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Hello Hello Friends from near and far ! Hope you are taking time off your busy schedules to enjoy the autumn Foliage and taste the Pumpkin lattes. My Partner and I have stocked up on our favorite ice cream, Halo Top’s Fall flavors!- Do share in comments your must try fall treats, we would love to give it a try.:) My charming friend, Sawsan and I had another opportunity to collaborate with the amazing CPSolvers Academy members to bring you this spooky, fun Halloween Edition of CPSolvers Magazine. We hope to make our good friend Laura, the bimonthly magazine is her brain child, proud with our 2.0 seasonal continuation of this amazing endeavor. The Halloween Edition is composed of the recap of the mysterious VMR episode by Masah , uncanny Podcast by Gerardo , subspecialty series episode by Abeer and mind boggling quiz of our previous May edition by Maryana . Apart from this we have an open ed section, including intriguing cases shared by an enthusiastic CPSolver member Yazmin and a a brilliant medical student Ryan . Saving the best for last, we have a book review of the one and only Prof.Rez’s book , “Finding Joy in Medicine”; which honestly introduced me to this nerdy, wizardy community committed to Clinical diagnosis and medical education. A quick tip on how I like using the magazine for Spaced learning is, solving the case on my own, and listening to the linked episode. Hope you enjoy working through this magazine or reading it in a jiffy, while waiting at the grocery billing counter..:) Cheers Kuchal and Sawsan
PODCAST EPISODE
VMR SUBSPECIALTY
VMR
Insight Exchange: Readers' Case Reflections
QUIZ
BOOK REVIEW
podcast episode Episode 359 – Neurology VMR – ALTERED MENTAL STATUS
Case presenter: #ValeriaRoldán
Discussants: #AaronBerkowitz #AyeThant Highlighted by: #Gerardo Luna-Peralta
Join us live!
Chief complaint: altered mental status
Quick reasoning on
Altered mental status
potential causes
Systemic
Neurologic
Psychiatric
Most of the patients
Localization Time course
Metabolic
Toxic
Brain Brainstem
Hemorrhagic >> ischemic stroke
Sudden
Other
Acute
Meningitis, encephalitis
You can also remember the MIST mnemonic: Metabolic, Infection, Structural, Toxin
Subacute
Limbic encephalitis, expanding mass lesion, multifocal lesions
Acute/subacute psychiatric symptoms
Young woman
HPI: 30 year old woman that presented to the ED with acute confusion, agitation and fear of dying. Her partner refers that for the last 2 days she has grown increasingly worried of dying, apart of being aggresive, agitated and talking alone. A week ago she had an URI while in a trip to the north of Perú
potential causes
Infection: HSV encephalitis
Demyelinating: ADEM Autoimmune: anti-NMDA encephalitis Toxic, metabolic
Neurologic examination: she was awake and didn’t speak, with sporadic growling. She also had impaired swallowing and apparent muscle stiffness, although limbs could be passively moved
subfebrile Buzzwords
autonomic instability
Catatonia
central hypoventilation
subacute
pseudoviral
personality changes
Orofacial dyskinesias
Dx/DDx: Time course + Localization
Unspecific prodrome
Psychiatric symptoms
Movement disorder
Final DX
Anti-NMDA receptor encephalitis
Serology
Basic labs & toxicology screen To review potential toxic/metabolic causes
Pelvic US
Imaging
CSF analysis
autoimmune encephalitis pannel
to look for a potential tumor on the ovaries
To look por signs of inflammation and antibodies (anti- NMODAr among others)
To look por patterns of inflammation (i.e. limbic encephalitis)
Aprox. 50% of patients have a unilateral ovarian teratoma
Anti-NMDA testing is more sensitive in the CSF rather than serum. It is not always the case for antibody-mediated encephalitis
VMR SUBSPECIALTY
OCT 1st
A 75 year old male patient has had progressive weakness and and difficulty walking for 4 months, difficulty walking for 4 months, described as “walking like a drunk..”
LL WEAKNESS
localization Journey brain → spine → peripheral nerves → NMJ → muscles What are you looking for in the history ?
