The Clinical Problem Solvers

https://clinicalproblemsolving.com/wp-content/uploads/2017/05/RLR-Diffuse-LAD.mp3Episode descriptionReza and Rabih talk through a caseRLR #1 – LymphadenopathyA woman in her 20’s with a history of prior possible thrombotic thrombocytopenic purpura (TTP) and recently treated secondary syphilis was transferred to a tertiary referral center for evaluation of generalized lymphadenopathy, new anemia, and thrombocytopenia. Laboratory workup was concerning for a Coombs-positive autoimmune hemolytic anemia, possible immune thrombocytopenia, and polyclonal gammopathy. Core and excisional lymph node biopsies were unrevealing for either infection or malignancy. Ultimately, anti-nuclear, anti-dsDNA, and anti-Sm autoantibodies were grossly positive and the patient was diagnosed with systemic lupus erythematosus.Teaching Points: Systemic Lupus Erythematosus(SLE) is a complex autoimmune disease that most frequently presents with inflammatory arthritis, malar rash, and nephropathy.Hematologic abnormalities are common in SLE and are components of both the American College of Rheumatology (ACR) and Systemic Lupus International Collaborating Clinics (SLICC) diagnostic criteria. Common features include leukopenia (both neutropenia and lymphopenia), autoimmune hemolytic anemias (generally Coombs-positive, warm-type), and thrombocytopenia. SLE is a recognized cause of secondary thrombotic thrombocytopenic purpura (TTP), which may present concurrently with or, in some instances, precede the diagnosis of SLE.

https://clinicalproblemsolving.com/wp-content/uploads/2017/05/VMR-15-4-26-20-5.52-PM.mp3Dr. Kushal Vaishnani presents a clinical unknown on Virtual Morning Report to student Dr. Jean-Claude Guidi and Dr. Ramya Ramachandran.Case Overview & Teaching PointsDownload CPSolvers App herePatreon websiteProblem RepresentationA 53-year-old woman with a history of rheumatoid arthritis and amiodarone-induced lung injury on immunosuppression presented with acutely progressive hypoxic respiratory failure and hypotension, found to have a serpiginous truncal rash, acute anemia, and elevated beta-d-glucan.SchemasIn this episode, we revisit the schemas for fever and rash (which highlights first addressing the life-threatening causes) and diffuse alveolar hemorrhage (which focuses on differentiating vasculitis from other etiologies).DiagnosisThe patient underwent bronchoscopy with bronchoalveolar lavage fluid demonstrating elevated leukocytes with a neutrophilic predominance as well as progressively bloody fluid, consistent with diffuse alveolar hemorrhage. Silver stain was diagnostic for Pneumocystis jiroveci, and pathology revealed helminthic larvae consistent with Strongyloides stercoralis. The patient was diagnosed with both Pneumocystis pneumonia and Strongyloides hyperinfection syndrome!Teaching Points: Beta-D-glucan(BDG) is a cell wall polysaccharide found in many fungal organisms (with notable exceptions including Cryptococcus, the zygomycetes, and Blastomyces dermatitidis) and is frequently used as a laboratory marker for invasive fungal infections. Caution is advised when interpreting this test, as it is imperfectly sensitive and false positives have been reported in association with certain hemodialysis filters, immunoglobulins (e.g., IVIG), albumin, and beta-lactam antimicrobials (thought to be more of an issue with older formulations). Strongyloides stercoralisis an important human pathogen in tropical and subtropical areas throughout the world. While many cases of chronic strongyloidiasis are mild and may go unrecognized, severe manifestations can include the strongyloides hyperinfection syndrome and disseminated strongyloidiasis. Hyperinfection occurs when there is accelerated autoinfection (i.e., the ability to complete the parasitic life cycle entirely within the host – a trait relatively unique to Strongyloides among human helminthiases) and most commonly occurs in the setting of immune dysregulation or exogenous immunosuppression. Pneumocystis jiroveciis an important opportunistic infection in immunosuppressed patients. Originally identified by Carlos Chagasin 1909, who believed it to represent a pulmonary manifestation of the parasite Trypanosoma cruzi, it was later reclassified as a fungus in 1988. The most frequent symptoms include subacute dyspnea, nonproductive cough, and low-grade fever, with hypoxemic respiratory failure being the most common manifestation of severe decompensation. 

