July 21, 2026 - VMR w/ Ravi & John - Fatigue and distended arm veins

[00:00:03]Hello everybody. Good morning and welcome to virtual morning report. Um just want to start off thanking Lorenzo and Jillian for doing our scribing and teaching points. Appreciate you.

[00:00:13]Appreciate you a lot. Wouldn't work without you. I have the pleasure of co-discussing a case with Ravi today.

[00:00:20]Want to say hi.

[00:00:23]>> Hi John. Long time. I know you've been busy but uh it's a great privilege again to discuss with you. Um, I hear you were just mentioning you you're learning a new language. What what language are you learning?

[00:00:34]>> Yeah, I'm learning to speak Chinese. My my wife's mom is my teacher. She's been very strict.

[00:00:41]>> Excellent. Excellent. That's awesome.

[00:00:44]Um, and then we'll just have uh our help today. So, Renzo, you're going to be scribing today. Thank you. Appreciate your help. You guys really drive this process. So, you're very appreciative of you. How are you?

[00:01:07]If not, I think Renzo's having trouble with this unmuting. Jillian is going to be Oh, there you are, Renzo.

[00:01:13]>> Yeah. How you doing?

[00:01:14]>> Hi. Hi, everyone. I'm doing pretty well.

[00:01:16]I'm pretty fondly pretty uh I'm pretty sure that we have fun in this session with Dr. Ravi and the case presenter. So looking forward to hear your thoughts guys.

[00:01:29]>> Awesome. I appreciate appreciate that again and Jillian uh who's going to be doing our teaching points. Really also really appreciate you and your help.

[00:01:38]>> Yeah, excited for the discussion.

[00:01:41]>> Absolutely wonderful. I have a newfound appreciation for scribing. I haven't done teaching points in a while but I did scribe yesterday and uh just going to say Kashal sometimes we have to slow it down because yesterday I was trying to describe and then my my brain to hand uh delay is about 3 milliseconds so yeah I guess for the scribe we'll have to gently present it so um Michelle how are you thank you for stepping up to the plate and presenting >> I'm actually doing good um it looks like it's going to rain I'm like um had just read yesterday the have you guys tried baked Alaska or heard about it. It's one of the hardest dishes which they keep mentioning in any cooking competition if you see and if you're like a huge fan of Master Chef Australia like I am. The hardest dish which they give a person to cook is baked at Baked Alaska. And last evening or last night at 11:00 a.m. I 11:00 p.m. I saw it's actually the first time it was made was in 1867 at a restaurant which is not too far away from where I am. So, I'm just waiting to go there today and have it.

[00:02:46]>> Wait.

[00:02:46]>> So, as soon as I'm doing the se presenting the case, I guess I'm just going to be going there.

[00:02:52]>> Baked Alaska. What is that made up of?

[00:02:55]>> It's an ice cream which and then they bring it to your table with the fruits and vegets in it and then they take the torch light and then they put the fire on top of it and bake it in front of you.

[00:03:06]>> Oh, wow. Make sure to post some pics uh afterwards. Definitely definitely would love to to see that. All right, let's uh get underway with the first aloquad and John you could take first stab at the aloquad.

[00:03:21]>> Awesome. Thanks everyone for joining in and I have shared the case also with Renzo so it's okay if I go a little fast the way I speak. Um so what we have today is a 71 years old woman who presents with a week of fatigue, shortness of breath and lower abdominal pain and or fullness and I'm going to stop that to see what you're thinking about Dr. Ravi and John.

[00:03:51]>> Okay. Right. So just working with M or it's a pretty common scenario if people come in with m sometimes multiple chief complaints and perhaps in morning report setting they end up neatly tying together in one clinical syndrome. I think in in contrast a lot of especially a lot of like older adults with multiple coorbidities do have multiple things going on at the same time but you have to it can be help taking the history you have to really sometimes you have to press the person to figure out what was it that actually brought you into the emergency department what changed what what crossed your threshold to come into the come in to seek care today. though. So we have a time course. It's like one week and that's such an important part of the history that worth even just asking multiple times to make sure you've got it right. So just changes your differential so much when you're on somebody with symptoms for a week, several weeks, months. Making sure you got the time course right is so important. So I heard fatigue, shortness of breath and abdominal fullness. Um perhaps amongst those what I'm working with initially might be the the shortness of breath. the differential for which includes life-threatening things. It's something with little, you know, that I can work work around.

[00:05:07]Although it's all it's also so many different things can do it. Um, so but I I think you know with with fatigue sometimes like fatigue can also mean somebody has shortness of breath or decreased exercise capacity. People mean different things when they when they say fatigue. But I'm probably with those three different things at once. I'm going to prioritize my different my my history around the shortness of breath at least at first after you let the person give them some time to talk on their own just hey tell tell me more uh which which of those things bothered you most tell me more about it so get some open-ended questions first with the combo of uh shortness of breath and abdominal fullness you do have to consider yeah point consider fluid overload and ask make sure you include questions about that in your in your history and look for it on your exam.

[00:06:00]Some people have more, especially if it's somebody who is more has a poor functional status, more bedbound. They may not have as much edema in their legs and they may accumulate it in the subq tissues in the midsection of their body.

[00:06:15]Or are they having a sites that's causing pressure in their abdomen and pressing on their diaphragm below causing a shortness of breath? Just, you know, something to consider with your questions and exam.