SENSORY COMPONENT ?
NMJ VS MUSCLES
Spine vs peripheral nerve
Weakness pattern fluctuating ?
autonomic Bowel /bladder ?
myopathy
NMJ pre vs post synaptic ? w/ activity ? Ocular?
spine / cauda equina
Improving
wosening+ ocular
Presynaptic ;LEMS
Post synaptic ;MG
Let's go back to the story and take a look .....
-No sensory, speech, urinary, or significant pain symptoms, but there is noticeable weight loss (24 pounds)!
-History of refractory constipation
NMJ VS Muscles dz?
NEUROLOGICAL EXAMINATION: PROXIMAL MUSCLE WEAKNESS, ABSENT REFLEXES. NONREACTIVE PUPILE B/L NO DIPLOPIA,
Autonomic involvement , pre synaptic ?
Diagnostic workup
L
NCS :incremental response after maximal exercise. EMG shows myopathic changes Anti-VGCC antibodies Positive * DX
Lambert-Eaton myasthenic syndrome
It is time to screen for underlying malignancy CT chest, abdomen, and pelvis
Lung cancer with biopsy confirmed SCLC
VMR RECAP!
September 06
81 y/o febrile Male from Texas presented with AMS & progressive symptoms of b/l LE weakness for 5 days.
2 sets blood culture
L P (r/o elevated ICP first)
IV Ceftriaxone+ Vancomycin + Ampicillin+ Acyclovir
IV Dexamethasone (reduces complications)
(to cover S.peumoniae, N. meningitidis, Listeria, HSV)
CSF Analysis:
CBC: Plt: 144K
WBC: 80 ( ) lymphocyte predominant protein: 80 ( ) glucose: 60
Lymphocytic pleocytosis
think viral
Viral Panel PCR:
West Nile Virus Serum & CSF IgM: positive
Negative HSV, VZV, Enterovirus
DX: West Nile Encephallitis
HA + Fever + AMS: meningoencephalitis + weakness: meningomyeloencephalitis
Decreased Level of Consciousness: Diffuse cortical problem
Atypical causes: (common in Texas)
Tick-borne illnesses eg. Rickettsia, Typhus, Ehlrlichia most will have thrombocytopenia - > track PLT if low - > Doxycycline
Reflective Insights: Case Stories from Readers
CASE PRESENTATION: A 36 year old male with no past medical history presented to the emergency department referred from the neurology clinic for work-up of acute urinary retention , saddle anesthesia and bilateral lower extremity numbness of 4 weeks duration. Case Presenter:Yazmin Heredia I am an International Medical Graduate, amateur gardener and language learner, passionate about Medical Education, with a special love for Infectious diseases #IDLove
Neurologic examination on admission revealed 3+ symmetric throughout reflexes . Sensory examination revealed loss of light touch and pinprick sensations on the bilateral soles.
CBC and BMP: within normal limits. A lumbar puncture was performed and showed an elevated CSF protein level of 64, WBC 65, and 88% of lymphocytes, IgG 8.4; CSF gram stain and culture for bacteria, mycobacteria, and fungi were negative. Blood cultures and serological evidence for infection by VZV, HSV-1, HIV, CMV, and Syphilis were negative, and HSV-2 IgG was positive . MRI showed extensive stable dorsolateral intramedullary enhancing lesions involving the visualized cervical and entire thoracic cord . The patient received three doses of acyclovir 800 mg IV every eight hours and methylprednisolone 1 g daily for five days. His urinary retention improved on his fourth day of admission and the urinary catheter was removed. He was discharged afterwards, asymptomatic.
