This morning our future chief resident and professorial R3, Alex Tong, presented a case of a young woman with recurring fever. He then elicited a broad differential from the residents on possible causes of recurring fevers by dividing it into the categories of: Infectious, Rheum, Malignant, and Misc. With the help of our expert discussant, Dr. Paul Hsu, residents walked through the differential to further clarified the HPI and physical exam. Together they reviewed what labs to order and based on patients clinical picture and lab abnormalities, highest on the differential was Adult Still’s Disease.
This morning our stellar R3 RACE TRACK Resident, Janna Raphelson, presented a case of a young female who came to clinic for pap smear but was found to have abnormalities on exam including bilateral upper extremity tremor and a tachycardic heart rate. Thyroid tests were abnormal!! Janna then reviewed the clinical syndrome and typical findings of thyrotoxicosis. Our residents then broke off into small groups to develop a differential for thyrotoxicosis. We then reviewed next steps (further testing, imaging, and consulting specialists). Janna then discussed management depending on etiology of thyrotoxicosis.
Today our captivating R2, Soumya Kurnool, presented a case of a man with history of DDKT who presented with fever and had a UA concerning for infection! With the help of our expert discussant, Dr. Tomasz Beben, she reviewed common immunosuppressive medications we see in patients with kidney transplants including calcineurin inhibitors, MMF, and prednisone.
We then reviewed the differences of approach for a transplanted kidney UTI depending on timing of <6 months, >6 months, and recurrent UTI. We also talked through the most common organisms that cause infection in the transplanted kidney, including typical and atypical bugs. Soumya then masterfully overviewed work up and treatment of UTIs in transplanted kidneys.
Take Home Points:
- UTI may have pain anteriorly by transplanted kidney
- Maintenance immunosuppression: prednisone, MMF/azathioprine, tacrolimus
- Early UTI/pyelo may increase risk of graft rejection
- Late UTI/pyelo treated more like conventional nontransplant patients
- Discuss holding immunosuppression such as MMF
This morning our inquisitive R2, Eddy Wang, presented a case of an elderly gentleman who presented with progressive dyspnea and cough. We reviewed his chest x-ray which showed a large pleural effusion that pushed the trachea left. With the help of our expert discussant, Dr. Peralta, we reviewed chest x-ray findings of pneumonia vs atelectasis vs effusion vs pneumonectomy; particularly what can happen to the trachea. The patient then underwent thoracentesis and our we reviewed what labs to order for the fluid, particularly given the CT abnormalities noted on the periphery of the pleura. Then a rapid response was called on our patient at and a repeat chest x-ray showed a new opacity. Eddy then reviewed the typical presentation and management of re-expansion pulmonary edema. Our patient’s labs returned and our patient was diagnosed with mesothelioma. Our residents then reviewed what military exposures are associated with lung cancer given our patient’s service history.
This morning our wonderful junior resident, Tally Desmarais, presented a case as part of her RACE Track pathway. She shared the initial presentation of an elderly female who presented with subacute, progressive shortness of breath and weakness. The patient was found to be hypotensive, anemic, and volume overloaded with acute renal failure. Our residents then got into groups to discuss initial management of this presentation. Then with the help of our brilliant expert discussant, Dr. Antoinette Birs, Tally reviewed the images of our patient’s echocardiogram which showed findings concerning for cardiac tamponade. They then reviewed physical exam findings, pathophysiology, as well as the common causes of cardiac tamponade.
Take Home Points:
- Common causes: neoplastic, postviral, uremic, and hemorrhagic
- Physical exam findings: “beck’s triad” of JVD, hypotension, and muffled heart sounds. Also look out for pulsus paradoxus, sinus tachycardia, and signs of right heart failure.
- Echo findings: pericardial effusion, right sided chamber collapse, plethoric IVC
We were joined by one of our awesome PCCM faculty, Dr. Timothy Fernandes, who helped us with a review of the pathophysiology of right heart failure. The residents also helped build the differential based on anatomical site (shown above). It was determined that his right heart failure was due to pulmonary hypertension secondary to methamphetamine use, and he improved with diuresis and supportive care.
Thank you so much to Revathy for this awesome case and to Dr. Fernandes for your expertise!
Today our stellar R2, Mehul Trivedi, gave a RACE Track case presentation of an elderly woman who presented with fatigue, DOE, and tachycardia. On initial labs our patient had a new anemia! With the help of our expert discussant, Dr. Gupal, he reviewed the initial work up for the new anemia and determining the etiology. As the work up results came in, our residents were concerned for a hemolytic anemia. Mehul then explained how a Direct Coombs Test works and we found that our patient had warm autoimmune hemolytic anemia! He then discussed primary vs secondary as well as treatment.
