Recap and Resources on Case Conference 7/8/2024

Thanks Sophia for sharing a great case and the teaching points with us at our Monday case conference. To follow up, I would like to share the following reflections and resources. For new interns especially, it is important to build your diagnostic framework for common problems upfront, and apply/refine those frameworks in your subsequent patient encounters.

Diagnostic journey recap: 

--We started with an elderly lady with diffuse abdominal pain. We used "VIPO" mnemonic” to help us consider the can’t miss diagnoses (often acute) - Vascular, Inflammation, Perforation, Obstruction. We can then use anatomical approach to help localize, and as it is diffuse, we considered bowel, vascular, peritoneum; some image-negative abdominal pain causes also fall into diffuse category. CT scan (+IV contrast if possible) is almost always indicated during the initial workup of abdominal pain. If negative we can consider image-negative abdominal pain.

—Vitals were notable for tachycardia - always consider tachycardia as a potential early sign of hypotension/shock, and use the 4 shock categories to organize your Ddx. Labs further supports presence of shock (lactic acidosis, hyponatremia, AKI, shock liver), despite normal BP. Together with the cardiac exam findings (JVD and pulses paradoxes), we should suspect tamponade as the cause of shock, which was further supported by the presence of large pericardial effusion seen on the CT scan. Tamponade needs to be confirmed with an Echo (showing its hemodynamic features). Some POCUS skills will be very valuable here.

— Giving negative abdominal imaging and presence of shock/tamponade, the center of gravity now shifts towards tamponade (while tracking abdominal pain in the back of our minds). It is important to recognize it as a medical emergency and know how to manage. Then consider Ddx of pericardial effusion, in this case a lung cancer as clued by her smoking history.

—We ran out of time in circling back to explain her abdominal pain and constipation. Some hypotheses include hypoperfusion to the bowel as a result of shock (and possible underlying vascular disease), hepatic congestion, and vagal stimulation. Follow up on symptom resolution after pericardiocentesis would be helpful.

Teaching point recap: please review the following schemas/topics

—Review Abdominal pain thought train (a more comprehensive version than what we discussed), Abdominal pain anatomical approach, and if you have time Image-negative abdominal pain as well

—Review Severe acute liver injury (ALT, AST >1000)

—Reflect on how to recognize shock early (eg, vitals/exam/lab features), and be familiar with Shock Ddx (4 categories)

—Build your illness script around Tamponade, make sure to understand its physiology and management (various resources online, such as this video)

As promised I am sharing an article from our hospitalist newsletter where I shared the two cases of tamponade I saw at HMC, with a focus on its physiology correlation with Echo features, along with some initial discussion on shock Ddx.

Additional tip: If you have not started building your external brain (ie, a digital notebook), this may be an opportunity to start - something you build throughout your residency training and future practice as part of lifelong learning.

Please let me or Michael know if you have any questions or reflections and we are happy to answer or reflect together!