Clinical Questions

Why Does Hypertriglyceridemia Lead to Pancreatitis?

October 4, 2007
Why Does Hypertriglyceridemia Lead to Pancreatitis?

Commentary by Daniel Frenkel, PGY-2

Case: A 46 year old male with diabetes on oral hypoglycemic medications is admitted to the hospital with one day of constant epigastric pain, nausea, vomiting, and an inability to tolerate oral intake. You are concerned about pancreatitis but laboratory analysis reveals amylase levels that are within the normal reference range. You notice that his glucose level is 410mg/dL and that the specimen is described as lactescent. Should you still be concerned about acute pancreatitis?

Lactescent or lipemic blood samples…

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Part II- Subclinical Thyroid Dysfunction: To Treat or Not to Treat?

August 8, 2007
Part II- Subclinical Thyroid Dysfunction: To Treat or Not to Treat?

Commentary by Melissa Freeman MD, PGY2

Please also see Part I of this series

In 2002, the American Association of Clinical Endocrinologists (AACE), the American Thyroid Association (ATA), and The Endocrine Society (TES) sponsored an evidence- based Consensus Development Conference with a panel of thirteen experts to address unresolved issues about subclinical thyroid dysfunction. Though these sponsors agreed with many of the recommendations made by the consensus, they felt that they relied too heavily on evidence-based medicine that did not yet exist. Two years later,…

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Are beta blockers indicated in cirrhotics with small varices?

August 1, 2007
Are beta blockers indicated in cirrhotics with small varices?

Commentary by Bani Chander MD, PGY-2

Esophageal varices are a common complication of cirrhosis and approximately one-third of all cirrhotic patients with varices will develop a variceal bleed . Each episode of variceal hemorrhage is associated with a 15 to 20 percent risk of mortality in patients with severe liver dysfunction.  The risk of bleeding is related to the location, size, and appearance of the varix, presence of red wale markings, variceal pressure, prior history of variceal bleeding, as well as the severity…

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Part I- Subclinical Thyroid Dysfunction: To Treat or Not to Treat?

July 31, 2007
Part I- Subclinical Thyroid Dysfunction: To Treat or Not to Treat?

Commentary by Melissa Freeman MD, PGY2

Modern day science has revealed to us the intricate relationships that thyroid hormones have with multiple systems of the human body.  Many of today’s physicians find themselves checking patients’ thyroid function tests (TFTs) almost as reflexively as a baseline basic metabolic panel. Yet, what seems to the physician to be a harmless bit of thoroughness can often turn into hours of inquisitive head scratching if the TFTs reveal subclinical thyroid dysfunction, especially since automated assays for TFTs are more…

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Clinical Question: How do you manage plantar fasciitis?

July 19, 2007
Clinical Question: How do you manage plantar fasciitis?

Commentary by Cathy Cruise, M.D. Director Department of Veterans Affairs Care Coordinator, Chair Rehabilitation Council

Case: A 25 year old woman with no significant past medical history presents to walk-in clinic complaining of several days of right heel pain. She notes that the pain is quite sharp and worst when walking. It is so severe that she has skipped her morning run for three consecutive days. She has tried taking acetaminophen which has provided minimal symptom relief. Physical exam reveals mild swelling and…

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How do you assess a patient’s risk for recurrent DVT?

July 6, 2007
How do you assess a patient’s risk for recurrent DVT?

Commentary by Sean Cavanaugh MD, Associate Editor, Clinical Correlations

A 51-year-old man with a history of DVT diagnosed seven months ago presents to your clinic for follow up. He has no family history of blood clots. He has been on coumadin since his DVT was diagnosed. No testing for thrombophilia has been done. How do you proceed?

Recently, The Annals of Internal Medicine released an excellent statement about the treatment of venous thrombosis (see prior post). Unfortunately, it does not address the more interesting questions…

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Should All Patients with Hepatitis C Be Screened for Hepatocelluar Carcinoma?

