During the new interns’ very first Hillcrest morning report today, we covered the quintessential medicine topic of hyponatremia. We shared the case of a frail elderly woman with a history of diffuse large B-cell lymphoma who presented with hyponatremia of subacute onset, down to a sodium of 122. She had nausea, vomiting, and generalized weakness and was admitted for treatment of her hyponatremia. Laboratory studies–including a low serum osmolality, a high urine sodium, and a urine sodium–were consistent with SIADH (syndrome of inappropriate antidiuretic hormone secretion). She was ultimately found to have a recurrence of her lymphoma affecting the hypothalamus, thought to be the cause of her SIADH. She was started on fluid restriction and urea.
We discussed one diagnostic algorithm for hyponatremia. The first step is to confirm that the hyponatremia is hypotonic (by measuring the serum osmolality) and not related to a laboratory error/artifact or the presence of another osmolyte (classically glucose). Then, measure the urine osmolality to determine whether ADH is the cause of hyponatremia. If urine osmolality is low (typically below 100-200), the process is ADH-independent; otherwise, the process is ADH-dependent (see diagram below). When the volume status is not apparent, the urine sodium can be used as a guide to determine whether the effective circulating volume is reduced (as in hypovolemic and most hypervolemic states), but keep in mind that diuretics can elevate the urine sodium and cloud the picture.
Our stellar nephrologist, Dr. Tyler Woodell, then talked us through the management of SIADH. If hyponatremia is severe and associated with significant symptoms, hypertonic saline (e.g., 100-150 mL of 3% NaCl repeated up to 2-3 times) can be given. Recall that isotonic fluids can in fact worsen hyponatremia in the setting of SIADH. Fluid restriction is the mainstay of SIADH treatment, but in some cases, additional solutes, in the form of salt tablets or urea packets, may be required. Our patient improved with treatment and was discharged with plans for outpatient treatment of her lymphoma.
Thank you to Dr. Woodell for being part of this memorable morning report!
Medical Spanish Word of the Day: el sodio = sodium
(Bonus: el potasio = potassium, el calcio = calcium, el magnesio = magnesium)
Congratulations to Aram Namavar for being appointed as a Resident Liaison to the San Diego Chapter of the Society of Hospital Medicine. He will be the first resident on the leadership team of this organization!
Congratulations also to our Associate Program Director and hospitalist extraordinaire, Ali Farkhondehpour who is the President-Elect of the SHM San Diego Chapter!
On Thursday morning at the VA, we discussed the management of acute COPD exacerbation. The patient was a 65 year-old man with GOLD class D COPD admitted several hours prior with increased productive cough and wheezing for the past 5 days. He developed worsening shortness of breath with evidence of diffuse wheezing and accessory muscle use on physical exam despite treatment with antibiotics, bronchodilators, and corticosteroids. His labs were consistent with an acute on chronic respiratory acidosis and the decision was made to initiate bi-level non-invasive ventilation. With the help of our expert pulmonologist, Dr. Mark Fuster, we discussed the variables to consider when initiating BiPAP as well as how to interpret the machine interface and waveforms.
We then discussed variable that indicate that hypercarbic respiratory failure is responding to NIV, and the need to remain at bedside to assess the patient in real time. An hour later, the patient continued to be tachypneic with evidence of worsening acidosis. We considered variables to troubleshoot, including assessment of tidal volumes, adequacy of EPAP, and evaluation of patient-ventilator dyssynchrony (including the need to watch out for dynamic hyperinflation!) The patient in this case had a large amount of leak around his face mask (due to a full beard) and improved when switched to a nasal interface and an increase in his driving pressure.
Special thanks to Dr. Fuster and all our participating residents!
The COVID-19 Vaccine is now available at the SD VA for our inpatients! You can order it by going to: Inpatient Meds and then clicking the Immunization/Skin Test menu.
One caveat to keep in mind: for patients going to a SNF, please discuss vaccination with the Social Worker. Vaccination can negatively impact disposition options, as some SNFs require other vaccines (pneumovax, influenza) and the CDC still recommends a minimum 14-day interval before or after administration of any other vaccine.
Reach out to Alex Cypro (firstname.lastname@example.org) with any questions or concerns. Go and vaccinate your patients today!
Tuesday morning report at the VA was all about diuretics. We presented a case of a 73-year-old man with history of CHF, CKD and T2DM who presented with progressive dyspnea, bilateral lower extremity swelling, orthopnea, and abdominal distension. Physical exam showed evidence of volume overload with 3+ pitting edema, elevated JVD, and bibasilar pulmonary crackles. We considered various common triggers of heart failure exacerbation before diving into a discussion of diuretics.
