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
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