tibia Neutrophils visible on Gram stain. S. aureus
grows in culture
Treatment Plan
Discussion
The most common organism causing osteomyelitis is still S. aureus. In diabetics or in
osteomyelitis contiguous to decubitus ulcers, gram-negative bacilli such as E. coli or
Pseudomonas are also common.
Bone biopsy is essential because there is no other definitive way to know the specific agent
causing the infection. Culture of the wound or draining sinus tract does not correlate well with
the organism causing the bone infection. Empiric treatment should be discouraged.
Oxacillin (or nafcillin) and ciprofloxacin or oxacillin and a third-generation cephalosporin are
adequate empiric treatment before knowing the results of the bone biopsy. Vancomycin to cover
the Gram-positive organisms can be used if the patient has had an anaphylactic reaction to
penicillin. Cephalosporins can be used if the penicillin allergy is only a rash. Other options for
empiric osteomyelitis therapy before knowing the results of bone biopsy are carbapenems or
the beta lactam/beta lactamase combinations, such as piperacillin/tazobactam or
ampicillin/sulbactam.
IV antibiotics for 6–12 wks; oxacillin or nafcillin if the organism is sensitive, vancomycin if
it is MRSA
Surgical debridement as necessary2.
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Biopsy is essential because gram-negative osteomyelitis can be treated with oral ciprofloxacin.
You cannot adequately treat the patient without the biopsy.
Final Diagnosis
Acute osteomyelitis
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Case 9
Chief Complaint
“I’m having fever, cough, body aches, and chest pain.”
History and Physical Examination
A 77-year-old man comes to the emergency department complaining of an episode of
shaking chills earlier that night. He has since developed right-sided pleuritic chest pain,
fever, sweats, malaise, and purulent sputum with mild hemoptysis. He has osteoarthritis,
but his past medical history is otherwise unremarkable. He has smoked 1 pack of
cigarettes per day for 30 years.
Vital signs are T 39.8 C (103.6 F), BP 90/60 mm Hg, pulse 106/min, and respirations
32/min. The patient is diaphoretic but alert. Lung examination reveals right basilar rales.
Examination of skin, heart, joints, and nervous system are normal.
Differential Diagnosis
Pneumococcal pneumonia1.
Legionella pneumonia2.
Haemophilus pneumonia3.
Aspiration pneumonia4.
Tuberculosis5.
Postobstructive pneumonia from lung cancer6.
Bronchitis7.
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Initial Management
Setting: emergency department
Diagnostic/Therapeutic Plan
CCS NOTE
Shaking chills suggest bacteremia and should always result in ordering blood cultures.
CCS NOTE
For dyspneic patients, an oximeter is very accurate in the assessment of hypoxia. ABG
is necessary when CO
2
retention is a possibility, such as in COPD.
Test Results
Mycoplasma pneumonia
8.
Chest x-ray
Sputum Gram stain
Sputum culture
Pulse oximeter
CBC
Blood culture
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Assessment
The history, physical examination, and chest x-ray confirm that this is pneumonia. The history
of shaking chills is indicative of the bacteremia that can accompany bacterial pneumonia. The
other symptoms, such as fever, cough, sputum, and hemoptysis, could present with bronchitis as
well. Chest x-ray is done to distinguish between pneumonia and bronchitis; with bronchitis,
chest x-ray is generally normal.
If the sputum did not reveal a specific organism then bronchoscopy with biopsy could be done
to confirm a specific bacteriologic diagnosis. Bronchoscopy is only necessary if the patient
does not respond to empiric therapy and is worsening.
Further Diagnostic Plan Results
Decubitus x-rays of chest Fluid in chest is free-flowing (i.e., presence of
an effusion)
CLINICAL PEARL
Clinical improvement in pneumonia may not be apparent for up to 72 hours after the
initiation of antibiotics. If symptoms do not improve after 72 hours, potential issues
Right lower lobe, infiltrate with blunting of right costophrenic angle
Abundant polymorphonuclear leukocytes with gram-positive, lancet-shaped diplococci in
pairs and chains
Sputum culture grows pneumococcus
Pulse oximeter 92% saturation
WBC count 23,000/mm
3
Blood culture negative
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include resistant organisms, metastatic foci, effusions, or non-infectious etiology. In this
case, chest CT and possible bronchoscopy should be considered.
CLINICAL PEARL
Consider community-acquired MRSA in IV drug users; concurrent or recent influenza
(high yield), severe pneumonia requiring intubation and ICU admission, and necrotizing
(cavitary) pneumonia.
Treatment Plan
Discussion
Outpatient therapy of pneumonia is best with the new fluoroquinolones: levofloxacin,
gatifloxacin, or moxifloxacin. These agents cover most penicillin-insensitive pneumococcus.
The fluoroquinolones can be used for inpatient therapy as well. Ciprofloxacin should not be
used for pneumonia. Other outpatient treatments include azithromycin and clarithromycin.
CCS NOTE
Hospitalize patient
IV antibiotics (ceftriaxone or fluoroquinolones)
Thoracocentesis of the parapneumonic effusion (may need drainage if complicated
parapneumonic effusion)
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