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UCSD eConsult Newsletter
Vol. 3 No. 2
Oct 2016














 





























 














 





















































 





















 















































 
There is a lot to anticipate over the next month: Halloween, Daylight Savings Time, and Election Day. And, on the heels of these events, there is an additional one that has been requested repeatedly and which is almost here: eConsults from the Division of Infectious Diseases! Templates are currently being finalized.  Stay tuned!

And - as always - enjoy this month's Exemplary eConsults.

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Exemplary eConsult:
Cardiology


PCP 'My Clinical Question': 
I am requesting an eConsult from Cardiology for my 68 yo female pt w/hyperlipidemia.

This pt has hyperlipidemia (TC 270, TG 127, HDL 49, LDL 196). Statins caused transaminitis (2 times normal) and were d/c'd.  Dietary changes have not helped.  Should we return to a statin as primary prevention (no fam history) and tolerate elevate liver enzyme numbers to 2-3 times normal or continue to monitor?  Also what is the role of calcium scoring in this patient?  She has mild disease seen on a CT scan of abdomen. 
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eConsultant
Luis R. Castellanos, MD, MPH
Associate Professor of Medicine
Division of Cardiovascular Medicine


Risk stratification with a coronary artery calcium (CAC) score can be helpful in asymptomatic adults, especially in patients that may have an adverse reaction to statin therapy. A patient with a CAC of zero has a very low risk of experiencing adverse cardiovascular events, i.e. acute MI. Based on the ACC/AHA guidelines, if the CAC score is < 75 percentile then patient can be treated with a low to moderate dose statin. If the patient has a CAC score > 75 percentile, then a high dose statin is recommended. If the patient needs high dose statin therapy but he/she cannot tolerate it secondary to side effects, we could try PCSK-9, but this would have to be discussed with the patient in Cardiology Clinic. As you may be aware, Dr. Tsimikas is our expert in lipid disorders.

Thank you for the eConsult.

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Help the Specialist to Help You
 
In order to respond to clinical questions electronically, specialists depend upon their primary care colleagues providing important data as requested in the eConsult templates. Please remember that --
  • When requesting review of an EKG tracing, please confirm the EKG is accessible in Epic PRIOR to ordering an eConsult
  • When requesting review of a radiologic study, please confirm the patient has completed the study PRIOR to ordering an eConsult
  • When requesting an eConsult where the answer hinges on lab test results, please confirm the results are available in Epic PRIOR to ordering an eConsult
  • When requesting a Dermatology eConsult regarding a puzzling rash or lesion, please confirm that photos are available in Epic PRIOR to placing an eConsult
Specialists can best answer eConsults in a timely manner when needed data is available at the time the chart is opened and reviewed.
 
Thanks for keeping the above in mind when ordering an eConsult.
 
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Exemplary eConsult:
Gastroenterology


PCP 'My Clinical Question':
I am requesting an eConsult from GI for my 23 yo female patient with chronic epigastric abdominal pain.

The pt describes her pain as a pressure sensation. She has had an extensive work-up in Northern Califronia as documented in my note, including multiple negative tests for H pylori, negative abdominal US, negative HIDA scan, negative abdominal/pelvic CT, and an EGD in 10/2015 with biopsies that just demonstrated mild gastritis.

My clinical question is: is there value to any additional work-up to consider such as small bowel overgrowth or a repeat endoscopy given the persistence of her symptoms before I label her as functional dyspepsia? I have referred her to integrative medicine to see if they can help her symptoms in a non-pharmacologic manner. Is there additional value of having her seen in GI Clinic if only for reassurance purposes?

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eConsultant
Denise Kalmaz, MD
Associate Professor of Medicine
Division of Gastroenterology

The patient is a 23 yo female with chronic epigastric abdominal pain/pressure for 3 years. Extensive prior work up (including EGD, CT, US, HIDA scan, H pylori testing and labs) all unrevealing. Diagnosis consistent with functional dyspepsia with early satiety/pain. Failed trial of PPI for one month. Does not want medication. Worried about family history of gastric cancer or that something is missed.
 
Patient should be reassured about the following:
- Extensive work up supports dyspepsia diagnosis
- EGD with gastric biopsies did not show intestinal metaplasia or H pylori which are main risk factors for gastric cancer
- CT abdomen did not show malignancy
- Gold standard testing for H pylori and celiac disease negative
- No biliary etiology on 2 tests
 
Recommendations:
- Reassurance as above
- Some patients with functional dyspepsia benefit from small, frequent meals (difficulty with gastric accomodation can lead to sensation of early satiety)
- Trial of over the counter FDgard - peppermint and caraway oil (natural and not a medication per patient preference)
- Trial of simethicone - safe and can take every 6 hours
- Avoid carbonated beverages (soda, beer) or chewing gum
- Avoid tight fitting clothes/bras
- Avoid NSAIDs - can take Tylenol as needed
- Recommend stress relief - meditation, yoga, exercise
- Go to MyGIHealth app to track symptoms and learn breathing techniques to help symptoms

If the patient remains worried or does not improve, can refer to GI clinic.

Thank you for the eConsult.

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Hot off the press ...

... 
some of the best and brightest eConsults for your reading pleasure! Nine academic medical centers from around the country contributed to this excellent resource. A significant number of eConsults in this collection were written by UCSD specialists.

If you are interested in obtaining a copy, on sale for $5, contact us at eConsults@ucsd.edu.
 
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Exemplary eConsult:
Neurology


PCP 'My Clinical Question':
I am requesting an eConsult from Neurology for my 54yo male patient with visual hallucinations.

The patient reports that when he is in a dark room, he sees a brightly colored tapestry with lights. First episode was two weeks ago. He has experienced this ~3 times per week, the most recent being last night.
He is uncertain how long the visual hallucination lasts because he falls sleep

New medication was bupropion, which he had been on for one month prior to first episode. He has been off this medication for 11 days and still had an episode yesterday.

No associated symptoms such as headache, numbness or tingling that is worse from baseline, no abnormal body movements.

Any input on possible diagnosis and/or recommended evaluation is appreciated.
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eConsultant
Revere (Rip) Kinkel, MD
Professor of Neurosciences


The question relates to new onset visual hallucinations at night in a 54yo patient with history of depression, peripheral neuropathy, chronic back pain, alcohol dependence, and Vit D and B12 deficiencies. Formed visual hallucinations in the dark that the patient recognizes as not real are referred to as Charles Bonnet syndrome. While typically seen in the elderly (even during daytime if vision is poor), this man appears to have enough risk factors and prior illnesses to qualify for this diagnosis
 
This does not sound like seizures. I would provide reassurance and make sure his vision is checked.
 
Further neurological evaluation is warranted if episodes occur during daylight or in a lighted setting with eyes open. Most occipital seizures are not well formed images but this can occur with temporal seizures

Thank you for the eConsult.

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Coming Soon: Infectious Diseases






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