A 49-Year-Old Woman Presenting With Cavitary Lung Lesions: A Case Report.

Granulomatosis with polyangiitis (GPA) can be a challenging diagnosis to confirm due to significant overlap with other small-vessel vasculitis syndromes and similar presentations to non-vasculitic processes such as infection or malignancy. We report a case of a 49-year-old woman presenting with several months of cough, chest wall pain, and weight loss, who was found to have several cavitary lung lesions on imaging, no renal involvement, and unusual anti-neutrophil cytoplasmic antibody (ANCA) serologies. After tissue biopsy, the patient was diagnosed with GPA and treated with steroids and rituximab with clinical improvement at follow-up. Due to a complex clinical course and non-classic symptomatology, her diagnosis of GPA was not discovered until several months after symptom onset. Clinicians should consider GPA in the case of progressive cavitary lung lesions even in the absence of renal involvement or positive ANCA serologies, as prompt tissue diagnosis is crucial to allow for early initiation of treatment.

A 60-Year-Old Man With Acute Chest Pain: A Common Presentation, But Unusual Diagnosis.

CASE PRESENTATION: A 60-year-old man with a history of COPD, uncontrolled diabetes (hemoglobin A1c, 10.6%), obesity (BMI, 33.4), and a family history of Ehlers-Danlos syndrome came to the ED with several hours of acute-onset severe left mid-axillary pleuritic chest pain without alleviating factors. The pain had no specific triggers, including activities or heavy meals. It was associated with nausea, chills, and diaphoresis; also, it was preceded by a few weeks of subacute flulike symptoms for which he did not seek medical attention. He denied previous similar symptoms, recent trauma, or surgeries.

Sweet and Salty: Diabetic Ketoacidosis in a Patient With Nephrogenic Diabetes Insipidus.

The co-existence of nephrogenic diabetes insipidus (NDI) with diabetes mellitus (DM) in a patient that presents in diabetic ketoacidosis (DKA) is rare and, to our knowledge, has not been described even in case reports. We report the case of a 16-year-old male with known NDI who presented to the pediatric emergency department (ED) for one day with generalized weakness and decreased appetite, found to be in moderate DKA from new-onset DM. The initial management of his dehydration and hyperosmolar state presented a unique challenge. Fluid resuscitation with isotonic fluids in a patient with NDI poses a risk of worsening hypernatremia, which can lead to seizures and death. However, the use of hypotonic fluids has the potential to lower serum osmolality too quickly, which can result in cerebral edema. Nephrology, endocrinology, and the pediatric intensive care unit (PICU) consultants were notified of this patient, and a discussion was coordinated between sub-specialists to determine the appropriate fluid resuscitation. The patient was allowed to drink free water in addition to receiving intravenous fluids (IVF) of dextrose 5% with 0.2% sodium chloride at a rate of one-and-a-half maintenance (150 mL/hr) in the ED prior to transfer to the PICU where insulin infusion was initiated. This case report provides guidance to inpatient providers on the management of patients with co-existent NDI and DM in DKA, a rare combination that requires thoughtful and urgent management.

The Spiritual Works of Mercy as a Tool to Prevent Burnout in Medical Trainees.

Burnout is highly prevalent among physicians and is associated with negative patient outcomes. Furthermore, medical training is a particularly vulnerable time as studies show that medical students, residents, and fellows experience burnout and emotional exhaustion at higher rates than both the general population and physicians in practice. Multiple recent studies have demonstrated the practice of religion and spirituality to be protective against burnout in trainees. Can Catholic academic physicians transfer these protective benefits of religion and spirituality to their trainees, who are at the highest risk, and who may or may not share their faith? An ancient Catholic tradition, the Seven Spiritual Works of Mercy, may hold the key. The Spiritual Works of Mercy are listed by the US Conference of Catholic Bishops as Counseling the Doubtful, Instructing the Ignorant, Admonishing the Sinner, Comforting the Sorrowful, Forgiving Injuries, Bearing Wrongs Patiently, and Praying for the Living and the Dead. Using this as a framework, examples of evidenced-based actions from the literature that have been shown to either prevent burnout or to improve the day-to-day experience of medical trainees were discussed. Examples include encouraging trainees to express doubts or to debrief after difficult and saddening cases. Academic physicians can provide instruction, feedback, or admonishment; demonstrate forgiveness of errors; and model the way in bearing wrongs patiently, all while uplifting their trainees in prayer. The Spiritual Works of Mercy can thus become a framework for academic physicians to uplift their trainees' spirits and potentially prevent against burnout. SUMMARY: Burnout is highly prevalent in medical students and in doctors during their residency or fellowship training, but multiple studies have shown regular practice of religion and spirituality to be protective against burnout. The Seven Spiritual Works of Mercy (Counsel the Doubtful, Instruct the Ignorant, Admonish the Sinner, Comfort the Sorrowful, Forgive All Injuries, Bear Wrongs Patiently and Pray for the Living and the Dead) provide a framework of powerful examples for teaching physicians, particularly Catholic teaching physicians, to uplift their students and potentially transfer this benefit to reduce their students' risk for burnout.