Case Presented by: Adrienne Yang, MS4 Great case this morning presented by Student Doctor Adrienne Yang from her acting internship at Moffitt. Patient in their 70s presenting with 8 months of progressive facial swelling, erythema and serosanginous drainage. He had undergone multidisciplinary work-up with facial cross sectional imaging, dermatology, and ENT referrals in the community without diagnostic yield. Over the course of these 8 months developed progressive fatigue, anemia (hgb 3.4) and syncopal episodes at which point he was transferred to UCSF for further evaluation. Associated 20 lb w ..read more

An older man with a history of recently diagnosed stage IV lung adenocarcinoma complicated by R-sided hydropneumothorax (s/p pleurex catheter placement) on Osimertinib presented with subacute progressive dyspnea. He had no change in pleurex catheter output, and denies any other new respiratory symptoms. On presentation he was found to have an oxygen saturation 71% on RA, with crackles on his respiratory exam. He had a CT pulmonary angiography which was negative for PE, but showed multifocal consolidations in all lobes. TTE bubble study was also negative for shunt. He was initiated on HFNC for ..read more

A 43-year old woman with a history of respiratory papillomatosis 2/2 congenital HPV infection requiring chronic tracheostomy, recent lung SCC diagnosis currently on chemotherapy presents with acute onset of shortness of breath without any other new respiratory or constitutional symptoms. On evaluation she was noted to be mildly hypoxic to 88% with some focal coarse breath sounds, but otherwise had normal vitals and a normal exam. Her labs were normal including a procalcitonin and chest imaging showed slightly worsened pulmonary burden of disease without any PE. Ddx acute onset shortness of bre ..read more

Great hand infx case with our Ortho co-management R1 Angel Xiao. Angel presented a case of a consult for R hand pain and swelling. Older (right hand dominant) gentleman with a hx of: Diabetes, Cirrhosis 2/2 to etoh use. Pearl #1: Prepare for consultation: Known mechanism of injury, time course, baseline function/loss of function, and risk factors for infection Mechanism: Was there trauma, or open wounds Onset and Time course: When did it start and how has it progressed? Function: What is the patient’s dominant hand and occupation Risk Factors: Immunocompromised state, intradermal injectio ..read more

A 59-year-old woman with a history of mild Sjogren’s disease presented with a few weeks of progressive cyanosis of her digits and bilateral foot drop in the setting of months of constitutional symptoms (night sweats, fatigue, unintentional weight loss). Her exam revealed the presence of gravity-dependent palpable purpura, digital ischemia, and foot weakness. Her evaluation demonstrated undetectable C4 levels, elevated cryoglobulins, negative ANCAs and RF, normal ABIs and an unremarkable CT angiography of her upper extremities. She was diagnosed with cryoglobulinemic vasculitis possibly second ..read more

For our final applicant morning report, Soham Rege presented a case of a young woman with a history of SCD (c/b prior severe ACS, fat embolism syndrome, and avascular necrosis), recent massive PE on AC, and RA who presented with rib and joint pain concerning for vaso-occlusive crisis. During the first day of her admission, she clinically deteriorated with a rapidly escalating oxygen requirement, Hgb drop from 8 to 4, and worsening tachycardia, ultimately requiring intubation and pressor support. Her decompensation was likely secondary to acute chest syndrome, for which she received exchange tr ..read more

This past Friday we were joined at virtual report by Dr. Henry Litt who presented a case of persistent abdominal pain. HPI: Older gentleman with history of recent dx of PE and lung mass (pending biopsy), presenting to the ED now for the second time with persistent diffuse aching lower abdominal pain for the last 2 weeks. On prior ED presentations the abdominal pain (last was 3 days prior to this presentation) had unremarkable work-up with negative abdominal CT with contrast. Meds: Apixaban, ASA, Amlodipine, Carvedilol, lisinopril Social Hx: From Brazil, Tobacco use with +60 pack year smoking h ..read more

Colleen McGourty (R1) presented the case of acute encephalopathy in a patient with bipolar disorder on numerous psychotropic medications. Her only other history was notable for recent vomiting for several days for which she had been taking tums. On exam the patient was disoriented but had normal tone, reflexes, pupil size/reactivity, and did not have any focal neurologic abnormalities. Her exam was also notable for warm and dry skin with generalized abdominal tenderness. Below is a helpful reference for evaluating patients with any concern for ingestion-related syndromes: The patient’s initia ..read more

Last month, Dr. Isabel Ostrer presented a case at ambulatory morning report of a 61 year old man with a history of Type 2 Diabetes, HTN, and stimulant use disorder in sustained remission who presented with subacute, bilateral, progressive, R>L lower extremity weakness. History This was the first time he had seen a doctor in 5 years. Two months prior he had been in his usual state of health – ambulatory and completely independent in all ADLs. At the time of this visit, he could only walk a few steps due to weakness and pain in his lower extremities. He was now unable to perform many ADLs ind ..read more

April Liang, one of our amazing R3’s, presented a case from her time on ZSFG nights with Karishma Patel. A middle-aged man with a history of latent TB presented with loss of consciousness at work while eating lunch. He bit his tongue and felt confused upon awakening. He had no presyncope symptoms, chest pain, palpitations, or history of TBI. The patient was originally from Central America. Learning point #1: Seizure vs. Syncope Workup For LOC, be sure to review the seizure and seizure mimic differentials (i.e. syncope). For patients with first time seizures, patients should have a CBC, CMP, LF ..read more