https://clinicalproblemsolving.com/wp-content/uploads/2017/05/OHSU-final-sp-aup.mp3Dr. Ruchit Rana presents a Human Dx unknown to Dr. André Mansoor and OHSU residents  – Drs. Logan Jones and Patricia Liu.Download CPSolvers App herePatreon websiteHuman Dx caseSchema #1Schema #2Dr. Logan Jones“Logan” Jones is a PGY-3 at OHSU in Portland, and will be joining the faculty as an assistant professor in the Division of Hospital Medicine with an academic focus on student assessment, curricular innovation, learner scholarship, clinical reasoning, and EMR proficiency. He is active in organized medicine with the American Medical Association and the American College of Physicians. Outside of medicine, he enjoys cooking with his sig fig Samantha, spending time on his yoga mat, and hiking throughout the Pacific Northwest.Dr. Patricia LiuPat is currently one of the IM chief residents at Oregon Health & Science University. She will be a hospitalist next year and is interested in medical education, empowering women in medicine and improving care for inpatients with substance use disorders. In her free time, you can find her running, snowboarding and teaching tricks to her cat, Pekoe.Dr. Ruchit RanaRuchit Rana is currently a second-year internal medicine resident at Baylor College of Medicine. He completed medical school at Baylor College of Medicine. He has a passion for practicing and improving medical education at all levels. In his free time, he enjoys cooking and baking dishes across all ethnicities and maintaining his multiple freshwater aquariums at home.Dr. André MansoorAndré Mansoor is an Assistant Professor of Medicine at Oregon Health and Science University in Portland, Oregon. His favorite book is the Count of Monte Cristo and his favorite band is Stone Temple Pilots. He is the author of an internal medicine textbook called Frameworks for Internal Medicine. https://www.amazon.com/Frameworks-Internal-Medicine-Andre-Mansoor/dp/1496359305. Case SummaryA 70-year-old man presented with six months of dyspnea on exertion, night sweats, and weight loss. He was found to be febrile and in distributive shock, with laboratory analysis demonstrating cytopenias, coagulopathy, and lactic acidosis. Computed tomography of the abdomen and pelvis was notable for hepatosplenomegaly, and a bone marrow biopsy revealed a monoclonal B-cell population with hemophagocytosis. The patient was diagnosed with diffuse large B-cell lymphoma complicated by hemophagocytic lymphohistiocytosis (HLH).Teaching Points: Hemophagocytic lymphohistiocytosis (HLH) is a life-threatening, immune-mediated disease caused by impaired NK and cytotoxic T-cell function. While genetic defects play a prominent role in triggering HLH in children, most cases of HLH in adults are secondary to another disorder, such as infections (e.g., EBV, histoplasmosis), hematologic malignancies (e.g., NK, T, or B-cell lymphomas), or autoimmune disease (e.g., systemic lupus erythematosis). 