A diagnosis of ES is rare and can present with a variety of clinical presentations. The most common presentation is as cauda equina syndrome, which includes symptoms of sensory impairment, saddle anesthesia, lower extremity weakness and bowel/urinary incontinence. It is usually associated with infectious causes such as SARS-CoV-2 , West Nile Virus , Varicella Zoster Virus (VZV) and Herpes Simplex Virus Type 2 (HSV-2), with HSV-2 being the predominate causative pathogen. in 2017 a diagnostic criteria was created by Savoldi, in which the diagnosis should be considered for individuals presenting with urinary retention or hesitancy. According to Savoldi 's criteria (2) , our patient' s diagnosis is "clinically probable", since he met the following criteria: A1, clinical symptoms and signs of cauda equina involvement, including urinary hesitancy or retention, bowel incontinence, or severe constipation; B1, time course indicating acute/subacute onset, no relapse, and progression over less than 3 months; B4, CSF pleocytosis.
SOUNDING LIKE A BROKEN RECORD A case of transient global amnesia Case Presenter : Ryan Masotti I am a third-year medical student at Emory University currently on my clinical rotations. CASE PRESENTATION: Ms. X was a 64 year old female with a history of myasthenia gravis, prediabetes, and hypertension presenting with acute onset memory loss. She was brought to the ED by a friend after the patient repeatedly called the friend Her friend stated that she last spoke to the patient over the phone the evening prior and stated that she was normal at this time. This morning, however, the patient has been having significant memory difficulty and has been repeating herself every few moments. The friend states that she is significantly confused and not at her baseline. The patient had no memory of her day leading up to her admission and did not know how she arrived at the hospital. She perseverates and repeats herself frequently. The patient’s only initial complaint was a left-sided headache without light or sound sensitivity. without any memory of each event. ----------------------------------------
------------------------------------------ A review of systems was otherwise negative.
Her vital signs at presentation were unremarkable. She was hemodynamically stable and afebrile. She was alert and oriented to her name only. She recalled 0 out of 3 objects after 1 minute.
She was able to spell “chair” backwards and do simple calculations. Language was intact and she was able to follow 3-step commands. The remainder of her neurologic exam, including fundoscopy, was unremarkable. ------------------------------------------- CBC, CMP, and urine toxicology were all within normal limits, with the exception of a mildly low potassium (3.3). ----------------------------------------- Non-contrast CT of her head was ordered and did not show any acute abnormalities. Her EEG was normal. A follow up MRI revealed small punctate lesions in the bilateral hippocampus. The patient was admitted to the medicine service and was followed by neurology. Eight hours after the initial encounter, her memory appeared to be back to baseline. --------------------------------------- She reported that her last memory prior to the event occurred at work approximately 12 hours earlier. The patient stated that she had recently been under an increased amount of stress at work. Her neurologic exam continued to be stable at this time and she remained afebrile. The following morning, the patient was discharged with a presumptive diagnosis of transient global amnesia and was counseled to follow-up in clinic with her outpatient neurologist.
TEACHING PEARLS After an extensive negative workup, transient global amnesia should be considered in a patient with self-resolving anterograde amnesia.
This condition typically affects middle- aged adults and is often seen in females more often than males. It can be associated with migraines but it is often thought to be related to a variety of triggers such as stress, environmental factors, and even some physical maneuvers, like Valsalva.
Patients often experience “broken record phenomenon” in which they frequently repeat the same phrase due to short term memory lapses. It is also reported that headache can be seen in up to 40% of patients that are found to have transient global amnesia. CT/MRI findings are typically normal, however some patients are found to have small punctate lesions in the hippocampus on MRI, as we saw in this patient. It is important to rule out other possible causes of anterograde amnesia prior to making this diagnosis. Stroke, infection, seizures, metabolic or toxic encephalopathy, and other structural causes must be ruled out. Management of this condition is supportive therapy and close monitoring until the symptoms resolve. Patients should be counseled to follow-up with a neurologist in order to monitor for recurrence. Subsequent events are atypical and should be further evaluated to assess for other causes.
