Today we talked about a case of community-acquired pneumonia, and we spent some time delving into the common organisms that lead to pneumonia, including those that cause typical vs atypical picture, and those that cause a hospital or ventilator-acquired picture. We also discussed common viral and fungal etiologies of pneumonia.
We then broke out into groups to discuss treatment regimens for patients in both the outpatient and inpatient setting, and for those with and without Pseudomonas and MRSA risk-factors.
Today at DOM Grand Rouns, former UCSD resident and heme/onc fellow now BMT attending Dr. Tiffany Tanaka presented the newest updates on AML therapies and staging. She discussed the various new drugs that were developed since 2010 and AML patients now have many more options on top of the traditional 7+3 (7 days of cytarabine and 3 days of anthracycline) chemo backbone that has been the staple for AML treatment for 40+ years. She specifically highlighted that a combination regimen of hypomethylating agent + venetoclax as being transformative and potentially beneficial for all sorts of patients. She also stressed the importance of assessing for genetic mutation to help determine AML staging. Thanks to Dr. Tanaka for this super interesting talk!
Today, we started our Wednesday School with heart failure attending Dr. Hilary Shapiro who gave our senior residents a fantastic talk on managing heart failure in the outpatient setting. She discussed a few practical tips on getting patients on guideline-directed medical therapy (ACEi/ARB/ARNi, beta blockers, MRAs, and SGLT2i) and how to titrate the dose appropriately. Our seniors had a few interesting questions on heart transplant patients! Next, one of our core faculty and cardiologist Dr. Luis Castellanos talked to us about valvular heart disease focusing on pathologies involving the mitral and aortic valves and management pearls of these diseases. We then had atherosclerosis expert Dr. Mike Wilkinson give us a review on lipid management where he discussed the various lipid treatment options in addition to statins including ezetimibe, PCSK9 inhibitor, bempedoic acid, and inclisiran. We finished our morning with an interactive EQIPs session with Dr. Greg Seymann.
Today we talked about a patient recently admitted with abdominal and lower extremity edema, found to have nephrotic range proteinuria, hypoalbuminemia and hypercholesterolemia! We then went into specifics about 5 conditions that we commonly see cause nephrotic syndrome, including: Minimal Change Disease, Focal Segmental Glomerular Sclerosis, Membranous Nephropathy, Diabetic Nephropathy, and Amyloid Nephropathy.
We broke up into groups to talk about the biopsy findings, associated conditions, and treatment of each of these specific syndromes. Our patient was ultimately diagnosed with Minimal Change Disease, and underwent a steroid taper which she responded well to!
Today at the VA our noon teaching conference was all about feedback! We learned about the difference between a growth mindset and a fixed mindset. We also learned how to frame feedback within the growth mindset. Take those seeds of feedback and grow your garden of skills. We also went through the importance of not only giving growth feedback but also fertilizer (aka positive) feedback to keep the garden you’ve grown healthy and strong. We learned about different feedback methods like ask,tell,ask and keep, start, stop. We then practiced these feedback methods with feedback bingo! Team 2 gave each other amazing feedback and were our bingo winners and were able to take home their own succulents!
Today we discussed a case of a 64 yo woman recently admitted with a one year history of fatigue, weakness and dizziness. She was found to be pancytopenic with a Hgb of 4.6, Plt 13 and WBC 1.4. We then walked through examples of diagnostic schema for pancytopenia, and used that to help us identify what tests we wanted to order for this patient.
One example of a schema is to split pancytopenia into a problem with the bone marrow vs a problem with the periphery. Bone marrow issues that lead to pancytopenia include decreased production (which can be caused by B12/folate deficiency, exposure to medications or toxins, MDS or aplastic anemia, and other autoimmune issues) and infiltrative processes (malignant or fibrotic vs infectious). Peripheral processes include increased destruction (ex. DIC) vs splenic sequestration (portal htn, cirrhosis, infection, malignancy).
We then worked as a team to figure out how to sign this patient out to our night team!
This month, for our September Clinical Reasoning Conference we were joined by our incredible diagnosticians Dr. Lizzy Hastie and Dr. Ben Hulley at the VA (left) and Dr. Janice Park and Dr. Cameron McGuire at Hillcrest (right) as we reasoned through the case of a 19-year-old female who presented with abdominal pain. We were excited to learn their diagnostic approaches to abdominal pain as they reasoned through the case together.
Our patient had no comorbidities, no history of liver disease or tangible risk factors for liver disease and presented with acute hepatitis and preserved liver function. Her symptoms, age, and enzyme profile favored a viral etiology and after extensive workup she was found to have CMV hepatitis! Of course, our diagnosticians had this entity high on their differential before her CMV PCR came back at 4150. While CMV hepatitis typically affects patients with compromised immune systems, this case in an immunocompetent host was an important reminder that CMV can cause a self-limiting mononucleosis-like syndrome in any patient! Thanks for an incredible case and to our amazing diagnosticians for sharing their clinical reasoning skills with us!
Today at DOM Ground Rounds, our world class heart failure and cardiomyopathy specialist Dr. Eric Adler gave a super interesting talk on Precision Medicine for Cardiovascular Care. He introduced genetic cardiomyopathies as a subset of rare diseases with unmet needs for therapy. He then shared his work on Danon Disease, a genetic disorder with mutation in the LAMP2 gene causing defect in the autophagy and phagolysosome pathway resulting in hypertrophic cardiomyopathy and other issues. An adenovirus-based gene therapy that helps restore LAMP2 gene function has shown promising results in an early Phase I trial and is in the process of moving on to Phase II trial. Thanks to Dr. Adler for this great presentation!
This morning, we started with a few SHOCKING cases led by former UCSD resident, cardiology fellow and chief fellow, now attending cardiologist Dr. Pre Bhatia as she went through the diagnostic and initial management pearls of cardiogenic shock. Keep a high index of suspicion and treat patients with suspected cardiogenic shock aggressively upfront. We then had Dr. Nick Phreaner (also former UCSD cardiology fellow and chief fellow!) gave us a super high-yield talk on the full spectrum of ischemic heart disease, starting with clarifying the different types of myocardial inFarction (MI) vs myocardil inJury. We then went through interactive cases where our residents worked on the initial diagnosis and management of ACS. Dr. Phreaner then moved on to talk us through diagnosing stable coronary disease and how to choose between different stress tests, then finished the session with medical management of stable CAD. We finished our morning with another great EQIPs session.
Today, one of our amazing PGY-1’s, Dr. Miguel Woodham, presented a case of a patient recently admitted to the medicine service with altered mental status, abdominal pain and a new O2 requirement, and a notable history of cirrhosis, recent SBO s/p ex lap and COPD. We talked about the differential for her encephalopathy which included infection and hepatic encephalopathy.
We then went through the history for the patient together, along with physical exam findings and labs before delving into what we would like to do for the patient. We ended the case by practicing signing this patient out, coming up with what active issues and contingencies we felt were relevant to share with the night team!