HC MTC 3/2: Rhabdomyolysis

Today our amazing R2 Dr. Natalie Prussak took us through an interesting case of a man with a history of seizures and polysubtance use who was found down with AMS. His AMS was determined to likely be due to seizures from med-nonadherence but his care team astutely also honed in on his metabolic acidosis, elevated LFTs and CK and was concerned about the possibility of rhabdomyolysis.

We walked through our differential for elevations in CK and why in this case this patient had the clinical signs concerning for rhabdomyolysis. We also discussed the diagnostic schema for causes of rhabdomyolysis and the things to complications to look out for/management tips.

Our patient had a CK that uptrended to >100K but thanks to the astute management of his team he never developed compartment syndrome or AKI and was safely discharged home with good follow-up for his seizures.

Take Home Points:

  1. Have a high clinical suspicion for rhabdo in a patient that has been immobile, had crush injury or seizure/ extreme hyperkinetic state. Check for elevated CK >5000 unit/L (rises in 2-12 hrs from inciting event), and myoglobinuria (look for blood in urine with low RBC count) as well as LFTs and LDH elevation as indicators for muscle damage.
  2. Early signs of rhabdo (within the first 12 hrs) include electrolyte derangements specifically hyper K, hyper phos, hypocalcemia, metabolic acidosis and hypovolemia. Be on the look out for these as you patient will be at risk for fatal arrhythmias!
  3. Later complications include development of AKI (most common complication!) so make sure you fluid resuscitate early and aggressively, 1L/hr until the CK drops below 5000 unit/L regardless of how well patients can take PO. Watch out also for signs of compartment syndrome and more rarely DIC.

Knee Pain and Non-Infectious Complications of HIV

Today Chief Resident Holly Greenwald presented a case of acute knee pain in a patient with well controlled HIV. We reviewed the characteristics of synovial fluid for multiple types of joint effusions and remembered that internists can perform arthrocentesis too!

We then discussed non-infectious complications of HIV. HIV is a pro-inflammatory state that leads to dysfunction in almost every organ system over time!

—-Joints: increased risk for seronegative spondyloarthropathies (ie psoriatic arthritis), RA, lupus

—-Increased triglycerides, decreased total cholesterol

—-Increase CVD risk

—-HIV nephropathy

—-Bone marrow abnormalitie

—-Smoking and smoking related illnesses (lung pathology, ILD)

—-Neuropsychiatric disorders

—-HPV related cancers

—-Less common: peripheral neuropathy, lipodystrophy

Thank you to Dr. Kadakia for serving as our expert discussant!

HC MTC 6/24 – Myositis

This morning Dr. Masha Barksy presented a great case of glucocorticoid induced myopathy/inflammatory myopathy. A 70 year old female was found to have progressive muscle weakness developing over a subacute period. The patient had a history of Sjogren’s syndrome, and had been exposed to high dose glucocorticoids prior to her presentation. The patient reported progressive proximal and and distal weakness involving initially the lower extremities, then subsequently involving the upper extremities. There was no associated rash. She was found to have an elevated ANA, SSA, but normal CPK. MRI of her lower extremities demonstrated diffuse symmetric perimysial edema, consistent with myositis. Muscle biopsy demonstrated inflammatory myopathy, but also Type II fiber atrophy, which is seen in glucocorticoid induced myopathy, disuse/aging, or paraneoplastic syndromes. We used this opportunity to discuss an initial differential for muscle weakness, but focused on inflammatory myopathies as well as steroid induced myopathy, discussed the clinical presentation, notable items for work up and treatment options of various

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Global MTC- Unhappy Feet

This morning, we conferenced with our colleagues in Maputo, Mozambique and learned how to evaluate foot and ankle pain in the outpatient setting. Dr. Kusuma Pokala presented an exciting case this morning of an atypical presentation of ankle and foot pain initially misdiagnosed as gout after the patient was seen in an urgent care clinic. An x-ray demonstrated no significant abnormalities, however an MRI was performed given the patient’s persistent pain, which revealed an infiltrating mass in the cuboid bone, consistent with malignancy. Pathology of the lesion revealed Diffuse Large B-Cell Lymphoma!

There were several teaching points from this morning including a general review of the anatomy of the foot and ankle and developed a thorough differential for pain for the ankle as well as the midfoot. Then, our expert discussant Dr. James Hubbard from the Orthopedic Surgery department demonstrated key physical exam maneuvers on a lucky volunteer, Dr. Shannon Devlin!

Finally, we reviewed the Ottawa Foot and Ankle rules, which help determine when it is appropriate to obtain radiographic imaging.

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Thank you to to Dr. Pokala for a great case and to Dr. Hubbard for his expert input!


