8/5/22 Friday School

For EQIPS conference, we were joined by our amazing hospitalist Dr. Bill Frederick who led us through a thoughtful discussion on Palliative Care, Home/Facility Hospice and GIP Hospice. We reviewed the nuts and bolts of each service and how to navigate the fantastic resources available at UCSD for compassionate, end-of-life care. Thanks to Dr. Frederick for walking us through such an important topic!

We then learned about obesity management with Dr. Grunvald, medical director of the UCSD Advanced Weight Management program. We discussed the pathobiology of obesity and the amazing advances that medications have made over the years, including the recent NEJM study exploring tirzepatide in this population.

Our seniors then concluded the afternoon with a high yield session on pituitary pathology and hypogonadism with endocrinologist Dr. Jodi Nagelberg, with key takeaways including always obtaining a repeat AM testosterone for workup of hypogonadism, knowing which hormonal/elemental labs are most helpful and candidly discussing treatment options with our patients.

Meanwhile, our interns were charged up to learn about acid-base with our fantastic nephrology faculty Dr. Tyler Woodell. They worked through several cases in small groups and discovered that this often stress-inducing topic can be somewhat basic with the right fundamentals paired with practice! Thanks again to all of our amazing faculty and housestaff for a highly impactful and engaging Friday School!

8/5 Jacobs EBM conference

Today our fantastic resident Dr. James Miller available evidence for diagnostic evaluation by colonoscopy of patients fulfilling ROME criteria for IBS, with the outcome being change in diagnosis or discovery of alternative organic pathology after colonoscopy. There were few prospective clinical trials, however he looked at three articles which had varying ROME criteria depending on year of publication. Interestingly, many of the studies either completely excluded or primary included alarm features with patients often already scheduled for colonoscopy based on prior clinical indication. Some studies included CRP and somatization scales which helped improve likelihood ratios of IBS diagnosis. We discussed that some of the alarm features in studies included age >45, which encompasses many patients presenting with IBS, so it may be difficult to discern whether colonoscopy is truly needed in that age bracket and more data is needed. Thanks to James for a great, thorough EBM on this interesting topic!

Noon Teaching Conference: Acid Base

Our incredible teams worked through some difficult acid-base problems today in groups. The delta-deltas were flying and no one was missing mixed disorders.

Key points:

  1. Look at the pH to determine the primary disorder
  2. Look at the PCO2 to determine whether it is primarily respiratory or metabolic
  3. Is it compensated? See quick calculations.
  4. Is there an anion gap?
  5. If there is an anion gap, what’s the delta/delta?

Hyponatremia in 3 labs!

 

You can know the hyponatremia diagnosis in just three labs!
Serum osm: The first step in the evaluation of hyponatremia is determining “is it real?” True hyponatremia is hypoosmolar hyponatremia. 
Urine osm: ADH is secreted by the pituitary in response to low volume, high serum osm and acts on the kidneys to reclaim water. This results in the urine becoming more concentrated (or ↑ urine osm). Thus, when ADH is “on,” the urine osm is high.
Urine Na: Low volume or effective circulating volume (ECV) prompts ADH secretion from the pituitary and activates the RAAS (renin-angiotension-aldosterone system). RAAS activation leads the kidneys to reclaim Na from the urine resulting in a low urine Na (<25). Essentially, the urine Na helps differentiate if “the kidneys are seeing enough fluid”.

Don’t forget that ethanol is not an effective osmole, so while you may have high osmolarity, you do not have high tonicity! And your body cares the most about tonicity. So you can subtract it from the serum osms to get a more reflective osm of tonicity.

Intern Report: Alcoholic Hepatitis

For intern report we discussed alcoholic hepatitis. We discussed diagnostic criteria, workup, presentation and prognostication tools.

Key Points:

  1. Calculate a Maddrey’s Discriminant function, if >32, start steroids
  2. Calculate a 7-day Lille score to determine if steroids should continue
  3. Manage complications: variceal bleeding, malnutrition, volume overload, and infections, etc.

AKI in Cirrhosis

We learned that cirrhotic patients can have many reasons for AKI and some can be quite subtle. We should have HRS in the back of our mind given its high mortality, but we need to do a thorough evaluation of other causes to rule other etiologies out! Thanks Dr. Mullaney, Dr. Jassal and Dr. Farkhondepour for your insights!