Key points that we highlighted:
Decongestion with resolution of symptoms and edema is achieved through “diuresis” = loss of sodium (natriuresis) + loss of water (diuresis). That is why sodium-limited diet is crucial in treatment of fluid overload.
Loop diuretics function as “threshold” drugs that need to achieve a sufficient concentration in order to work. The natriuretic threshold is higher in patients with acute CHF than in healthy persons. That is why hospitalized patients require loop diuretic doses that are higher than stable outpatient doses.
Loop diuretics exhibit a “ceiling” effect and doses above the ceiling will not increase the amount of natriuresis. Acute CHF shifts the relation between plasma diuretic concentration and sodium excretion to the right and reduces the “ceiling.”
Patients with chronic diuretic use develop post-diuretic sodium retention and decreased efficacy with each subsequent loop diuretic dose. That is why loop diuretics are dosed multiple times daily and why patients need a net negative sodium balance each day.
Chronic loop diuretic use leads to distal tubular hypertrophy and once maximum loop diuretic effect is reached, auxiliary diuretics are sometimes used (thiazide, aldosterone antagonists, carbonic anhydrase inhibitors). We discussed specific situations you may consider using these agents.
Ethacrynic acid is the loop diuretic of choice in patients with sulfa allergy.
For further reading, check out this review from the NEJM:
Ellison DH, Felker GM. Diuretic Treatment in Heart Failure. N Engl J Med. 2017 Nov 16;377(20):1964-1975.
We are excited to announce that the applications for all our pathways are open!
This includes the following pathways:
– Global Medicine Pathway
– Hospital Medicine Pathway
– Integrative Medicine Pathway.
– Primary Care Pathway
– RACE (Residents As Clinician Educators) Track
The deadline is November 20th at 11:59pm PST. You may apply to as many of them as you would like, and we will work with you to match into one of them based on competitiveness, interest, and fit. Please note that you may do the Integrative Medicine Pathway concurrently with another pathway.
Please read the application requirements carefully (listed at the bottom of each google form) to ensure that you submit the required documents before the application deadline!
This morning one of our stellar resident, Dr. Mandy Mohindra, presented a patient who developed a fever six days into a hospitalization for volume overload. The patient reported a history of worsening chills with rigors, loss of appetite, nausea and vomiting, and fatigue. He had an infiltrated IV with right upper extremity swelling on exam. The patient’s history was significant for liver transplantation three years before (on tacrolimus), diabetes, and severe aortic stenosis. We discussed the decision to start empiric antibiotics, and the workup eventually revealed MRSA bacteremia. The most likely source was the infiltrated peripheral IV.
We were lucky to have our Infectious Disease expert extraordinaire, Dr. Annie Cowell, to lead us through the management of Staph Aureus bacteremia as we discussed the need to evaluate for potential sites of metastatic MRSA infection. A wrinkle in our patient’s case was that his blood cultures were persistently positive for MRSA. This prompted a change of antibiotics from vancomycin to ceftaroline and daptomycin and a search for endocarditis. A transthoracic echocardiogram did not reveal valvular vegetations, but a subsequent ECG revealed a new 1st degree heart block. The patient underwent a transesophageal echocardiogram which ultimately demonstrated a paravalvular abscess for which cardiothoracic surgery was consulted. Thank you to all of our resident teams for participating in the discussion. And thank you to Dr. Cowell for adding context to our patient’s clinical course!
Who: Residents can take this course prior to obtaining their own DEA – your completion will be recorded for use later.
What: AAAP Buprenorphine Half and Half Course (½ online independently and ½ “in person” via Zoom)
Where: YOUR OWN HOME via Zoom! You MUST RSVP in advance, attendance will be taken
When: September 17th, 2020; 8 am -12:30 pm (you must attend the entire time for the waiver)
Why: To be qualified to get a DEA waiver to prescribe buprenorphine products (one common brand name is Suboxone) AND to feel confident managing this growing patient population
This course is designed to equip prescribers with the information necessary to understand and prescribe buprenorphine in a safe and effective manner. It also meets the 8-hour requirement (½ in person; ½ on line) for MD’s and DO’s to apply for the DEA waiver to prescribe buprenorphine.
This training is for ½ of the 8-hour requirement. The remaining 4 hours must be done online, and you must pass a self-study exam to apply for the waiver. Contact Carla Marienfeld (email@example.com) if you are interested in attending.
Today our amazing future chief Dr. Averie Tigges discussed a case of a young man with SCI admitted for UTI, but used the case to discuss the greater concept of malnutrition. Averie walked us through some of the prior rationale for using pre-albumin and then discussed why it is actually not a useful bio-marker for malnutrition (its a negative acute phase reactant!) . She then discussed the different clinical scores available to assess malnutrition and highlighted the choosing wisely recommendation to utilize one of these scores over pre-albumin for assessment of malnutrition.