Major kudos to Dr. Steven Ma for doing an amazing job as the night senior this past week! It was much busier than usual, but he juggled back-to-back patient admissions like the pro he is! Thank you Steven for all of your hard work!
We continued the PCCM Friday School block today with four great sessions on pulmonary disease! To start off the afternoon, Dr. Jenny Yang discussed the different types of pulmonary hypertension. The residents were tasked with the challenging job of matching 8 different case presentation to pulmonary hypertension group and right heart catheterization group. Though difficult, they all did a great job, and the winners (above) took home a COVID-19 plush.
For the next hour, Dr. Kim Kerr taught us about CTEPH and the amazing CTEPH team we have here at UCSD. A guest speaker joined us to share her personal experience with CTEPH. We cannot thank her enough for taking the time to share her story!
Once the interns arrived, we jumped into NTM pulmonary disease. The incredible Dr. Rebecca Sell and Dr. Annie Cowell went through a patient case and then Dr. Wael Elmaraachli discussed his approached to work-up and management of NTM pulmonary disease. Dr. Elmaraachli emphasized the importance of distinguishing NTM pulmonary disease versus infection since NTM can be a contaminant and is found in the environment.
Lastly, Dr. Bernie Sunwoo discussed interstitial lung disease. Her biggest take away, history is key!!
Thank you to all the amazing experts and the guest speaker today!
Today we reviewed a case of a 62 year old male who presented with 2 weeks of easy bruising and bleeding from his gums in the setting of 2 months of fatigue and weight loss. We discussed labs we would order and the residents were given a CBC that showed a leukocytosis, anemia, and thrombocytopenia. They next wanted to review the diff on the CBC.
Residents broke off into small groups and were given different diff values for the same CBC. We then had them come up with a differential based on the CBC w/ diff. With the help of our knowledgable expert discussant, Dr. Ida Wong, we reviewed a normal differential and then what to have on your differential for an elevated neutrophil count, lymphocytosis, a count with immature myeloid cells, and a count with blasts. We then reviewed the cell line lineage of myeloid cells and what findings you would see in CML, CLL, and acute leukemias. Precursor cells and blasts in the differential IS NEVER normal!
We returned to our case and diagnosed out patient with an acute leukemia based on him having >20% blasts in his count. He was diagnosed with AML through identification of auer rods on peripheral smear and we reviewed the clinical presentation and diagnosis of AML.
Rapidly progressive glomerulonephritis can be a confusing topic. Thankfully, Dr. Margaret Ivanov, one of our awesome nephrologists, dropped by our Hillcrest morning report today and offered some clinical pearls. We discussed the case of a middle-aged man with no history of renal disease who presented with an elevated serum creatinine to the mid-5’s. He has no significant medical history and takes no medications. His urinalysis revealed significant proteinuria and hematuria. Serum studies are positive for ANA and anti-dsDNA, and a renal biopsy showed thrombotic microangiopathy superimposed on a background of class IV lupus nephritis.
In a patient with new renal impairment, you should always ask about medication use, urinary symptoms, and other associated symptoms. Constitutional, mucosal, respiratory, GI, neurologic, hematologic, and dermatologic signs/symptoms may suggest the presence of an underlying disorder. Be sure to also do a good volume assessment to help determine if the patient requires diuresis and/or renal replacement therapy.
A urinalysis is an important first step in the evaluation of AKI. RPGN is a clinical syndrome characterized by rapid loss of renal function (over days or weeks) and a nephritic UA (hematuria with or without proteinuria). Urine microscopy will reveal RBC casts and dysmorphic RBCs. Dr. Ivanov pointed out that the automated process used to result UAs will not disclose the presence of RBC, WBC, and other casts and that urine microscopy will have to be done separately.
We then talked about the workup of RPGN (see below). These studies are typically sent in parallel because the etiology of RPGN cannot be reliably determined based on history and exam alone. (Many of these studies are send-outs and may take days to over a week to result.) Reasons to pursue a renal biopsy include unexplained AKI and an active urinary sediment. The classic pathologic finding in RPGN is crescentic glomerulonephritis. Light microscopy, electron microscopy, and immunofluorescence can help identify the cause of the RPGN. In some cases, multiple processes may be seen on renal biopsy. The biopsy also helps inform treatment and prognosis.
