July 14, 2017

Pearls of the Week 

Olesya & Dylan presented a patient with a right hemiparesis due to basal ganglia CVA found to have troponin elevation and biphasic T waves in 2 EKG leads. 

WELLEN'S SIGN:

Should make you worried about proximal LAD occlusion in a patient presenting with chest pain & this finding on EKG.

 

Dr. Sanders presented a case of dizziness & we discuss using the hints exam to separate central from peripheral causes of stroke. 

THE HINTS EXAM:

Kattah, J. et al. "HINTS to Diagnose Stroke in the Acute Vestibular Syndrome: Three-Step Bedside Oculomotor Examination More Sensitive Than Early MRI Diffusion-Weighted Imaging". Stroke. 2009. 40(11):3504–3510.

HINTS is a 3-part oculomotor physical exam designed to help differentiate between a peripheral and central etiology of vertigo.

ONLY for use in patients with ongoing/continuous vertigo.

THE THREE COMPONENTS

Rainer, Spiegel et. al. Dizziness in the emergency department: an update on diagnosis. Swiss Med Wkly. 2017;147:w14565. https://doi.org/10.4414/smw.2017.14565. 

h-HIT (Horizontal head impulse test):

• How to:
• Ask patient to focus on your nose.
• Rotate the patient's head 20-40 degrees to the right or left
• Observe for nystagmus. Watch for one eye to lag and then catch up with a quick saccade. 
• Lots of examples starting at 15 minutes in this video:  https://www.youtube.com/watch?v=XpghlvnrREI
• Normal result in peripheral vertigo: One eye will lag and then catch up with a quick saccade. 
• HINTS positive: If there is no lag/saccade & the patient's eyes stay fixed on your nose. That's right, if the test is normal/negative, you should be worried about stroke.  

Nystagmus: 

• How to: 
• Observe the patient & have them move their eyes laterally. 
• Normal Result: If nystagmus is present it should be unidirectional. 
• HINTS positive: If any other type of nystagmus is seen (vertical, bidirectional). 
• Video example at 2:30 --> https://www.youtube.com/watch?v=1q-VTKPweuk

Skew:

• How to: 
• Alternately cover one eye and then the other without touching the patient. Watch for vertical or diagonal movement of the uncovered eye. 
• Normal Result: No eye movement.
• HINTS positive: Vertical or diagonal movement of the uncovered eye. 
• Video example at 3:35 --> https://www.youtube.com/watch?v=1q-VTKPweuk

HINTS exam Positive (i.e. central) if:

✓Patient with at least 1 stroke risk factor
✓Any one of the 3 tests (HIT, nystagmus or skew) are positive
✓No history of recurrent vertigo

HINTS Exam operating characteristics according to the Kattah et al study:  “100% sensitive and 96% specific for stroke”

Eric & James presented a case of a young man with severe back pain and spasms found to have numerous spinal compression fractures. 

Eric reviewed with us back pain red flag symptoms:

Trauma​
Unexplained weight loss​
Neurologic symptoms​
Age > 50​
Fever​
Intravenous drug use​
Steroid use​
History of cancer

 

Kelly presented a young patient petechiae & fatigue that was found to have a new diagnosis of acute lymphoblastic leukemia.

Kelly reminded us a bit about ALL:

ALL is uncontrolled proliferation of clonal lymphoid cells.

Sub-types: B or T cell (B is more common)

Incidence: Mostly kids but there's a 2nd peak of incidence in patients (more men) > 60 yrs.

BCR-ABL mutation testing is important to decide treatment

She then reviewed for us the basic tenants of ALL treatment:

Induction​

Rapidly kill tumor cells to attain remission (less than 5% blasts in marrow)​

Monitor for tumor lysis syndrome​
Should include intrathecal chemotherapy for prophylaxis against CNS spread​
Typically includes vincristine, steroid, anthracycline, (TKI for Ph+)​

Consolidation ​

High dose therapy to further reduce burden​

If high risk can consider autologous vs allogenic stem cell transplant​

​Maintenance ​

Kill any residual cells, lasts about 2 years​

Typically methotrexate, mercaptopurine +/- vincristine, steroids