Interesting Cases Abound at Baptist North Mississippi
Posted by [email protected] on May. 13, 2021 / Subscribe 0
By DAVE DUDDLESTON, MD
Core Faculty
Internal Medicine Residency | Baptist North Mississippi
What kind of patients do we get in Oxford?
We have a rich variety of patients and pathology here, partly because we have become a regional referral center from facilities from eastern Arkansas, western Tennessee and north Mississippi. Based on our population draw of almost 2 million people within a 120 mile radius (excluding Memphis), one could expect a lot of variety. I will highlight a couple of patients from just my last rotation here.
A middle aged female presented with symptoms of pyelonephritis. She was quite ill, with a temp of 101, BP 100/58 and pulse of 120. Complicating this was a sodium of 117 and a potassium of 2.1, related to her history of Gitelman syndrome. Interestingly, she had been well controlled with diet and a combination of triamterene and hydrochlorothiazide, although her potassium never gets above 3.0. She also had a history of chronically low blood pressure and frequent headaches. Although she grew E. coli in her blood cultures, her pyelonephritis improved with usual care. Her magnesium was normal and she required large amounts of potassium to get her level to a whopping 3.1 at discharge. Her sodium came up with saline hydration alone. We entertained changing her Gitelman management but elected to keep her on her usual medication under guidance of her excellent local internist. We did recommend consideration of adding an NSAID or a low dose of ACE inhibitor to preserve her potassium. For her headaches, we recommended cessation of all pain relievers +/- a headache blocker such as amitriptyline since she likely has “rebound headaches.” This can be a tough sale for someone who hurts, but we pointed out that her analgesics don't really work for her anyway – worth a try and the literature suggests an 80% improvement rate with this strategy.
To quote Dave Barry, “I'm not making this up,” a second patient on my hospitalist team was a 52-year-old male with Type II diabetes and only fair control of his diabetes for several years until 6 months prior to admission, when it miraculously improved. He then went into hypoglycemic episodes and his treatment was stopped. He continued to have hypoglycemia and his A1c dropped from 9.3 to 5.7. He had a history of significant mental illness. An exhaustive workup ensued over a few hospitalizations. Insulinoma was suspected but no tumor was found on special imaging. Utilizing an extensive chart review in Epic, a matrix was developed and showed that all other diagnoses, including factitious insulin use, were ruled out. During cross-reading in UpToDate, it was noted that multiple, tiny insulinomas can occur in MEN I. We queried the patient regarding a family history of related tumors and it turned out that his father had had a parathyroid tumor removed in the past. We believed his insulinoma represents MEN I and he has been referred to endocrinology at Vanderbilt for further assessment. This author has diagnosed only one other case of insulinoma in a 30-year career and has a home video of that case (chief complaint: “He's scaring the children”).
These are punctuations in the usual care of pneumonia, unstable angina, stroke, COVID-19, cellulitis and the myriad other disorders that occur in our practice. Like the grammatical symbol, they add excitement to the tapestry of life in our care of individuals here in Oxford.
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