The Clinical Problem Solvers

https://clinicalproblemsolving.com/wp-content/uploads/2017/05/HDx_Mercy__Sharmin_PREAU_UPDATED.m4aEpisode DescriptionDr. Julia Burns presents a Human Dx unknown to Sharmin and Mercy residents  – Drs. Brady Alling and Aaron Sabal.Download CPSolvers App herePatreon websiteHuman Dx caseDr. Brady AllingBrady is a PGY 3 at Mercy Health in Muskegon, MI. Next year, he will be doing a fellowship in pulmonary & critical care in Colorado. His favorite thing about internal medicine is is the profound sense of accomplishment he feels when replacing electrolytes that are just slightly below the normal range.Dr. Aaron SabalAaron was born and raised in Westland, MI (Detroit metro area). He went to Wayne State University for my undergraduate studies thinking he would be a physical therapist, massage therapist, and dietitian (yes, all three of those). However, about one week prior to starting my massage therapy program, he had an epiphany and decided to go to medical school instead. He was fortunate to be accepted to MSUCOM and fell in love with Internal Medicine. His passions include all things medical. In particular, he is passionate about medical education, how best to help physicians learn, diagnostic reasoning, and creating an environment of learning where no one is afraid to express what they’re thinking. When he is not pursuing his love of learning, He is spending time with his wife and their boys (2 cats and a dog), playing with his animals, doing DIY home-improvement projects, exploring national parks, or reading a good non-medical book with a cat or dog in his lap begging for his love and attention.Dr. Julia BurnsJulia is currently a geriatrics fellow at Mount Sinai Hospital in Manhattan. She earned her undergraduate degree from Fairfield University. She then went on to obtain a master of science in biomedical sciences from New York Medical College followed by her medical degree at Albany Medical College. She completed her internal medicine residency at NYU Winthrop Hospital on Long Island. Her academic interests include medical student and resident education.

https://clinicalproblemsolving.com/wp-content/uploads/2017/05/Human-Dx_Utah_Arsalan-FINAL.m4aDr. Kavea Panneerselvam presents a Human Dx unknown to Arsalan and Utah residents  – Drs. Marja Anton and Guinn Dunn.Download CPSolvers App herePatreon websiteHuman Dx caseDr. Marja AntonMarja is a chief medical resident at the University of Utah. She is originally fromChicago, IL and received her undergraduate degree from the University ofWisconsin-Madison (go Badgers!). She then moved back to Chicago for medicalschool at Loyola University Stritch School of Medicine. In her free time, you can find her traveling with her husband in their camper van, rock climbing with friends, tending to her garden or listening to the Clinical Problem Solvers! Next year she is excited to stay on at the University of Utah as an academic hospitalist.Dr. Guinn DunnGuinn is a first year Internal Medicine resident at the University of Utah. She wasborn and raised in Salt Lake City, received her undergraduate degree at theUniversity of Puget Sound, then headed back to Utah for medical school andresidency. She is interested in academic hospital medicine and quality improvement. She enjoys skiing, backpacking, and is looking forward to the birth of her first kiddo in a few weeks.Dr. Kavea PanneerselvamKavea Panneerselvam is about to complete her intern year at Baylor College of medicine in Houston, TX. She grew up in the Houston area and completed her undergraduate at the University of Texas at Austin and is a proud Longhorn, and obtained her medical degree at UT Houston. After residency she hopes to pursue a career in gastroenterology. Specifically, she has an interest in IBD. In her free time she enjoys playing board games, discovering new movies, and making art for her friends and family.

https://clinicalproblemsolving.com/wp-content/uploads/2017/05/Parteon-Announcement-Final.m4aEpisode descriptionReza and Rabih have an important announcement about the RLR series.More about the RLR series here.

