Learning

Issues
1. Signs and symptoms of ACE or ARBS induced
cough.
5-30%
ARBs alternative
therapy
Failure to decrease
after 1 mo (negative)
2. Cardiothoracic Ratio
● Ratio between maximum diameter
of heart to maximum internal
diameter of chest/ thoracic cavity.
● It is measured on PA chest
● Normal measurement or range of
CRT ratio is 0.42-0.50
● Or we can say that normal should
be less than 1:2 or CRT should be
less than 0.5 on PA chest.
2. How to measure CRT ratio?

FORMULA:
A+B/C
3. Streaming for downstreaming of antibiotics in
pneumonia.
 4. Normal elevation of right diaphragm by how
many cm from the left?
The right hemidiaphragm is up to 2 cm (1-1.5cm) higher
than the left in 90% of normal individuals. In about 10% of
normal individuals the right hemidiaphragm is more than 3
cm higher than the left, the hemidiaphragms are at the
same level, or the left hemidiaphragm is higher than the
right.
INFECTIOUS
CASE
SGD 8
 Week 3

A 32 year old previously healthy male came in to the Emergency Room

with the chief complaint of fever.
The patient noted undocumentad intermittent fever for 1 week
associated with chills, headache which is localized at the frontal area
with pain scale 5/10 , nausea, abdominal pain, body malaise and myalgia
Week 3

He denied diarrhea and cough but noted decreasing urine output. On

further history, patient reported that he joined triathlon in Samar 2
weeks ago,and heavy rain preceded the said event.
The patient does not have any comorbidities as claimed. He exercise 30
mins to an hour everyday and denies smoking and drinking alcohol.
Heredofamilial disease includes hypertension and diabetes on paternal
side.
On physical examination patient was awake, conscious coherent,
cooperative with the following vital signs:
BP: 110/80 mmhg
HR:118 bpm
RR: 22 cpm
Temp: 38.4 C
O₂ sat.: 98%

Icteric sclera, conjunctival suffusion and calf tenderness were

noted ches examination was unremarkable.
Abdominal examination revealed soft, liver span 15 cm
midclavicular line and tenderness on right upper quadrant.
Laboratory results
Urinalysis
 Table of contents
01 Salient features
Define fever and
examples of diseases…
04

02 Interpret lab results Sprirochetal diseases 05

03
Clinical impression &
differential diagnosis
Clinical manifestations
Risk factors, complication and
prognosis
06
 TABLE OF CONTENTS
07 Pathophysiology

Diagnostic plan 10
08 Define acute kidney injury
And give bilirubin level when scleral
icterus is detected

09 Diagnosis based on Hx & PE

Enumerate steps measuring liver span
Treatment plan
11
 Salient
Features 01
 HISTORY PHYSICAL EXAMINATION

● Travelled to Samar (Tropical ● Fever (38.4 *C)

province) ● HR (118 bpm)
● Triathlon event (swimming) ● Icteric Sclera
● Heavy rains preceded the said ● Conjunctival suffusion
event ● Calf tenderness
● 2 weeks since the event ● Soft liver (15cm span MCL)
● Onset of symptoms before 1 week: ● RUQ tenderness
● Fever with chills
● Frontal headache
● Nausea
● Abdominal pain
● Body malaise
● Myalgia
● Low Urine output
 Interpret
lab results 02
 Clinical
impression
and DDx
03
 Moderate to
Severe
Leptospirosis
 DDx:

●MALARIA
● HEMORRHAGIC DENGUE FEVER
● ENTERIC FEVER
 MALARIA
RULE IN RULE OUT
Hx & PE: DIAGNOSTIC WORK-UP: Hx & PE:
❌Travel History (Samar)
✅ TROPICAL COUNTRY ✅ Elevated ALT ❌Conjunctival suffusion
✅ FEVER ✅ Acute Kidney Injury ❌Calf tenderness
✅ CHILLS (elevated CREA & BUN)
✅ HEADACHE ✅ Leukocytosis DIAGNOSTIC WORK-UP:
✅ NAUSEA ✅ Anemia ❌ Leptospira IgM reactive
✅ ABDOMINAL PAIN ✅ Thrombocytopenia
✅ BODY MALAISE ✅ Prolong PT
✅ MYALGIA ✅ Hematuria OTHERS:
✅ DECREASED URINE OUTPUT✅ Proteinuria ❌Hyperparasitemia
✅ TACHYCARDIC ❌Not associated with rash
✅ TACHYPNEIC
✅ JAUNDICE (icteric sclera)
✅ HEPATOMEGALY
 DENGUE HEMORRHAGIC FEVER
RULE IN RULE OUT
Hx & PE: DIAGNOSTIC DIAGNOSTIC WORK-UP:
WORK-UP: ❌ Leukocytosis
✅ TROPICAL COUNTRY ❌ Leptospira IgM reactive
✅ FEVER ✅ Elevated ALT
✅ CHILLS ✅ Acute Kidney
✅ HEADACHE Injury (elevated CREA
✅ NAUSEA & BUN) OTHERS:
✅ ABDOMINAL PAIN ✅ Thrombocytopenia ❌An elevated hematocrit ≥20% above the population
✅ BODY MALAISE ✅Lymphocytosis mean hematocrit for age and sex
✅ MYALGIA ✅ Hematuria ❌Presence of pleural effusion or detected by
✅ TACHYCARDIC ✅ Proteinuria radiography or other imaging method
✅ TACHYPNEIC
✅ CONJUNCTIVAL SUFFUSION
✅ CALF TENDERNESS
✅ JAUNDICE (icteric sclera)
✅ HEPATOMEGALY
 ENTERIC FEVER
RULE IN RULE OUT
Hx & PE: Hx & PE:
❌Anorexia
✅ TROPICAL COUNTRY ❌Diarrhea
✅ TRAVEL HISTORY ❌Conjunctival suffusion
✅ FEVER ❌Calf tenderness
✅ CHILLS
✅ HEADACHE DIAGNOSTIC WORK-UP:
✅ NAUSEA ❌Lymphocytosis
✅ ABDOMINAL PAIN ❌Leukocytosis
✅ BODY MALAISE ❌Acute Kidney Injury (elevated CREA & BUN)
✅ MYALGIA ❌ Leptospira IgM reactive
✅ JAUNDICE (icteric sclera)
✅ HEPATOMEGALY OTHERS:
❌Rash (Rose spots)
DIAGNOSTIC WORK-UP:
✅ Elevated ALT
✅ Anemia
Fever; examples of
diseases where
temperature pulse
dissociation occurs
04
Spirochetal
diseases 05
 Clinical
manifestation
Risk factors, complications and prognosis
06
Pathophysiology
07
 2-20 days

