UCSD eConsult Newsletter
Vol. 3, No. 1
June 2016








Happy Anniversary!

The UCSD eConsult Project officially celebrates its two-year anniversary this month. Shared below are some of the greetings and well wishes we have received, along with ideas for future direction:
This program has exceeded our own optimistic expectations. It has been especially helpful to patients, by keeping their care with their PCPs and eliminating the need for many specialty visits. --  Lawrence Friedman, MD
The program has benefited both primary care and specialty faculty. The introduction of subject templates has greatly improved the quality and effectiveness of specialty visits. --  Angela Scioscia, MD
Congrats on the 2-year anniversary! The eConsult service has opened another avenue of communication between PCPs and specialists, leading to improved physician interaction and patient care.  --  Dan Crouch, MD
A well executed eConsult will often make it unnecessary for the patient to be seen in the specialty clinic. For benign Hematology, that's a huge 'plus' because of our long wait times.--  John Adamson,  MD
As a dermatologist, I enjoy doing eConsults. Hopefully, this service will lessen the number of patients needing to be seen in Derm Clinic, thereby improving our overall access. --  Daniel Synkowski, MD
eConsults have lessened patient wait times, reduced unnecessary referrals, and improved collaborative efforts amongst providers. Hope to see all specialties utilizing eConsults in the future. --  Sonya Ahmed, MD
eConsults are a great idea; we hope to see more Ortho/Hand questions in the future. Sprains, non-displaced fractures, and many other nonoperative conditions could efficiently be addressed by PCPs with our electronic input as needed. --  Reid Abrams, MD
I think any urgent consult should begin as an eConsult. This is a way to get the patient to the correct doctor quickly and facilitate any necessary testing while the patient waits to be seen. --  Rip Kinkel, MD

We look forward to the next year of the Project, with more specialties and more enhancements planned.

Exemplary eConsult:

PCP 'My Clinical Question':
I am requesting an eConsult from Urology for my 63yo male patient regarding lack of ejaculate.

The patient has a history of vasectomy. He was started on Flomax two years ago for BPH symptoms. After a few weeks on this medication, he could no longer ejaculate. He denies urinary discomfort or urgency. There is no evidence of ejaculate in urine after attempted ejaculation. He has continued on Flomax. We started him on finasteride, which has improved his BPH symptoms significantly (AUA score of 22, now down to 11); however, he continues to be incapable of complete ejaculation.

Could this be a medication side effect? Related to his vasectomy history? Given that this is his only symptom, is any other workup indicated?

Roger  Sur, MD
Director - UCSD Comprehensive Kidney Stone Center

Although the patient doesn't sense that he has semen in his urine, he is clearly having retrograde ejaculation from Flomax. All alpha blockers have this side effect (anectodally almost 99%). Patients will not know or feel it but the absence of visible ejaculate makes the diagnosis. Since there is no need for fertility in this patient, I would simply give reassurance.

Thank you for the eConsult.

Clinical Pearl: Is it fatty liver or something more?  Increased echogenicity of the liver on U/S usually means either fatty infiltration or fibrosis or both. In the absence of a liver biopsy, fatty liver disease is a diagnosis of exclusion. If fatty liver is suspected in a patient with elevated aminotransferases and increased echogenicity of the liver on U/S, management focuses of stopping all alcohol and controlling the 4 known risk factors: central obesity, diabetes mellitus, hypertriglyceridemia, and hypertension. If appropriate, I generally recommend dietary and lifestyle modification for 6 months. If the liver enzymes remain elevated, I would then recommend referring to Liver Clinic for possible biopsy to rule out NAFLD vs non-alcoholic steatohepatitis.
-- from an eConsult by Alex Kuo, MD,
 Division of Hepatology

Onward and upward ...
Take a look at the bar graph below, to get a sense of how the eConsult Project continues to grow.
[Click on image to enlarge]
Exemplary eConsult:

PCP 'My Clinical Question':
I am requesting an eConsult from Otolaryngology for my 51yo female patient w/an oral cavity lesion.

The pt noticed 2 new lesions on the floor of her mouth several weeks ago. She is asymptomatic. She has never smoked. On exam, the lesions feel bony. No noted ulceration or fluctuance.I suspect these are normal anatomic variants. Any cause for concern?


Sapideh Gilani, MD
Assistant Professor of Surgery
Division of Otolaryngology

I have reviewed the picture.  She has a torus of the mandible, also known as torus mandibularis.  

I typically point out this finding to patients and discuss the benign nature of these lumps on the floor of the mouth. If the torus becomes irritated, then the area can be surgically addressed.  Since your patient does not have any symptoms related to the torus, no intervention would be needed.

Thank you for the eConsult.

Exemplary eConsult:

PCP 'My Clinical Question':
I am requesting an eConsult from Hematology for my 51yo male patient regarding his longstanding IVC filter.

The pt had an IVC filter placed prophylactically in 2004 due to prolonged immobility following hip replacement surgery and osteomyelitis. He has no history of DVT. The IVC filter currently remains in place. My question relates to long term management of the filter. Any need for re-imaging? The patient is currently taking ASA 81 mg daily.

Rafael Bejar, MD, PhD
Assistant Professor of Medicine
Division of Hematology-Oncology

This pt is a 41 year-old man with a medical history notable for Type I diabetes, chronic hip pain, and prior prophylactic IVC filter placement. The filter was placed in 2004. Without anticoagulation, no DVT's have been reported since then. The patient does not have any currently known risk factor for thrombosis. He and his PCP inquire about ongoing management of the IVC filter.

Approximately one third of IVC filters will occlude after 9 years. This is often associated with lower extremity edema, and unfortunately, anticoagulation does not necessarily prevent this complication. Patients with IVC filters are at increased risk of developing a DVT even in the absence of IVC filter occlusion. Should a patient develop a DVT (or acquire a significant clotting risk), life long anti-coagulation should be considered. In addition, IVC filters can migrate or fracture over time. If no imaging has been done recently, AP and lateral abdominal films could be performed to evaluate the device. If edema is present and the patient is thin, ultrasound imaging of the IVC could be performed to look for occlusion or limitation of blood flow, otherwise CT scanning may be better.

There is no data evaluating daily aspirin use to prevent DVT in the setting of an IVC filter, but this is reasonable to continue given its relatively low risk and potential other benefits in this diabetic patient. Please let me know if you have additional questions.

Thank you for the eConsult.

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