The Clinical Problem Solvers

https://clinicalproblemsolving.com/wp-content/uploads/2017/05/RLR-15-Ascites-Patient-and-Tears-RR-.mp3Episode descriptionReza and Rabih tackle a case of Ascites.More about the RLR series here.Ascites SchemaEpisode SummaryAn elderly woman with a history of progressive weakness, falls, and recently diagnosed ascites presented with weight loss and functional decline. Her workup was notable for ascites with a low serum-ascites albumin gradient (SAAG), thrombocytosis, and imaging evidence of peritoneal enhancement with omental nodularity and multiple pancreatic lesions. Biopsies of the peritoneal nodules were initially unrevealing for infections or solid malignancies. Ultimately, further tissue examination revealed primary peritoneal mesothelioma. The patient was not started on treatment and passed away one month later.  Teaching Points The most common causes of low SAAG ascites include malignancy and infection. Malignancy can cause low SAAG ascites via peritoneal carcinomatosis (seen most commonly ovarian, bladder, or gastric cancer) as well as peritoneal mesothelioma. Tuberculosis is an important and difficult to diagnose infectious cause of low SAAG ascites. Ascitic fluid often reveals a lymphocytic predominance with elevated protein. Additionally, an elevated ascitic adenosine deaminase level (ADA) can suggest peritoneal tuberculosisAsbestos exposure can lead to an array of benign and malignant diseases. Manifestations within the pulmonary parenchyma include asbestosis (a form of diffuse pulmonary fibrosis resulting in interstitial lung disease) and lung cancer (both small cell and non-small cell lung cancers). Pleural complications of asbestos exposure can include pleural effusions, pleural plaques, and malignant mesothelioma. Rarely, asbestos-related complications can occur in extra-pulmonary sites and present as peritoneal mesothelioma, with diffuse peritoneal nodules and low-SAAG ascites. 

https://clinicalproblemsolving.com/wp-content/uploads/2017/05/VMR-100-7-25-20-10.25-AM-1-2.mp3Dr. Rezigh presents a clinical unknown on Virtual Morning Report to CPSolvers, Rabih and Reza.Download CPSolvers App herePatreon websiteSchemaWhiteboardEpisode Summary A 75-year-old-woman with multiple chronic medical problems presented with right arm pain, anorexia, and diffuse erythematous nodular plaques. Her work up was notable for an elevated serum lactate and S1Q3T3 pattern on ECG. Computed tomography of the chest, abdomen, and pelvis demonstrated a right pleural effusion as well as nodular soft tissue thickening surrounding the right atrium extending to the interatrial septum with local mass effect and narrowing of the superior vena cava. Biopsy of her rash revealed abnormal lymphoid proliferation. Further studies led to a diagnosis of diffuse large B-cell lymphoma (DLBCL) with prominent cutaneous manifestations.Teaching PointDiffuse large B-cell lymphoma (DLBCL) is the most common subtype of non-Hodgkin’s lymphoma and can have a diverse range of manifestations. Most often, patients present with a rapidly enlarging mass and/or systemic “B-symptoms” (e.g., fever, night sweats, weight loss). Laboratory abnormalities classically include elevated lactate dehydrogenase levels, which occur in >50% of patients. In a minority of patients (about 40%), DLBCL presents in extramedullary and extranodal locations, including the soft tissues, lung, endocrine organs, and central nervous system. Diagnosis requires histologic examination and immunophenotyping (flow cytometry, immunohistochemical staining). 

https://clinicalproblemsolving.com/wp-content/uploads/2017/05/WDx_Episode1_FINAL.mp3Episode DescriptionEmma, Lindsey and Sharmin tackle a case presented by Sarah.Want to learn more about Women in Diagnosis (WDx) series?Blog post– by Smitha

https://clinicalproblemsolving.com/wp-content/uploads/2017/05/hdx-ss-clc-final.mp3Dr. Hastie presents a Human Dx case to Sharmin & Cleveland Clinic residents – Drs. Almaaitah and Montane.Download CPSolvers App herePatreon websiteSchema #1Human Dx CaseDr. Bryce MontaneBryce Montane is a Floridian born and raised! He went to University of South Florida as part of the 7-year medical program for undergraduate and medical school. He is now a PGY-3 Internal Medicine resident at the Cleveland Clinic. He is part of the inaugural Clinician Educator Track. He will be staying at the Cleveland Clinic next year as a Chief Resident and will then be pursuing a career in academic medicine.Dr. Saja AlmaaitahSaja Almaaitah was born and raised in Jordan and graduated from the University of Jordan school of medicine. She then moved to the United States and joined Cleveland clinic for her internal medicine residency. During which, she was part of the clinical research scholar track. She has recently graduated residency and joined the rheumatology department at Cleveland Clinic. She hopes to pursue a career in academic medicine and research. In her free time, she enjoys hiking, reading and cooking.Dr. Elizabeth HastieElizabeth (Lizzy) Hastie is currently a third year internal medicine resident at UCSD. She completed her undergraduate education at the University of Colorado Boulder, and she attended Emory University for medical school. Lizzy is a member of the Resident as Clinician Educator (RACE) track at UCSD and will be a Chief Medical Resident for the 2021-2022 academic year. She is interested in pursuing an infectious disease fellowship following her chief year.