[00:06:26]Let me pass the mic over to Robbie to see what else he has to add.

[00:06:32]>> John, I just love you. We're kind of on the same track. Um I have a newfound appreciation to gather data, right? So we go ask like you said essentially which one of these is really lifealtering for the patient. They're saying they're presenting this symptom complex and I kind of just my mental model was this kind of a Michelin person. So the patient or the person is existing in this world of fatigue but what is causing that fatigue uh is the shortness of breath and the abdominal fullness. So this is driving this fatigue. So sort of moving beyond the fatigue but these two areas are definitely um in play here and um when gathering the data you have to I do a lot this because this my this is my clerkship brain here that is this is going to be driving the the the questioning. So what makes it worse?

[00:07:22]What makes it better? You mentioned yeah time course one week. Has it been ramping up? Has it been the same? Why why do they come after the end of the week? Why didn't they come one day before? So all these questions as well as the review system getting a very broad review system will be helpful because with this with this fatigue is can we also put fever uh chest pain is there um lower pelvic pain is there movement disorder. So this will define this syndrome that we're trying to to to uh develop here for this patient. So that will be you know before jumping into diagnosis I think gathering more data will be essential and how you gather that data will really be effective in you getting to the to the solution of this case. Um any other thoughts John before we pass the mic back to Kachan?

[00:08:12]That's just like sometimes just getting that chief complaint is it could be it can be an art. it sometimes can take some time and be and be challenging and I'm just I'm reminded of a person who's like we just recently discharged from my hospital service where they're presented to me like the so everyone's kind of unsure what the chief complaint was and I probably had to just ask like five or six times and just be you had to be very patient you know it's kind of you know a little bit tangential in conversation um but yeah it can sometimes be tough to get there um all right I'm ready her next aloquat.

[00:08:50]>> Awesome. I just love the way you guys are discussing both of you. Um, so she was apparently normal a week ago. Then she started having a shortness of breath which is positional. She says that she feels short of breath like when she lies down supine and she feels relieved when she lies either to her right lateral or left lateral position or sitting up and she doesn't have any shortness of breath when she walks. So she describes her abdominal fullness like feeling like air is moving up and down within her belly and over the last day it got worse and now she's having nausea and two episodes of non-bly vomit and non-belieas also and containing recently ingested food particles and um she also reports an increased urination which is and increased thirst which occurred throughout the night with poor her asleep which woke her up too many times and she feels fatigued and that's what brought her to the hospital.

[00:09:56]And um review of system uh she complains of six pounds of weight loss over the past 3 months and increased sweat and heat intolerance and denies any cough for anorexia.

[00:10:18]So, and the past medical history, she's got a history of hyper lipidmia and gird.

[00:10:25]She lives with her son and nephew, independent in her daily activities, is a non-smoker and drinks um occasional alcohol. And I'm going to stop right there.

[00:10:37]>> Oh, wow. Kashal, that's such a complex second alleg. There's so much. You could just take one of those things and just talk an hour about it, but I'm just going to try my best and leave some of those points for John to to elaborate on. Um, so a week ago, I love this. I always ask what was your last well-known um like time like when were you fine?

[00:11:03]And she said a week ago she was absolutely fine and then this this happened. But then you can go beyond a week back to 3 months and something's been building up which is this weight loss weight loss night sweats very peculiar on VMR when we have these kinds of symptoms present it always has an ominous sight that [clears throat] something has been gradually building up like why would you have night sweat? So it's almost akin to your body trying to mount inflammation without the febal response or the white count building up or having other sign symptoms of um of inflammation pain somewhere back pain headache joint pain so on. The weight loss is one signal for inflammation. The night sweats kind of peculiar. And why at night time? Usually at night time temperatures may tend to go down, may tend to go you could have a a mild fever at night time. But then sweating is just indicating your thermmore regulatory response is out of whack. So I would just equate it to to inflammation.

[00:12:11]Something is building. Nausea, vomiting, going back to my diagram. So, nausea voming the the abdomen. Again, we're going to focus in on this area. I don't know why I feel like drawing today. Um I actually do draw quite a bit. And then what was it what was interesting she's she's uh lying down and a shortness of breath. She's very unhappy, but when she's sitting up, she's very happy. So, I think there the breathing has this orthopic kind of flavor to it. the abdominal issue, nausea, vomiting, weight loss, sweating, something is up and all of this just kind of manifesting over this this week's time. So, it's come to this big, what do you call it?

[00:12:56]Um, conclusion and that's what brought her into the hospital. So, I think we're dealing with something that is kind of playing a game, a twister. your arms, your legs in every dot available that is empty and trying to come up with a multi-system complex which is causing this urination and thirst. I'll let John kind of talk about that. I don't want to I don't want to hoard all the uh the different presenting complaints, but uh I'll turn the mic over to you, John.

[00:13:25]>> Cool. Yeah. So, we've taken a little bit of a turn with this bit of the history now. We have there's these background weight loss sweats. I was I didn't even catch if it was like at night time or all the time, but now I'm wondering like is so is there some kind of chronic perhaps inflammatory process that has progressed to the point where they're having symptoms and gets perceived as acute or sometimes in these scenarios there's some chronic illness in the background that has made somebody vulnerable to an acute illness. for example, somebody with in the background has HIV and they have some systemic symptoms from that and then they're imunosuppressed and develop an an acute illness for for example.

