We continued our Neurology and Emergency Medicine resident school block! We started off with a high-yield lecture on alcohol withdrawal management by one of our medical toxicologist and emergency medicine attendings Dr. Aaron Schneir. We reviewed the clinical signs of alcohol withdrawal and the importance of preventing progression to delirium tremens. Our 2nd session was a Journal club session where we reviewed two of our esteemed faculty members’ (Dr. Samir Gupta and Dr. Brandon Nokes) publications! It was the first session of its kind where we had the chance to review their papers and ask them questions firsthand about study design, strengths/limitations, and other aspects of their papers! Our 3rd session was a continuation of our excellence in quality improvement and patient safety lecture series with an awesome session on High Value Care led by Dr. Jessica Wen and Dr. Nikolas Marino. They walked us through the fundamentals of high value care and we had an excellent discussion on how we can apply high value care in our day-to-day decisions, as well as reviewed cases together. Lastly, we had a RACE4ALL (Resident as Clinical Educators) session led by one of our amazing outpatient attendings and former resident, Dr. Melissa Wong, on how to teach in the outpatient clinical setting!

Today at Grand Rounds we were very lucky to have Dr. Borok talk to us about her research into alveolar epithelium and the role that barrier proteins play in pulmonary disease as well as the potential therapeutic targets they provide.

In particular, one protein she has been studying, Claudin 18, has been implicated in both gastric and pulmonary tumors, and has spurred several new therapeutic antibodies that show promise in the treatment of these cancers.

Dr. Borok also shared advice with us on what she learned from her career, which included the importance of perseverance and finding a research topic that is interesting but also importantly one that not many others are researching.

Thank you Dr. Borok!

We had one of our excellent 2nd year residents, Romir Maheshwary, present VA noon teaching conference today! He presented a case that he took care of while on VA wards of a patient with acute onset of fatigue, night sweats, and a diffuse non-blanching rash. With the help of our expert discussant, Dr. Ida Wong, we discovered the patient had a diffuse petechial rash with evidence of leukocytosis (50k WBC, with differential and peripheral smear concerning for blasts), as well as thrombocytopenia. We reviewed the patient’s peripheral blood smear, which revealed >20% blasts and concerning for acute leukemia. Flow cytometry is required to differentiate acute lymphoblastic leukemia from acute myeloid leukemia, except in situations where Auer rods are present! Lastly, we discussed the initial management of acute leukemia, including watching out for known complications like tumor lysis syndrome, disseminated intravascular coagulation, and symptomatic hyperleukocytosis.

We continued our high-impact Intern Curriculum Friday School today! We had two amazing lectures on Hemodynamics & Swan numbers taught by some of our amazing Cardiology fellows (Dr. Lin – 3rd year fellow and Dr. Birs – Advanced Heart Failure fellow), as well as an excellent Wellness talk on Mind over Medicine led by a UCSD IM alumni and current Scripps Cardiology fellow Dr. Epstein! In our first talk we reviewed over how to interpret key data from Swan catheters that can help us manage critically ill patients, such as central venous pressure and mean pulmonary artery pressure. In our second lecture we reviewed over important strategies, such as self-compassion (treating yourself as you would to your best friend) or prioritizing your free time, to be able to help reframe our way of thinking so that we can have increased feelings of satisfaction and self-worth as busy resident physicians and to help address burnout.

First off – congrats to all of our amazing residents for matching into fellowship!! We continued our 2nd week of our Neurology/Emergency medicine block with three high-yield lectures given by Dr. Laverty (Neuromuscular diseases), Dr. Aronowitz (Clinical Images, also our Medicine grand rounds speaker), and Dr. Clark (Management of overdoses and poisoning).

Dr. Laverty, who practices both at UCSD and Rady Children’s Hospital, reviewed over key neuromuscular diseases such as Guillain-Barre syndrome, autoimmune myasthenia gravis, and polyneuropathy! We learned the most common causes of polyneuropathy are secondary to diabetes (even pre-diabetes), as well as chronic heavy alcohol use. It’s also important to screen for a monoclonal gammopathy and vitamin B12 deficiency in a patient with polyneuropathy.

Dr. Aronowitz presented an array of cases paired with eye-opening clinical images! His talk highlighted the importance of rounding at the bedside to visualize and observe key physical exam findings that might be missed if not inspecting closely!

Dr. Clark took us back to the fundamentals of resuscitating an undifferentiated patient with altered mental status. He taught us key exam differences between a patient altered due to use of a stimulant and anti-muscarinic agent (such as diphenhydramine) – which included more subdued confusion/paranoia and dry skin (for antimuscarinic agents). We also reviewed various how to manage various overdoses or ingestions, including using activated charcoal and whole bowel irrigation.

Dr. Aronowitz gave a wonderful talk on bedside rounding. This entails the student or resident presenting the patient case at the patient’s bedside to the team; involving the patient in their own care and empowering the students and trainees. Once common place, now unfortunately less and less teams bedside round; opting to round in conference rooms or hospital hallways. Sited factors for this including: overwhelming volume of clinical tasks, less emphasis on the physical exam, and lack of time to name a few. He shared his own experiences with bedside rounding as well as the perspective and opinions from all participants involved, including medical students, residents, attendings, and patients. Reminding us that 85% of patients like to be a part of bedside rounding. Bedside rounding should take the same amount of time as it does to table round. Pro tip: do not bedside round on every single; instead pick certain patients to see as a group. Dr. Aronowitz suggests the students’ patients, sick patients, etc..  This will enhance the amount of learning for all members of the team and can improve relationships with our patients!! Feel free to ask your attendings, Dr. Jassal, the APDs, or Chief Residents any questions you have about bedside rounding.

For our NTC today at the VA, one of our amazing 4th year Med-Peds residents Jed Bell presented a case of a 65-year-old woman with new-onset pancytopenia. With the help of our expert Dr. Ida Wong, we carefully reviewed the differential diagnosis of pancytopenia and the importance of reviewing the patient’s previous labs to not miss a concurrent process (in this case the patient had an undiagnosed microcytic anemia due to iron deficiency). We reviewed the patient’s blood smear, which was consistent with pancytopenia, but also had hypersegmented PMNs (more than 5 distinct lobes) which clued us into a bone marrow process. After discovering the patient had severe vitamin B12 deficiency, we obtained an Intrinsic Factor (IF) Ab which clinched the diagnosis of Pernicious Anemia. This is caused by destruction of parietal cells in the stomach, which are responsible for production of IF, and lead to the inability to absorb VitB12. Don’t forget to look at your patient’s peripheral blood smears!!