This week in Morning Report, we debuted Rapid Fire Rounds — a quick overview of 10 different cases seen on a busy day in AACU. The goal of these rounds was to get you to think about how you would approach a differential diagnosis/management/follow up plan for each of these patients, and to learn a few high-yield pearls and approaches.

My favourite aspect of Internal Medicine is the incredible diversity of patient presentations and referrals. The cases we discussed spanned the gamut from bread-and-butter (hypertension management) to more complex conditions (hyperferritinemia NYD, isolated hepatomegaly), and involved nearly every medical subspecialty. Ambulatory medicine in particular challenges you to be comprehensive, but also a good steward of resources at the same time — in other words, this is a great setting in which to practice your Leader and Manager skills!

Let’s recap some pearls we learned from this Morning Report!

1. Inter-provider and inter-disciplinary communication is a hugely important and underappreciated competency

What do CTU attendings and seniors do all day?! I remember wondering this often as a PGY1, because there’s so much behind-the-scenes work that is invisible: emailing subspecialists, calling family doctors, carefully reviewing past ConnectingON charts, ensuring that pathology didn’t fall through the cracks, setting up appropriate follow up plans. These managerial and communication skills are difficult to learn in junior years because you’re constantly rotating between teams, services, rotations, and hospitals. You’ll spend plenty of time doing this as CTU Seniors, but ambulatory medicine is a particularly ripe environment in which to practice these skills. Here are a few tips I’ve picked up over the years:

• When filling in PMHx (or Discharge Summaries), try to identify by name the specific consultant who saw the patient or follows the patient (e.g., saw her gastroenterologist, Dr. John Doe). This is very helpful for other providers reading your notes.
• When creating follow up plans with family doctors, make the action plan clear, succinct, and as detailed as possible (family docs are busy!). For example, rather than ‘have routine CBCs monitored via family doctor’, it is more useful to write ‘have CBC checked q3months as per XYZ guidelines’.
• Always address family doctors by name in your notes (e.g., I find ‘family doctor to follow CBCs’ not ideal — prefer ‘Will request Dr. Jane Doe to please follow CBCs q3 months’)
• If patients are followed by long-term subspecialists (e.g., nephrologists), don’t hesitate to email them (give your staff a heads up) to clarify details, give them a heads-up on follow up, or keep them informed of new events. This is particularly important in the era of COVID when services may be running largely virtually or at decreased capacity. I have often come away with lots of insights into patients’ care plans (and picked up clinical pearls) from very kind attendings over email! The same is true for family doctors (email them or pick up the phone!)

2. Hypertension Pearls (Cardiology/Nephrology)

• Check out this previous CMR blog post on an Approach to Secondary Hypertension (hint: very high-yield for Royal College exams and for real life!)
• We briefly mentioned the CREOLE Trial: Comparison of Dual Therapies for Lowering Blood Pressure in Black Africans. The bottom line: in black patients from Sub-Saharan Africa, Amlodipine + HCTZ or Perindopril > Perindopril + HCTZ. Much more to be discussed re: methods and generalizability — we will be discussing this at an upcoming Journal Club, so stay tuned!
• Recognize that hypertension in black patients has very different incidence and rate of complications than other patient populations, both for reasons of physiology and due to social determinants of health. The AHA 2017 Guidelines on hypertension address the need for special attention to this patient subgroup.

3. Edema pearls (Cardiology/Nephrology/GIM)

• Check out this previous CMR blog post on an Approach to Edema. I’ve also updated this in our Royal College Scenario Prep slides from earlier this block, also summarized below.

4. Hepatomegaly pearls

• We discussed a brief approach to isolated hepatomegaly, organized into ‘buckets’. An easy way to think of this is to think of all the ways in which the liver can be enlarged (fluid backing up, acute inflammation, stuff depositing into the liver, etc.). I’ve summarized our approach below.

5. Adrenal incidentaloma pearls

• Another very high yield Royal College exam (and real life) topic! With any adrenal incidentaloma, ask yourself 2 questions: Is it malignant? Is it functioning?
• There is a fantastic new review by Sherlock et al. in Endocrine Reviews on approach to adrenal incidentaloma. I especially like their summary graphic, below.

I hope you enjoyed this Rapid Fire Morning Report!