Category Archives: Primary Care

VA Ambulatory Report 4.4.18 – New Atrial flutter

Thanks Anne for presenting your patient from clinic last week.  The patient is a 60 yo F with a pmhx of HTN and DCIS who presented to clinic with dyspnea on exertion found to have atrial flutter with rates in the 130-150s.

Sam Brondfield joined us and dropped some knowledge bombs about DOACs

DOAC MOA Reversal agent? Things to consider
Dabigitran Thrombin inhibitor idraucizumab -Common SE: dyspepsia
Rivaroxaban Xa inhibitor -Once daily dosing
-Least amount of data in elderly patients
Apixaban Xa inhibitor -Lowest bleeding risk
-Least dependent on creatinine clearance, safest in renal disease
Other considerations: insurance coverage, drug interactions


How is Aflutter different from Afib?

  • Background
    • Afib – associated with some underlying heart disease causing large atrium, increased atrial pressures or inflammation
    • Typical Aflutter – reentrant circuit involves the cavo-tricuspid isthmus
      • sawtooth negative flutter waves in the leads II, III, and aVF
    • Atypical flutter – not involving the cavo-triscupid isthmus
  • Work-up of new onset of atrial flutter is the same as afib
    • Any disorder that causes Afib can also cause Aflutter
      • Also commonly occurs after treating Afib with an antiarrythmic or ablation
      • It is an uncommon complication of acute MI in the absence of other symptoms
    • Assess for hyperthyroidism, heart failure, pulmonary disease
    • Tests to order
      • Echo: Looking at size of artia and ventricles, ventricular function, and valves and TEE if plan for cardioversion without optimal anticoagulation
  •  Management
    • Rate Control: Same general approach as Afib, but harder to achieve
      • Use non-dihydropyridine CCB or BB
      • Consider dig or amio if decompensated HF
    • Rhythm control
      • Cardioversion should be urgently in patients with rates >150 or in those who have hemodynamic compromise or who have WPW
      • Ablation is the treatment of choice given the high rate of recurrence of aflutter and the high success rate of the procedure
    • Stroke prevention
      • Limited data to suggest the optimal approach to anticoagulation in atrial flutter given rarity of persistent A flutter and the frequency of co-existence with Afib
      • Thromboembolic risk may be lower than in Afib, but most recommend approaching anticoagulation the same as they would in a patient with Afib as these patients may also be having episodes of Afib

VA Ambulatory Report 3.14.18 – The other FUO: Fistula of unknown origin

Okay, fistula of unknown origin is not a real phrase, but today’s case brought up a good discussion about fistulas. Bennett and Huat presented a case of a 50 yo male with air bubbles in his urine found to have a colovesicular fistula possibly due to diverticulitis.

Colovesicular fistula pearls

  • Most common presentation: pneumaturia or fecaluria.  Less common presentations: UTIs, urinary frequency, hematuria.
    • Pneumaturia is a rare manifestation of a UTI and should strongly raise your suspicion for a colovesicular fistula
  • Despite what we may expect, studies have shown urine culture more often grows one species (40-70% of cultures) instead of mixed flora.
  • Thanks Daniel for reminding us the benefit of oral contrast – Abdominal CT with oral or rectal contrast is the test of choice.  IV contrast is excreted renally and can cloud the picture.
  • Next step is identifying the cause of the fistula.  If no cause is identified on abdominal CT, next step is colonoscopy and/or cystoscopy to assess for malignancy given this will change your management.
  • Causes of bowel-vesicular fistulas
    • Diverticular disease: most common cause
    • Post-op
    • Spontaneous
    • IBD
    • Malignancy: Colon, bladder, cervix, prostate
    • Radiation
    • Other
  • Key Management Principles of Colovesicular Fistulas
    • Treat infection if present, but do not need suppressive antibiotics
    • Definitive treatment of fistula with surgery in majority of cases
      • If the cause is non-malignant, minimally symptomatic patient, and considered high surgical risk you can opt for watchful waiting

Check out this American Journal of Surgery article on Colovesicular fistulas.