leptospiremic phase
 08
Acute kidney injury;
give the bilirubin
level when scleral
icterus detected
Acute kidney injury (AKI)
defined by the impairment of kidney filtration and excretory
function over days to weeks, resulting in the retention of
nitrogenous and other waste products normally cleared by the
kidneys.
PRERENAL ACUTE KINDEY INJURY
● Most common form of acute renal injury
● A rise in serum creatinine or BUN concentration due
to inadequate renal plasma flow and
intraglomerular hydrostatic pressure to support
normal glomerular filtration.
● Most common clinical conditions associated with
prerenal azotemia:
○ Hypovolemia
○ Decreased cardiac output
○ Medications
■ NSAIDs and inhibitors of angiotensin II
Intrinsic Acute kidney Injury

● In many cases, prerenal azotemia

advances to tubular injury. Classically
termed “acute tubular necrosis”.
● The most common causes of intrinsic
acute kidney injury are:
○ Sepsis
○ Ischemia
○ Nephrotoxins
● In intrarenal/ intrinsic AKI, the kidneys
lose the ability to filter the blood
properly and the cells are often
damaged such that reabsorption and
secretion are impaired.
Postrenal Acute Kidney Injury

● Bladder neck obstruction is a common

cause of postrenal acute kidney injury
which impacts both kidneys. This can
be due to:
○ Prostate disease (BPH or
tumors)
○ Neurogenic bladder
○ Therapy with anticholinergic
drugs.
● By current definitions the presence of AKI is defined by
○ Elevation in the serum creatinine
■ Rise from baseline of at least 0.3 mg/dl within 48 hours or at least 50% higher than
baseline within 1 week
○ Reduction in urine output.
■ Reduction of <0.5ml/kg/hour for longer than 6 hours
● Acute kidney injury is common in severe disease, presenting after several days of illness, and can be
either nonoliguric or oliguric.
○ Typical electrolyte abnormalities include hypokalemia and hyponatremia.
○ Loss of magnesium in the urine is uniquely associated with leptospiral nephropathy.
○ Hypotension is associated with acute tubular necrosis, oliguria, or anuria, requiring fluid
resuscitation and sometimes vasopressor therapy.
Abdominal Exam
09
 Inspection
Skin
● Temperature
● Color
● Scars
● Striae
● Dilated veins
● Rashes and ecchymoses
Umbilicus
Contour of the abdomen
Peristalsis
Pulsations
Auscultation
Abdominal Bruits and
Friction Rub

Aorta

Renal artery

Iliac artery

Femoral artery
 Percussion

Dullness and Tympany

Palpation
Percussion: Liver Dullness
4–8 cm in midsternal
line

6–12 cm in right
midclavicular line
 Palpation: Liver
Palpate liver edge
Percussion: Spleen
Palpation: Spleen
Diagnostic
plan 10
CDC:https://www.cdc.gov/leptospirosis/pdf/fs-leptospirosis-clinicians-eng-508.pdf
Treatment
plan 11
 Treatment plan
-Severe leptospirosis= should be treated with IV penicillin as soon as the diagnosis is
considered.

-Leptospires are highly susceptible to a broad range of antibiotics, including the β-lactam
antibiotics, cephalosporins, aminoglycosides,and macrolide, but are not susceptible to
vancomycin, rifampin, metronidazole, and chloramphenicol.

- Early intervention may prevent the development of major organ-system failure or lessen
its severity.

-Ceftriaxone, cefotaxime, or doxycycline is a satisfactory alternative to penicillin for the

treatment of severe leptospirosis.
 Treatment plan
mild cases- oral treatment with doxycycline, azithromycin, ampicillin, amoxicillin is
recommended.

Regions were rickettsial diseases are coendemic=doxycycline or azithromycin is the DOC

Aggressive supportive care is essential & can be life saving;

Patients with nonoliguric renal dysfunction=aggressive fluid and electrolyte resuscitation

to prevent dehydration and precipitation of oliguric renal failure.

Patients with oliguric renal failure=peritoneal dialysis or hemodialysis should be provided.

Patients with pulmonary hemorrhage=mechanical ventilation

mild cases- oral treatment with doxycycline, azithromycin, ampicillin, amoxicillin is

recommended.

Regions were rickettsial diseases are coendemic=doxycycline or azithromycin is the DOC

Treatment plan
 Prevention
- Individuals who may be exposed to Leptospira through their occupations
or their involvement in recreational freshwater activities should be
informed about the risks.
- Measures for controlling leptospirosis include avoidance of exposure to
urine and tissues from infected animals though proper eyewear, footwear,
and other protective equipments.
- Vaccines for agricultural and companion animals are generally available,
and their use should be encouraged.
- Chemical prophylaxis can be recommended (post-exposure
chemoprophylactic agent)
Thank you, doc !!