[00:14:11]So the time course is interesting and now we have the orthop reported orthopia which we classically associate with heart failure but the rest of a picture not being you know really supporting that as well. You have weight loss instead of weight gain short. Usually people with with orthopia they're also not have no shortness of breath when they're up walking kind of short of breath with activity but also can't can't lie flat.

[00:14:44]But yeah orthopia it's not specific for heart failure either like anything that is pressing on your diaphragm liat.

[00:14:54]people with just um high you know high class obesity.

[00:14:58]Um if somebody does have a sightes and you lay down flat and that's pressing on your abdomen from below that can contribute to orthopia as well.

[00:15:09]The yeah in the so we have this increased thirst and drinking in in the background too. So that's interesting.

[00:15:18]Probably the most classic association.

[00:15:20]First thing that comes to mind with excessive thirst and drinking is somebody with you know new presentation of of diabetes [snorts] and hyper they have hypoglycemia acting intestine osmotic diuretics. So they're peeing peeing peeing and then in turn become become thirsty.

[00:15:40]But it's also things like uh you know di diabetes and cypitus or there like concerning other endocrine things too.

[00:15:49]So with excessive sweating um weight loss have to also consider anything you things that are ramping up your metabolism ex excess thyroid hormone could be considered. Um so lot of pieces kind of coming together. I think the physical exam may be interesting to help us kind of lock into a more defined clinical syndrome.

[00:16:13]Um, yeah. So, that's that's my thoughts for for this aloquat for now.

[00:16:21]>> Back to you, Kashan.

[00:16:23]>> Uh, I just love the way you guys have teased the symptoms so far and what's happening with her so far. And to add to the whole drama, her vitals in the ED, her BP was 85 over 32 and her heart rate was 86 per minute and her respiratory rate was 40 and her temperature was 101.9 Fahrenheit and SPO2 was 100% in the room air initially but later um she she started requiring at least 10 liters of oxygen by simple mask to maintain her saturation.

[00:17:01]On general examination, um not ill appearing, no acute distress, but an abdomen was distended. It was soft with a diffused tenderness and palpable mass with guarding, no rebound.

[00:17:19]CVS normal heart sounds which were a little distant and um her pulmonary examination normal breath sounds and no crackles and neurologically there was no focal neurological deficit and Renzo are you able to share the image of her clinical exam I'm not quite sure if the image is going to be clear but that was something which we could also notice for Do you want me do you want me to show the picture?

[00:17:54]>> Yeah, >> sure.

[00:17:55]>> If you're Yeah, thank you.

[00:18:20]here while we try to get the picture up.

[00:18:22]You know what's interesting, John? Um, early in morning reports, we usually use the pneummonic vindicate, right? So vindicate is a great way to sort of flesh out your differential diagnosis.

[00:18:36]So it gives you a framework vascular infection uh neoplasia and so on. You know, it's interesting with all this this multitude of complaints, I'm kind of drawn to go back to those buckets of vindicate because this has a flavor like you said, you took the endocrinopathy, right? So there there is that kind of flavor to it, but you can't help weight loss, neoplasia, and it was interesting.

[00:18:59]I just posted a a little scheme of orthopia and yes, abdominal distension with the pressure up into the chest can cause it. I had a patient with massive ascitis once and they just had trouble breathing and they they manifested with that but um we have the picture up now but yeah hyper and hypothyroidism can also cause orthopia um as per that schema but let's get to this picture.

[00:19:27]>> Hey guys, are you able to see my screen?

[00:19:30]>> We can see it. Thanks Renzo.

[00:19:31]>> Perfect. Um >> what am I trying to see? What do you think, John?

[00:19:39]>> I'm I'm looking I'm trying to trying to figure out what I'm looking at.

[00:19:44]>> Exactly what I think you're right.

[00:19:50]>> I can describe it in case you if you find it very difficult just for the lighting.

[00:19:56]>> I think Sana has it. She put in the chat veins. So, there is prominent veins and I see access there in the forearm. But you know what? I don't know if it's the view, but the forearm is in the foreground and looks much bigger than the upper part of the arm. Is that me?

[00:20:13]Even if you look at the shoulder, I mean, all the way down and then the forearm looks massive compared to the rest. Is that And then the veins are popping.

[00:20:22]Uh, anything else? And there's access in there. Do you see that as well, John?

[00:20:28]>> Yeah, I wasn't sure. I was trying to determine like is it just it's closer to the camera and the angle or does he got these big like kind of you know buff forearms or is he having gorged veins but the guy overall just kind of looks uh looks very thin >> thin like a observation perhaps >> I think he has a good appetite too he finished all of his meal I have a bad habit when I go around on patients I like to see if they eat their meals or not if they have a good appetite. What do you think, Kashal? Did we do the picture justice?

[00:21:01]>> Yeah, you actually did. I was pretty disappointed that the the lighting wasn't as good, but I think you picked up everything which I wanted you to pick up. Um, so there were prominent veins on the neck as well. And then you can't really see that clearly. And then there was also prominent veins on the whole of the right arm. And she's and very thin compared to her hands were a little swollen. And I'm not quite sure if it's because of the access of the fluid and she was wait and um that's about her physical exam for the labs. Um the next part her CBC was uh WBC was at 15.84.