https://clinicalproblemsolving.com/wp-content/uploads/2017/05/MUSC-FINAL-.m4aRabih and Reza tackle a clinical unknown at MUSC with host, Dr. Marc Heincelman.Download CPSolvers App herePatreon websiteSchema #1Schema #2Dr. Marc HeincelmanMarc Heincelman is an assistant professor within the Department of Medicine at the Medical University of South Carolina, where he also serves as director of the Medicine Clerkship and Acting Internship.  He received his undergraduate degree from the University of Pittsburgh, medical degree from Loyola University of Chicago, and completed his combined internal medicine/pediatrics residency at the Medical University of South Carolina in 2014.  His passion for medical education stems from his mission to motivate and inspire learners to become the best physicians possible for their future patients.Case SummaryA middle-aged woman with a history of treated breast cancer and unspecified uveitis presented with subacute fever, arthralgias, and headache. She was found to have elevated inflammatory markers, extensive lymphadenopathy, and a cholestatic pattern of liver injury with an unrevealing evaluation for infectious and autoimmune pathologies. She remained febrile despite broad-spectrum antibiotics. She was then started on empiric doxycycline, which resulted in prompt resolution of her fevers. A serologic test for Rickettsia rickettsii returned positive, confirming the diagnosis of “spotless” Rocky Mountain Spotted Fever.Teaching Points: Rocky mountain spotted fever(RMSF) is an acute, life-threatening febrile illness caused by the intracellular pathogen,Rickettsia rickettsii. Endemic  to the southeastern and south central regions of the United States, it is transmitted by ticks (esp Dermacentor ). The classic triad of symptoms includes fever, headache, and rash (often beginning on the wrists and ankles, progressing from maculopapular to petechial). Roughly 10-12% of cases may present without rash (i.e., “spotless” RMSF), more commonly reported in elderly and/or African American patients. Given its high mortality rate, prompt initiation of empiric doxycycline is important for improving outcomes.

https://clinicalproblemsolving.com/wp-content/uploads/2017/05/51920_VMR_Audio-QT.m4aEpisode descriptionDrs. Kimberly Manning and Gurpreet Dhaliwal discuss an unknown case as part of the 50th CPSolvers Virtual Morning Report.Virtual Morning ReportClick here to learn more about joining VMR and learn together, live.Dr. Kimberly ManningKimberly D. Manning, MD is a general internist/hospitalist who serves as Associate Vice Chair of Diversity, Equity, and Inclusion for the Department of Medicine at Emory University School of Medicine. Manning was recently promoted to Professor of Medicine and additionally serves as residency program director for the Transitional Year Residency Program at Emory. She has a strong commitment to supporting underrepresented minorities in medicine, serving underserved populations, and creating better understanding of our patients and each other through storytelling and narrative medicine. A huge fan of the CP Solvers, Dr Manning is as enthusiastic about being a teacher as she is being a lifelong learner. Dr. Gurpreet DhaliwalDr. Dhaliwal is a clinician-educator and Professor of Medicine at the University of California, San Francisco. He is the site director of the internal medicine clerkship at the San Francisco VA Medical Center, where he teaches medical students and residents in the emergency department, urgent care clinic, inpatient wards, outpatient clinic, and morning report. His academic interests are the cognitive processes underlying diagnostic reasoning and clinical problem-solving and the study of diagnostic expertise. Dr. Dhaliwal enjoys playing pickup basketball with his two sons … even though both can handily defeat himCase SummaryA 69-year-old man with a history of prior cerebrovascular accident (CVA) presented with acute onset right leg weakness and paresthesias. Laboratory analysis was notable for elevated inflammatory markers. A magnetic resonance image of the brain showed a ring-enhancing lesion in the left parietal lobe, with fine needle aspiration revealing gram positive cocci in chains. Cultures grew Streptococcus intermedius (a member of the S. anginosusgroup), and the patient was diagnosed with a bacterial brain abscess.Teaching Points: Brain abscesses can be caused by bacteria, fungi, and parasites. Bacterial brain abscesses can arise via contiguous spread of bacteria from head and neck sources or by hematogenous routes. The causative organism often varies with the underlying immune status of the host. Among immunocompetent hosts, the most common organisms are Staphylococcusand Streptococcus spp (e.g., S anginosus). Neurosurgical sampling may be required to identify the pathogen and achieve source control.Lacunar infarctions are an important form of ischemic strokes (representing ~20%) caused by cerebral small vessel disease. Pathophysiologically, the most important risk factor is uncontrolled hypertension, which can lead to small vessel injury and subsequent occlusion. Most lacunar strokes involve the basal ganglia, pons, and subcortical white matter structures (e.g., internal capsule). While many clinical syndromes have been described, the 5 most common include pure motor, pure sensory, mixed sensorimotor, ataxic hemiparesis, and dysarthria-clumsy hand syndrome. 

