Patient: RG NKDA RG presented to the ED complaining ofjonmanocchio.weebly.com/uploads/8/9/7/8/8978432/case_presentation.pdf · Patient: RG DOB: 09.26.1959 NKDA RG presented to the

Patient: RG

DOB: 09.26.1959

NKDA

RG presented to the ED complaining of new onset generalized weakness

Difficulty walking, fatigued with exertion, feeling off balance, dry mouth, and dysphasia

HPI: approximately two days

PMH: Chronic back pain, remote heroin addiction (possible current addiction based on patient exam), positive for Hepatitis B and C

FH: unavailable

SurH: Cataract surgery

SH: Admits to 10 cigarettes per day, denies alcohol use, and denies current illicit drug use

Home Medications

› Dolophine® (methadone)

› Bactrim DS (sulfamethoxazole/trimethoprim)

› Vibratab® (doxycycline)

Hospital Medications

Review of Systems

Vitals

BMP

› Renal Function

CBC

Electrolytes

LFT’s

Miscellaneous

Cultures

Radiology

Neuro Labs

AchR Antibody

MuSK Antibody

EMG

Physical Exam

Myasthenia Gravis (MG)

Pulmonary Embolism (PE)

Aspiration Pneumonia

Acute Respiratory Distress Syndrome (ARDS)

Wound Abscesses

Myasthenia Gravis › Generalized weakness spreading in an

ascending fashion

› Per review of neurologist, noted classic signs of MG

› RG quickly progressed to a proposed myasthenic crisis (involving respiratory failure)

› Goals:

Confirm diagnosis with tests

Begin therapy for MG based on severity of symptoms

Manage further complications, if needed

Myasthenia Gravis

› Pyridostigmine 90mg q6h

› Plasmapheresis

› Monitor for improvement of symptoms

› Potential adverse effects

DUMBBELSS

Pulmonary Embolism (PE)

› Despite prophylaxis, RG developed a PE

Possibly too low of a dose

› Goals

Increase anticoagulation (possible filter

insertion)

Consider warfarin therapy upon discharge

Monitor for signs of recurrent PE

SOB

Swollen lower extremity

Pulmonary Embolism (PE)

› Enoxaparin 60mg q12h (60kg patient)

› Monitor for signs of bleeding

RG developed bleeding from an unknown

source.

Counsel on use of filter (patient denied use)

› Continue heparin

› Ambulate RG as soon as clinically safe

Aspiration Pneumonia

› Developed secondary to barium swallow

Most likely due to dysphasia

› Goals

Manage with broad spectrum antibiotics

Especially anaerobes

Reduce risk of progressing infection

Aspiration Pneumonia

› Vancomycin 1250mg IV QD

› Pipercillin/tazobactam 4.5g IV q8h

› Therapy changed to ampicillin/sulbactam 3g IV q6h

› Monitor for adverse reactions and symptom improvement

Acute Respiratory Distress Syndrome

(ARDS)

› RG quickly developed ARDS

› Can exacerbate already proposed MG crisis

› Goals

Increase oxygenation

Reduce inflammation

Provide respiratory support (intubation)

Acute Respiratory Distress Syndrome

(ARDS)

› RG should be placed in a pronator bed

Sedate patient with midazolam (1-2mg PRN)

and fentanyl (4mg QD)

Paralytics are inappropriate

Corticosteroids are inappropriate during MG

crisis

Maintain pronation until symptoms improve

Wound Abscesses

› Significant on the inner right and left thighs

Possibly secondary to heroin injections

› Home regimen of antibiotics did not improve

› Goals

Begin empiric antibiotic therapy

Obtain wound cultures

Narrow antibiotics when appropriate

Wound Abscesses › Vancomycin 1250mg IV QD

› Pipercillin/tazobactam 4.5g IV q8h

› Metronidazole 500mg IV q8h was started after vancomycin was discontinued

› Therapy changed to ampicillin/sulbactam 3g IV q6h (targeted therapy)

› Negative for botulinin toxin

Not indicative of absence of disease

Summary

› RG was discharged to the general medicine

floor

› After a few days, he developed suspected

HCAP

› Transferred back to the ICU for treatment

› Antibiotic therapy was changed

Tobramycin 420 mf QD

Pipercillin/tazobactam 4.5g q8h

Introduction

› Autoimmune

› Presentation

› Broad range of symptoms

Epidemiology

› Prevalence

› Gender

› Age

Risk Factors › Family History

› Female

› Exacerbating disorders

Etiology › Three mechanisms of receptor destruction

Accelerated turnover

Blockade

Damage

› Thymus involvement

Signs and Symptoms

› Weakness

› Fatigability

› Ocular issues

Ptosis

Diplopia

› Cranial Issues

› No sensory impairment

Diagnostic Procedures

› Acetylcholinesterase Test

› Electrodiagnostic test (EMG)

› Pulmonary Function Test

› MuSK Antibody Test

› Acetylcholine Receptor Antibody Test

Treatment

› Acetylcholinesterase Inhibitors

Cholinergic agents may be inappropiate

› Thymectomy

› Immunosuppression

› Plasmapheresis

› Management of crisis

Follow-Up

› Monitoring

Signs and Symptoms

Number of receptors

› Prognosis

Chaudhuri A and Behan PO. Myasthenic Crisis. Q J Med. 2009; 102: 97-107.

Drachman Daniel B, "Chapter 381. Myasthenia Gravis and Other Diseases of the Neuromuscular Junction" (Chapter). Fauci AS, Braunwald E, Kasper DL, Hauser SL, Longo DL, Jameson JL, Loscalzo J: Harrison's Principles of Internal Medicine, 17e: http://0-www.accesspharmacy.com.polar.onu.edu

Jamal BT and Herb K. Perioperative Management of Patients with Myasthenia Gravis: Prevention, Recognition, and Treatment. OOOE. 2009; 107 (5): 612-615.

Lexi-Comp Online. 2011.

Taylor Palmer, "Chapter 10. Anticholinesterase Agents" (Chapter). Brunton LL, Chabner BA, Knollmann BC: Goodman & Gilman's The Pharmacological Basis of Therapeutics, 12e: http://0-www.accesspharmacy.com.polar.onu.edu/content.aspx?aID=16660859.

Witoonpanich R, et al. Electrophysiological and Immunological Study in Myasthenia Gravis: Diagnostic Sensitivity and Correlation. Clin Neurophysiol. 2011; Epub ahead of print.