https://clinicalproblemsolving.com/wp-content/uploads/2017/05/CPSolvers-Human-Dx-AD-Duke-FINAL-.m4aDr. Alexandra Rojek presents a Human Dx unknown to Arsalan and Duke residents – Drs. Stacy Bagrova & Micah Schub.Download CPSolvers App herePatreon websiteSchema #1Schema #2Human Dx CaseDr. Alexandra RojekAlexandra Rojek is currently an internal medicine resident at the University of Chicago, interested in pursuing hematology/oncology with an interest in translational research. She attended Harvard University for her undergraduate education in chemical and physical biology, and then medical school at UCSF. During medical school, she developed an interest in medical education, particularly in her research on implicit bias in medical student evaluations. She has always had an interest in diagnostic reasoning and loves being a contributing editor at the Human Dx Project, and is excited to work with CPSolvers on sharing this case!Dr. Micah SchubMicah Schub is a third year internal medicine resident at Duke. He grew up in Los Angeles, CA and got his undergraduate degree in (slapping the) Double bass performance at the Juilliard School and a masters at the Manhattan school of music. He returned to LA to play in Cirque du Soleil’s “Iris” for a couple years before making a sharp turn and attending University of Pittsburgh School of Medicine. He is interested in nephrology, clinical reasoning and medical education. Outside of work, you can find him playing sweet tunes with his residency Weezer cover band “Wheezer.”Dr. Stacy BagrovaStacy grew up in Donetsk, Ukraine and was lucky enough to move to the US just in time for college. She completed medical school at the University of Florida (Go Gators!).  Currently, she is trying to learn as much as possible and provide lots of (mostly unsolicited) teaching to junior learners as a third-year medicine resident at Duke University Medical Center. Her ideal career combines clinical rheumatology and medical education focused on diagnostic reasoning. In her free time, she loves to get lost in a good mystery novel, cook or bake while tuning in to one of her favorite podcasts, or go for a run, listening to a 70s-80s classic rock mix.

https://clinicalproblemsolving.com/wp-content/uploads/2020/07/RLR-10_Hypotension.mp3Episode descriptionReza and Rabih tackle a case of hypotension.More about the RLR series here.

https://clinicalproblemsolving.com/wp-content/uploads/2017/05/Gurpreet-and-Anna-7-10-20-10.04-AM.mp3Dr. Costello presents a clinical unknown to Dr. Dhaliwal.Download CPSolvers App herePatreon websiteDr. Anna CostelloAnna Costello is a Pediatric Hospitalist at the Children’s Hospital of Philadelphia, where she completed her residency and chief residency. Her interests within Medical Education include clinical reasoning and linguistically and culturally competent care. Outside of the hospital, she is an avid reader, painter, and soccer player. 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 him

https://clinicalproblemsolving.com/wp-content/uploads/2020/06/HDxNYU_Arsalan_FINAL.mp3Dr. Ryan Haran presents a Human Dx unknown to Arsalan and NYU residents – Drs. Jenny Whealdon and Greg Rubinfeld.Download CPSolvers App herePatreon websiteHuman Dx caseDr. Jenny WhealdonJenny was born and raised on Bainbridge Island in Seattle, Washington. She attended Haverford College where she studied religion and theoretical chemistry; ultimately staying in the Philadelphia area to attend the University of Pennsylvania School of Medicine. There, she developed an interest in behavioral economics and decision making, particularly in the critical care setting. She completed her internal medicine training at NYU and is staying on as a Chief Resident.Dr. Greg RubinfeldGreg is currently a chief resident at NYU Grossman School of Medicine.He aspires towards a career in academic cardiology where he hopes to find a marriage of his interests in thrombosis and coronary artery disease.When he is not in the hospital or at home with his wife and son, you might find him scuba diving wrecks along the east coast, nose deep in classic literature, or playing pick-up street hockey and collecting more bruises than he cares to admit.Dr. Ryan HaranRyan grew up in Oregon and after attending Oregon State University went to medical school at Virginia Commonwealth University in Richmond, Virginia.He completed an internal medicine internship then spent a year as a radiology resident at Northwestern University in Chicago, Illinois before deciding that while radiology is cool and all he had learned too much medicine to just go and forget everything. As such, he decided to return to medicine and has now completed an internal medicine residency at his home institution of VCU where he will be staying on faculty as a hospitalist.Case Recap A 55-year-old previously healthy woman presented with subacute abdominal distension and acute emesis. On examination, she was found to be hypotensive and hypoxemic with evidence of ascites. Laboratory evaluation was notable for severe transaminase elevation (AST 2500, ALT 1300), leukocytosis to 53,000 per cubic millimeter, hemoglobin of 20 mg/dL, and a mildly elevated erythropoietin level. Imaging demonstrated an acute portal vein thrombus as well as a right-to-left intracardiac shunt. A bone marrow biopsy revealed trilineage hypercellularity with an erythroid predominance and JAK-2 positivity. The ultimate diagnosis was polycythemia vera with a secondary EPO-dependent polycythemia (likely secondary to her intracardiac shunt).Teaching pointsAn absolute erythrocytosis refers to elevation in the red blood cell (RBC) mass and can be due to primary bone marrow, secondary (e.g., hypoxia, erythropoietin secreting tumors), and congenital etiologies. A key branch point is evaluation of the erythropoietin level (the primary stimulus for RBC synthesis), with normal/suppressed levels suggesting the presence of a primary or congenital disorder. Polycythemia vera (PV) is the most common primary erythrocytosis and lies on the spectrum of myeloproliferative neoplasms. Thrombosis and bleeding are life-threatening complications.

