AMY DA site - i can identify - Video 5


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    Primary care doctors are really the gatekeepers to this puzzle,
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    because they’re looking at the whole patient.
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    A primary care doctor should start thinking about cardiac amyloidosis,
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    AL amyloidosis, when they see signs of worsening heart failure,
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    worsening dyspnea on exertion,
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    worsening ascites and pedal edema,
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    along with signs of other organ involvement.
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    So, they will commonly see nephrotic syndrome— a lot of protein in the urine.
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    They will commonly see acquired Factor X deficiency.
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    They will see patients developing bruising under their eyes, so-called "raccoon eyes".
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    They will start noticing that a patient is getting light-headed when they stand up.
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    And then, they will start thinking about where to send the patient
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    and a lot of times they’ll refer the patient to a cardiologist or a nephrologist.
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    So, I think the primary care doctor actually is key to
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    an early diagnosis of cardiac amyloidosis
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    because they will be the first person to see this disease.
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    The other test that they might start doing is, you know,
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    looking for a plasma cell dyscrasia with serum-free light chains
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    and urine-free light chains, and things of that nature.
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    And, all of this can also be done in consultation with a haematologist.
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    But, the most important test, I think, for a primary care doctor to order
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    when somebody has worsening heart failure symptoms,
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    is an echocardiogram and an electrocardiogram, an ECG.
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    So, it is crucial that the primary care doctor considers
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    this diagnosis as an emergency
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    before organ dysfunction progresses and the organs fail.
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    The 75-year-old lady
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    who presented to primary care doctor with symptoms of
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    congestive heart failure with reduced exercise tolerance,
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    shortness of breath with exertion, and swelling of her legs.
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    The primary care doctor called me personally,
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    and asked what workup should be done, and I suggested her to get the
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    plasma cell dyscrasia markers done
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    and I would see her in my clinic.
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    The plasma cell dyscrasia markers were already obtained before
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    the patient came to my clinic,
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    and they were significantly abnormal; with elevated serum-free light chain levels,
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    as well as immunofixation, which was positive.
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    So, by the time the patient arrived in my clinic, which was three weeks later,
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    the patient already had the diagnosis of plasma cell dyscrasia
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    with infiltrative cardiomyopathy,
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    and I just needed to do an abdominal fat pad aspiration in my clinic
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    and subject it to Congo red staining, which came back as positive.
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    And, she has already begun treatment for her AL amyloidosis
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    within three weeks from her initial presentation.
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    So, this again speaks very highly of the primary care doctor,
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    who did not wait for the consult to go through electronic medical records,
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    to be seen by a doctor in cardiology, seen by a doctor in haematology,
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    seen by a doctor in echocardiography.
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    But, she took it upon herself to make the phone calls so that
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    her diagnosis was obtained in a timely fashion to
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    prevent further deterioration of her congestive heart failure and cardiac involvement.