What do you do during a telehealth encounter when a patient says they are weak? You can’t examine them! This morning during morning report at Hillcrest Dr. Abeles, expert discussant and PCP extraordinaire, helped us explore the many ways we can help our patients virtually. Today we discussed a case in which an otherwise healthy 43 yo woman presented via video visit with years of chronic, progressive, proximal muscle weakness and myalgias. She also had dyspnea on exertion and dysphagia. She did not have rash, arthralgias, or fevers/chills.
We discussed potential exam techniques that can be done over video, such as watching the patient walk or observing their range of motion. Laboratory workup revealed elevated CK, aldolase, and SSB. MRI showed evidence of myositis in both legs, and subsquent muscle biopsy confirmed polymyositis.
We also created a diagnostic schema for neuromuscular weakness, adapted from Clinical Problem Solvers’ Weakness Thought Train:
Key Learning Points:
- When approaching neuromuscular weakness, the differential can be separated into different anatomic etiologies – neuropathy, demyelinating disorders, neuromuscular junction disorders, and myopathy
- Triaging a patient virtually can be hard. It is OK to ask patients to come in person to be evaluated! Remember that labs can take longer to result in the outpatient setting, so have a contingency plan when you order them.
- Polymyositis often presents with proximal muscle weakness and myalgias. They may also have GI involvement (think dysphagia/GERD) or ILD. Workup often shows elevated CK and aldolase. We classically think of Anti Jo 1 antibodies as being positive, but this is only true 20-49% of the time.
Thank you Dr. Abeles for your expertise!
Today we reviewed a case of an elderly female with PMHx of symptomatic bradycardia s/p PPM initially transferred from OSH to cardiology service for PPM site infection and MSSA bacteremia. Patient was found to have worsening oliguric AKI and was transferred to medicine for further workup and treatment.
Residents and medical students broke out into teams and came up with an initial differential for the etiology of the AKI based solely on patient’s hospital course and medications. They were then given the results of the urinalysis and urine protein/Cr ratio and we discussed how these results change and narrow our differential. (It really was all in the urine!). We then went through a model schema for intrinsic AKI based on anatomical locations: vascular, glomerular, tubular, and interstitial. We then returned to the case with a diagnosis of infectious glomerulonephritis and reviewed renal biopsy findings. Thank you to our expert discussant, Dr. Abdelmalek, for teaching us how to narrow our differentials for AKI and how to narrow initial testing based on most likely etiologies!
Spanish Word of the Day: urine = orina
Today we had one of our excellent VA primary care doctors, Dr. Madhusree Singh, help us through three real life primary care cases. We focused our approach to how we would respond to patient’s questions in real time and what we would need to prioritize in the limited clinic appointment time.
Case 1: Patient lost to follow up who is re-establishing with primary care. Has a remote history of RCC s/p nephrectomy. Do you refer to oncology?? We discussed the NCCN resource for surveillance guidelines and the utility of e-consult.
Case 2: Patient with new onset diabetes (A1c 7.0%). We went through the co-morbid conditions PCP’s need to screen for and treat – especially in a new diagnosis. Nephropathy (microalbumin/creatinine), neuropathy (foot exam), retinopathy (refer for retinal exam at diagnosis!), CAD (start statin on patients >45 yo), HTN (important to screen in everyone, but especially our diabetic patients). And of course, we started metformin along with lifestyle changes.
Case 3: Patient who returns for routine follow up. We discover that she is sexually active, does not desire pregnancy at this time and does not have a reliable form of birth control. We identified this situation as a medical emergency and practiced ways to discuss birth control options with patients. We also learned specific history questions that will help us guide our patient to the safest and best choice for her.
-National Comprehensive Cancer Network: cancer treatment and screening guidelines https://www.nccn.org
-Hopkins Modules: Required for graduation and oh-so helpful for primary care knowledge!! https://ilc.peaconline.org
-Bedsider: an interactive website to discuss birth control options with patients https://www.bedsider.org
Our awesome rising R3 and baby chief, Dr. Erin Roberts, presented an interesting case of a young man with recently diagnosed HIV not on anti-retroviral therapy. This patient had presented to the Emergency Room with 1 month of fevers and weight loss, and was ultimately found to have miliary TB!
Dr. Laura Bamford, a fantastic ID attending, helped us construct a differential for fever and abnormal chest x-ray findings in the setting of HIV. We considered how the pattern of pulmonary infiltrates can inform our differential. It is important to remember, though, that a normal chest x-ray does not rule out pulmonary disease in these patients!
- When evaluating patients with HIV presenting with fever and abnormal chest x-ray findings, consider infectious etiologies (both common and opportunistic!), autoimmune conditions, malignancy, and other etiologies.
- When treating patients with HIV and TB coinfection, you still use RIPE therapy as you would with HIV-negative patients. However, Rifabutin is often preferred over Rifampin in HIV-positive patients, as it confers fewer drug-drug interactions with ART agents.
