This case was presented by Dr. Lou Xie, an internal medicine intern, at ambulatory morning report this week! A middle aged man, previously out of care, presented to clinic with subacute unilateral arm swelling and pain (worst at the elbow and upper arm). He otherwise had no systemic symptoms, and past medical history was only notable for diabetes and hypertension. Pause for a moment to consider: What is your differential diagnosis for unilateral arm swelling? Consider an anatomical approach! moving from outside to inside: skin, muscles, tendons, bursae, joints, lymph nodes, and blood vessels ..read more

An elderly patient with pancreatic cancer with recent cytotoxic chemotherapy was admitted for bacteremia. While he was receiving IV antibiotics inpatient, he was noted to have progressive anemia and thrombocytopenia. Pause for a moment: How do you approach the workup for progressive thrombocytopenia in the hospital? We can organize etiologies of thrombocytopenia into 3 categories: Decreased production: aplastic anemia, bone marrow infiltration, bone marrow suppression (due to infection, malignancy, or chronic inflammation), vitamin deficiencies Sequestration: splenomegaly Increased destructio ..read more

An elderly man with a history of Hodgkin’s Lymphoma on maintenance therapy with a checkpoint inhibitor (PD-1 inhibitor) presents after recent percutaneous cholecystostomy for malignant biliary tract obstruction with fatigue and generalized weakness. Initial vital signs were normal, and physical exam was only notable for dry mucus membranes; neurologic and muscular examination was normal. Laboratory workup revealed Na 114, K 4.1.  Take a moment to consider: What is your approach to evaluating the cause of hyponatremia? Here is one very simplified approach that uses physiology to help us ke ..read more

Thank you to Laila Fouzini for presenting this case in Ambulatory Morning Report this week! A middle-aged man presented to primary care clinic for 2 months of asymmetric right lower arm swelling and bilateral leg swelling. Close review of the chart revealed a 20 pound weight-gain over the past year. Pause for a moment and think to yourself: What lab tests might you order? Remember your differential for volume overload includes: cardiac disease (heart failure), liver disease (cirrhosis, hypoalbuminemia), and kidney disease (specifically nephrotic syndrome). Workup should reflect this different ..read more

At Medical Student Case Conference last week, MS3 Bianca Obiakor presented the case of a patient admitted with AST and ALT elevations over 1000. Bianca taught us about the interesting differential for severe LFT elevations: Severe LFT elevations Toxin/Drug exposure Acetaminophen Mushroom poisoning (Amanita phalloides aka Death Cap Mushroom) Idiosyncratic drug reactions (i.e. Isoniazid) Ischemia Hypoperfusion aka “Shock Liver” Acute venous congestion, Budd Chiari Infection Viral Hepatitis: A, B, C, D, E Herpes Viruses: HSV, VZV, CMV Autoimmune Autoimmune hepatitis Malignancy Liver ..read more

Last week, we presented a case of an elderly male veteran who presented with new hypoxia, altered mental status, and transient left-sided weakness.  Pause for a moment to consider: What studies might you obtain to workup these concerns further? On initial evaluation, stroke workup with CT head non-contrast and CT head and neck angiogram was negative for bleed or large vessel occlusion. His left-sided weakness resolved without intervention.  On exam, he had a soft voice, increased work of breathing and clear lungs. He was alert and oriented, however he had subtle diffuse muscle fascic ..read more

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