Dissecting Connections with Kirtan Patolia

We take a deep dive into the way learners and educators make connections between clinical concepts to better understand the clinical reasoning process.

Welcome! Tell us a bit about yourself.

Hello, my name is Kirtan Patolia. I am a final-year medical student from B.J. Medical College, Ahmedabad, India. I am looking forward to pursuing my future residency in Internal Medicine in the USA by applying through this year’s Match cycle.

As for my interests, I have always been fascinated by the art of clinical reasoning. That’s why since my second year of med school, I have spent extensive time on studying various cases from medical journals to gain insights on how theoretical knowledge translates to real-world problem-solving. I also absolutely love reading vintage medicine books like Harrison’s and Nelson’s. It’s like reading a novel, everything is so lucid and pleasant that time just flies by.

Germ cell tumors can secrete hCG and even cause amenorrhea by infiltrating the pituitary (hypogonadism) causing a classic script for false-positive pregnancy.

Mediastinal germ cell tumors can cause SVC obstruction leading to positive Pemberton’s sign (arm elevation–> facial plethora)

Mediastinal germ cell tumors increase the risk for Acute leukemias (leukocytosis), especially megakaryoblastic types. Can also elevate JVP due to SVC.

Can cause PTHrP mediated humoral hypercalcemia of malignancy!

See Kirtan’s Twitter post for more details.

When you first saw these cards, what was your approach to creating your teaching points?

When I first saw the cards, I was wondering about Occam’s Razor, in that simplest explanation is the best one and there has to be an entity that can explain everything.  So for my first connection, I focused on making the connection between hCG and the rest of the cards. I tried to think about possible reasons for elevated hCG levels. And I realized that certain tumors can secrete hCG, AFP, and so on.

Once I figured that, the rest of the connections were easy as we know that germ cell tumors can cause infiltration of various structures including the pituitary gland, hypothalamus, meninges (carcinomatous meningitis), brain parenchyma (mimics neurosarcoidosis and gliomatosis cerebri), mediastinum causing SVC and numerous other manifestations. I learned most of this during my second and third year of med school from case reports. 

Why did you choose these particular connections?

I didn’t do that because it was exquisitely rare and difficult. I chose that because the potential consequences of misdiagnosing germ cell tumors can have profound consequences. For instance, pituitary germ cell tumors can cause hypogonadotropic hypogonadism by lowering the FSH and LH levels leading to amenorrhea, whose standard workup will begin with the pregnancy test. Since tumor cells will secrete lots of hCG causing false-positive pregnancy tests, everything will be attributed to the pregnancy test without investigating further. Similarly, intracranial features of germ cell tumors can mimic neuro-inflammatory disorders radiologically and clinically leading to inappropriate treatment.

How long did it take you to come up with the connections?

It took around 15-20 minutes to make these connections. After that, I reviewed a few articles for another 5 minutes or so to ensure that what I had in my mind was indeed true and has been documented before. I am sharing the links for necessary articles and references below.

Interview by Paulius Mui, MD

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