Travis Smith, DO Profile picture
Aug 19, 2020 24 tweets 28 min read Read on X
Time for some #SpacedRepetition: @CPSolvers @DxRxEdu @rabihmgeha
Chat recap of the #ClinicalPearls #VirtualMorningReport

August 17th Episode 119: clinicalproblemsolving.com/morning-report…
W / @MohitHarshMD @KromerHaylie & Ninand Bhat Image
Let's start with an initial problem representation:

A 75 y/o M w/ a PMH of COPD, CAD, & aortic valve replacement p/w 2 weeks of dyspnea on exertion, 1 month of LE edema, 20 lb weight loss & recent onset PND and Orthopnea
invoke the dyspnea pyramid (cardiac, pulmonary, anemia, metabolic) but addition of progressive edema and weight gain concerning for cardiac pathology

whenever we see dyspnea on exertion and bilateral LE edema we jump straight to CHF
more features concerning for CHF but thinking also about liver and kidney leading to excess fluid as well

possible mechanical hemolysis from bio prosthetic valve contributing to dyspnea from anemia

Does the SOB improve when sitting up? concern also for hepatopulmonary syndrome
Prence of constitutional symptoms to suggest inflammation

How long after sitting up can he lie back down - very important in defining PND.

(PND) is a sensation of SOB that awakens the pt, often after 1- hours of sleep, and is usually relieved in the upright position. Image
PND article from prior tweet. ncbi.nlm.nih.gov/books/NBK213/#….

Does he have Bendopnea as well?

alcoholism/liver dysfunction could lead to third spacing?? = weight gain
There are many reasons to awake at night and sit up. COPD, sleep apnea, both allow immediate recumbency -

Add to the PR physical exam: BP 170/90, he is chronically ill appearing, peri-orbital edema, exp wheezes, 2+ pitting edema, 2-3 cm gluteal mass & 4-5 cm thigh mass
The preorbital edema suggests nephrotic syndrome or thyroid disease

He looks volume overloaded but there are no signs of volume overload in the lungs. hmmm

Would want to see the albumin, u/a, urine protein/creatinine if albumin decreased
Don't forget about amlodipine assoc LE edema

also wondering if that mass is some kind of sarcoid/amyloid/malignancy that contributes to nephrotic syndrome

subcutaneous nodules + volume overload, also consider Rheumatic disease
isn’t there a weird parasitic infection that can cause periorbital edema from eating pork?

Trichinela spiralis can do it, ncbi.nlm.nih.gov/books/NBK53851…

A soft tissue sarcoma- can originate from cardiac and are soft. In the heart can cause congestion/pericardium
Add to the PR some labs: Nml WBC, hgb 9.7, nml plts, elevated Cr from baseline at 1.63, a Gamma gap, NT-BNP of 8000, nml trop, UA: 3+ protein, 24 hr urine 9g

CXR: left pleural effusion with nodules in the left lung
There is a huge gamma gap!! ncbi.nlm.nih.gov/pmc/articles/P…

We have renal dysfunction, anemia, volume overload, & a protein gap. will want to determine monoclonal from polyclonal

And we know that 3 + protein has a strong association with increased ACR or PCR
Conversion of Urine Protein–Creatinine Ratio or Urine Dipstick Protein to Urine Albumin–Creatinine Ratio for

Use in Chronic Kidney Disease Screening and Prognosis: An Individual Participant–Based Meta-analysis: Annals of Internal Medicine: Vol 0, No 0 acpjournals.org/doi/10.7326/M2…
Is this amyloid? autoinflammatory disease? Waldenstrom’s? any history of hep C?

he would be in the age group that has increased risk of chronic HCV infection

He does have a PMH of IV drug abuse and that can also result in amyloidosis
Can we get some BCx...

