Simplicity in Complexity - Clinical Reasoning VMR

I. URTI in asthmatics: can be complicated by asthma exacerbation or, a secondary superadded bacterial infection (so, sometimes in a visibly sick patient with viral pneumonia, more harm in not giving antibiotics) Pleuritic chest pain: may be explained by viral pleurisy as well. II. Hyperferritinemia: ?Anemia of chronic disease; ?MAS III. Right hilar “mass”: Malignancy (symptoms of dysfunction from its spread) - Lung cancer, Lymphoma - biopsy (definitive) Invasive infections (mostly atypicals - activates immune system in a way causing fibrosis) - Mycobacteria, endemic mycoses (Coccidioidomycosis, Blastomycosis, Actinomycosis) - and can invade tissues from there. - Ask who the patient is - immune status/ exposures? Inflammatory - eg: Sarcoidosis IV. Histiocytic disorders : rare and tricky; first-rule out infection in this patient; Some of the disorders are – Reactive histiocytosis or Langerhans cell histiocytosis - not much mass-forming; other two more mass-forming histiocytic ds are- Erdheim Chester disease: long bone involvement - look for signal outside the lungs; Rosai Dorfman disease; another possibility Histiocytic sarcoma -biopsy and special stains; To differentiate reactive from primary- look for sheets of histiocytic cells; and look for special stains. V. Why PE without overt risk factors? - true thrombus (hypercoagulability/malignancy) vs external compression VI. Multiple myeloma: cancer of plasma cells; measured kidney function from UA, UPCR, UACR; not just creatinine (no gamma gap/ hyperCa) - signals: ESR 140, anemia of chronic disease - final: extramedullary MM