[00:21:45]Um did you guys want to discuss anything else about the physical findings before I give you the labs?

[00:21:50]>> Yeah, that's not a bad yet. It's 1028.

[00:21:52]What do you think, John? So large arm, veins are popping. What comes to mind?

[00:21:57]She she also mentioned there was veins in the the face as well.

[00:22:01]>> Yeah. Nice. Like first thing that comes to mind with with this overall is like is there something obstructing Venus flow back to the heart? Um so kind of it's some so-called like you have like either you know SVC syndrome. you think about some kind of mass, malignancy, thrombosis.

[00:22:24]Um, I'm not sure like the if if it's like the the forearm itself and if like the the proximal part of the arm, you know, isn't so swollen, then that's I'm not quite sure how to put that together or if that's or if that's even the case.

[00:22:36]What do you think?

[00:22:38]>> Yeah, if we think of it just mechanistically, you're right. So, something in the vein, something outside the vein. Um so in the vein was everything that you wonderfully described. Something outside the vein again bringing back all that symptomatology of something ominous infection came to mind. Neoplasia came to mind something could be pushing from the outside. So could it be some tumor mass thyroid something superior mediainum that's impinging the vessels and these are the vessels that go to the face and the arm. So you have to go deep and central. So like SVC syndrome, could that be could that be maybe a cause here that we should pursue or with this patient being on dialysis, you know, with frequent instrumentation of the veins, you do tend to get some sort of um I guess buildup of fibrosis or maybe an obstruction because of that. A lot of times with diialysis patients, right, the nefrology don't they don't like us putting in pick lines and other lines because it does ruin the vascular access that they will need it for future AV grafting and so on. So um the vessels here could have an extrinsic compression or an intrinsic uh compromise. So that that would be my thought and I guess imaging imaging would be key. If you see this, you need to go deep and central.

[00:24:03]You need to look at an image to look at the vascular territories. So CT with contrast will be helpful.

[00:24:11]>> And one thing to like if we have worry for some something if thinking SVC syndrome something obstructive [snorts] we always entertain a high degree of suspicion for for malignancy. And with weight loss being part of the picture too, actually we still haven't clarified if the abdominal fullness oropia if there's but we have some clues about ascites. If there's ascites as part of the disease process for whatever is causing this happening in the face and the arm perhaps the weight loss is more dramatic than you might think just from measuring their weight. So if if somebody has malignant ascites and they have pretty dramatic sarcopenia, but their weight hasn't perhaps hasn't changed as much because they've got several pounds of mites fluid lingering in their in their abdomen. So one one other thing I was thinking about as as we were talking.

[00:25:02]>> Yeah, I'm gl I'm glad you pointed that out. I completely escaped me, but yeah, this with the we were focused in on that picture, but the abdominal findings are are quite remarkable. Yeah, something that's palpable.

[00:25:14]What could be palpable? Could it be a mask originating off one of the one of the organs? I'm thinking I don't know why liver is coming to mind.

[00:25:24][clears throat] Could it be something soft tissue? Could it be coming off the stomach? Could it be a lymph node? You know, we we've had patient with um lymphoma with a large massive lymphoma.

[00:25:36]Um I think it was follicular lymphoma, the more inulent type. So here rather than a more of an aggressive lymphoma you have the um insiduous sort of indolink is types of lymphoma. So felicular is the most common uh type of that uh that would be something to look at. So again imaging here is key the I don't know about the you could there be ascites I mean malignancy plus ascites there could there also been infection infection of the lymph nodes lymphoma the these sort of things are coming to mind but I think imaging will really help us push the diagnostic compass further all right oh Renzo we're getting a lot of different screens so all right all right back to you Kasha Awesome.

[00:26:27]Um so to just summarize so far what we have is a 71 years old woman with whose weight loss of 30 lbs over six month over 3 months or so six pounds over 3 months and then also increased sweating and comp coming with complaints of one week of fatigue shortness of breath breath and abdominal pain and fullness and only significant past history is hyper lipidmia and gird on an examination she was having a low blood pressure of 85 over 32 and heart rate of 86 and technic at 40 and temperature 101 um and.9 and spo2 as 100% and there's abdomen is distended there's some fullness and a vague mass with g with diffused tenderness and guarding and no rebound so the labs what we have so far is CBC as 15 point WB sorry WBC at 15.84 84 hemoglobin 10.9 MCB 78.6 and platelet at 126 BMP sodium was at 135 creatinine 1.3 EGFR at 43 glucose 256 anion gap was at 18 initial BBG what we have is the pH is 7.2 2 and PCO2 50 and bicarb 20 and lactate at 5.2 and the repeat WBG which was two uh 2.5 hours later at PH at 7.16 PCCO2 at 44 by carp at 16 lactate at 7.2 2 and hemocrit had dropped from 34 to 27.

[00:28:20]So we do have a repeat vbg again and that pH was 7.26, lactate at 4 and hemogrit at 23.

[00:28:29]So A was at 40, ALT at 16 and tropenin was 0010. Lipes were normal and the urine trace blood and 100 protein WBC at 10.9 uh RBC's at 8.3 numerous granular as well as highland cas and I'm just going to paste also the labs over here just in case.

[00:29:04]All right. I forgot who who goes first.