Evernote link:

VA Ambulatory Report 3.7.18 – TB in clinic

Thanks Chris for presenting your patient who is an elderly man with a history of CAD and HTN who presented to clinic with history of tuberculosis and chest xray findings of apical scaring and pulmonary nodules.  We had a great discussion about the challenge of diagnosing TB and management strategies for active and latent TB in the outpatient setting.

TB Epidemiology

  • In countries with a low incidence of TB such as the US, the most common cause of active TB is reactivation of old disease.
  • In San Francisco the most common risk factor for TB is being foreign born in particular individuals from China, the Philippines, and Vietnam.
    • Check out this SFDPH Disease Control and Prevention Report for more epidemiology of TB in San Francisco.

Diagnosing TB 

  • Tuberculin skin testing (TST) vs. Interferon Gamma Release Assay (IGRA)
    • The decision to use TST vs. IGRA is based on patient characteristics, local resources, and cost.
    • The CDC recommends sending IGRA testing over TST in patients you have decided to test due to risk of exposure AND have a history of BCG vaccination or are unlikely to return for ppd read.
    • In other adult patients TST or IGRA are reasonable testing choices, although IGRA is slightly preferred due to better test characteristics (it is more specific)
    • A negative reaction in either test does NOT exclude TB
  • Sputum – AFB smear, culture, and gene expert
    • The policies at our hospitals have been updated and you only need 2 AFB smears and gene experts to decide about airborne isolation discontinuation for inpatients
  • Check out these clinical practice guidelines on the diagnosis of TB.

Management of TB

  • Is this active TB?
    • The diagnosis of active TB is based on symptoms, imaging, sputum AFB smear, culture, and gene expert
    • If a diagnosis of active TB is confirmed, most patients will be treated with directly observed therapy at TB clinicW
  • Which patients with LTBI should be treated?
    • There is a push these days to treat nearly all patients with confirmed LTBI if the patient agrees to be treated
    • There is a strong recommendation to treat patients who are at high risk of reactivation
      • Risk of activation in immunocompetent host is 5-15% over their lifetime
        • ~5% risk within the first 2 years of exposure and ~5% risk over the rest of the lifespan
      • Risk factors for reactivation TB or high incidence of TB: age (young children and elderly), HIV, meds that inhibit cellular immunity (TNF alpha inhibitors, steroids), history of head and neck or hematologic malignancies, organ transplant candidates/recipeints, ESRD, silicosis, low body weight, history of bypass surgery, prisoners, illicit drug use, smokers, homelessness, healthcare workers, foreign born, diabetes, or recent seroconversion.
    • Treatment regimens: Should be based on patient preference, comorbidities, side effects, and drug interactions
      • INH for 6-9 months
      • Rifampin for 3-4 months
      • INH + Rifampin for 3-4 months
      • Rifapentine + INH for 3 months

More TB related resources

Evernote link:

VA Ambulatory Report 2.28.18 – Don’t forget about the EAR! Barotrauma and Syphilis

We had two great mini cases both involving the ear!

Thank you Manoj for presenting your young patient who presented with 2 weeks of ear fullness that started immediately after skydiving and found to have hemotympanum.

Key learning points

  • Remember to ask your veteran patients about their service time and duties.  Vets that were part of airborne or parachute teams may have musculoskeletal problems (spine and heels in particular) from frequent forceful landings
  • Barotrauma
    • Remember the anatomy of the ear: the eustachian tubes allow pressure to differential on each side of the tympanic membrane to requilibrate by yawning, valsalva, or swallowing
    • Barotrauma to the middle ear can result when the pressure between the middle ear and outside of the tympanic membrane cannot equilibrate such as in air travel, scuba diving, or exposure to a blast
    • Extreme pressure differences can result in hemotympanium or ruptured TM
  • If you are worried about a basilar skull fracture, look for the following
    • Battle sign: Retroauricular or mastoid ecchymosis
    • Raccoon eyes: periorbital ecchymosis
    • Cranial Nerve VII paralysis
    • Clear rhinorrhea or otorrhea
    • Hemotympanum
  • In patients with hemotympanium without hearing loss or other concerning findings (vestibular findings, basilar skull fracture, facial weakness) can be observed.  If there is hearing loss or concerning findings, the patient should be evaluated urgently by ENT.
  • Check out this great review article of barotrauma after sky diving and scuba.