Key Learning Points:
- RPGN is a clinical syndrome characterized by a rapid loss of renal function (typically over days/weeks) and nephritic syndrome (hypertension, hematuria, variable proteinuria, dysmorphic RBCs, RBC casts).
- The classic pathologic finding is cellular crescent formation in the majority of examined glomeruli due to fibrin deposition and cell proliferation (“crescentic glomerulonephritis”).
- A renal biopsy is generally indicated in patients presenting with rapidly progressive glomerulonephritis to ascertain the etiology, determine its chronicity, and inform patient prognosis.
Thank you, Dr. Ivanov, for joining us today!
Medical Spanish Word of the Day: (el) análisis de orina = urinalysis
Today Dr. Gold, specialist in lung and head and neck cancers, joined us to discuss lung cancer! She reminded us that small cell lung cancer is more common in people with a smoking history, while the vast majority of lung cancer patients who have never smoked have adenocarcinoma. Staging lung cancer is very complex, and it’s easier to understand treatment options as we think of lung cancer as early stage, locally advanced, or metastatic. In NSCLC, early stage lung cancers are often amenable to treatment with surgical resection alone. Locally advanced cancer usually involves mediastinal lymphadenopathy or a primary tumor invading into the mediastinum. These patients are usually treated with a combination of chemotherapy and radiation. In metastatic disease, we consider chemotherapy, immunotherapy (think PD-L1 inhibitors such as pembrolizumab), and targeted therapy (test for EGFR, ALK, ROS1).
Dr. Gold encouraged us to support efforts to prevent people from starting smoking in the first place, as smoking cessation is incredibly hard. Efforts such as high taxes for cigarettes have been shown to effectively prevent people from starting smoking.
Today former UCSD preliminary intern, current UCSD IR resident, and all-around awesome human John Do taught us about abdominal radiographs. The framework he recommends is Gasses, Masses, Bones, and Stones. When evaluating intraluminal gas, use the 3-6-9 cm rule! The small bowel should be smaller than 3cm, the large bowel should be smaller than 6 cm, and the cecum should be smaller than 9cm! Identifying haustra and plicae circulares can help you differentiate between small and large bowel. We went through several abdominal radiographs together. Thank you Dr. Do for your excellent teaching!
For our first Clinical Reasoning Conference of the academic year, our expert diagnostician was the incomparable Dr. Lori Daniels, cardiologist extraordinaire and a former chief resident of our program. Dr. Daniels walked us through the mystery case of a relatively healthy young woman who presented with acute-onset, sharp midsternal chest pain and was found to have dynamic EKG changes, elevated cardiac biomarkers, and apical hypokinesis on echocardiogram. A computed tomography of the coronary arteries showed abrupt tapering of the mid- to distal left anterior descending artery, which was consistent with spontaneous coronary artery dissection (SCAD). With treatment and cardiac rehabilitation, the patient had a good cardiac recovery. She was ultimately diagnosed with an arteriopathy.
We took this opportunity to discuss the uncommon but important diagnosis of SCAD, caused by hematoma formation within the tunica media, which then leads to intimal separation from the underlying vessel. Triggers include stress, Valsalva, intense exercise, hormonal changes, and medications. Most cases occur in young women with few traditional cardiac risk factors. SCAD can be associated with pregnancy and can occur in the postpartum setting. SCAD can present similarly to other causes of acute coronary syndrome (ACS), with typical chest pain, elevated cardiac biomarkers, EKG changes (including ST segment elevations), and wall motion abnormalities. Most cases are diagnosed through cardiac catheterization. Thrombolytics are generally avoided as they may cause extension of the dissection or hematoma. The role of antiplatelet agents and anticoagulants in SCAD is unclear, but these agents are often given. Neurohormonal block with β-blockers and ACE inhibitors (or ARBs) is also typically initiated. Percutaneous coronary intervention and coronary artery bypass graft surgery may be appropriate in select patients.
We were fortunate to have been joined by the patient, who shared her unique perspective on the experience. The classic teaching that women with ACS tend to present atypically is flawed. Studies suggest that women who have ACS report typical chest pain at similar rates as men who have ACS. Although women have higher rates of insurance and primary care than men, women who develop ACS report more difficulty receiving care than their male counterparts. In addition, despite having a higher cardiac risk burden and risk of severe myocardial infarction, women who have ACS are less likely to be appropriately diagnosed on presentation and less likely to be reperfused in a timely manner. Indeed, health inequities related to sex and other social determinants of health remain pervasive today.
