Yesterday we discussed the case of a young man with no past medical history who presented with subacute onset progressive unilateral facial swelling and B symptoms unresponsive to oral antibiotics
Our differential diagnosis included infectious etiologies (bacterial abscess, EBV, Mumps, TB lymphadenitis), malignancy (lymphoma, squamous cell carcinoma, Burkhitt’s lymphoma), and Lemierre’s syndrome (thrombophlebitis of IJ).
On CT Neck, patient was found to have multiple mandibular abscesses, and apical lung cavitary lesions concerning for septic emboli. While neck ultrasound did not find a thrombus within the internal jugular vein, given cavitary lesions in the lungs, Lemierre’s syndrome was thought to have been the diagnosis.
TCRHC is a single-story, 73 bed, Native referral hospital about 90 minutes from Flagstaff, Arizona, and 60 minutes southeast of the Grand Canyon National Park. The health center, provides services to a 6,000 square mile area and serves as a referral center for the western part of the Navajo and Hopi Reservations, and serves the Navajo, Hopi, and Southern Paiute tribes. During your time at TCRHC, you will be exposed to the broadest possible practice scope to provide a glimpse of what their providers do on a daily basis. Your rotation will include, but not be limited to, experience in the outpatient department, the inpatient service, as well as home visits with community health nurses. In the outpatient portion, you will be working with not only several providers, but also with many specialists (neurology, cardiology, nephrology, dermatology, and rheumatology). Your days will be split into half day portions – a morning portion and an afternoon portion. You will be working with different providers each half day. When you are on the inpatient service, you will be primary call for the ER and outside facilities wishing to transfer patients to Tuba City. You will work closely with an inpatient attending to manage patients from admission to discharge. Upon your arrival at Tuba City, you will discuss your schedule with the rotation director, Dr. Trung Pham.
Residents who have rotated at TCRHC have described it as one of the most unique and rewarding experiences they have had. They have enjoyed being a hospitalist, intensivist, and primary care physician all at the same time while caring for some of the most underserved patients in the United States and developing an understanding of how to provide care in a resource-poor setting. In addition, you’ll have weekends off and are only a short drive away from numerous national parks and opportunities for outdoor recreation. You may have the ability meet visiting residents from other institutions.
Please note, you need a car for this away elective, so driving to Arizona or flying there and renting a car are both options. There is also a nominal, out of pocket fee for lodging (about 20 dollars per day). This rotation is best if you can go with another resident (to offset travel costs and to have a hiking buddy for the weekends). Rotations are 2-4 weeks in length (preferably 4 weeks).
Today we discussed the case of a young woman with history of bulimia nervosa and secondary ESRD due to recurrent AKIs, who presented with subacute encephalopathy, found to have metabolic alkalosis with partial compensation with respiratory acidosis in addition to concomitant anion gap metabolic acidosis.
Metabolic Alkalosis – due to emesis
Respiratory Acidosis- compensatory
Anion gap metabolic acidosis – Renal failure, given lactate, and beta-hydroxybutyrate were normal.
In this case, we saw that after SLEDD treatment, patient’s metabolic alkalosis and anion gap metabolic acidosis resolved and she was left with her compensatory respiratory acidosis.
A thanks to former chief resident, Dr. Saloni Kumar for her teaching of this material to us back in 2017!
Today we talked about a young male who presented with ascites of unclear etiology who was initially thought to have cirrhosis, but ended up having a mucinous appendiceal tumor that ruptured and led to peritoneal seeding and the syndrome: Pseudomyxoma Peritonei
Today we talked about a female who presented with a R pleural effusion, ascites, and an ovarian mass, suggestive of Meigs Syndrome. It was eye-opening to broaden our differential for ascites and important to recognize as treatment is via resection, not diuretics!