internal medicine inpatient ob 12/11/2021

12/11/2021, with Dr. L

1) Case 1: Mrs. X, ~60 y.o., low strength of extremities, arm weakness.

No control of bladder, incontinence (失禁, 不排小便)， low strength of extremities but can feel the touch of fingers. No pronator drift (无旋前漂移).

MRI test, and neurologist don't have answerer for that. Suggest HIV test for this lady.

What does no pronator drift mean?

Downward drift of the arm without pronation, is usually the result of functional paresis. Conversion Disorder is a Psychiatric Disorder and the finding of 'Pronation without Drift' appears to be very sensitive and specific for this.

2) Case 2: Mr. M, ~65 y.o., Heart failure, the doctor is recommending ablation.

bleeding: endoscope to find the place of bleeding

Treatment: Digoxin 250mg, iv, 3 dose (stopped), enoxaparin (依诺肝素), heart transplantion.

BP is low (85/47 BP when pee 小便), and the attending has found gram (-) bacterial in blood culture, suggesting sepsis. Cefepime (头孢吡污) is given.

3) Case 3: Mr. M, ~65 y.o., non-ST elevation MI (myocardial infarction)

Pt follows commands but does not answer questions properly. Airway secretion noted. Orophargyngeal dysphagia (口咽性吞咽困难). Pt has mental status fluctuates. Transaminitis (转氨酶) is high. Carvedilol (a beta-blocker) is given.

Code: DNR (do not resuscitate). Follow up with PT (physical therapy) and OP.

HPI: history of present illness.

OT: ocupational therapy.

bolus infusion: 30min, injection. (not continuous injection). Bolus infusion is a single dose of a drug or other substance given over a short period of time. It is usually given by infusion or injection into a blood vessel.

BMP: basic metabolic panel (a blood test to test body's fluid balance, levels of electrolytes like sodium, and potassium, and how well the kidney is working).

4) Case 4: Mrs. R, ~65 y.o., renal failure, acute on chronic systolic heart failure (HCC)

Pt speaks spanish only.

congestive heart failure (HCC)， GFR↑

lactic acid to monitor the severity of heart failure.

Foley catheter (福利导尿管) to dispel urine，rales (啰音) on both lungs.

5）Case 5: Mr. G, ~65 y.o., male, feel lightheaded (头晕目眩) and falls in the bathroom. Cardiac amyloidosis (心脏淀粉样变)，atrium fibrillation (AF, 房颤)

HPI: Apple watch called 911 and was sent to the hospital. Has orthostatic hypotension （体位性低血压）and vertigo. Bruises are found from the fall. This is the second episode of syncope. No tonic-clonic (强直阵挛) movements, eye-rolling, tongue biting, or incontinence. No AV block or pauses were noted. Denies chest pain and palpitations. Denies orthopnea (端坐呼吸). Denies dysuria (排尿困难). No acute events o/n. ↑ Troponin T, abnormal EKG.

Discuss with Pt about ablation for AF, defibrillation (depace), and the amyloid could form a clot in the heart. Apixaban (brand name Eliquis) is given to pt to prevent blood clots and to prevent stroke in people with nonvalvular atrial fibrillation through directly inhibiting factor Xa (monitor INR =2.0). 同时和Pt说明了amyloidosis的不同stages, like stage I, stage II, etc. Cardiomyopathies (CMPs) consultation for cardiac myopathy. Metoprolol (美托洛尔) 2mg.

wear a "king of heart monitor" to monitor heart problems.

instructed pt to do a hand maneuver to help with orthostatic hypotension, such as grip (紧握) the hand when standing up. compress stocking (可以挤压小腿的袜子) ordered.

some markers for heart failure:

Troponin T (肌钙蛋白 T)

NT-Pro

Creatine (肌酸)

lactic acid

医生们讨论了当BNP<3000, Troponin T <65 时， the prognosis is good.

我到网上查询了BNP和NT-Pro

NT-proB-type Natriuretic Peptide (BNP) blood test

B-type natriuretic peptide (BNP，B型利钠肽 ) is a hormone produced by your heart. N-terminal (NT)-pro hormone BNP (NT-proBNP) is a non-active prohormone that is released from the same molecule that produces BNP. Both BNP and NT-proBNP are released in response to changes in pressure inside the heart. These changes can be related to heart failure and other cardiac problems. Levels goes up when heart failure develops or gets worse, and levels goes down when heart failure is stable. In most cases, BNP and NT-proBNP levels are higher in patients with heart failure than people who have normal heart function.

In healthy people an INR of 1.1 or below is considered normal. An INR range of 2.0 to 3.0 is generally an effective therapeutic range for people taking warfarin for disorders such as atrial fibrillation or a blood clot in the leg or lung.

telemetry (遥测，指心电图)

What does a troponin level of 40 mean?

What level of troponin indicates heart attack? The level of troponin that indicates a heart attack is the level above the reference range. For example if the normal reference range is listed as 0.00 – 0.40. Then 0.41 is technically positive although very weakly so, and 10 is very positive. 有患者的 troponin有48-47？

其他ECG的描述：wide GRS tachycardia (心动过速)， upper quadrant, and multiple episodes.