VA MTC 7/29: Differential Diagnosis for a CBC Differential

Today we reviewed a case of a 62 year old male who presented with 2 weeks of easy bruising and bleeding from his gums in the setting of 2 months of fatigue and weight loss. We discussed labs we would order and the residents were given a CBC that showed a leukocytosis, anemia, and thrombocytopenia. They next wanted to review the diff on the CBC.

Residents broke off into small groups and were given different diff values for the same CBC. We then had them come up with a differential based on the CBC w/ diff. With the help of our knowledgable expert discussant, Dr. Ida Wong, we reviewed a normal differential and then what to have on your differential for an elevated neutrophil count, lymphocytosis, a count with immature myeloid cells, and a count with blasts. We then reviewed the cell line lineage of myeloid cells and what findings you would see in CML, CLL, and acute leukemias. Precursor cells and blasts in the differential IS NEVER normal!

We returned to our case and diagnosed out patient with an acute leukemia based on him having >20% blasts in his count. He was diagnosed with AML through identification of auer rods on peripheral smear and we reviewed the clinical presentation and diagnosis of AML.

VA MTC 7/28: Acute Gallstone Pancreatitis

For today’s MTC, we discussed a patient who presented with acute LUQ abdominal pain who was found to have a lipase > 190 and imaging consistent with acute pancreatitis. With the help of our fabulous GI expert, Dr. Fady Youssef, the medical students and residents walked through the work-up and management of acute pancreatitis:

The patient was treated with early fluids and underwent an ERCP after imaging was concerning for choledocholithiasis. Prior to discharge, he had a cholecystectomy.

Key take away points:

  • Early, aggressive fluid resuscitation is essential and most beneficial within the first 24 hours! Our expert, Dr. Fady Youssef, likes to give a 1-2 L bolus followed by 250 mL/hr of LR
  • Severe pancreatitis is associated with a high mortality
    • While complex scoring systems exist for determining severity of pancreatitis, an elevated hematocrit and BUN and evidence of SIRS are just as accurate and much simpler to use! Dr. Youssef said he never uses the other scoring systems.

Thank you so much to our expert, Dr. Fady Youssef, for joining us this morning!

VA MTC 7/27: Initial Inpatient COVID-19 Pneumonia Management

For MTC today, we discussed a patient who presented after a syncopal episode who reported a 4 day history of diarrhea, chills, and decreased appetite. Two of his family members were diagnosed with COVID-19 earlier in the week and no one in the household, including himself, had been vaccinated. On initial presentation, his vitals were within normal limits including a normal oxygen saturation and respiratory rate. Work-up revealed lymphopenia, an AKI, and mildly elevated liver enzymes. After reviewing the imaging with the help of our expert discussant and amazing PCCM attending, Dr. Erica Lin, the residents created a plan for the management of this patient’s COVID pneumonia.

Key points:

  • Severe COVID-19 is primarily defined by need for supplementary oxygen. There are some lab features that may be associated with severe COVID-19 including CRP, ferritin, and lymphopenia.
  • Dexamethasone is not recommended for patients without an oxygen requirement.
  • If there are no contraindication to ACEI/ARB (AKI, hypotension) or aspirin (bleeding), these medications should be continued on admission. Similarly, statins should also be continued on admission, even if there is a mild elevation in transaminases. Ischemic events have been reported in patients admitted with COVID-19 pneumonia, and patients with severe disease frequently have comorbidities that benefit from continuation of these medications.

Thank you to Dr. Erica Lin for joining us today!

7/26 VA MTC: Legionella in the water, Antigens in the Urine

Today our residents reviewed a case of an elderly gentleman presenting after 1 week of symptoms that includes fevers, chills, SOB, malaise, nausea, vomiting, and diarrhea. He reported recent travel to Las Vegas and stayed at a hotel with his wife and other friends. Then ~8 days ago his wife started to have symptoms and the next day his symptoms started.

Patient was found to be febrile, hypoxic, and tachycardic on admission. Labs showed a hyponatremia, AGMA, a significant AKI, leukocytosis, and elevated LFTs. We then reviewed the CXR and discussed a differential for our patient’s presentation. Based on the clinical presentation we discussed additional labs/studies to order. These included ESR, CRP, COVID PCR, RPNA panel, hepatitis panel, Legionella Urine Antigen, and Cocci serologies.

