Thank you, Max, for presenting a case of a middle-aged man, HIV negative, with 2-3 weeks of cough, fevers, and scant hemoptysis, started on azithromycin and prednisone who 1 day later develops acute onset of a painless rash including the lips, hard palate, and bilateral ear canals. UPDATE: Derm feels strongly that this is a herpetic rash!!
Approach to Hemoptysis:
- Is it really hemoptysis?
- Massive vs. not-massive – definitions vary tremendously by source. Greater than 300cc in 24 hours relatively well accepted.
- Airway protection! Patients with massive hemoptysis are at greater risk of asphyxiation than bleeding out.
- Big categories:
- Other: ** often forgotten – pulmonary edema! Hemosiderin-laden macrophages with pulm edema from heart failure can appear pink or bloody **
Oral-cutaneous vesicular rashes
- Can’t miss SJS/TEN!
- Coxsackie – hand foot and mouth
- Atypical infection with reaction (mycoplasma, legionella)
- Other drug reactions
- Erythema multiforme
- Pemphigous vulgaris
- Bulous pemphigoid
- Bullous impetigo
- Niacin deficiency
Finally, thanks to Jesse for presenting a mini-EKG case of a patient with grouped beating and sinus bradycardia felt to be 2/2 to mobitz 1 sinus exit block vs. mobitz 2 AV block à with p waves possibly buried in the t-wave identified by HH of course – every ID doc has his Cards day!!
–>There a good summary (below) of SA and other Blocks on Life in the Fast Lane!
First Degree SA block
= Delay between impulse generation and transmission to the atrium.
- This abnormality is NOT detectable on the surface ECG.= Progressive lengthening of the interval between impulse generation and transmission, culminating in failure of transmission.
Second Degree SA block, Type I (Wenckebach)
- The gradually lengthening transmission interval pushes successive P waves closer together.
- This results in grouping of the P-QRS complexes.
- Pauses due to dropped P waves occur at the end of each group.
- The P-P interval progressively shortens prior to the dropped P wave.
- This pattern is easily mistaken for sinus arrhythmia.= Intermittent dropped P waves with a constant interval between impulse generation and atrial depolarisation.
Second Degree SA block, Type II
- This pattern is the equivalent of Mobitz II.
- There is no clustering of P-QRS complexes.
- Intermittent P waves “drop out” of the rhythm, while subsequent P waves arrive “on time”.
- The pause surrounding the dropped P wave is an exact multiple of the preceding P-P interval.