Next Santo presented the case of an elderly man who presented to primary care for chronic hearing loss and STI screening in the setting of high risk sexual behavior found to have otosyphilis.

  • We refreshed our memory of Weber and Rhine which are notoriously hard to inteprete!
    • In a patient with unilateral hearing loss, the weber and rhine can help distinguish between sensineural hearing loss (SNHL) and conductive hearing loss (CHL).  Air conduction measures CHL and bone conduction measures SNHL.
    • Weber: Remember this test is comparing both ears ability to hear with bone and air conduction.  Patients report which ear hears the sound louder
      • If there is conductive hearing loss on one side, the patient will only be getting input from bone conduction (without ambient noise) and therefore report a louder sound on the side with conductive loss.  CHL lateralizes to the bad side.
      • If there is SNHL on one side, the patient will not be getting bone input on the bad side and therefore will report that side is quieter.  SNHL lateralizes to the good side.
      • If there is normal hearing or symmetric hearing loss the sound in each ear will be equal
    • Rhine: This is only testing one ear and comparing bone vs. air conduction
      • If there is CHL –> Bone will be louder
      • If there is SNHL –> Air will be louder

Evernote link:

VA Ambulatory Report 2.21.18 – Sarcoid Diagnosis and Hematuria

We had two great case discussions today.

First Jeff presented an image of incidentally discovered pulmonary nodules and hilar lymphadenopathy.  The patient was diagnosed with sarcoid based on these imaging results alone.

Learning points:

  • How to diagnosis sarcoid:
    • If a patient is asymptomatic with characteristic radiographic findings – this is sufficient to make the diagnosis
    • For symptomatic patients, biopsy confirming noncaseating granulomas is required
  • For a new diagnosis of sarcoid monitor for complications and extrapulmonary involvement: EKG, eye symptoms, vitamin d levels, UA
  • In an asymptomatic patient with low grade radiologic changes, the management is observation only


Second, Akshai presented a patient seen in clinic the day prior with gross hematuria.

Learning points:

  • Gross hematuria should strongly increase your suspicion of malignancy. The incidence of malignancy in microscopic hematuria vs. gross hematuria  is ~2% vs. 20%.
  • Smokers are 4-7 times more likely to develop bladder cancer than non-smokers
  • CT Urography is the test of choice to evaluate for malignancy and nephrolithiasis.  CTU provides both functional and anatomic information about the kidney and ureter.  The pre-contrast phase evaluates for nephrolithiasis and hydronephrosis.  The post contrast phase evaluates renal and urothelial malignancies and can assess kidney function in the setting of obstruction.


Evernote link:

SFPC Ambulatory Report 2.21.18 – Funky Tongue and Secondary Amenorrhea

We had a mini case of Glossitis and Xerostoma.  Here are the key learning points:

  • Nutritional deficiencies that result in atrophic glossitis: B2, B6, and B12
  • Grace brought us back to our days of Step studying reminded us aboutPlummer-Vinson syndrome.  It is a rare disease that results in iron deficiency anemia, glossitis, esophageal webs.

    The goal of treating xerostomia is to alleviate symptoms and prevent complications such as dental caries, candidiasis, halitosis includes prevention: 1)hydration, avoid oral dessicants, avoid meds with anticholinergic side effects, and reduce mouth breathing; 2) treatment with sugar free gum or lozenges, artificial saliva, high strength fluoride toothpaste


Grace presented a great case of young woman with secondary amenorrhea likely due to stress.