https://clinicalproblemsolving.com/wp-content/uploads/2017/05/HDX_BMCBrigham_Sharmin_FINAL-2.mp3Dr. Leela Chockalingam presents a Human Dx unknown to Sharmin and BMC resident – Dr. Amir Gilad and Brigham resident  – Dr. Hannah Chen.Download CPSolvers App herePatreon websiteHuman Dx caseAbdominal pain schemaDyspnea schemaAltered mental status schemaAmir GiladAmir Gilad is a PGY-1 (very soon to be PGY-2!) at Boston Medical Center. Born and raised in Toronto, he attended Boston University for medical school and loved it so much that he stayed on for his internal medicine residency. He’s an aspiring cardiologist who is passionate about medical education. Outside of medicine he enjoys cheering on his beloved Toronto sport teams, jogging along the Charles River, and exploring the beautiful city of Boston. Hannah ChenHannah Chen is a second year internal medicine resident at the Brigham & Women’s Hospital. She graduated from the University of North Carolina School of Medicine.  She has an interest in hospital medicine, nephrology, and health equity.  In her spare time, she enjoys eating/cooking and hiking.  Leela ChockalingamLeela Chockalingam grew up in Rochester, NY. She studied Chemistry at Carnegie Mellon University and then attended medical school at the Icahn School of Medicine at Mount Sinai in New York City. During medical school, she spent a year in Vietnam doing tobacco use treatment research. She is currently an Internal Medicine resident at the University of Colorado in Denver, CO. She is interested in pursuing pulmonary critical care fellowship, and would ultimately love to be a clinician educator focused on clinical reasoning and evidence based medicine. Her hobbies include reading fiction, being outside, and cooking for family and friends. Case recapA 47-year-old man with alcohol and meth use presented with acute dyspnea, abdominal pain, and encephalopathy, and was found to be in acute congestive heart failure with atrial fibrillation and rapid ventricular rate. While in the emergency department, his oxygen requirement rapidly increased and he required intubation for hypoxemia and airway protection. Further evaluation revealed a suppressed thyroid stimulating hormone with an elevated free T3 and free T4, confirming a diagnosis of thyrotoxicosis meeting criteria for thyroid storm.Teaching pointsHyperthyroidism refers to increased synthesis and release of thyroid hormones from the thyroid gland, whereas the term “thyrotoxicosis” represents the clinical syndrome produced by excess circulating thyroid hormone. The most common causes of hyperthyroidism include Grave’s disease, toxic nodular goiter/adenoma, and drug induced thyroid dysfunction. Thyrotoxic states can also occur when thyroid hormones are released from an injured thyroid gland in thyroiditis (autoimmune, viral, suppurative) or ingestion of exogenous thyroid hormone.The clinical manifestations of hyperthyroidism can result from the thyrotoxic state itself (e.g., palpitations, fatigue, tremor, weight loss) or be related to the underlying cause of hyperthyroidism (e.g., grave’s ophthalmopathy, globus sensation/dysphagia from enlarged goiter). Complications of thyrotoxicosis include atrial fibrillation (with possible heart failure), thyrotoxic periodic paralysis, osteoporosis, and reproductive issues. Thyroid storm represents life-threatening thyrotoxicosis and its diagnosis is supported by the Burch & Wartofsky Score, which takes into account temperature, central nervous system effects, gastrointestinal/hepatic dysfunction, cardiovascular dysfunction, and the presence/absence of a precipitating trigger.

https://clinicalproblemsolving.com/wp-content/uploads/2017/05/Episode-100-Juneteenth.m4aDr. Kimberly Manning and her father, Mr. William Draper, commemorate Juneteenth, the holiday that celebrates the day when all remaining enslaved Black Americas were freed in Galveston Texas, on June 19th, 1865, with this hour-long storytelling event. Click here to watch the video on the CPSolvers Virtual Morning Report platform