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
Pathway Directors: Dr. EB Sladek & Dr. Samantha Spilman
CMR: Armando Martinez
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:
Today was our first day of the Rheumatology Friday School Block and part of our Resident As Clinician Educator for All (RACE 4 All) curriculum!
From 1-3pm, RACE Track Director, Dr. Supraja Thota shared tips on how to be an amazing team leader and teach on rounds. She included a mini-workshop on the “holdover game,” helping residents to make holdovers into a rich, interactive cognitive reasoning exercise that can help avoid anchoring!
From 3-5pm, residents and interns gathered in small groups to come up with creative questions to test their co-residents on the clinical manifestations, work up and treatment of SLE! Dr Maripat Corr from our Rheumatology Department then reviewed SLE with us! With her help, and the help of our new resident experts in SLE, we were able to answer all the fun (but difficult) questions made by each small group! While we were able to cover a lot, learning about SLE is not restricted to Friday School! Check out this amazing article on SLE for the internist in the Annals of Internal Medicine! Click Here!
Today one of our amazing RACE track residents, Dr. Eric Low, discussed a fascinating case of an elderly woman who presented with altered mental status and was found to have a profound metabolic acidosis secondary to metformin overdose! Dr. Low used this case as the impetus for an excellent discussion on the general approach to acid/base disorders as well as ensuring our ability to identify the rare triple acid/base disorder! Thank you to our expert discussant Dr. Warda Zaman for her helpful pearls as well!
Take Home Points:
Remember the difference between emia (the state of being) and osis (the process).
Develop a system for approaching acid/base disturbances (try Eric’s!).
Make sure to work through acid/base disturbances completely to rule-out concomitant disorders.
An elevated anion gap is never normal and always implies an underlying acidosis (make sure to correct for albumin!).
Today, RACE track superstar Masha Barsky presented a fascinating case of a patient in their 40s with newly diagnosed HIV/AIDS (CD4 27, VL 126K) who had 2 weeks of dry cough and progressive shortness of breath. We went through a great diagnostic schema of approaching respiratory disease in an HIV/AIDS patient, including both HIV/AIDS-specific diagnoses and diagnoses pertinent to immunocompetent and immunocompromised patients. The patient underwent a multitude of tests which revealed a positive AFB sputum and MTB-PCR, as well as chest imaging concerning for miliary TB! We then reviewed miliary TB, including distinctions between pulmonary vs miliary (disseminated) TB and additional work-up needed to evaluate for extrapulmonary involvement. Thank you to our expert discussant, Dr. Jocelyn Keehner, for her insights!
Use a diagnostic schema for an HIV patient with respiratory symptoms that includes bacterial/fungal/parasitic/viral infectious causes as well as several non-infectious causes – consider HIV/AIDS-specific diagnoses and the CD4 counts associated with them, but don’t forget diagnoses that can occur in anyone as well!
Evaluate carefully for extra-pulmonary involvement in miliary TB, including dedicated imaging for any suspected organ abnormality and a lumbar puncture for any neurologic symptoms.
Pulmonary TB can occur in HIV/AIDS patients with any CD4 count, while miliary TB is more likely to occur in HIV/AIDS patients with CD4 count <100-200.
Today our amazing RACE track resident Dr. Kusuma Pokala presented a great case of a young man who presented back to the ED after failing outpatient treatment of presumed CAP! We started by discussing the most common DDx for a non-resolving PNA: loculated infections, infections 2/2 bronchial obstruction, or infection from atypical organisms (Cocci, NTM, TB, etc.). After repeat imaging demonstrated a new unilateral effusion, Kusuma had the group walk us through Light’s Criteria and the different stages of parapneumonic effusions (see her table below)! Our patient underwent thoracentesis with chest tube placement and ultimately had a full recovery after a prolonged course of antibiotics. Special thanks to Dr. Michael Lam (former UCSD IM resident!) for adding his pulmonary knowledge to Kusuma’s teaching points!
Loculated infections (such as parapneumonic effusions) should always be on the differential for a non-resolving pneumonia.
Light’s criteria are used to distinguish between transudative and exudative effusions — this can dramatically narrow your differential!
Once you establish the presence of a parapneumonic effusion, remember that the stage of disease will significantly change your management.
Today one of our amazing Resident as Clinician Educator (RACE) track residents Dr. Maggie Kozman led us through a fascinating case of a young woman with HIV and priorly diagnosed disseminated MAC affecting the liver who presents with diffuse abdominal pain and fevers after restarting ARVs for 6 weeks. We learned that she had markedly elevated alkaline phosphatase and GGT levels and diffuse abdominal and pelvic lymphadenopathy.
Dr. Kozman lead us through a diagnostic schema for an HIV patient coming in with fever and abdominal pain, with the help of our expert Owen discussant, Dr. Jill Blumenthal and taught us about HIV cholangiopathy. Ultimately, we learned that the patient had likely IRIS from MAC infection in the setting of her recently restarted ARVs, as her CD4 count had a marked recovery with a corresponding significant drop in the viral load.
Thank Dr. Kozman for that interesting case and excellent teaching, and Dr. Blumenthal for your additional clinical pearls!