https://clinicalproblemsolving.com/wp-content/uploads/2017/05/Human-Dx-IU-FINAL.m4aDr. Anand Patel presents a Human Dx unknown to Rabih and Indiana residents  – Drs. Devika Gandhi and Cody Hill.Download CPSolvers App herePatreon websiteHuman Dx caseSchemaDr. Devika GandhiDevika Gandhi is a second-year internal medicine resident at Indiana University. She is originally from Dayton, Ohio and received her undergraduate degree from the University of Akron. She earned her medics degree from Northeast Ohio Medical University in Rootstown, Ohio (Go Walking Whales!). After residency, she plans to pursue a career in gastroenterology/hepatology. During her free time, she enjoys reading, cooking, and going out to trivia with friends.Dr. Cody HillCody Hill is a second-year Med-Peds resident at Indiana University. He attended Clemson University for his undergraduate/graduate studies and the University of South Carolina School of Medicine Greenville for medical school. Although he loves taking care of patients, his true passion lies in medical education, especially when it relates to clinical reasoning and evidence-based medicine. He is also very invested in resident wellness and mentorship, which led him and a fellow classmate to start their own podcast called The Resident Lounge (@resident_lounge). After residency, he plans to pursue a career as a Med-Peds hospitalist and a medical educator with the ultimate goal of one day becoming a program director. Cody also just became a father, so in addition to taking care of his newborn daughter, he and his wife enjoy walking their dog, gardening, cooking and exploring Indianapolis for new craft beers.Dr. Anand PatelDr. Anand Patel is a hematology-oncology fellow at the University of Chicago and the Medical Education Lead at the Human Diagnosis Project. He attended University of Missouri-Columbia for medical school and completed both his internal medicine residency and chief residency at Northwestern. Anand’s academic interests include medical education and clinical reasoning. Specifically within hematology-oncology, he is interested in clinical trial design using targeted therapies for patients with leukemias and myeloid neoplasms.Case SummaryAn 83-year-old woman with acute myeloid leukemia and psoriasis (on immunosuppression) presented with six weeks of fatigue, weight loss, and a dry cough. Her medical history was notable for two indeterminate interferon-gamma release assays. Computed tomography of the chest demonstrated a 3 x 3 cm right lower lobe mass, with subsequent biopsy revealing necrotizing granulomas and acid-fast bacilli. Cultures ultimately grew Mycobacterium avium complex (MAC).  Teaching Points: Mycobacterium avium complex (MAC) is a ubiquitous water and soil-based organism. Clinical manifestations include pulmonary infections, lymphadenitis, and disseminated disease in severely immunocompromised patients (e.g., those with HIV and CD4 counts < 50 cells/µL). Pulmonary manifestations of MAC include cavitary upper lobe disease similar to tuberculosis, fibronodular bronchiectasis that often develops in the right middle lobe or lingula, solitary pulmonary nodules, and hypersensitivity pneumonitis. 

https://clinicalproblemsolving.com/wp-content/uploads/2017/05/University-of-Colorado-Human-Dx-FINAL.m4aDr. Anand Jagannath presents a Human Dx unknown to Reza and U of C residents – Drs. Alec and Austin Rezigh.Download CPSolvers App herePatreon websiteHuman Dx caseSchemaDr. Alec RezighAlec Rezigh is a third-year internal medicine resident at The University of Colorado. He is originally from Houston, TX and received his undergraduate degree at the University of Texas at Austin. He then went back to Houston for medical school at the University of Texas at Houston (McGovern) Medical School. In his free time, he loves all things basketball, traveling with his wife, and napping on the couch with his dog. Following completion of his training, he will return to Houston to be an academic hospitalist. He wishes to thank Dr. Juan Lessing for his amazing mentorship and inspiring his interest in clinical reasoning – and introducing him to Rabih and Reza!Dr. Austin RezighAustin Rezigh is a third-year internal medicine, primary care track resident at the University of Colorado. He completed medical school at UT Southwestern and is excited to pursue a career in academic general internal medicine. In his free time, he enjoys trying new cuisines, exercising, and spending time with his fur-niece, Kensie.Dr. Anand JagannathDr. Anand Jagannath is a clinician-educator at the University of California, San Diego (UCSD) and hospitalist at the VA San Diego. He completed medical school at the Tufts University School of Medicine and internal medicine residency and chief residency at Albert Einstein College of Medicine/Montefiore Medical Center. At UCSD, Anand’s interests include bedside team rounding, teaching clinical reasoning to medical students and residents, learning from his learners, and promoting a safe and inclusive learning environment. He is also a Section Editor for adult medicine cases at the Human Diagnosis Project. When he’s not getting excited about medicine, you’ll probably find Anand cooking food, watching shows about food on Netflix, running, or playing basketball or his violin. Human Dx Case SummaryA 66-year-old man with alcohol use disorder and chronic NSAID use presented with one day of abdominal pain and nausea. Laboratory analysis was notable for hypercalcemia to 16 mg/dL (with low parathyroid hormone and vitamin-D levels), metabolic alkalosis, and an acute kidney injury. The patient disclosed that he had recently consumed large amounts of calcium carbonate for his abdominal pain, and he was diagnosed with the milk alkali syndrome. His serum calcium normalized after receiving intravenous fluids and withholding further calcium supplementation.Teaching Points: The milk alkali syndrome, the third most common cause of hospital admission for hypercalcemia, develops from excess consumption of calcium supplements (e.g., calcium carbonate). Patients classically present with hypercalcemia, metabolic alkalosis, and renal insufficiency. The metabolic alkalosis is thought to be due to hypercalcemia-induced nephrogenic diabetes insipidus, while renal insufficiency develops as a result of calcium-induced renal tubular damage and vasoconstriction of the renal afferent arteriole. Treatment includes intravenous fluid resuscitation and cessation of calcium supplementation.

