Pearls from 3/16/21 Medicine LEADS

The March 16, 2021 session of Duke Medicine LEADS featured a discussion led by George Sipa Yankey Jr., MD, "Altered Mental Status...Oh No!"

Panelist included, Anna Lisa Crowley, MD, Dorlan Kimbrough, MD, and Andrew Vekstein, MD, who weighed in for the diagnostic reasoning discussion.

In this session, we learned from a patient who presented with fever and altered mental status 2 months after he underwent an AFib ablation and was found to have an atrioesophageal fistula. Here are pearls and takeaways: 

  1. The differential for altered mental status is broad but focusing on the differentiating characteristics (severity, duration, affected cognitive domains, and lateralizing/localizing features) can help narrow the differential. 
  2. AFib ablations can lead to several complications including vagus nerve injury and gastroparesis, atrioesophageal fistula, esophageal perforation, and pericardial effusion/cardiac tamponade.
  3. Atrioesophageal fistulas are very rare (incidence of ~1/2500) but have a high mortality rate (anywhere from 33-100% mortality). An interdisciplinary approach is important to consider possible options for these patients. 
  4. Intracardiac masses can represent a variety of things, not just infective vegetation. This includes things like myxomas, sarcomas, lipomas, thrombus, metastases, etc. 
  5. Personally reviewing imaging studies that the patient undergoes, particularly with clinical context, can help uncover findings that may have been previously overlooked.
  6. When a patient repeatedly presents to medical attention with the same complaint, it is important to broaden our differential and truly take heed of what the patient is saying bearing in mind that most people don't want to be returning to the hospital again and again unless they have something truly bothering them. It is our responsibility to uncover what this is.

This session was not recorded.

Duke Medicine Learning, Education, and Discussion Series (LEADS) takes place each Tuesday at 12 p.m. Learn more and see schedule of upcoming sessions.