1) When thinking of the differential for fever and focal infectious symptoms consider the categories of 1) common infections 2) opportunistic infectious and 3) IRIS.
2) HIV/AIDs cholangiopathy is a cause of secondary biliary sclerosis in HIV patients. Patients who have had infections with cryptosporium or CMV may be more at risk. They can present with fever, RUQ pain and diarrhea and can have a markedly elevated AP and ggt, as well as biliary strictures visualized on MRCP.
3) IRIS or immune reconstitution syndrome is a diagnosis of exclusion in HIV patients presenting with fever, particularly those with an initial low CD4 count and high VL who have a significant response and immune recovery after restarting ARVs. Infectious etiologies should be ruled out prior to patients being diagnosed with IRIS and getting treated with steroids.
The “Michigan Difference” linked up with UCSD awesomeness as this week’s grand rounds speaker Dr. Sanjay Saint from the University of Michigan had dinner with some our RACE track & Hospital Medicine pathway residents and faculty. He shared some great advice on pursuing a career in medical education and quality improvement research. Thanks for coming, Dr. Saint!
Our awesome PGY-2 and RACE tracker Averie Tigges presented a great case on a patient in their 50s who presented with shock of unclear etiology. We reviewed the different etiologies of shock, and a CT A/P incidentally found a large pericardial effusion. However, we recalled that tamponade cannot be diagnosed from a CT! In order to evaluate whether the patient’s pericardial effusion may be causing the hemodynamic instability, we reviewed various diagnostic tools to aid in what is ultimately a clinical diagnosis. In particular, we reviewed how to do a pulsus paradoxus, and our expert discussant Dr. Kahn discussed key echocardiographic findings such as RV diastolic buckling, IVC dilation, and mitral inflow variation.
The patient was found to have equivocal findings on bedside echo. However, in light of his Beck’s triad on physical exam, relatively low voltage on EKG, and subsequent cardiac arrest without other likely etiology, his shock was attributed to cardiac tamponade and an emergent pericardiocentesis was performed with 1L drained. The patient achieved ROSC and was ultimately discharged from the hospital.
Keep a broad differential for shock, as it may not always be so straightforward.
A large pericardial effusiondoes NOT equaltamponade. Utilize physical exam findings, EKG findings, pulsus paradoxus, echocardiographic findings to evaluate for tamponade.
Cardiac tamponade is a clinical diagnosis. No single diagnostic tool can confirm or rule out tamponade.
Today, PGY-2 and RACE track star Alex Cours presented a case of a 66 year old woman with concerns for memory impairment. We took a thorough history, finding out she had a history of depression on two antidepressants, extensive supplement use, and regular marijuana use. We reviewed a diagnostic schema for memory impairment, discussed various screening tools for dementia, and diagnostic work-up and definition of dementia.
Not all memory impairment means dementia, or even mild cognitive impairment! Keep a wide differential to consider organic causes of memory impairment. Remember the three “D”s: delirium, dementia, and depression.
Screening tools such as the mini-cog and MOCA may be positive when abnormal but are NOT diagnostic of dementia
Screening should only be considered in those with “red flags” or concerns expressed either by individual or family
Yesterday, Second year RACE track resident Ashley Scanlon presented a fantastic case of an elderly gentleman who presented with the chief complaint of right wrist pain. There was no history of IVDU, recent trauma, or high risk sexual activity. The patient was not known to be immunocompromised, though did have a history of “chronic diarrhea” and recurrent UTIs. Physical exam was not notable for oral lesions, rash, but did reveal multiple involved joints including multiple small joints of the hands, bilateral wrists, elbows and shoulder.
Dr. Scanlon discussed the rough differential diagnosis for a patient who presents with acute polyarthralgia, which included both non-inflammatory causes such as severe multi joint OA and hemarthroses, but also inflammatory causes including autoimmune processes, reactive arthritis, sarcoidosis, crystal arthropathies and a large swath of concerning infectious causes. Dr. Scanlon revealed that the patient that had undergone serial arthrocenteses in order to help diagnose the etiology and discussed features of a synovial fluid analysis that might help us narrow the differential.
The patient’s knee synovial fluid analysis revealed 48K WBCs with 100% PMNs, but had a negative gram stain. Suspicion for at least an infectious process was high, and therefore a more extensive infectious work up was obtained, including blood cultures, additional arthrocenteses, all of which were negative. Given the patient’s relatively high WBC count, the patient was started empirically on broad spectrum coverage, but ultimately did not improve. The patient’s history also included recurrent UTIs, which were felt to be a possible inciting event trigger reactive arthritis. Ultimately, the patient received a course of oral corticosteroids, which was effective in relieving his arthritis.
Take home points:
Maintain a high index of suspicion for infectious causes of polyarthritis even when initial gram stains and cultures are negative as the sensitivity of such studies is limited.
Interpretation of synovial fluid analysis with cell count, gram stain, culture, crystal analysis can help you with distinguishing different etiologies of arthritis, however if you were to pick the most important items to order with a limited sample, opt for the culture and gram stain.
Empiric antibiotics should be used in patients that have a moderate pre-test probability of infectious poly or monoarthritis based on WBC >50K. It is safer to start early and de-escalate when appropriate than to leave an untreated septic arthritis.