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UCSD eConsult Newsletter
Vol. 3 No. 3
Jan 2017


















 



















































 









 


























































 







 





































































 
Wishing everyone health and happiness for the coming year. And, an abundance of erudite and beautiful eConsults in their Inbox!

Enjoy the latest Exemplary eConsults below --

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Exemplary eConsult:
Otolaryngology


PCP 'My Clinical Question': 
I am requesting an eConsult from Cardiology for my 46 yo male pt w/tinnitus. This has been an ongoing problem for 18+ months. Any suggestions regarding further evaluation and/or management?
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eConsultant
Sapideh Gilani, MD, FACS
Associate Professor of Surgery
Division of Otolaryngology



I have reviewed the patient's chart and note that he has a history of bruxism. Prior to his recent visit, he was also seen in June 2015 for headache and tinnitus. 

For tinnitus, I typically counsel the patient about the condition. We discuss associations with tinnitus including an initial upper respiratory infection, hearing loss, and noise exposure. I discuss the relationship between NSAIDs, stress, alcohol use, TMJ arthralgia, and worsening tinnitus. We also discuss monitoring for potential triggers of tinnitus such as certain foods, caffeine, and stress. We discuss initial conservative management for tinnitus which include white noise, loud noise avoidance, and evaluation of hearing, which I see has already been arranged. We discuss other treatment options for tinnitus, including medical treatments which are less well proven and have associated medical side effects. 

Given the chart history of TMJ disorder I would recommend that the patient wear a mouthpiece at night which can be bought from the helmet section of the sports store. Dip the mouthpiece in hot water then bite onto the mouthpiece so that it fits the teeth nicely. Using the mouthpiece at night will help decrease the stress on the temporomandibular joint when grinding the teeth while sleeping. For heat, fill a water bottle with warm water and leave it up against the joint. Massage the masseter and temporalis muscles. Avoid chewy foods such as gum. Avoid hard to chew foods such as carrots and avoid chewy meat until the inflammation has subsided, which will help with tinnitus in patients with a history of TMJ disorder.

Thank you for the eConsult.

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Welcomed words ...
 
After receiving an eConsult response, a PGY-3 resident physician replied with a short message back to the specialist:

Hi Dr. Choe,
Thank you so much for completing this e-Consult.  I very much appreciate your insight.


Specialists appreciate knowing their response was received and was helpful. PCPs are encouraged to send a return message. 'Got it,' 'thanks,' and 'much appreciated' are always welcomed.

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Exemplary eConsult:
Renal


PCP 'My Clinical Question':
I am requesting an eConsult from Renal for my 80 yo female patient regarding biphosphanate use with CKD. She is not currently taking NSAIDs.

This patient has CKD Stage 3 (based on a creatinine of 1.11 and GFR of 47). Is this CKD from renovascular disease / chronic HTN or is there a secondary etiology? Also, any recommendations for medication optimization? We are trying to find a bisphosphonate she might be able to use for her severe osteoporosis but her CrCl is nearly an absolute contraindication at this time.  

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eConsultant
Scott Mullaney, MD
Professor of Clinical Medicine
Clinical Service Chief of Nephrology
 

It is difficult to diagnose this 80yo patient as having chronic kidney disease as opposed to age related changes to her renal function. She has had hypertension but no proteinuria at least since 2013 when our labs start. Her GFR is likely 35 - 45ish.

I would not be too concerned about her renal function and the risk of any progression. Her creatinine has been stable X 3 years. The question of a safe bisphosphonate is an interesting one.

From studies:

Risedronate and alendronate appear to have (+) impact on BMD and vertebral fractures without increase serious risks in those with GFR>30.

Zoledronic acid - HORIZON used GFR 30 cut off.

Currently contraindicated If GFR<35.

Ibandronate - very little data in chronic kidney disease of this level

Denosumab - not renally cleared but can cause drop in calcium. 

So for her, if you can get it, maybe try denosumab and watch the serum calcium closely. General recommendations for patients with eGFR <30 would be to monitor serum calcium, phosphorus, 25-OH Vitamin D, and PTH every four months and after denosumab administration check calcium ~1 week later. For those w/GFR of 30 - 45 range would treat similar to those without chronic kidney disease but with closer monitoring, particularly calcium and phosphorus.

Thank you for the eConsult.

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eConsults are NOT...

Please remember: eConsult requests are being fielded by senior-level faculty who are sharing their time and expertise. Please do not order an eConsult to -
  • request an earlier appointment in the specialty clinic
  • ask a logistical question ('where can my patient get X?')
  • ask a question that could readily be answered by consulting a textbook or clinical guideline
The good news is that the vast majority of eConsult requests continue to be appropriate low-complexity questions that specialists can answer with the information available in the medical record.
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Exemplary eConsult:
Orthopedics


PCP 'My Clinical Question':
I am requesting an eConsult from Orthopedics for my 35 yo female patient with a non-displaced foot fracture.

This patient has a 3rd metatarsal shaft oblique fracture, sustained when (accidentally) kicking a stool one week ago.  Pain is tolerable. However, she has limited active and passive plantarflexion at the PIP joint. I am wondering if fracture is mechanically inhibiting flexion. Does she need surgical evaluation?
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eConsultant
Alexandra Schwartz, MD
Chief of Orthopedic Trauma
Department of Orthopaedic Surgery
 

I reviewed the recent Progress Note and images from 12/29/16. Xrays consistent with minimally displaced proximal phalanx fracture.

Patient is concerned regarding decreased ROM.

At this time, limited ROM is common due to acute fracture DOI 12/20/16. Very unlikely tendon involved based on mechanism and no open wounds.

Recommend weight bearing as tolerated in supportive/ comfortable shoe or can obtain post op shoe from cast room at Hillcrest (order 'Ortho Cast Room' in Epic and call 619 543-2876). Ice and elevate as needed for pain/ swelling. Patient should be advised swelling can take months to resolve and months for ROM to return. May do following exercises:



 

Follow up xrays in 6-8 weeks if painful. 

Thank you for the eConsult.

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