https://clinicalproblemsolving.com/wp-content/uploads/2017/05/SLS-AKI-and-Hyponatremia-FINAL.m4aThe CPSolvers share a case of hyponatremia and AKI – let’s practice those schemas together!Download CPSolvers App herePatreon websiteHyponatremia schemaAKI schema

https://clinicalproblemsolving.com/wp-content/uploads/2017/05/Aimee-Zaas-EPpost-aup.mp3Dr. Ellie Garbade presents a clinical unknown to Dr. Aimee Zaas and CPSolvers.Download CPSolvers App herePatreon websiteLearn-Live!Dr. Ellie GarbadeEllie Garbade is a current chief resident at the University of Rochester Medical Center, where she completed her internship and residency in Internal Medicine. Following chief year, she plans to continue her career at the University of Rochester as an academic hospitalist.Dr. Aimee ZaasAimee Zaas is an Associate Professor of Medicine at Duke University School of Medicine in the Division of Infectious Diseases and International Health. She serves at the Program Director for the Duke Internal Medicine Residency Program and spends her clinical time on the general medicine service with residents and students as well as on the Transplant Infectious Diseases consultative service at Duke Hospital. After completing her medical school at the Feinberg School of Medicine at Northwestern University, she completed her residency and Assistant Chief of Service (Thayer!) at The Johns Hopkins Hospital and her Infectious Diseases fellowship at Duke. She enjoys spending time with her husband, two boys (but, let’s face it, they are teenagers so are never home) and two dogs, cheering on her kids’sports, the Duke Blue Devils and St. Louis Cardinals as well as trying out new restaurants and excellent coffee.

https://clinicalproblemsolving.com/wp-content/uploads/2017/05/Sal-Reza-Boateng_Human-Dx-3-21-20-7.18-PM.mp3Dr. Sneha Thatipelli presents a Human Dx case to student doctor Boateng Kubi and CPSolvers Sal and Reza.Download CPSolvers App herePatreon websiteSchemaHuman Dx caseStudent Doctor Boateng KubiBoateng Kubi is a third-year medical student at Johns Hopkins University School of Medicine and will be applying to residency programs this fall.He is excited to pursue a career in academic surgery and has developed an early interest in cardiothoracic surgery. He is interested in outcomes research, medical education, and clinical reasoning. His clinical interests include cardiovascular infections, thoracic malignancies, and heart & lung transplantation. A Maryland native, he enjoys spending his free time with family, working out, or exploring restaurants in Baltimore with friends.Dr. Sneha ThatipelliSneha Thatipelli is a third year internal medicine resident at Northwestern Memorial Hospital. She completed her medical school at UCSF, and is excited to pursue a career in Infectious Disease with a focus on HIV medicine. She is passionate about medical education and understanding barriers to provide equitable care for vulnerable populations. She will be a graduate of the Health Equity and Advocacy Clinical Scholars (HEACS) program at McGaw and hopes to use this training for clinical care and also medical education of trainees.