  • Approach to amenorrhea
    • Step 1: Pregnant or not
    • Step 2: Primary vs. secondary – did the patient ever experience menses
    • Anatomic Approach to Secondary Amenorrhea – the HPO-axis
      • Hypothalamus
        • Hypothalamic hypogonadism
          • Functional: stress, excessive exercise, weight loss
          • Injury: infarct, tumor, infection
          • Systemic Illness
        • Hypothyroidism
        • Cushings
      • Pituitary
        • Increased prolactin
          • Prolactinoma
          • Breastfeeding
          • Meds such as antipsychotics
        • Injury: infarct, tumor, infection
      • Ovarian
        • Premature ovarian failure (can be due to chemo, radiation, autoimmune, adrenal insufficiency)
        • Menopause
        • PCOS
      • GU Structural Causes
        • Asherman’s syndrome
        • Cervical Stenosis
  • Check out an old blog post by Rabih for the hormone based approach to secondary amenorrhea.
  • What does the Progestin withdrawal bleeding test tell us?
    • If the patient bleeds after a progestin withdrawal challenge it signifies she is making estrogen but is anovulatory
    • If the patient does not bleed it means there are low estrogen levels or obstruction in the GU tract
  •  Functional Hypothalamic Hypogonadism
    • Due to decreased caloric intake, increased caloric expenditure due to excessive exercise, and stress
      • In the setting of stress high levels of cortisol and corticotroponin releasing hormone inhibit GnRH production
    • Is the cause of 25-35% of secondary amenorrhea

Evernote link:

VA Ambulatory Report 2.7.18 – Double case – Facial numbness and Arm Swelling

Morning report today was like a regular primary care clinic day – one daily ditty and two patients all in one hour no problem!  Thanks Lily for presenting two awesome cases.

Case 1: A young woman on OCPs with right sided facial numbness and facial droop sparing the forehead found to have MS.

Unilateral Facial Paralysis:

  • The key to evaluation is determining if the lesion is central vs. peripheral
    • The forehead is spared in a central process due to bilateral innervation
    • There are possible peripheral causes that spare the forehead BUT forehead sparing should raise your suspicion for a central process
    • Pearl from Jody is that forehead weakness can be subtle as patients try to overcome it with muscles of the scalp. In addition to having the patient raise their eyebrows, have them maintain raised eyebrows against your force.
    • Central
      • Stroke
      • Malignancy
      • Demyelinating diseases
      • Migraines
    • Peripheral – Facial nerve palsy
      • Infections: Herpes zoster, otitis media, lyme, HIV
      • Immune-mediated: GBS
      • Autoimmune: sarcoid, Sjogrens
      • Idiopathic (Bell’s palsy)


Case 2: A 45 yo G1P0 female with recent spontaneous abortion and RUE DVT with chronic right arm pain and skin changes found to have complex regional pain syndrome.

  • We reviewed indications for thrombophilia work-up.
    • We should not test every individual with an unprovoked VTE because for most people it will not change management.
    • Who does it change management in?
      • Women planning conception
      • Possible need to treatment with pro-thrombotic agents such as estrogen
    • In general we should consider testing in the following populations:
      • Young patients (<50) with weak provoking factors or strong family history
      • Arterial clots
      • Unusual locations: Splanchnic veins, cerebral veins
    • Check out this awesome NEJM review article.
  • And remember the Budapest criteria when considering the diagnosis of complex regional pain syndrome
    • Continuing pain, which is disproportionate to any inciting event

    • Must must report at least one symptom in three of the following four categories:

    • 1 – Sensory: hyperaesthesia (an abnormal increase in sensitivity) and/or allodynia (pain caused by usually non-painful stimuli);

    • 2 – Vasomotor: skin colour changes or temperature and/or skin colour changes between the limbs;
    • 3 – Sudomotor/oedema: oedema (swelling) and/or sweating changes and/or sweating differences between the limbs.
    • 4 – Motor/trophic: decreased range of motion and/or motor dysfunction (weakness, tremor, muscular spasm (dystonia)) and/or trophic changes (changes to the hair and/or nail and/or skin on the limb).
    • There is no other diagnosis that better explains the signs and symptoms