Grand Morning Report - Friday April 20, 2012

Thank you to Dr. Y. Patel for hosting Grand Morning Report.  Last night, we had 10 cases, but they had a few themes in common.

The first theme is GI bleeding.  We discussed that stools can be black for a number of reasons (including iron supplementation).  It is important to decide whether the patient is having melena (by a digital rectal exam) and also to elucidate the temporal relation of dark stool to other events (such as beginning of iron supplementation).  We also discussed that fecal occult blood test is meant for a screening test for colon cancer and that its utility in a bleeding patient is not tested.  We also discussed the importance of establishing good IV access.

We also discussed when to transfuse.  There is a recently published clinical practice guideline in the Annals of Internal Medicine (March 26, 2012) (linked here) on transfusion threshold for hemoglobin.  For patients who are not bleeding and stable (without ACS), transfusion threshold of 70-80 is commonly used.  However, for bleeding patient, it depends on patient stability, symptoms, whether bleeding is on-going, etc …

We then moved on to the second theme of stroke.  We discussed that there are investigations that are sometimes helpful in patients presenting with a stroke, but not necessarily in ALL patients.  We must understand the purpose of each test before ordering.  For example, an MRI brain is sometimes ordered to confirm the diagnosis of strokes (for example, in the posterior circulation).  However, if the diagnosis is already very clear (e.g. on CT imaging), this may not be necessary.  Also, echocardiogram is used to look for source for cardio-embolic stroke.  If a patient is known to have atrial fibrillation and is already anti-coagulated, and that anticoagulation is planned to continue when safe to do so, there may not be a need for an echocardiogram as it does not change management.  We also discussed that carotid endarterectomy for symptomatic carotid artery stenosis has evidence-based support.  However, the benefit for asymptomatic disease is marginal.  See this review in the Mayo Clinic Proceedings (linked here).

The latest AHA stroke guidelines can be found here.  The “2010 update on the guideline for the prevention of stroke in patients with stroke or TIA” and the “2007 Guidelines for the early management of acute ischemic stroke” may be the most relevant to those on call.