Patient was found to have a positive Legionella urine antigen, confirming diagnosis of Legionnaires disease. We then discussed clinical factors that should raise clinical suspicion for Legionella and patient risk factors associated with infections. We reviewed IDSA recommendations for testing all patients with moderate or severe pneumonia given potential severity of symptoms if not treated early. Lastly we discussed different ways to test for legionella, noting that Urine Antigen is the fasted and most common, BUT it only tests for one serogroup of 1 species. Given that serogroup is responsible for >80% of cases worldwide it is still a good initial test, but it does not rule out Legionella if clinical suspicion is still high!

Key Points:

  • Clinical factors that raise suspicion for Legionella- GI symptoms, hyponatremia, elevated LFTs, CRP levels >100 mg/L
  • Recommended to test for legionella in all patients with moderate or severe CAP (hospitalized)
  • Test with PCR or Urine Antigen (remember urine antigen only tests for L. pneumophilia serogroup 1)
  • Cases of Legionella have been increasing steadily over the past two decades

VA MTC 7/22: Metastatic Lung Cancer with PDL-1= Immunotherapy option

Today we reviewed a case of an elderly female who presented to primary care clinic for ED follow up. She had been evaluated for shoulder and knee pain after mild injuries to both 3 days prior. She had undergone knee xray and shoulder xray without evidence of fracture. However her shoulder Xray had an incidental finding of a right hilar nodule.

Our incredible R3 and future chief, Alex Sykes, took us through her thought process when she saw this patient in clinic. Together with her attending she came up with a plan to repeat imaging with a CXR for further evaluation. Because the opacity was still present she then ordered a CT chest with IV contrast. Dr. Jassal shared advice on how to tackle abnormal results in the outpatient setting when you are not sure what to do, reminding us that there is a support system for residents in these situations and you don’t have to figure out the answer by yourself!

Given the concern for malignancy the patient was sent to pulmonology for consideration toward biopsy. Our expert discussant, the one and only Dr. Renate Pilz shared clinical pearls regarding exposure history, red flag symptoms, and initial work up for lung cancer. We reviewed patient’s imaging which showed enlarged LNs, bone mets, and a brain met. We reviewed her biopsy results which showed 70% expression of PDL-1. Dr. Pilz explained that patients with >50% expression can be offered monotherapy with an immunotherapy agent ( like anti-PDL-1 antibody pembrolizumab).

Key Points:

  • You are not alone when you get primary care clinic results! If you are not sure what to do with an alert, you are encouraged to contact your mentor. You are not expected to always know exactly what to do.
  • If lung nodule concerning/persistent, good plan of action is CT chest and then refer to pulmonology. Even if biopsy can not be done by pulmonology, they cane make that decision and refer to IR
  • Staging requires PET/CT and MRI brain (typically CT chest has already been done)
  • Biopsies are tested for PDL-1 expression, and in advanced NSCLC patients with >50% expression can be offered monotherapy with an immunotherapy agent (anti PDL-1 antibody pembrolizumab)

VA MTC 7/21: Coccidioides is common, but treatment doesn’t have to be!

Today, our amazing 3rd year resident, Dr. Elizabeth Epstein, presented a very interesting case of a 40-year-old gentleman who re-presented after treatment for community acquired pnuemonia with ongoing fevers, night sweats, and weight loss. Despite being treated with a course of Augmentin/Azithromycin, his chest x-ray revealed pulmonary nodules concerning for multifocal pneumonia.

Elizabeth shared that the patient has a very interesting social history including multiple environmental exposures at work (animals, soil, nuts), and travel history when he served in the Navy. His labs were most notable for a peripheral eosinophilia and elevated inflammatory markers. Putting the case together, Elizabeth’s team was most concerned for coccidioidomycosis!

We then dug into some details of coccidioidomycosis from epidemiology to treatment!

Major Take Aways: Many cases of community acquired PNA are caused by Coccidioides in endemic areas, but the majority of patients have self-resolving disease! A mild pulmonary infection in immunocompetent patients does not need to be treated with antifungals.

Thank you so much to our expert discussant, Dr. Rehan Syed, for joining us today! You’re the best!

VA MTC 7/20: No More Effusion Confusion

Today for VA MTC, one of our fantastic 3rd year residents, Dr. Ana Lucia Fuentes, presented the case of a 74-year-old gentleman who presented with dysarthria and was incidentally found to have a left-sided pleural effusion. With the help of our expert discussant and PCCM attending, Dr. Erica Lin, we discussed when a patient should undergo a diagnostic thoracentesis and what studies to send.

In general, a thoracentesis is indicated in a newly diagnosed pleural effusion of unknown etiology (that is large enough to tap).

