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Paucis Verbis: Neutropenic fever in cancer patients

ThermometerA 65 y/o man with a history of prostate cancer presents to your ED from home appearing fairly well and a mild cough for 3 days. His vital signs are:

  • Temperature 39 C
  • BP 160/80
  • HR 60
  • RR 14
  • Oxygen saturation 99% on room air

His absolute neutrophil count (ANC) comes back at 300 cells/mm3. His chest xray shows a right middle lobe pneumonia and a central line catheter tip ending in the SVC.

  • Is this patient “high” or “low” risk per the Multinational Association for Supportive Care in Cancer (MASCC)?
  • Does this person require inpatient admission?
  • What antibiotics would you start on this patient?

Answers

  • The patient’s MASCC score is 5 (mild symptoms) + 5 (no hypotension) + 4 (no COPD) + 4 (solid tumor) + 3 (no dehydration) + 3 (outpatient) = 24 = LOW RISK
  • NOTE: “Burden of febrile neutropenia” is a subjective scoring of the patient’s symptoms
  • The patient is, however, ultimately HIGH RISK clinically because of the finding of pneumonia on CXR. Admit.
  • Abx = Cefipime + Vancomycin

FYI: Vancomycin is not always indicated in cancer patients with a neutropenic fever.

PV Card: Neutropenic Fever in Cancer Patients (IDSA 2010)


Adapted from [1]
Go to ALiEM (PV) Cards for more resources.

Thanks to Alissa and Hemal for suggesting the topic!

Reference

  1. Freifeld A, Bow E, Sepkowitz K, et al. Clinical practice guideline for the use of antimicrobial agents in neutropenic patients with cancer: 2010 update by the infectious diseases society of america. Clin Infect Dis. 2011;52(4):e56-93. [PubMed]
By |2021-10-12T15:54:10-07:00Oct 7, 2011|ALiEM Cards, Heme-Oncology, Infectious Disease|
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Trick of the Trade: Opioids for air hunger

BipapA patient presents with significant shortness of breath from a COPD exacerbation. His room air saturation is 80%, respiratory rate of 30, and is uncomfortably seated in a tripod position. You administer the usual regimen:

  • Oxygen by face mask
  • Nebulized albuterol and atrovent
  • Solumedrol
  • Bipap
  • Set up for possible intubation

With the Bipap mask on, the patient’s subjective sense of dyspnea and “air hunger” seems to make it harder for him to tolerate the tight-fitting mask.

 

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By |2016-11-11T18:51:57-08:00Oct 4, 2011|Tricks of the Trade|
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Trick of the Trade: Needlestick hotline 888-448-4911

NeedlstickGlove

You are a fourth-year medical student and super-excited to be doing your first supervised central line procedure on an actual patient. You have done so many central lines on mannequins and simulations. You feel ready. In your excitement, however, you stick yourself with the 22 gauge finder needle after you successfully get a flash-back of the patient’s venous blood.

After handing off the procedure to your senior resident, you go into a mild panic. Your patient is a known HIV patient with an unknown CD4 count and viral load. After taking off your gloves and washing your hands, you report this to the attending.

Should you start post-exposure prophylaxis medications for HIV? You remember that if post-exposure HIV medications are recommended, you should start it immediately and definitely within 2 hours of exposure.

It’s difficult to concentrate when faced with so many questions whirling in your mind.

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By |2019-01-28T22:38:19-08:00Sep 27, 2011|Infectious Disease, Tricks of the Trade|
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Paucis Verbis: Does this DM leg ulcer have osteomyelitis?

diabetic foot ulcer

We sometimes see diabetic patients in the ED for a worsening foot ulcer. Sometimes it’s the chief complaint. Other times, however, you just notice it on physical exam. So, be sure you examine the feet of your diabetic patients. Occasionally, you’ll be surprised by what you find.

Several questions come up with diabetic foot ulcers:

  • Is it a true diabetic foot ulcer, or is it an arterial or venous insufficiency ulcer?
  • Is there underlying osteomyelitis?
  • How can I best diagnostically work this foot ulcer up for osteomyelitis?
  • What is the Wagner grade of this ulcer? (I think it’d be Grade 2.)

Thanks to JAMA‘s Clinical Rational Examination series, there is a systematic review of diabetic leg ulcers and osteomyelitis. Here are the highlights:

PV Card: Diabetic Leg Ulcer and Osteomyelitis


Adapted from [1]
Go to ALiEM (PV) Cards for more resources.

Below is the Fagan nomogram to help you plot out your post-test probability based on your likelihood ratios. The example given is if your pretest probability is 25% and your LR is 10. Your post-test probability would be 80%.

BayesFaganNomogramLine

Reference

  1. Butalia S. Does This Patient With Diabetes Have Osteomyelitis of the Lower Extremity? JAMA. 2008;299(7):806. doi: 10.1001/jama.299.7.806
By |2021-10-12T15:56:51-07:00Sep 23, 2011|ALiEM Cards, Infectious Disease, Orthopedic|
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Trick of the Trade: Pediatric ear exam

ChildEaraches2

Performing a physical exam on frightened pediatric patients can often be challenging. I am always thrilled to add more child-whisperer techniques to my arsenal of tricks. I have written in the past about:

What’s your trick on performing an otoscope exam of the ears?

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By |2019-02-19T18:08:03-08:00Sep 20, 2011|ENT, Pediatrics, Tricks of the Trade|
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Paucis Verbis: Legionella pneumonia

Legionella Infection

Did you know that there was an unexplained spike in Legionnaire’s disease (pneumonia caused by Legionella pneumophila) during the 2009 H1N1 flu pandemic?

Since the flu season is rapidly approaching, I thought I would review what Legionnaire’s disease looks like. Yes, they will have a fever, cough, and pneumonia on CXR. These patients are generally pretty sick and almost always need hospitalization. What makes it unique? The trick is to look for extrapulmonary findings, which help to distinguish it from other atypical pneumonias. Relative bradycardia is a sure tip.

Why do we want to differentiate it from other pneumonias? Legionnaire’s disease requires reporting to your state’s health department to help track for outbreaks.

PV Card: Legionella and Legionnaire’s Disease


Adapted from [1]
Go to ALiEM (PV) Cards for more resources.

More information on Legionella from the CDC website.

Reference

  1. Cunha B. Legionnaires’ disease: clinical differentiation from typical and other atypical pneumonias. Infect Dis Clin North Am. 2010;24(1):73-105. [PubMed]
By |2021-10-12T16:00:57-07:00Sep 16, 2011|ALiEM Cards, Pulmonary|
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