https://clinicalproblemsolving.com/wp-content/uploads/2017/05/RLR-Transient-Loss-of-Conciousness.mp3Episode descriptionReza and Rabih talk through a caseRLR #4 – Transient loss of consciousness A 43-year-old man with a history of epilepsy, coronary artery disease, and pulmonary sarcoidosis presented after experiencing an unheralded transient loss of consciousness. His initial evaluation revealed no abnormalities. Ambulatory cardiac event monitoring demonstrated an episode of complete heart block, and myocardial perfusion imaging showed a focal perfusion defect in the left ventricle (thought to represent a prior myocardial infarction versus sarcoidosis). He underwent pacemaker and implanted cardiac defibrillator (ICD) placement and was discharged home.Teaching Point: Small-cell lung cancer(SCLC) is a primary pulmonary malignancy of epithelial origin that most commonly occurs in older patients with long-standing smoking histories. Clinically, it typically presents aggressively with pulmonary symptoms (e.g., cough, dyspnea, hemoptysis), manifestations related to intra- or extra-thoracic spread, or with a variety of paraneoplastic syndromes (e.g., endocrine, dermatologic, neurologic). Prognosis is poor, with median survival without treatment being 2-4 months.Sarcoidosis is a multisystem granulomatous disease that most often affects the lungs, skin, and eyes.Cardiac manifestationsof sarcoidosis include arrhythmias, cardiomyopathy, sudden cardiac death, and, rarely, coronary artery vasculitis. Diagnosis can be made by endomyocardial biopsy or with compatible imaging findings (e.g., delayed gadolinium enhancement on cardiac MRI) or cardiac manifestations (e.g., complete heart block, ventricular arrhythmias, or otherwise unexplained heart failure) in a patient with known extra-cardiac sarcoidosis. 

https://clinicalproblemsolving.com/wp-content/uploads/2017/05/RLR-Scrotal-Pain.mp3Episode descriptionReza and Rabih talk through a caseRLR #3 – Scrotal pain A 75-year-old man with a history of Alzheimers dementia presented with 2 weeks of bilateral scrotal pain. Genital exam was unremarkable. Chest radiography revealed a right lower lobe opacity and computed tomography of the abdomen was notable for diffuse retroperitoneal lymphadenopathy. Biopsy was performed of a mediastinal lymph node which revealed findings consistent with metastatic small-cell lung cancer.Teaching Points: Acute scrotal pain is a common complaint encountered in the emergency department and can be caused by pathology within the scrotum, abdomen (i.e., inguinal hernia), or referred from the retroperitoneum. The most common causes of acute scrotal pain include torsion of the testicular appendage, epididymitis, and testicular torsion. The initial evaluation is focused on excluding the presence of testicular torsion (a surgical emergency) by exam and, often times, doppler ultrasonography. 

https://clinicalproblemsolving.com/wp-content/uploads/2017/05/Racial-Disparities-in-the-COVID-19-Pandemic.mp3Student Dr. Dereck Paul, Dr. Utibe Essien and Dr. Kimberly Manning join the CPSolvers to discuss racial disparities. This all-star crew discusses the role of race and inequality in the current COVID-19 pandemic and medicine more broadly. Don’t miss out on this truly powerful episode. Student Dr. Dereck PaulDereck Paul is a 4th-year medical student at the University of California, San Francisco School of Medicine and applying into residency this fall. He studies the relationships between homelessness and health under Dr. Margot Kushel at the UCSF Center for Vulnerable Populations. He was a 2018 Student National Medical Association David E. Satcher MD, PhD Health Disparities Research Fellow for his work mapping the role of structural racism in susceptibility to housing insecurity and homelessness. Outside of his studies and research, he writes about health policy, medical education, and the underrepresented medical trainee experience.Dr. Utibe EssienUtibe Essien is an Assistant Professor of Medicine at the University of Pittsburgh and a health disparities researcher in the VA Center for Health Equity Research and Promotion. He completed Primary Care residency and General Internal Medicine fellowship at the Massachusetts General Hospital and Harvard Medical School. Dr. Essien’s research focuses on developing interventions to advance equity in the management of cardiovascular diseases.Dr. Kimberly ManningKimberly D. Manning, MD is a general internist/hospitalist who serves as Associate Vice Chair of Diversity, Equity, and Inclusion for the Department of Medicine at Emory University School of Medicine. Manning was recently promoted to Professor of Medicine and additionally serves as residency program director for the Transitional Year Residency Program at Emory. She has a strong commitment to supporting underrepresented minorities in medicine, serving underserved populations, and creating better understanding of our patients and each other through storytelling and narrative medicine. A huge fan of the CP Solvers, Dr Manning is as enthusiastic about being a teacher as she is being a lifelong learner. 