https://clinicalproblemsolving.com/wp-content/uploads/2017/05/Einstein-HDX-FINAL.mp3Dr. Hajduczok presents a a Human Dx case to Einstein residents, Dr. Gandhi and Dr. Bressman, and Rabih.Schema Human Dx CaseDownload CPSolvers App herePatreon websiteDr. Himali GandhiI graduated from NYU medical school and am now finishing my PGY-3 year at Montefiore Medical Center in the Bronx, NY. My clinical interests include preventative cardiology and medical education and I am excited to be starting my cardiology fellowship at Northshore University Hospital- Northwell in Long Island. When I am not in the hospital I love hiking, running, cooking, and exploring different styles of dance.Dr. Max BressmanI went to Swarthmore College where I played tennis for the college team (ranked top 25), went to NYU Medical School (switched to golf, now attempt to qualify for the US Open every year and came 1 stroke from making the US national amateur championship last year). Finishing PGY-3 year at Montefiore in the Bronx, NY. Was originally planning on cardiology, but changed my mind and am going to stay as a Hospitalist at Montefiore and get involved in education. While at Montefiore, published abstracts, posters, and just got a manuscript into AJM. Anand Jagannath was my chief as an intern and we wrote and abstract/poster (along with Firm-1 leader Matt Shaines) that won the top prize at SHM in 2018.Alex HajduczokAlex Hajduczok is a second-year internal medicine resident at Penn State Hershey Medical Center. He is originally from Buffalo, New York and completed is undergraduate degree in biochemistry at the University of Rochester and stayed at the University of Rochester School of Medicine & Dentistry for medical school. After residency, he plans to pursue a career as a clinician-investigator in cardiology. He is currently engaged in heart failure remote monitoring research at Penn State Hershey. In his free time, he enjoys working out, coaching CrossFit, and playing hockey.

https://clinicalproblemsolving.com/wp-content/uploads/2017/05/Case-Based-COVID-FINAL.m4aEpisode descriptionStudent Dr. Emma Levine moderates a COVID-19 case discussion with expert input from Drs. Brian Block, Neeta Thakur and Peter Chin-HongDr. Peter Chin-HongPeter Chin-Hong is Associate Dean for Regional Campuses at UCSF School of Medicine. He is a medical educator who specializes in treating infectious diseases, particularly infections that develop in patients who have suppressed immune systems, such as as solid organ and hematopoietic stem cell transplant recipients and HIV+ organ transplant recipients. He directs the immunocompromised host infectious diseases program at UCSF. He has been involved in the COVID19 clinical consultation and treatment team.Dr. Neeta ThakurNeeta Thakur is a Pulmonary Critical Care Physician and health disparities researcher at UCSF. Her main research interests are in understanding how the social environment contributes to disease and modifies disease course in low-income communities and communities of color. Dr. Thakur’s experience as a clinician and Medical Director of the Zuckerberg San Francisco General Hospital Chest Clinic, gives her first-hand insight on how social and environmental stress negatively affect asthma and other health outcomes, and practical knowledge of the existing barriers to adoption of evidence-based interventions into practice. With the evolving COVID-19 epidemic, her research focus has shifted to better understand the fears, needs, and socioeconomic impact in low-income, diverse communities.Dr. Brian BlockBrian Block is an Instructor of Medicine and Research Fellow in the Division of Pulmonary and Critical Care Medicine at UCSF. He has interests in medical ethics and critical illness communication. He graduated from Harvard Medical School and completed Internal Medicine training at Columbia University where he was also a Chief Resident. He then came to UCSF to complete fellowship training in Pulmonary and Critical Care medicine. His UCSF bio also describes him as a “mediocre golfer” and now he can’t figure out how to have that removed.