CPS Bingo!
April 13, 2010
Presenter: Erin Snyder, MD
B5
Today’s speaker has no conflict of interest to disclose.
The Unive...
Case 1
 58 year old African American Male presents toVA ER with
AMS
 Alternately agitated and somnolent
 C/O pain all o...
Physical Exam
 Vitals: 98.2, 185/90, 95
 Somnolent, slow to respond, sitting in bed, eyes closed, no acute distress
 Ey...
Data
141 102 28
4.3 29 1.6
8.4
11.4
32.8
176
CK: 146, MB: 2, troponin 0.188
EKG: +LVH, Q waves in II, III, AVF,
no acute S...
More Data
PTH: 7.3 (15-65)
PTHrP: 16 (14-27)
SPEP: normal
Serum IFE: not done
UPEP: 2 bands c/w paraprotein
Urine IFE: + f...
Hypercalcemia:
Differential Diagnosis
 Hyperparathyroidism
 Often chronic, asymptomatic, normal physical
exam
 Malignan...
 Granulomatous Disease:TB, sarcoid
 Vitamin D intoxication
 Medications:Thiazides, lithium, theophylline
 Etc: Hyperth...
Hypercalcemia: evaluation
Check PTH
Elevated or
High Normal
Low
Primary
Hyperparathyroidism
Familial
Hypocalciuric
Hyperca...
Low PTH
PTHrP Vitamin D
SPEP/UPEP
IFE
TSH
1,25 OH
Vitamin D high:
Granulomatous
Disease
25 OH
Vitamin D high
ingestion
Hyp...
Multiple Myeloma
 Approximately 1% of cancers in US
 Men>Women (1.4:1), Blacks>Whites>Asian
 Median age at diagnosis 66...
Multiple Myeloma: diagnosis
 SPEP/UPEP detects monoclonal band, IFE determines type
 Sensitivity of SPEP= 82%
 add IFE ...
Case 2
 49 year old African American Female
 Chief complaint: Hematuria
 Intermittent x2 days
 Painless
 No dysuria
...
Past Medical History
 Frequent urinary tract infections
 Hospitalization for urosepsis 2006
 Hypertension: on HCTZ sinc...
 Family History
 Both parents died with CAD in their 70s
 Sister alive with HTN
 No family with renal disease or kidne...
Review of Symptoms
 No fever, chills, weight changes
 No nasal congestion, pharyngitis, rhinorrhea
 No abdominal pain, ...
Physical Exam
 142/85, 79, temperature 97.3, weight 151.
 General, HEENT, CV, Lungs all benign
 Abdomen: soft, non tend...
Data
141 104 9
3.6 29 0.8
110
5.7
13.6
42
318
PTT 30
PT 14, INR 1.07
UA: red, pH 6.0, specific gravity 1.017
3+ blood, 1+ ...
Resolution
 Urology referral
 Cystoscopy normal
 Renal scan with mild delay, consistent with UPJ obstruction
 OR Lapar...
Red Urine
Examine Urine
Sediment
- Red Cells + Red Cells
Glomerular
Extra-
glomerular
Hemoglobinuria/
Myoglobinuria
Gross Hematuria:
Differential Diagnosis
Extraglomerular Glomerular
Renal Mass Post streptococcal glomerulonephritis
Vascul...
Extraglomerular Hematuria:
Evaluation
 Urine Cytology
 Sensitivity 40-76% for bladder cancer
 Imaging
 CT urography: p...
Stone prevention
 Increase fluid intake: increases urine flow rate and decreases urine
solute
 Decrease animal protein, ...
Stone Prevention: medication
 Check 24 hour urine for calcium, protein, creatinine, uric
acid, oxalate, citric acid, pH
...
Case 3
 30 year oldWhite Female
 Chief complaint: “Worst headache of my life”
 Presentation: sudden onset 2 days ago
 ...
Past Medical History
 Migraines
 This HA is different
 Usual migraine meds don’t help
 Depression
 Medications
 OCPs...
More History
 Family History
 No aneurysm
 No Polycystic Kidney Disease
 Social History
 Single, two children
 No to...
Physical Exam
Vitals: AF, 144/90- improves to 120/90 in the room
HEENT: sharp optic disc, fundi normal, EOMI, CN intact
Ne...
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
 In...
Migraine
 Unilateral (60-70%) or bilateral
 gradual onset, crescendo pain pattern
 Throbbing pain
 Worse with activity...
Cluster Headache
 Always unilateral, usually around the eye
 Begins quickly, quick rise to peak
 Explosive, deep, conti...
Tension Headache
 Usually bilateral
 Pain waxes and wanes, described as tightness, stiffness
 Duration variable, often ...
Headache danger signs
 Sudden onset, reaches maximal intensity in seconds/minutes
 First or Worst Headache
 Worsening h...
Cervical artery dissection
 Headache most common presenting sign
 60-95% of carotid dissection
 70% of vertebral dissec...
References
 UpTo Date 17.3
 Mazhari R, Kimmel PL. Hematuria: An algorithmic approach to finding the cause.
ClevelandClin...
CPS Bingo!
CPS Bingo!
CPS Bingo!
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  • Bingo question: upper level- approach to pt with no history available
  • Bingo question: Focused PE
    Labs to order with AMS
    Imaging to order with AMS
  • Bingo: ddx hypercalcemia, what other tests do you need.
    Interpret SPEP/UPEP
  • Step one- confirm, check ionized calcium/albumin
    FHH: 24 urine calcium with <100mg/24hrs
  • Myeloma casts: waxy laminated casts from light chains, no proteinuria on dip because light chains are not detected.