- In patients will new diagnoses of both TB and HIV, ART should typically be initiated within 2-8 weeks after starting TB treatment. Significant delays in initiating ART, particularly in patients with CD4 counts <100, has been associated with additional complications of untreated HIV. Keep in mind that the initiation of ART can place these patients at risk for IRIS, so adjunctive steroids are sometimes considered (particularly if there is TB CNS involvement!).
You can read more about the guidelines for managing TB, including TB and HIV co-infection, at the links below:
Medical Spanish Word of the Day: X-ray = la radiografía
“Championing the role of science as the route to better health remains essential to spurring new discoveries to advance women’s health.”
Cynthia A. Stuenkel, M.D., and JoAnn E. Manson, M.D., Dr.P.H.
One of UCSD’s amazing endocrinologists, Dr. Cynthia Stuenkel, recently published a perspective for NEJM on the important advances in women’s health over the past 50 years. She discusses the milestones in women’s health from the 1970s to today from treatment of breast cancer to the coverage of mammograms under the Affordable Care Act.
While a lot of progress has been made, she notes that we have many more challenges to address and inequities to overcome to improve health care for everyone.
“Moving forward, it will be essential to recognize and study intersectional health disparities, including disparities based on sex, race, ethnicity, gender identity, sexual orientation, income, and disability status.”Cynthia A. Stuenkel, M.D., and JoAnn E. Manson, M.D., Dr.P.H.
Check out the article here!
Today, we kicked off our primary care MTC series with a discussion of preoperative medication management!
With the help from the BEST expert discussant, Dr. Jassal, we reviewed how to approach medication management in a patient with the following history and medication list:
- Coronary artery disease with a drug eluting stent placed 2 years ago, HFrEF, HTN, and HLD on aspirin, lisinopril, atorvastatin, and lasix.
- Type 2 diabetes (HgbA1c of 7.6%) on metformin, empagliflozin, and glargine.
- Non-valvular atrial fibrillation on apixaban and amlodipine.
What we quickly found out is that there is not a lot of clear evidence for continuing or holding most medications. Beta-blockers are an exception as evidence has clearly shown that they have multiple potential benefits including reducing myocardial oxygen demand and suppressing arrhythmias. Abrupt withdrawal of beta-blockers can result in tachycardia, hypertension, and ACS!
Medications we may see more frequently because of their cardiovascular and weight loss benefits are SGLT2 inhibitors (e.g. empagliflozin). We learned that these medications need to be held about 3-4 days before surgery due to their long half-lives and increased risk for hypovolemia, hypotension, UTIs, and euglycemic DKA.
When deciding whether or not to hold a patient’s DOAC, the main question you need to answer is how high of a bleeding risk is the procedure. We also discussed whether or not patients on DOACs need to be bridged before surgery, and the overwhelming conclusion is no! A bridge only needs to be considered in patients at a very high risk of thromboembolism such as patients who have a mechanical heart valve or who had a recent stroke (these patients are typically on warfarin).
Main Take Aways:
First, getting a thorough medication history is key!
Second, perioperative medication management is not always straight forward, but there are a lot of resources to help you decide what to do including pharmacists, the surgical team, and anesthesia. Excellent online resources include the Hopkins module on perioperative management and UCSF’s tool for diabetes medication management. The Curbsiders also have a great podcast on the topic!
Thank you again to Dr. Jassal for your expertise today!
Medical Spanish Word of the Day: Los medicamentos = medications
This morning, Dr. Lainey Flatow-Trujillo, one of our amazing R2s, shared with us the case of a young woman with a history of biliary colic who presented with 5 days of epigastric pain radiating to the back and an initial lipase > 3000. The group quickly arrived at the diagnosis of gallstone pancreatitis.
We then spent some time delving into the management of acute pancreatitis. Because gallstones are the most common cause, an abdominal US is required. Patients in whom the diagnosis is unclear or whose symptoms persist may benefit from a CT with contrast. In patients without gallstones or heavy alcohol use, other etiologies, such as hypertriglyceridemia, hypercalcemia, and medications, should be investigated. Other less common causes include post-ERCP, traumatic, infectious, and autoimmune pancreatitis.
The key to management is aggressive hydration (e.g., 4 liters in the first 24 hours). Patients are often volume-depleted, so a bolus followed by a continuous infusion (e.g., 2 L up front followed by 100 mL/hr for 20 hr) is reasonable. IV analgesics are indicated. Oral (or at least parenteral) feeding should be started as soon as the patient is able to tolerate it, as this has been shown to decrease the risk of complications such as infection.
ERCP, a therapeutic procedure, is indicated when there is concern for ascending cholangitis or persistent obstruction. Otherwise, MRCP or EUS can be considered (not required for mild episodes). Laparoscopic cholecystectomy is recommended during the same admission to reduce the risk of recurrence for mild cases of gallstone pancreatitis. Debridement of necrosis, if present, should be avoided unless the patient is unstable.
Thank you to Dr. Wilson Kwong, our expert discussant, for offering his clinical pearls!
Medical Spanish Word of the Day: la piedra (colloquial), el cálculo (formal) = stone