[00:29:07]Is it?

[00:29:09]>> Yeah, I can I can go through first. I'll make sure I save some of the some of the stuff for you. So, I think I had I'm trying to make sure I caught all of the important labs. So in summarizing we have like a neutrfilic luccoytosis some microitic anemia that seems to be worsening on subsequent measurements.

[00:29:28]It's like some some renal dysfunction with a creatinin of 1.3 and I got metabolic acidosis with elevated lactic acid. Um and a new way with some uh granular and highin casts.

[00:29:45]So see some of the some of the key findings here. So was first like I when I was listening to this I actually somehow didn't like catch the whole like the the the so this the palpable mass and the key things at the exam this this patient's extremely sick and some some we have to work to figure out the underlying cause but sometimes the at the same time they also have to be stabilized so the person's hypotensive febrial and so if I saw like a respiratory rate of 40 so that that's um you know highly concerning. And if somebody has uh is truly breathing 40 times a minute and they're they're that if that's persistent then yeah they're they're going to be at high risk for quickly having their respiratory muscles tire out and having impending respiratory failure and some depending you may see if they're have if they're effectively you know ventilating having their you know PCCO2 start to start to rise. Um but yeah, sounds I'm very worried about the respiratory status of the of the person. Sounds like the other the they're breathing 40 times a minute.

[00:30:56]work of breathing is going to become a concern and the very high risk of requiring you intubation mechanical ventilation and with the the labs we have a rising I'll talk a little bit about the so the person's also hypotensive we have to think about why it's interest just don't want to spend too much time in the vitals but was interesting is when somebody's hypotensive but their heart rate is normal So normally no matter what the cause if if somebody's going into shock usually the for one of the first things that happens to compensate is you'll become tacocartic um sometime if people are on nodal blocking agents or older person with sick sinus maybe they just can't mount that tacocartic response or sometimes you can see interesting or somebody has adrenal insufficiency in the background maybe they're not going to be able they're not going to have such a you know a heart rate response but yeah it's interesting the discrepancy between the the heart rate and the blood pressure.

[00:31:57]But in summary, like just a a very sick patient who seems like they're getting getting worse. Um their their hemoglobin's continuing to drop. They have to worry like are they bleeding somewhere we can't see? Um are they hemalizing as part of the disease process going on with this palpable abdominal mass? And with the hemoglobin dropping, it's not no obvious cause right in front of you to think about like gastrointestinal bleeding that just hasn't made its way out into the world yet or bleeding into any other, you know, space in the body into the the abdominal cavity, the thigh. So carefully looking the looking the person over. But I think you know with with a high concern for malignancy, concern for some lymphoma or other kind of now apparently rapidly progressing tumor in the background. Could there be a a hemolytic anemia as part of this?

[00:32:54]Uh I'll touch on the lactic acid. Lactic acid being high often times it's a clue of tissue hypoerusion there globally.

[00:33:03]somebody's has um any kind of any kind of shock and the tissues aren't being well perused, we see the lactic acid rise. If we have can also have like local hypopusion, there's some structure that's vulnerable due to due to a blood clot or you can also have lactic production that you know that's not being cleared. If you have a sick liver, lactic acid isn't being cleared or you can have you know some um some tumors may have excess lactate production too.

[00:33:32]So some thing that within the bucket of lymphoma, you may have excess lactate production from from cancer itself.

[00:33:40]So those are some of the things I'm thinking about. But yeah, sounds like unfortunately this person's very sick, seeming to to get worse. Let me pass the mic to Ravi for next thoughts.

[00:33:52]>> Absolutely wonderful breakdown, John.

[00:33:54]You just went at it like an itemized checklist. Okay, this is this is a abnormal signal. This is an abnormal lab. This is very concerning. So, I'm very worried about this patient just like you are with the Y count. Let's say you put the Y count 15,000 plus the lactate is this sepsis. I'm just thinking this has to be sepsis, but we could also be mistaken. But I don't blame anybody for initiating the SEP one bundle. You know, as in in practice nowadays, we are running against the clock with SEP one and we are being judged by CMS. So uh at this rate within um the first few hours we need to you know get that get that lactate trended give the fluids give antibiotics antibiotics gives you the best bang for the buck in survivability for these patients and also get blood cultures.

[00:34:44]Meanwhile this may not be an infection.

[00:34:47]And so breakdown of white count infection is number one. Inflammation pain and stress that's exemplified by posttop patient or somebody having severe pain complex. Um inflammation eskeeia tissue infarction ciff is a big infection also you have to worry about any white count 15,000. Then you have to think about leukemias and malignancies and things like that. So that's sort of my checklist when I have a new white count.

