Wednesday School 11.22.23

Today was the first day of our Neurology/Emergency Medicine Wednesday School Block and it was a great start! Our Vascular Neurology Fellow: Dr Claire Davila presented an overview of Strokes and shared with us the Acute Stroke Decision Tree (see below) that goes through her mind when assessing a stroke code. When we see the stroke team at bedside after calling a stroke code be prepared to share: current vitals, POC Glucose, last known well, why the code was called and ABCs (check out the “Questions you will be asked” slide as well).

Next, our NCC Fellow Dr Jasmine Singh gave a lecture on status epilepticus. She shared pearls in status management, dose of initial Ativan IV pushes (2mg-4mg), when to start a loading dose antiseizure medication (if refractory status epilepticus – consider this if not resolving after 2 IV pushes of Ativan), and when to get EEGs. Amongst the topics she shared with us relevant clinical trials studies including: RAMPART study and ESETT trial. For fun shared the Neuro “AMS trinity”: LP, EEG & MRI (See photo).

Next Dr DJ Gaines gave an important and thought provoking AHEAD Lecture on the use of Race and ethnicity in medical equations and the lack of evidence to support their use. We went into detail on the use of the race based equation for PFTs used at most hospital systems! Due to this equation used in PFT calculations Black patients can be underdiagnosed with obstructive lung disease – it is important to think about this when you have a Black patient who’s PFTs are borderline normal. We also discussed how Race is utilized when calculating BMI using calibers.

The last Wednesday School topic was an EQIPs case led by our own residents: Dr. Niki Bernstein, Dr. Rodrigo Rubarth, Dr. Greg Peterson. We had a great discussion on system’s based improvements to assist with identifying patients at risk for in-hospital decompensation. Thank you to our expert discussants: Dr. Laura Crotty Alexander, Jim McNair RN, & Caitlin Berdijo RN for your insightful comments on this case, we look forward to working with you on the wards and in the ICU!!

Hillcrest 11/21 Noon Teaching Conference: Abnormal Uterine Bleeding

Today, during Hillcrest Noon Teaching Conference, we discussed the case of a 51-year-old woman presenting for an acute primary care visit with 12-days of heavy uterine bleeding. The diagnostic journey unfolded with significant findings, including severe iron deficiency on labs, the identification of fibroids through pelvic ultrasound, interspersed regions of adenomyosis revealed by MRI, and an endometrial biopsy indicating an inactive endometrium with a polyp fragment, leading to the diagnosis of AUB-P/A/L.

We learned that there are four key parameters used to characterize abnormal uterine bleeding: duration, frequency, regularity, and volume. Next, we reviewed the PALM-COEIN mnemonic as a tool for categorizing the causes of AUB. Structural causes (PALM) include polyps, adenomyosis, leiomyoma (fibroids), and malignancy/hyperplasia. Non-structural causes (COEIN) encompass coagulopathy, ovulatory dysfunction, endometrial issues, iatrogenic factors, and the catch-all “Not yet classified.” Finally, we learned about the diagnostic approach to abnormal uterine bleeding which includes a pelvic exam, labs (pregnancy test, CBC, iron studies), imaging (transvaginal ultrasound), and sometimes a biopsy!

Thanks for a great outpatient case!!!

VA NTC 11/21 Cancer Screening for Transgender Patients

This month at the VA is transgender and gender diverse awareness month and 11/20 is transgender remembrance day. In honor of these occasions our noon conference was on primary care for transgender patients, specifically cancer screening. We reviewed a framework for creating a welcoming environment and establishing care with a gender diverse patients. Normalize introducing your name and your pronouns. We also reviewed different gender affirming therapies. It is important to take an organ inventory so you know what care your patient needs. If you have it, screen it!

Friday School 11/17/23

We continued our high impact Intern Curriculum Friday School today! Starting with Oncology Emergencies with Dr. Ida Wong, we worked through interactive cases as a group in a fun interactive game to learn about SVC syndrome, APL, and symptomatic brain lesions!