They were negative on admission

Echo showed no evidence of endocarditis but the presence of diastolic dysfunction

PET scan showed hypermetabolic gluteal mass

And you guessed it. We need a biopsy.
And the final Dx is Minimal Change Disease secondary to an extranodal marginal b cell lymphoma

MCD occurs in only ~0.4% of lymphomas, so incredibly rare, but always taught on UWorld

pubmed.ncbi.nlm.nih.gov/21594766

Teaching points illustration by @sukritibanthiya Image
Minimal change nephrotic syndrome (MCNS) is the most frequent glomerular disease

It is an acquired glomerular disease of unknown origin, characterized by heavy proteinuria without inflammatory lesions or cell infiltrations.

ncbi.nlm.nih.gov/pmc/articles/P…
The pathogenesis of this disorder remains poorly understood; but there is evidence to suggest an immune origin

MCNS is caused by a putative circulating factor, which increases glomerular capillary permeability and leads to podocyte cytoskeleton disorganization and proteinuria

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More from @RosenelliEM

May 30, 2021
Some cool #Syphilis Pearls from an article that @k_vaishnani shared ncbi.nlm.nih.gov/pmc/articles/P… Primary syphilis first manifests into a painless chancre at the site of inoculation 1 to 6 weeks later…
Hematogenous dissemination then can occur typically 4 to 10 weeks later, giving rise to secondary syphilis. <40% of pts w/ syphilis have primary syphilis diagnosed. These “Secondary” lesions last for several weeks before spontaneously resolving. Coined “early, latent infection”
What does late infection mean? When syphilitic lesions recur after 1 year from the initial eruption, or seropositivity is detected more than 1 year after the initial eruption, it is termed late latent syphilis.
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Some optics neuritis pearls in a short #Medtweetorial 🧵…. We all know that optic neuritis is frequently associated with multiple sclerosis (MS). But optic nerve inflammation can exist from autoimmunity, infection, granulomatous disease, paraneoplastic disorders, & demyelination Image
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Oct 1, 2020
If you have not listened to the @CuriousClinPod most recent podcast (Episode 10: Why does metronidazole treat both bacterial and parasitic infections?) then I suggest you tune in.

curiousclinicians.com/2020/09/30/why…

I'll summarize their show notes here in short #medtweetorial
First a question:

Was metronidazole first used as an antibiotic or as an antiparasitic?
If you guessed antiparasitic, then you would be correct!

It was developed in the 1950s to treat the parasite trichomonas & then was used in the 1960s to treat other parasitic infections, like giardia and amoebiasis.
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Oct 1, 2020
When you order a serum alcohol level, what does the lab measure? An answer and a quick #Medtweetorial on false elevations in #ETOH
If you guessed NADH, you would be correct.
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Thereby reducing present NAD+ to NADH.
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Sep 26, 2020
A Teal pain in the neck:

Follow along for a short #medtweetorial on #CervicalArteryDissection

or see the full handout here emboardbombs.com/s/Cervical-Art…

from @EMBoardBombs @blakebriggsMD @IltifatMD
This review will focus on spontaneous dissections, not traumatic, as well as the pathophys, risk factors, presentation, diagnosis, and management.

Cervical artery dissections are a common cause of stroke in young(<50 years )w/ some reports of up to 20% being from dissections
Much like aortic dissections, there is some loss of structure along the wall of either the internal carotid artery or vertebral artery

This allows blood to collect within the intima.

In patients <50 years old, cervical artery dissections account for 20% of ischemic strokes.
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Sep 26, 2020
Time for some #SpacedRepetition from @CPSolvers @DxRxEdu @rabihmgeha

Some chat recap #ClinicalPearls and bonus pearls from #VirtualMorningReport on Friday Sept 25th clinicalproblemsolving.com/morning-report…

Case by the brilliant @Rafameed Image
A 31-year-old M born and raised in Brazil w/ no PMH presented with a 3 mon history of worsening DOE, orthopnea, 7kg weight loss, abdominal distention, dry cough, and syncope

Base rate of disease for an ID case with @k_vaishnani and @Rafameed is very high
An interesting fact from @3owllearning : Depending on the clinical problems, the studies of disease probability for differential diagnosis often show 10 - 25% of cases are unexplained, even after careful examination and testing.
Read 17 tweets

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