Key Learning Points:
- SCAD is an important cause of acute coronary syndrome, particularly in young women who have few traditional cardiovascular risk factors.
- Not all chest pain is from atherosclerotic plaque rupture. Consider other diagnoses such as aortic dissection, pulmonary embolism, pneumothorax, and SCAD.
- In SCAD, most medications used to treat other causes of acute coronary syndrome can be delayed and administered after an angiogram without significant issues.
- Discrepancies related to sex and other social determinants of health in the management of individuals who present with chest pain remain commonplace.
Thank you to Dr. Daniels and our other expert discussants for participating in our conference today!
Today at Hillcrest, we reviewed a case of a middle-aged woman presenting with recurrent C diff infection (CDI), which is defined as recurrent symptoms within 2-8 weeks after completing appropriate treatment for C diff infection with initial resolution of symptoms. We discussed the criteria for non-severe, severe, and fulminant presentations of CDI. We then reviewed the treatment options for initial and recurrent episodes of CDI, incorporating the updated IDSA guidelines from just last month!
- PCR testing for the C diff toxin B gene, which is the C diff test that we use here at UCSD, is not specific for active C diff infection. This test can also be positive in the setting of asymptomatic carriage. Therefore, we need to use our clinical judgment and interpret the test result in the context of the patient’s presentation. Consider the following features:
- Is my patient having frequent (>3 episodes in 24 hours) liquid stool?
- Does my patient have other explanations for diarrhea (ie recent laxative use)?
- With the new IDSA guidelines, Fidaxomicin is first-line for initial and recurrent episodes of CDI. However, oral Vancomycin is still an acceptable alternative. Consider the high cost of Fidaxomicin as well as your patient’s specific factors (ie recurrent disease, immunocompromise) when choosing your antibiotic regimen.
- Recurrent CDI occurs in about 25% of patients. Bezlotoxumab, a monoclonal antibody that binds to the C diff toxin B, is FDA-approved for the prevention of CDI recurrence in high-risk patients. It is given as a single IV dose, in conjunction with standard antibiotic treatment.
- Fecal microbiota transplantation (FMT) is recommended for patients with multiple recurrent episodes. Further investigation into the potential benefit during an initial C diff infection is needed.
- Surgery may be considered in select patients with fulminant disease.
*Check out the updated IDSA guidelines for the management of C diff infection here!
Medical Spanish Word of the Day: diarrhea = diarrea
For today’s MTC, we discussed a patient who presented with acute LUQ abdominal pain who was found to have a lipase > 190 and imaging consistent with acute pancreatitis. With the help of our fabulous GI expert, Dr. Fady Youssef, the medical students and residents walked through the work-up and management of acute pancreatitis:
The patient was treated with early fluids and underwent an ERCP after imaging was concerning for choledocholithiasis. Prior to discharge, he had a cholecystectomy.
Key take away points:
- Early, aggressive fluid resuscitation is essential and most beneficial within the first 24 hours! Our expert, Dr. Fady Youssef, likes to give a 1-2 L bolus followed by 250 mL/hr of LR
- Severe pancreatitis is associated with a high mortality
- While complex scoring systems exist for determining severity of pancreatitis, an elevated hematocrit and BUN and evidence of SIRS are just as accurate and much simpler to use! Dr. Youssef said he never uses the other scoring systems.
Thank you so much to our expert, Dr. Fady Youssef, for joining us this morning!
Lauren Ibarra (yes! Allison Ibarra’s sister) is the co-Director of the IHC Tijuana Free Clinics. The International Health Collective (IHC) is a UCSD, student-run, non-profit organization that provides continuity care for underserved areas throughout Tijuana, Mexico. They are currently working with two neighboring rural communities, Tijuana Progreso and Girasoles, both of which share family oriented, pediatric and geriatric demographics. One of their primary goals is to provide medical care in underdeveloped communities through urgent care clinics. They are currently recruiting providers for the Saturday, August 14th clinic. It will run from 9AM-3PM for providers to see 10 patients in the scheduled time.
Due to the COVID-19 pandemic, they have successful hosted telemedicine clinics since September 2020. The virtual clinic will consist of a medical provider having a phone consultation with the patient and prescribing medication from their pharmacy. Spanish is helpful but not required (interpreters provided).
If you are interested in being a medical provider, please reach out to email@example.com !