https://clinicalproblemsolving.com/wp-content/uploads/2017/05/AVI-Jack-and-Reza-MR-pre-aup-1.mp3Dr. Avital O’Glasser presents a clinical unknown on Virtual Morning Report to CPSolvers, Jack and Reza.Case overview and teaching pointsDownload CPSolvers App herePatreon websiteSchemaDr. Avital O’GlasserAvital O’Glasser is an Associate Professor of Medicine at Oregon Health & Science University (OHSU) in the Division of Hospital Medicine. She is the medical director of OHSU’s hospitalist-led Pre-Operative Medicine Clinic, as well as The Curbsiders Kashlek Memorial Hospital Chief of Perioperative Medicine. She is also the Assistant Program Director for Social Media and Scholarship for OHSU’s Internal Medicine Residency Program. She has been a member of the OHSU faculty since completing her internal medicine residency training there, and she is a graduate of Jefferson Medical College. She enjoys spending time with her husband, two young boys, and labradoodle Matilda.Case SummaryA 31-year-old man with no prior medical problems presented with subacute abdominal pain, recurrent fevers, and weight loss. His work-up was notable for stigmata of endocarditis, although bacterial blood cultures were persistently negative. Ultimately, he underwent aortic valve replacement, and pathologic examination of the valve tissue demonstrated coliform bacteria with molecular testing confirming a diagnosis of Streptobacillus moniliformis. Further history confirmed that he owned a pet rat and had experienced repeated bites prior to his illness. Teaching Points Streptobacillus moniliformisis a pleomorphic, gram-negative rod that is the predominant cause ofrat bite fever (RBF). This pathogen is found across the United States and is most commonly transmitted by rat bites, with numerous cases being acquired from pets or laboratory animals. Clinical manifestations include fever (potentially relapsing), arthralgias, and rash. Serious complications include infective endocarditis, meningitis, systemic vasculitis, and other organ involvement.

https://clinicalproblemsolving.com/wp-content/uploads/2017/05/RLR-Episode-2_Hoarseness.mp3Episode descriptionReza and Rabih talk through a caseRLR #2 – HoarsenessA 54-year-old man with a history of PTSD, depression, and a recent diarrheal illness presented with acute dysphagia to liquids and solids. Neurologic exam was initially unremarkable, but the patient returned the next day with diplopia and ataxia. Exam was notable for new bilateral cranial nerve III palsies and areflexia. Laryngoscopy revealed unilateral vocal cord paralysis. Cerebrospinal fluid analysis was notable for elevated protein and positive GQ1b antibody testing. He was diagnosed with Miller Fisher’s syndrome, a variant of Guillain-Barre Syndrome.Teaching Points: Miller Fisher’s Syndrome(MFS) is a rare variant of Guillain-Barre syndrome (acute inflammatory demyelinating polyneuropathy) that primarily affects the bulbar nerves. MFS is suggested by the classic triad of acute-onset ophthalmoplegia, ataxia, and areflexia and often occurs following a prodromal illness (upper respiratory infection or gastroenteritis). Diagnosis is supported by elevated cerebrospinal fluid protein as well as demonstration of GQ1b ganglioside autoantibodies (which are positive in 85% of cases). Prognosis is typically favorable, and most cases are self-limited.