[00:35:17]um you great job on the lactate. This is a really mega lactate right and as you know lactate as it edges towards 10 the mortality risk is very very high at this point. So the 7.2 might correlate directly to the to the patient being very ill. I'm just going to take this this EKG was interesting was thrown in in to the middle of this is a new right bundle branch block and I'm wondering what kind of uh uh information is this is this trying to tell us something I mean this could be nothing it could also be an indicator like why would you develop a right bundle branch block could it be an direct correlate direct indicator of um stress on the right side of the heart so you start wondering what kind of things would stress the right side. So then you go further upstream upstream into the pulary vascular maybe an acute pulary embolism. We talked about P earlier, right? Or John did talk about it possibly pommy embolism and uh also maybe wall stress on the right side of the heart STEMI uh ACS could be a cause fluid overload congestion although it would have to be extreme to cause ripe bundle branch block. And John actually highlighted maybe sick sinus syndrome. So maybe a sick heart, cardiammyopathy, myocarditis, things of that nature. So there is something going on with the heart. If you were able to track down an old EKG and it showed no evidence right bundle and now you have a right bundle, that's something you have to entertain. One other cause is rate related right bundle branch block. So sometimes you can have tachiardia induced because the AV node you can have a refractory phase right. So you got all these impulses traveling down then you get a refractory phase and then you may get a rate related right bundle branch block happening but John also already mentioned the patients uh got normal heart rate no no tachi cardia which we we would um anticipate in due to due to the patient's hypertension and so on and anemia. So this is a very sick patient.

[00:37:25]I don't know. There's a lot of data points here. At some point, we will have to bring it all together. But right now, I think we we have an X-ray here. Uh we'll take a look at that to see if it helps us get to a conclusion over this case. Kosal, back to you.

[00:37:41]>> Awesome. And then if you just had when you have time when you um just this for the all the others who have joined in just try going through the BBGs and ABGs and then you would see the delta delta ratio is actually one and uh which really means that the patient's having a pure acidosis and like John and Dr. or Ravi were mentioning it's likely because of the muscle fatigue that the patient was also having a respiratory acidosis over the metabolic and the lactate being high could be because of the warberg phenomena of I mean yeah or and it could also be because of the hyperfusion like the type A and the type B this is a mixture of all of them that's for a separate rapid fire probably so the rest of the things so you could see the chest X-ray imaging and then um Renzo will you be able to share the CT scan.

[00:38:33]>> Sure, let me show you.

[00:38:44]>> That would be pretty much like the last I'll acquire before I relieve the um reveal the diagnosis.

[00:38:50]>> Yeah, Ron, you bring the the imaging up.

[00:38:52]Um yeah, I didn't really really pay attention to the acid base, but but yeah, the if the normal gap 12, you add the 7.2 18. So the anine gap is explained by the lactic acidosis.

[00:39:08]Okay, we have the cat scan.

[00:39:12]I'm seeing a little eusion on the right side there.

[00:39:17]It's looking looking a little raggedy there. and maybe some allectasis and then infiltrate and it goes all the way down a big cyst on the left kidney.

[00:39:28]Um we have to go back slow but stop there a second. So this this looks awkward. I don't know. This calcified within the bladder.

[00:39:55]This may be abnormal. And there was a little the the density was a little off.

[00:40:00]It was a little hypo dense below this. I don't know. Maybe I'm reading too much already. Good. Maybe track it back a bit with some air there. So that because the rectum's in the back, there's air there.

[00:40:14]And then you look proximal proximal to it. It could be the this could be the uterus. Um so it could be a a leyoma. It could be something of that nature. And then the bladder is there somewhere. Okay. Let's move it more proximal and see.

[00:40:41]Yeah, that was pretty big. Did you appreciate that, John?

[00:40:45]Yeah. Like my my like non-raiologist is like some like you know large mass with seems to be prep starting from the lower abdomen.

[00:40:55]>> Yeah.

[00:40:55]>> Including calcifications, >> right?

[00:41:00]>> And then below the liver there was this conglomeration of grayish matter. I don't know if there was bowel there's no bowel um contrast that was administered to really delineate the bowels. But here there becomes a lot of so we can see small bowel. We see the the plea circular. So we can delineate that. But then you see to the left the the kidney there's a big cyst and then there's something that's right next to it as well.

[00:41:30]So it may just be if they put the arrow there but keep actually keep going.

[00:41:38]Yeah. So all this on the left there. See that? Stop there. Stop there. See that?

[00:41:42]That looks very homogeneous, right?

[00:41:47]Doesn't look like bal. What should be there? Bal.

[00:41:52]Um, that's that's too homogeneous to be >> that's all like the density. It's like a depth of density like similar to some of the the muscles in right >> in a place where [clears throat] it shouldn't be. And that's like the within and next to the kidney. I wasn't sure if cyst. It was kind of uh almost kind of mass-like there too. I don't know if that's like a perhaps bulky uh is it some mass or metastatic disease?

[00:42:20]>> Right. So, this is definitely something.

[00:42:22]I really appreciate bringing the the image. It really allows us to understand what's going on with this patient.

[00:42:28]Michelle, what's the official read?

[00:42:30]>> Awesome. And I think you pretty much covered everything. And so, but radiological terms, what they mentioned was in the chest they see a 5.5 into 8.5 into 10.6 6 cm antior mediastinal mass abiting the ascending iota and the main pulmonary artery extending along the right atrial border highly concerning for malignancy probably lymphoma to left low lower long lobe of the lungs soft tissue masses 1.6 6 into 1.5 cm and multiple sub cm bilateral pulmonary nodules small right plural eusion and the abdomen they mention as 13.2 into 6.4 4 into 9.7 hetrogenous retroparatonial mass inferior to the right kidney encasing the perrenal space displacing the diodinum inseparable from the IVC encasing the seeum ascending colon extending into the pelvis with deposits in the culdesac and misorum um so suggested does pancreatic hypodensities asite is with paratonial deposits and paricardial eusion.