July 3, 2007
Should All Patients with Hepatitis C Be Screened for Hepatocelluar Carcinoma?

Should patients with Hepatitis C (HCV) with no evidence of cirrhosis undergo screening for hepatocellular carcinoma (HCC)? Is there any reason to check for HCC when the liver associated enzymes (LAEs) are normal?

-Sandeep Mangalmurti, PGY-2

Commentary by Mike Poles MD, Associate Editor Clinical Correlations and Assistant Professor, Division of Gastroenterology

HCC continues to be one of the most common solid malignancies worldwide. Further, almost all cases of HCC occur in the background of a histologically-abnormal liver; approximately 90% of cases of HCC occur in…

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How Do you Approach a Patient with Primary Hyperaldosteronism?

June 28, 2007
How Do you Approach a Patient with Primary Hyperaldosteronism?

An 80 year old male with atrial fibrillation, hypertension, hypokalemia is diagnosed with hyperaldosteronism with an aldosterone to renin ratio of 34.5/0.15=230 . CT scan reveals a right adrenal 1 cm presumed adenoma

Questions:
1. How do you accurately diagnose primary hyperaldosteronism?
2. Do medications which the patient is taking influence the work-up?
3. Can you have primary hyperaldosteronism in the absence of hypokalemia?
4. Can the adrenal mass be incidental? Should the patient have additional testing?

-Anna Dvorak PGY-3

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Can You Give A Cephalosporin to a Patient Who is Allergic to Penicillin?

June 21, 2007
Can You Give A Cephalosporin to a Patient Who is Allergic to Penicillin?

-Commentary by Susan Morey, PharmD. Pharmacy Practice Resident

A true allergy to penicillin is known to occur in less than 10% of patients exposed to penicillin. 1, 2 The cross-reactivity to cephalosporins has been reported to be approximately 8% to 18% in patients with a documented penicillin allergy. True allergic, type I reactions are IgE mediated, with a spectrum of presentation ranging from urticaria to severe anaphylactic shock.1, 2

The beta-lactam ring has been implicated as the structure responsible for cross-reactivity…

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Hyperparathyroidism in Chronic Kidney Disease

June 13, 2007
Hyperparathyroidism in Chronic Kidney Disease

Commentary by Sarah Berry MD, PGY-3 and Joseph Weisstuch, MD Clinical Assistant Professor of Medicine, Divsion of Nephrology

Case: Mr. K is a 59 year old gentleman with a past medical history of hypertension, non-insulin dependent diabetes mellitus, dyslipidemia and worsening chronic kidney disease (CKD) over the last six years, despite compliance with his medications and optimized glucose and blood pressure control. His current medication regimen includes metoprolol, hydrochlorothiazide, aspirin, simvastatin, glyburide, and monopril. Mr. K’s most recent lab work indicates that his…

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Can you switch a patient from insulin to oral agents?

June 6, 2007
Can you switch a patient from insulin to oral agents?

  A 48 year old male is diagnosed with type 2 Diabetes Mellitus after presenting to the emergency room with symptoms of hyperglycemia. He was immediately started on insulin and has been very compliant with his regimen. His initial Hemoglobin A1C at the time of diagnosis was 15.  However, over the past few months, due to hypoglycemia, his insulin dosage has been titrated down. He is currently on low doses of NPH and aspart, with an A1C of 6.6. Would it be possible to

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How should you approach a pregnant patient with chronic kidney disease?

May 25, 2007
How should you approach a pregnant patient with chronic kidney disease?

A 31 year old female with hypertension and proteinuria secondary to IgA nephropathy, currently treated with an ARB, presents to clinic stating that she would like to become pregnant.

What is the risk of fetal morbidity in the setting of ARBs/ACE-inhibitors? What antihypertensive medications are used during pregnancy? At what point would you switch a patient’s medications if she is trying to become pregnant? What is the natural course of IgA nephropathy during pregnancy?

-Minisha Sood MD, PGY-3

Pregnancy and Chronic Kidney

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