Take Home Points:
- LDH, Indirect Bilirubin, Haptoglobin, Reticulocytosis are all markers of hemolysis
- Blood smears can be helpful in ruling out MAHA/TTP, also in showing spherocytes
- Positive Coombs test is diagnostic for warm autoimmune hemolytic anemia
- Treatment depends on whether it is primary vs secondary and consists of transfusion for acute cases, and steroids/rituximab chronically
Tonight, we were joined by all of the UCSD IM pathway directors, pathway CMRs, and current pathway residents for a Pathway Open House! Thank you to everyone who joined! Don’t worry if you weren’t able to make it tonight, all the info you need is on the blog. Also, feel free to reach out to the pathway directors and chief residents at any time!
We will be sending all the residents more information about how to apply this coming Winter soon!
- Hospital Medicine Pathway
- Pathway Director: Dr. Ali Farkhondehpour
- CMR: Ashley Scanlon
- Primary Care Pathway
- Pathway Director: Dr. Stacy Charat
- CMR: Lauren Haggerty
- Integrative Medicine
- Pathway Directors: Dr. EB Sladek & Dr. Samantha Spilman
- CMR: Armando Martinez
- RACE Track
- Pathway Directors: Dr. Supraja Thota and Dr. Connie Chace
- CMR: Averie Tigges & Lizzy Hastie
- Global Health Pathway
- Pathway Director: Dr. Annie Cowell
- CMR: Lizzy Hastie
The pathway powerpoints and a recording of the presentations can be accessed here:
You can also access more details about the pathways on the blog:
Today at the VA we were lucky to have Dr. Cathy Cichon give us a talk on SCAD (aka Spontaneous Coronary Artery Dissection) a real, cool, and scary type of ACS!! With Dr. Nick Phreaner backing her up, Cathy took us through an initial chest pain evaluation, and a strange elevation of troponins in a young female patient without a single risk factor for atherosclerotic disease. So let’s define SCAD and hit our takeaway points for learning!
SCAD – spontaneous (non-traumatic or iatrogenic) separation of the coronary arterial wall. A rare cause of acute MI more common in younger patients and women. It accounts for roughly 0.5-1% of all ACS.
Now for some key takeaways about this condition!
- The initial endothelial/intimal insult isn’t well understood. But the result is a false lumen where blood pools into an intramural hematoma. This can (and often does) expand until it can obstruct the vessel lumen, leading to MI.
- There is often a predisposing risk identified, but up to 20% of SCAD cases have no underlying risk and are labeled as idiopathic. >80% of cases are in women. Risk factors for this condition include:
- Fibromuscular dysplasia
- Postpartum status, multiparity (≥4 births)
- Connective tissue disorders
- Systemic inflammatory conditions
- Hormonal therapy
- Diagnosis is a challenge, but the big options are CTA Coronary vs Coronary Catheterization. CTA has the downside that it can miss the disease in a portion of patients. Catheterization has the downside of risking further damage to the vessel wall or invasion of the false lumen. The decision of which to do should be made by the Cardiology team, and weigh the pros/cons and expertise at your particular institution.
- What is done for SCAD in terms of management is usually conservative therapy, which allows resolution in the majority of cases. Revascularization with PCI again risks further damage to the wall, but sometimes could be necessary depending on the location of the lesion. In severe cases bypass grafting could be necessary. There aren’t many studies done with these patients, but it seems like beta-blockers may help prevent recurrence.
Today we were lucky to have RACE Track Senior Dr. Alex Cours, and her expert Dr. EB Sladek talk us through a case of a patient presenting for “memory issues”. Alex walked us through a focused differential for altered mental status, specifically honing in on memory impairment. Her patient was concerned because some recent genetic testing had shown her that she was (+) for ApoE, had an MRI consistent with “cognitive impairment”, and had an aunt diagnosed with some type of dementia. Ultimately the patient was not showing any signs of memory issues, but rather her concerns and fears drove her to present for further evaluation after a misleading workup outside of our system. Check out below for some key takeaways from Alex’s talk and teaching!!
- ApoE testing is NOT recommended for workup of AMS, Memory Impairment, or Major Cognitive Disorder. Unless it is necessary for a research protocol, it is ultimately not particularly useful diagnostically, and only those homozygous for E4 have an increased susceptibility (not certainty) to develop dementia.
- Neuroimaging is useful for the following populations, but otherwise is not generally helpful for memory or cognitive assessments:
- Symptoms in those < 65
- Those with focal neurological defects
- Sudden or rapid progression of symptoms
- Specific concern for NPH
- History of fall or other head trauma
- Assessments that are helpful, particularly in screening for dementia in patients who are not acutely ill, are the MoCA (Montreal Cognitive Assessment) and the SLUMS examination (used primarily at the VA).
Great job Alex and Dr. Sladek!! Thanks for all the excellent teaching!!