[00:43:55]So next what we did was to get the IR to do a biopsy. And did you want to take a dig what the diagnosis was?

[00:44:06]>> The CT scan is just abnormalities in so many places that we didn't even like name name everything. It's like hey looks like there's something in the abdomen going down into the pelvis next to the kidneys. [snorts] also uh medius mediainal mass. Um yeah. Um and it's like before we even get get to the final diagnosis, I think just kind of talking about the when you have this like this mass in the chest too, we were one of the things we're talking about is like the the hypotension that causes just kind of just for going through the causes of of shock. We you know Robbie was talking about the possibility of sepsis with with the white count. But I think with with a clinical picture like this too, you also have to entertain compression on the on the heart impairing your Venus return and basically causing causing obstructive shock could be something to think about too. You mentioned there's some paricardial eusion. I didn't catch like how big it is, but if it's accumulating more quickly, even ones that aren't huge can cause hemodynamic compromise. And wonder like could that be part of the the hypotension?

[00:45:12]We were just kind of struck by how sick the patient is to not be tacocartic. Um, if you probably like present this, Robbie and I have us leave out the heart rate and have us guess the heart rate, we probably say like 120, 130 with the whole rest of the clinical picture. It's interesting. So, I don't know if the dis if there's something underlying that's affecting the is this disease affecting the conduction system of the of the heart as well. Um yeah, I think like terms of like specific you know diagnosis um we had like within the world some some type of aggressive lymphoma um maybe I'll turn to Robbie for some you know able to expand further but you know could consider like a diffuse large B cell. Um yeah Robbie what do you think? Yeah, I agree. It [clears throat] spread is so much and it's sort of central and if you think about hodkins non-hodkins epidemiologically uh this would be non-hodkins and remember like hodkins will travel together. So start with the neck and then move down contiguous lymph nodes.

[00:46:22]This is all over the place. So this is above the diaphragm um below the diaphragm and then the next branch point for lymphas um would be would it be B cell or T- cell and then inulent non-indingulent so the inulent ones I mentioned like one of the most common is follicular lymphoma but then beyond that what is the aggressive non-indingulent kind diffuse B cell um large cell lymphoma would be would be something to think about. You could potentially get CLL with RTOR's transformation.

[00:47:02]So here with the the degree involvement centrally up and down the body and with diffuse devastation everywhere. Yeah, it could yeah diffuse B cell large cell lymphoma um would be my thought. Uh any other thoughts there? I mean there's these others marginal mantle cell so on there's no spleen involvement here so I wouldn't think it would be of that variety but I would go with the most common ones.

[00:47:33]Yeah. And I'll just be honest like it's something like in in real time I'd be brushing up on my knowledge of the different lymphomas. If I'm going to try to predict the biopsy I need to kind of re review the some of the ep epidemiology and I'm just kind of reading off in the in the chat too. People brought up perhaps remiss not to mention like things that behave like lymphoma lymphoma mimics brought up IGG4 related disease. Um I don't know that I have like that's you I think mostly retroparitinal um for things like that. There's lymphoma mimics things like in some infectious diseases but like castleman's but I think I'm I'm more in the lymphoma camp or uh some aggressive saroma with metastatic disease could also still be on my contenders list. So yeah, I'm curious what the uh the pathology shows and then practically speaking taking care of the patients and a lot of times the next step is to think about you know you're going to need tissue to make a diagnosis and think about what's the least invasive way to get tissue and in a way that will also be perhaps be able to stage disease at the same time. So if you have a you know some you know primary site that's hard to get to and you find that there is evidence of perhaps metastic disease in the liver you can do so you may be able to do like a you know less invasive like a liver biopsy to both stage and get a tissue DX at the same time and it can be helpful even to you if there's something near the surface that's often times an easier biopsy to to get um if there's not something easily accessible near the surface it could be helpful to call your radiologist, review the study, and say, "Can you help me find the best biopsy target?" So, that's that's all I got.

[00:49:21]>> Awesome. And so it turned out to be a thymic carcinoma with metastasis and um like you mentioned they took the biopsy from the anterior of the mediainum and then they took a part of also from the abdomen biopsy they had taken and they taken also a biopsy through the doing a broncoscopy from the left lower lung masses which they me which has been described in the CT scan and all of them were showing the same pathology. So it uh turned out to be a thyic carcinoma with metastasis and the patient did choose to uh have a paleative management and initially she she was okay with an octriotide uh injection but she didn't really want anything aggressive and um and the oncologists were like it wasn't for a chemotherapy and they said it wasn't yet. So, so that's where she is and she's so they're going to be in surveillance and yeah >> that's the key that I >> amaz it was so well presented Kushal thank you for bringing this case so yeah anterior mediastinal tumors right the te's uh this is exactly one of them um it's so widespread though so it's it's amazing I've never seen anything um maybe emanating um from from thymus or thyroid being um so diffusely spread. But uh again, it was like this wasn't this didn't just happen a week or two weeks ago. This was happening for a while and explains the weight loss and it explains the night sweats and so on. So B type be like symptoms that the patient was having. But uh really appreciate you bringing this and the image well to really help us understand what was going on in the patient. John, any reflections?

