Hey #MedTwitter! It’s time for our first #TeachingThursday post! We’ll start with a thread highlighting #MedEd #Pearls from our first #CPC of the year with @Nathanrm0616 @HimaAtluri

28M w/ no PMHx p/w 3 months dyspnea, fatigue, and recent syncope

What’s on your mind?

Prior to sx onset he was in good shape. This is during #COVID19 and due to stress he started drinking a gallon of hard liquor weekly

He’s lost 40lb. He’s been socially distant. Recently went to grocery store and fainted with no seizure activity, preceding chest pain, etc

ddx?

His symptoms of fatigue and weight loss with the history of heavy drinking may make you #Anchor on liver dysfunction.

This is a common #CognitiveBias that can occur

We love this thread and reasoning through the cc of fatigue by @rabihmgeha @CPSolvers https://twitter.com/rabihmgeha/status/1279817460556824576

Additional Hx: no really, no PMHx

His father has DM2 and HTN

He worked in the service industry
Previously smoked 2-3 cigars weekly
Weight loss unintentional
Sex w/ 5 female partners – consistent condom use

Has this hx changed ur thoughts? How?

Schema for weight loss

Time for a #PhysicalExam #Pearls

What could you look for to confirm hx of recent 40lb weight loss? The Belt Sign!

Inspect their belt for new holes punched in or change in hole that is used. Usually recent grooves will have sharp borders while older ones have abrasions/be wider

His PE was unremarkable except for scleral icterus and conjunctival pallor.

This thread on Likelihood Ratios was a solid read through by @dmottacalderon and some #Anemia pearls from @nsrosenberg

Here’s a worthy read on a case of anemia by @DxRxEdu

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4471018/ https://twitter.com/nsrosenberg/status/1309476016621060096

Now that we’re suspicious of #Anemia let’s get some labs

WBC 2.6/Hgb 3.8 (!!!)/Plt 17
MCV 105
BMP unremarkable
T bili 2.9, Direct 0.6
Haptoglobin undetectable
LDH 8300
Uric Acid 10.8
Retic count, abs 0.028, 2.2%, index 0.28

Here’s a great #HemeOnc thread highlighting common ?s https://twitter.com/anand_88_patel/status/1275229803369676801

Ok so now we are REALLY suspicious for acute hemolytic anemia causing his presentation. hapto, LDH, hgb. But something ain’t right...what about that MCV?

MCV in acute hemolysis if enough big reticulocytes are being produced.

Chronic hemolysis consumes folate, MCV

HIV, Hepatitis Panel, and other infectious serologies were negative. Yeah, COVID19 was negative too

Peripheral smear showed Anisopikilocytosis and schistocytes and...hypersegmented Neutrophils

What’s highest on your ddx now?

@Nathanrm0616 nailed the dx early on

The patient’s B12 level was <150, MMA and Homocysteine were elevated. The patient had Anti-Parietal Cell and Anti-intrinsic Factor antibodies

Final Dx was Severe B12 Deficiency 2/2 pernicious anemia causing hemolysis and pancytopenia

Severe B12 Deficiency can cause a megaloblastic anemia and hemolytic anemia!

B12 level <200 is consistent with deficiency

Common Causes: Pernicious anemia, bariatric surgery, malabsorption syndromes, strict vegan diet, medications (metformin, PPI)

Tx is supplementation PO/IV

Thankfully our patient got supplemented IV and in follow up has some exceptionally well.

Hope you enjoyed this thread!

Tomorrow’s CPC is a case of a 70M w/ HTN, HLD, tobacco use who p/w 2 months fatigue, dyspnea, and weight loss

Tune in next Thursday for a recap!

#HereWithUs

@dcoscomd @SteveFuest @AavaKhatiwada @taylor_geisman @amaad_md @HimaAtluri @AlyssaSelf6 @AmberDeptola @kao_patricia @CalineMattar @MDdreamchaser @RakheeBhayaniMD @WUSTLmed @WUDeptMedicine