Pearls - July 21, 2020

Rachel, Cody, & Dr. Dechet presented a patient with lung cancer who presented with what was thought to be a thromboembolic CVA & was started on heparin who subsequently developed thrombocytopenia and digital skin necrosis concerning for Heparin Induced Thrombocytopenia.

Dr. Dechet reminded us that HIT occurs when heparin & platelet-factor 4 combine to form complexes that are bound by auto-antibodies which result in platelet activation & consumption.

We were reminded that if a patient with exposure to heparin develops thrombocytopenia (potentially also with evidence of thrombosis), the 4Ts score should be used to evaluate their pretest probability of having HIT before a HIT antibody test is sent.

Pretest probability for HIT based on score:

Low probability (4T’s score of ≤3)

Intermediate probability (4T’s score 4-5)

High probability (4T’s score 6-8)

The Introduction to Outpatient Medicine interns (Laura, Cody, Reid) taught us some amazing pearls during IOM report last week.

Laura taught us about the red flag signs & symptoms to watch for when someone is presenting with a red eye!

Cody taught us that when women present with hair loss, we should look for scalp scarring and this can guide us through our alopecia framework:

Cody also gifted us this beautiful slide he made of various non-scarring forms of alopecia that we might see in our clinics:

Reid reminded us of who can be managed outpatient for alcohol withdrawal and who should be admitted:

Outpatient

Mild withdrawal (CIWA < 15)

Tolerating PO

No hx of DT

Inpatient:

Possibility of severe withdrawal (old age, hx of seizures, dehydration, BMP/LFT abnormalities)

Unstable medical comorbidity

Multiple substances

Limited social support

Sarah presented a 75 yo F with pmhx of AD polycystic kidney disease (ADPKD), CKD presenting with ascites who was found to have numerous hepatic cysts causing Budd-Chiari syndrome (through compression of the IVC by the cyst filled liver parenchyma) with subsequent portal hypertension & ascites.

Sarah reminded us that when a patient presents with ascites calculating a SAAG is vital! And should be one of your first steps. 

SAAG = serum albumin level - ascites albumin level

A framework for the etiologies of ascites, broken down by SAAG & ascitic protein:

Sarah also reminded us a little about polycystic liver disease...

Polycystic Liver Disease

Polycystic liver: defined as > 20 cysts 

Hepatic cysts are fluid-filled cavities that arise from the intrahepatic biliary tree

Two types

ADPKD-associated (67-83%)

Autosomal dominant polycystic liver disease (rare)

Symptoms

Increased abdominal girth/distention

Early satiety

N/V

Complications

Cyst infection, hemorrhage, rupture

Compression of hepatic vein, IVC, or bile duct