    Plasma cells usually not seen in circulating blood
  • Bingo questions: ddx gross hematuria, what do you want to know from hx, physical
  • Bingo questions: hypertension history? h/o kidney stones
    Any family/social history that you want to know
  • Bingo questions: specific family history questions (sickle cell, polycystic kidney)
    Any ROS specifics? Pharyngitis, viral syndrome, exercise
  • Bingo question: physical exam
  • Bingo: how do you start the work up? What is the first test you want?
  • Bingo question: workup?, what are you looking for in UA, imaging test?,
    Is this enough to make the diagnosis?
    air in the collecting system?
  • Bingo questions? How to prevent calcium oxalate stones
  • Glomerular: nephrology referral
    Extraglomerular: imaging + urology referral
  • Sickle cell disease: papillary necrosis
    Young patients usually benign Study: 1000 young men who had yearly urinalyses 18-33 yo; 39% hematuria once, 16% twice or more.
    Study: up to 13 percent of men and postmenopausal women
    Older patients more likely to be malignant
  • Calcium oxalate, calcium phosphate, uric acid, cystine, struvite
  • Low pH seen in uric acid, cysteine, calcium phosphate stones
  • Bingo question: ddx headache
    Medical student: Seven cardinal features of a pain complaint
    Danger signs of headache- what PFISH questions, what physical exam do you do
  • Ocp and headache?
  • Bingo: what next?
  • Common headache syndromes: migraine, cluster, tension
  • Imaging +/- LP in patients with these danger signs
  • Bingo: what is horner’s syndrome: miosis, ptosis, anhydrosis
  • CPS Bingo!

    1. 1. CPS Bingo! April 13, 2010 Presenter: Erin Snyder, MD B5 Today’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.
    2. 2. Case 1  58 year old African American Male presents toVA ER with AMS  Alternately agitated and somnolent  C/O pain all over when he is awake enough to respond to questions  Followed atVA inTuscaloosa, Remote Data is “down”  Family not present
    3. 3. 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 wallTTP  CV: RRR without murmur  Abd: soft nontender  Extremities: no edema, no clubbing, +2 pulses
    4. 4. Data 141 102 28 4.3 29 1.6 8.4 11.4 32.8 176 CK: 146, MB: 2, troponin 0.188 EKG: +LVH, Q waves in II, III, AVF, no acute ST changes UDS: negative Ammonia: 20 TSH: 1.80 RPR: negative HIV: negative 184 Ca: 14.6 Mg: 2.1 PO4: 4.4 LFTs: Normal UA: trace protein, 4+ glucose, 1+ blood, 6 RBC, <1WBC
    5. 5. More Data PTH: 7.3 (15-65) PTHrP: 16 (14-27) SPEP: normal Serum IFE: not done UPEP: 2 bands c/w paraprotein Urine 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
    6. 6. 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
    7. 7.  Granulomatous Disease:TB, sarcoid  Vitamin D intoxication  Medications:Thiazides, lithium, theophylline  Etc: Hyperthyroidism, Adrenal Insufficiency, pheochromocytoma, milk alkali syndrome, immobilization,TPN Hypercalcemia: Differential Diagnosis
    8. 8. Hypercalcemia: evaluation Check PTH Elevated or High Normal Low Primary Hyperparathyroidism Familial Hypocalciuric Hypercalcemia
    9. 9. Low PTH PTHrP Vitamin D SPEP/UPEP IFE TSH 1,25 OH Vitamin D high: Granulomatous Disease 25 OH Vitamin D high ingestion Hypercalcemia: evaluation
    10. 10. 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
    11. 11. 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
    12. 12. Case 2  49 year old African American Female  Chief complaint: Hematuria  Intermittent x2 days  Painless  No dysuria  Never happened before
    13. 13. Past Medical History  Frequent urinary tract infections  Hospitalization for urosepsis 2006  Hypertension: on HCTZ since 2006  PulmonaryThromboembolism 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
    14. 14.  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
    15. 15. 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
    16. 16. 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
    17. 17. Data 141 104 9 3.6 29 0.8 110 5.7 13.6 42 318 PTT 30 PT 14, INR 1.07 UA: red, pH 6.0, specific gravity 1.017 3+ blood, 1+ ketones, 2+ LE, +nitrite, 3+ protein, - Glucose >25 RBC, 6-10 WBC, Many bacteria No 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 system A small amount of the air in the right collecting system.
    18. 18. 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
    19. 19. Red Urine Examine Urine Sediment - Red Cells + Red Cells Glomerular Extra- glomerular Hemoglobinuria/ Myoglobinuria
    20. 20. 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, Fabry disease, sickle cell nephropathy Nephrolithiasis Analgesic nephropathy Bladder disease: schistosomiasis, bladder mass, cystitis Prostate disease Urethritis
    21. 21. 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
    22. 22. 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
    23. 23. 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
    24. 24. Case 3  30 year oldWhite 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
    25. 25. Past Medical History  Migraines  This HA is different  Usual migraine meds don’t help  Depression  Medications  OCPs  Prozac  Zolmatriptan prn
    26. 26. More History  Family History  No aneurysm  No Polycystic Kidney Disease  Social History  Single, two children  No tobacco, ETOH, illicits
    27. 27. 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
    28. 28. Evaluation  CT head: L cerebellar infarct  MRI brain: Left vertebral artery dissection
    29. 29. 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
    30. 30. 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
    31. 31. 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
    32. 32. Tension Headache  Usually bilateral  Pain waxes and wanes, described as tightness, stiffness  Duration variable, often at end of the day
    33. 33. 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
    34. 34. 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)
    35. 35. References  UpTo Date 17.3  Mazhari R, Kimmel PL. Hematuria: An algorithmic approach to finding the cause. ClevelandClinic 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. NewYork Times.http://www.nytimes.com/slideshow/2009/11/12/us/1112BINGO_index.html
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