I
September 19, 2024 VMR with Rabih & Maryana - tingling, numbness, and burning sensation of b/l LE
Neuromyelitis Optica Spectrum Disorder (NMOSD) is a rare autoimmune condition that primarily affects the central nervous system, particularly the optic nerves and spinal cord. It is characterized by recurrent episodes of optic neuritis (inflammation of the optic nerves) and transverse myelitis (inflammation of the spinal cord), which can lead to vision loss, paralysis, and other neurological symptoms. The disorder is often associated with the presence of anti- Aquaporin-4 (AQP4) antibodies, which target water channels in the central nervous system, leading to inflammation and damage. NMOSD is sometimes mistaken for multiple sclerosis (MS) due to overlapping symptoms, but it is a distinct condition with different underlying mechanisms and treatment approaches. Treatment typically involves managing acute attacks with high-dose corticosteroids or plasma exchange, while long-term therapy focuses on immunosuppressive agents to prevent relapses and reduce the risk of permanent neurological damage. Early diagnosis and treatment are crucial for improving outcomes and preserving quality of life in affected individual
I
September 19, 2024 VMR with Rabih & Maryana - tingling, numbness, and burning sensation of b/l LE
A 34-year-old woman presents with recurrent episodes of bilateral optic neuritis and longitudinally extensive transverse myelitis. She reports progressive vision loss and lower extremity weakness over the past year. MRI of the spinal cord reveals a longitudinally extensive lesion extending over 5 vertebral segments. Brain MRI shows no significant periventricular or cortical lesions. Her anti- Aquaporin-4 (AQP4) antibody test returns negative, and a follow-up test for anti-Myelin Oligodendrocyte Glycoprotein (MOG) antibodies also returns negative. Which of the following would be the next best step in managing this patient? a) Repeat anti-AQP4 antibody testing b) Diagnosis of seronegative NMOSD and initiation of immunosuppressive therapy c) Empirical treatment with disease-modifying therapies for Multiple Sclerosis (MS) d) Referral for further genetic testing e) Observation and symptomatic management only
I
September 19, 2024 VMR with Rabih & Maryana - tingling, numbness, and burning sensation of b/l LE
Correct Answer:
Diagnosis of seronegative NMOSD and initiation of immunosuppressive therapy
This patient presents with classic clinical features and MRI findings highly suggestive of NMOSD, despite being seronegative for both anti-AQP4 and anti-MOG antibodies. A diagnosis of NMOSD can still be made based on clinical and radiologic criteria, even in the absence of detectable antibodies, as seronegative NMOSD is a well- recognized subset. Early recognition and initiation of immunosuppressive therapy are critical to preventing relapses and reducing the risk of long-term disability.
EP I
Book Review
TITLE OF THE BOOK FINDING JOY IN MEDICINE BY DR.REZA MANESH
BY KUCHAL AGADI
Book Review
SUMMARY OF THE BOOK
Finding joy in medicine is Dr.Manesh’s reflection on his life. His authenticity makes it relatable to anyone who reads it. His curiosity to understand the pathophysiology of the disease and his ability to communicate complex infomration with simple mathematical (pun intended) flow charts and schemas comes through by organising his content into three main categories. The pandemic has unwrapped essential conversations about mental health and work-life balance to the forefront. Through this book, Reza eloquently shows how to connect the dots between purpose,passion and impact to finding joy. maybe the best way to summarize, “finding joy in medicine”, would be in aghajoon’s words, “purpose allows protection from the challeges of life.”
Book Review
FAVORITE AUTHOR: DR.AARON BERKOWITZ, MD PHD
IF YOU COULD ADD ANOTHER CHAPTER CO-AUTHORING WITH RABIH,WHAT WOULD IT BE ABOUT? CPSOLVERS ACADEMY
KNOW THE AUTHOR DR. REZA MANESH
WHAT WOULD FINDING JOY IN MEDICINE 2.0 BE ABOUT POST RESIDENCY CHALLENGES: # FINDING THE RIGHTJOB #FINANCIAL HEALTH #FOLLOWING YOUR PASSION
FAVORITE COFFEE: STAR BUCKS- HOT GRANDELATTE WITH ALMOND MILK
IS YOUR BOOK GLOSS/MATTE FINISH MATTE
Every educational case is a unique learning opportunity, and we want to hear your story! As we look ahead to future seasons of our magazine, we invite our readers to share their educational cases and reflections that highlight valuable lessons learned.
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