GIM Week 4 Summary

Question 16

You are called to the ward because a patient is requesting a sleeping aid.

1. What are important questions to ask this patient?
   Insomnia in the hospital setting can have many causes. The best treatment for insomnia is managing the underlying cause.
   Questions to ask the patient include:
   • Why are they unable to sleep?
   • Pain/ breathlessness/ nausea/ anxiety/ discomfort
   • Have they had difficulty sleeping in the past?
   • Do they take sleeping aides regularly?
2. What non-pharmacological strategies can you use for insomnia?
   Non-pharmacological treatments are preferred when possible. These include reorientation (providing a familiar environment and family members) and use of earplugs if the patient is bothered by noises.
3. What medications can you offer this patient?
   Pharmacologic options include:
   • Non-benzodiazepine medication – Zopiclone
   • Benzodiazepines – diazepam, lorazepam, temazepam
   • Melatonin receptor agonists (contraindicated in liver failure)- ramelteon
   • Antihistamine (not as effective at inducing sleep, and has anticholinergic properties, so be careful in elderly) – diphenhydramine, doxylamine, hydroxyzine
   • Antidepressant (have anticholinergic properties) – amitriptyline, trazodone, mirtazapine
4. What is your first choice medication?
   If a patient was on a sleeping medication prior to admission, start that patient on the same medication. If not, benzodiazepines or non-benzodiazepine medications are often first choice since they have a rapid onset and less anticholinergic properties.

Resource
Ramakrishnan K and Scheid DC. Treatment Options for Insomnia. Am Fam Physician. 2007, 76:517-526.

Question 17

A 78-year-old woman suffers a transient ischemic attack. She is a type 2 diabetic, and has hypertension. There is no history of coronary artery disease. An ECG done in emerge demonstrates atrial fibrillation.

1. Calculate her annual stroke risk.
   The CHADS2 score can be used to evaluate a person’s annual risk of stroke with atrial fibrillation.
   This woman’s annual risk of stroke (without anticoagulation) is 12.5%, corresponding to a CHADS2 score of 5. Points are allocated for the following factors:
   • History of congestive heart failure +1
   • History of hypertension +1
   • Age ≥75 +1
   • History of diabetes +1
   • History of stroke or TIA +2

   CHADS2 Score	% Annual Stroke Risk
   0	1.9
   1	2.8
   2	4.0
   3	5.9
   4	8.5
   5	12.5
   6	18.2

   (Adapted from Gage BF, 2001.)

2. What medications should she be on based on her risk, and for how long?
   Because this patient is in the high-risk of annual stroke, she should be taking either warfarin or a novel oral anticoagulant (NOAC).
   • If starting warfarin, she would require bridging anticoagulation with low molecular weight heparin until her warfarin dose is titrated to an INR of 2.0-3.0.
   • Examples of NOACs include: dabigatran (anti-thrombin), rivaroxaban and apixaban (anti-Xa).

   She should be taking this medication for life, or until the risk of complications outweighs the risk of stroke.

Resources

1. Camm AJ et al. 2012 focused update of the ESC Guidelines for the management of atrial fibrillation: an update of the 2010 ESC Guidelines for the management of atrial fibrillation. Developed with the special contribution of the European Heart Rhythm Association. Eur Heart J. 2012, 33:2719-2747.
2. Gage BF et al. Validation of Clinical Classification Schemes for Predicting Stroke. Results From the National Registry of Atrial Fibrillation. Jama. 2001, 285:2864-2870.
3. Lip GY, Nieuwlaat R, Pisters R, Lane DA and Crijns HJ. Refining clinical risk stratification for predicting stroke and thromboembolism in atrial fibrillation using a novel risk factor-based approach: the euro heart survey on atrial fibrillation. Chest. 2010, 137:263-272.

Question 18

What symptoms may a patient with symptomatic aortic stenosis complain of on history?

A patient with symptomatic aortic stenosis may present with dyspnea on exertion, decreased exercise tolerance, angina with activity, and presyncope/syncope with activity.

What features would you look for on clinical exam to help determine the severity of aortic stenosis?

Features on physical exam for severe aortic stenosis may include:

• Grade ≥3/6 late-peaking systolic murmur with radiation to the carotids
• Paradoxically split S2 sound
• Delayed carotid upstroke
• Delayed brachial-radial pulse

These features on physical exam are specific but not sensitive to aortic stenosis. A normal S2 may be present in aortic stenosis, but not in hemodynamically significant aortic stenosis.

Aortic sclerosis can be clinically differentiated from aortic stenosis by the presence of a midsystolic ejection murmur, a normal carotid pulse and a normal S2.

Resource
Nishimura RA et al. 2014 AHA/ACC Guideline for the Management of Patients With Valvular Heart Disease: A Report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines. J Am Coll Cardiol. 2014, 63:e57-185.

Question 19

Interpret the following acid/base disorders, and provide a differential diagnosis for each case.

1. pC0₂ 25, pO₂ 80, pH 7.50, HCO₃ 18
   
   Acute Respiratory alkalosis
   Differential diagnosis includes (think conditions that cause hyperventilation):
   • Sepsis
   • ASA overdose
   • Theophylline toxicity
   • Asthma exacerbation
   • Tachyarrhythmia
   • Angina/MI
   • Hyperthyroidism
   • Panic disorder
   • Pneumonia
   • Pneumothorax
   • Congestive heart disease
   • Pulmonary embolism
   • Idiopathic pulmonary fibrosis.
2. pCO₂ 34, pO₂ 80, pH 7.25, HCO₃ 16
   
   Metabolic acidosis
   Differential diagnosis includes:
   • Anion-gap metabolic acidosis
     • Lactic acidosis
     • Ketoacidosis
     • Methanol, ethylene glycol, diethylene glycol, propylene glycol
     • ASA overdose
     • Advanced renal failure
   • Non anion-gap metabolic acidosis
     • Diarrhea
     • Renal tubular acidosis

Question 20

What are causes of pericarditis?
The causes of pericarditis include:

• Infection – viral (most common infectious), bacterial, tuberculosis
• Transmural myocardial infarction
• Aortic dissection
• Trauma
• Neoplasm
• Chest wall radiation
• Uremia
• Autoimmune or inflammatory disease
• Drugs (adverse reaction)
• Idiopathic (most common)

What changes might you see on ECG in a patient with pericarditis?
ECG changes from pericarditis include:

• Diffuse ST segment elevations (concave appearance)
• Diffuse PR segment depression
• Widespread T wave inversion may occur later, but once the ST and PR segments return to baseline

What physical exam findings are classically associated with cardiac tamponade?
Classic physical exam findings in cardiac tamponade are: tachycardia, elevated JVP, pulses paradoxus, pericardial rub, diminished heart sounds (sometimes), hypotension (sometimes)

Resources

1. Lange RA and Hillis LD. Acute Pericarditis. N Enlg J Med. 2005, 351:2195-2202.
2. Maisch B et al. Guidelines on the diagnosis and management of pericardial disease executive summary; The Task force on the diagnosis and management of pericardial disease of the European society of cardiology. Eur Heart J. 2004, 25:587-610.
3. Spodick DH. Acute Cardiac Tamponade. N Engl J Med. 2003, 349:684-690.