This morning at the VA Dr. Wu presented the case of a 73yo woman with history of hypothyroidism, pernicious anemia, AAA repair with AVR who presented with subacute intermittent periodic fevers to 102, night sweats, weight loss and neck pain. We came up with a differential including the categories of malignancy, infection, autoimmune disease, and drug effects. After more history we left this list at the first three categories and called this syndrome FUO. (Noting that technically as the diagnosis still stands this requires one week in hospital evaluation without clear etiology). With this in mind we did a thorough physical exam including mucous membranes, skin, cardiopulmonary, abdominal, lymph node, musculoskeletal and neurological exams. Notable positives from this were a 2/6 harsh systolic murmur and S2 click, tenderness to palpation of the deltoids bilaterally, full cervical range of motion. Dr. Corr showed us how to do an exam of the hand joints and which joints you would expect to be

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MTC: EBM in action at the VA

Today we had one of our monthly EBM sessions with Dr. Ben Hulley. We reviewed the PICO approach to EBM’s, and learned that it is best applied to a series of studies, rather than a single study. We then heard EBM presentations from three of our excellent 3rd year residents! Dr. Stephen Schale presented his EBM on PO vs. colonoscopic fecal microbiota transplants (FMTs) for patients with recurrent C.diff infections. We learned that there are no good, large studies looking into these; however, there are several smaller, retrospective studies that suggest that PO FMT may be a reasonable alternative to colonoscopic FMT for those patients who are strongly opposed to colonoscopy. Dr. Jessica Galant-Swafford presented her EBM on chiropractic manipulation in addition to usual care for the treatment of chronic low back pain. She gave us an in-depth review of several large studies that show chiropractic manipulation gives patients a perceived improvement in pain; however, there is no clear objective measurement

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MTC: Secondary Osteoporosis

A young male patient in his 20s presents to endocrinology clinic after a recently diagnosed T9 vertebral compression fracture.  The patient reports that he fell off his bed (about 2-3 feet off the ground) that caused the injury.  He reports a prior history of multiple wrist and finger fractures in his childhood and teenage years, which he attributed to baseball related injuries.  He also notes that his height is now 6’3″ though he was 6’5″ about 3 months ago.  He has a normal diet and no other medical problems.  His parents are both of normal height, but his sister is “tall and skinny” and had prior work up for Marfan’s syndrome, with at least an echo that was unremarkable. During the clinic visit, the patient has unremarkable vitals.  He is noted to be tall and thin.  He has normal appearing sclera.  He has mild pectus exacavatum.  He has no joint hypermobility or bowing of the shins.  He has some vertical

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MTC: Ankle Pain / Hemochromatosis

Dr. Will Stendardi presented today’s primary care focused morning teaching conference! CC: 44yo M presents to the clinic for a routine check up prior to running the Boston Marathon. He is hoping to discuss some R heel pain has been having as well as discuss some lab work he had done recently outside the office. HPI: The patient reports his R heel pain has been ongoing for almost 4 years. It is worse in the morning and while running and improves with movement and stretching.   He took 6 months off from running and it improved, but now has recurred. Despite the discomfort, he is still able to run 50 miles per week. The patient has no other past medical history and does not take any medications aside from vitamin C, fish oil and a multivitamin. RLE Exam: Inspection – Bulbous nodularity present, no Haglund deformity (pump-bump) Palpation – Achilles tendon, thickened and TTP over insertion and 4cm proximal to insertion

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MTC: Thyrotoxic Periodic Paralysis

A 22yo M presents with “weakness in his extremities.” The patient reports upper and lower extremity weakness intermittently for the past 2 months. He reports 4 episodes of weakness, typically last 2-3 days but 3 days prior to admission, he had drastically worsening weakness to the point of near paralysis. ROS notable for flu-like illness 2 months ago, diaphoresis, tremors, palpitations, diarrhea. Vitals: T 97.8F, HR 105 (sinus tachycardia), BP 110/60, RR 16, SpO2 98% RA Exam: Regular tachycardia. Normal rectal tone. Alert and oriented. CN2-12 intact, EOMI, no lid lag or proptosis. No sensory deficits or saddle anesthesia. Normal DTR, Babinski’s present Strength: Shoulder abduction/adduction: 3/5 Elbow flexion/extension: 4/5 Hand grip: 4/5 Hip flexion/extension: 3/5 Knee flexion/extension: 4/5 Plantarflexion/Dorsiflexion: 4/5 Labs: Notable for K of 1.7 and Phos of 2.1 The patient’s potassium was repleted and he has subsequent improvement of his weakness. Differential was broad at this point. Initial additional testing started with thyroid function studies and demonstrated

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MTC: Brucellosis

Dr. Paulette Gabbai-Saldate presented today’s morning report at Hillcrest for our residents and IM applicants. Thank you to Dr. Tony Lopez and Dr. Torriani for serving as our expert discussants in primary care and ID, respectively! A 70yo M with history of chronic low back pain presents to his PCP’s office complaining of worsening back pain. How do we approach back pain in adults, which is one of the most common complaints in the primary care setting? It is important to remember that ~80% of adults have low back pain at some point in their lives, with most cases of acute or subacute back pain resolving regardless of treatment. Only about 1% of cases are due to “Can’t Miss” etiologies, which we should be screening for carefully in our history and exam. The patient described mid back pain that had acutely worsened in the past 3 weeks. He described the pain as sharp with radiation in a band-like pattern around

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