[00:51:08]>> Yeah. Yeah. Thanks. Thanks so much for bringing the the case. Yeah, I think like the going to go go through the like the focus of the forts like anterior mediainal mass been helpful in in hindsight to roll through. But yeah, so like there's disease in so many places. I'm also, you know, wondering like where the kind of where the center of gravity was was for this. Um yeah, sad to hear the outcome of the case. Um um had any reflections on like actually on taking care of the patients? um how was it kind of guiding them through this journey?

[00:51:46]So I um for me it was more about trying to understand what she wanted and what was whether if she had a full understanding of what was happening with her and uh the patient seemed to be quite on top of it and she understood what was happening and um so we we were I think like for it was like uh having a longer conversation trying to understand her goals of care and what she really wanted and then what she expected from the whole treatment or stay in the hospital and if she had enough support to be able to go through the process and to be able to provide her with the support. Um so she chose I think she didn't want anything invasive to be done for her and she felt like she had a full life and she wanted to not have anything too aggressively done. Um she's still doing good. Um I mean as good as she learns I mean she sleep she the last time I me I saw her last week was she said she learning to sleep on one side then to supine to not feel short of breath you know things like that so um she's currently in surveillance and every 6 months she would be coming to the clinic or in and then whichever way we could support her we're going to be supporting her. But I thought it was an amazing case and there's so much of learning to do and um more than the images like you mentioned what happens to the patient and there's a human being at the other side and um I thought I would share it with you all.

[00:53:26]>> Yeah, thanks so much. And like a lot of times the big part of the journey for us is the the generalist is is kind of being in the supportive role. the, you know, the diagnosis ultimately comes with input from specialists and getting a getting a tissue diagnosis. And sometimes we're the ones with the time and availability to support the person and their family through coming through understanding the diagnosis, through trying to understand what life will will look like if you pursue treatment and to decide on how aggressive to be with with this. Yeah. Um, and I think like it's it's such a personal decision. It' be like uh there's a couple people that been taken care of in the hospital with my team this week where they got this devastating, you know, new diagnosis of of cancer and they're still just kind of struggling with the decision like am I going to pursue chemotherapy or am I going to be focused on on on comfort and wanted input from multiple different family members. So, it's been a a whole whole process and time and balancing like trying not to rush them through it too. There's always pressure when people are diagnosed in the inpatient setting, but also want to give them the space to come to grips with everything. Could be hard.

[00:54:49]>> Wonderful reflections. Yeah. We just have to remember that at the center of each case that we do there is a patient that's um being discussed. So appreciate yeah every patient that we do think about on this platform.

[00:55:05]We'll turn the mic over to Jillian to do teaching points to take us on. Thanks Jillian.

[00:55:12]>> Thank you all so much for sharing your reflections. This was an amazing case and a great journey. I think um I'll start by just talking about we started here with a 71year-old woman who presented with what seemed like just a week of um multiple symptoms and the first teaching point I think here is that how we should think about a patient presenting with multiple many symptoms and the idea is we should first talk about determining the threshold event what what ultim what brought the patient in today and brought them over the threshold to present. Um, also not to assume that all of the symptoms will necessarily tie together, although in this case we did have a nice resolution that could explain everything. Often times they don't. Um, in terms of prioritizing chief complaints, it's often good to prioritize the most urgent differential diagnosis or if that if there isn't one, maybe the one with the most narrow differential diagnosis or the most directive differential and that it's important to gather data by asking over uh like open-ended questions before deciding how to represent the problem. And in this case, it was really important to define the chronicity of the problem and not to assume that what the patient says first is necessarily true to defining the full chronicity. In this case, the patient stated that she had one week of symptoms, but then when we see uh symptoms like weight loss and night sweats, then we h know that we might be dealing with a more chronic inflammatory syndrome. We learned a lot about the differential diagnosis of different individual symptoms. I won't go through all of them, but I think learning to first split all of the different symptoms and go through a thorough differential diagnosis for orthopnia, abdominal fullness, um, polyura, weight loss helped us to sort of get the lay of the land of all the different symptoms and then ultimately come to an understanding of how they all came together. I think we learned about physical exam localization. Prominent veins can be from intrinsic compromise like thro fibrosis or thrombosis or extrinsic as in this case like a tumor mass. Then when we have a palpable abdominal mass we want to think about enlarged organs like liver or spleen fluid or holoviscus or mass like a retroparitinal mass ovarian colon lymphoma but imaging really defines this. And then um I think when we're uh thinking about a large med mediainal mass, we know that these can have huge compromises as in this case with um invasion into the paricardium um and can cause shock both from um inflammatory point of view but also obstructive shock. uh and that tissue is really the issue that there are multiple causes of large mediainal masses but in this case we have thyic carcinoma which really only could be defined through biopsy. And lastly, you know, talking with the patient at the end about what how they want their journey to go when they have a diagnosis like this is is really important is just as important as figuring out what the right right diagnosis is. Thank you for the amazing teaching points teaching today.

[00:58:34]>> Amazing. Julian, did you start your clerkship yet?

[00:58:39]>> Uh, yes. I'm I'm in orientation.

[00:58:42]>> Oh, wow. You're going to be a rock star.

[00:58:44]You higher performing than some of the other people I know that start clerkship. So, you're just learning so much uh while attending CPS here.

[00:58:54]Appreciate it again. And also, Renzo, thank you for doing the scribing. Have a wonderful day. Take care everybody.

[00:59:00]Five.