The three steps in pleural fluid analysis include:

  1. Assess Fluid Appearance
    • Color can help narrow the differential
  2. Determine if it is Transudative or Exudative
    • Use Light’s criteria!
  3. Pleural Fluid Studies
    • Cell Count & Differential
    • Gram Stain & Culture
    • LDH
    • Protein
    • pH
    • Glucose
    • Cytology
    • Others: Amylase, Triglycerides, Cholesterol, Creatinine, Adenosine Deaminase

This gentleman had a bloody, exudative effusion with a WBC of 4,400 with 80% lymphocytes, a negative Gram stain and culture, and a normal glucose. Cytology did not reveal any malignant cells. While this information has helped us narrow down the differential, the etiology is still unknown. He is scheduled for follow-up in pulmonology clinic where the utility of repeat imaging and thoracentesis will be discussed.

Key Point: Cytology has about a 60% sensitivity, which is increased with a second thoracentesis. After the second thoracentesis, yield is low and other diagnostic modalities such as thoracoscopy with pleural biopsy is the net best step if malignancy is of concern.

Thank you so much to Dr. Ana Lucia Fuentes for sharing this case and to Dr. Erica Lin for all your expertise!

7/19 VA MTC: Primary Care Series- Workup and Treatment of Hypertension

This morning we went through a case where a patient presented to clinic to establish care and was found to have an elevated blood pressure in the office. With the help of our awesome primary care expert discussant, Dr. Joseph Diaz, we reviewed initial evaluation in patients with suspected hypertension. We discussed the importance of confirming diagnosis with home blood pressures or ambulatory monitoring.

We also reviewed initial physical exam and work up once diagnosis is made. This includes listening for abdominal bruit, cardiac exam, thyroid, and considering fundoscopic exam if concerned HTN is long-term or malignant. The goal of labs and studies are to determine if there is evidence of end organ damage and to characterize the patient’s overall cardiovascular risk profile.

Lastly we discussed treatment including specific lifestyle modifications that have been proven to help lower blood pressure. We reviewed options for monotherapy initiation and in small groups went over additional benefits, side effects, and contraindications for ACE, ARB, CCB, and thiazides.

7/15 VA MTC: Hyponatremia Treatment Tool Belt

At the VA we went through a case of a 62 year-old male presenting with acute mental status changes and found to have a Na of 117. After reviewing patient’s labs it was determined that etiology was likely ADH independent given low urine Osm and urine Na. HPI revealed increased water intake of up to 6L a day with a decreased PO intake of solutes.

With the help of our expert discussants, Dr. Rifkin and Dr. Abdelmalek, we reviewed the tools available to treat hyponatremia and important things to consider when starting treatment. They explained that the goal of correcting is resolving symptoms which occur at an increase of 4-6 mEq/L while avoiding osmotic demyelination syndrome, which is high risk at correction rates of 10 mEq/L/day or greater. Lastly we went back to the case and noted correction was happening at a rapid rate so our experts reviewed the use of D5W and DDAVP for controlling over correction.

Take Home Points:

➢Treatment Toolbelt for Hyponatremia includes: Fluid Restriction, Salt or Urea Tabs, NS, Hypertonic Saline, and Monitoring

➢Treatment choice depends on presumed underlying cause and symptom severity

➢Goal of treatment is to resolve symptoms of HypoNa without correcting too rapidly, goal rate of 6-8mEq/day

➢Risk of ODS if correcting rapidly, manage with D5W +/- DDAVP

7/13 VA MTC: Evaluation of Hyponatremia

Today at the VA we reviewed a case of an elderly man who presented after 1 week of confusion and fall in setting of 2-3 weeks of decreased PO intake and recent up-titration of his HCTZ. He was found to have a sodium of 117 on admission.

We started our evaluation by confirming true hyponatremia (aka hypotonic hyponatremia) by ruling out isotonic hypoNa (psuedohyponatremia) and hypertonic hypoNa (hyperglycemia, mannitol, etc) by measure serum Osm. We also wanted to start our initial work up by repeating serum sodium and ordering urine Osm, urine Na, and a urinalysis if not already done.

With the help of a pair of amazing kidney experts, Dr. Rifkin and Dr. Abdelmalek, we then reviewed the physiology of tonicity and how the kidneys use ADH and the medullary gradient to regulate it. We evaluated the patient’s tonicity, volume status, ADH activity, and RAAS activity through the history, physical exam, and our labs. Our patient appeared volume down on exam and had a low urine sodium. It was determined that patient likely had hypovolemic hyponatremia due to poor intake over 3 weeks with uptitrated thiazide diuretic dose.