Then, Dr. Connie Chace taught us about Growth Mindset as part of our RACE4ALL curriculum! We learned about Growth Vs Fixed Mindset! Those with a fixed mindset believe intelligence and talent are fixed at birth with a growth mindset believe in intelligence and talent can go up at down! We learned a growth mindset can be cultivated and it’s something worth practicing as our mindset dictates how we experience failure AND impacts learning/achievement!!

Thanks for a great Friday school!

VA NTC 11/16/23 PRES

We had an amazing NTC with our resident Alisse Singer and expert Dr. Karanjia where we took a diagnostic dive into altered mental status. We reviewed the MIST (Metabolic, Infection, Structural, Toxin) mnemonic but when it didn’t help us reach our diagnosis we expanded our differential to VIITAMINS. Through this expansion we discovered our patient had PRES! PRES stands for posterior reversible encephalopathy syndrome and is a syndrome comprised of nonspecific neurological symptoms so is important to keep on your differential! MRI findings will help clinch the diagnosis. It is important to recognize PRES because untreated PRES can result in intracerebral hemorrhage and high ICP which can lead to brain herniation.

Grand Rounds 11/15 – Physician-Scientist Journey of CAR-T Cells Grand Rounds

At grand rounds today, we had our inaugural Paul A. Insel endowed lecture in Physician-Scientist Training where we had Dr. William Go, former UCSD MSTP, IM grad and current Chief Medical Officer of A2, speak to us about his journey.

Dr. Go spoke to us about CAR-T cell therapy and how he was able to participate in the clinical trials that led to FDA approval for YESCARTA, a CAR-T therapy for people with Diffuse B Cell Lymphoma who failed first round therapy. He spoke to us about how he participated in the phase-1 clinical trials for the therapy, and how he was able to use the lessons learned during his training as a physician scientist to help him along his career.

We also got the chance to learn about Dr. Insel, and the instrumental role he played in starting and growing the PSTP program at UCSD, one of the largest and most diverse in the nation!

Thank you so much Dr. Insel and Dr. Go for the illuminating talk!

Wednesday School 11/15/23

This morning marked the grand finale of our PCCM Wednesday school block! First, Dr. Joshua taught us about Restrictive Lung disease with a special focus on ILD. Next, Dr. Lin brought out the black lights as we tested our ability to discriminate COPD and asthma, and took a deeper dive into Asthma-COPD overlap syndrome. We couldn’t have scheduled this lecture for a better day, 11/15/23 is COPD Day!!

Then we split into smaller groups for high yield shock topics, with Dr Odish and Dr. Lin. Dr. Odish taught us about Cardiogenic shock with advanced mechanical support. Dr. Lin worked through some interactive cases of Obstructive shock.

We finished the morning with a CMR feedback session. These are monthly opportunities for residents to provide feedback about the program without any ADPs or PDs present. This feedback is then presented anonymously to the rest of the leadership team, and addressed in a noon teaching conference the following week. At UCSD, we love feedback and are always looking for ways to improve our excellent program!!

Thanks for an incredible PCCM Wednesday school block! But don’t worry, the learning won’t stop here! We’ll be back next week to start our Neurology/Emergency Medicine Wednesday school series!!!

11/14/23 – Hillcrest Turkey Crafts

Today, at Hillcrest’s Noon Teaching Conference, we set aside our stethoscopes for a creative twist. The mission? Craft paper turkeys with our co-residents!

The beauty wasn’t just in the finished turkeys, but in the process itself. As residents, we often find ourselves absorbed in the demands of patient care and academic responsibilities. Turkey Crafts allowed us to tap into a different part of our brains, providing a welcomed mental break. Not only did we get to showcase our artistic talents (or lack thereof), but we also had the opportunity to spend quality time connecting with our co-residents.

The best part? The camaraderie and teamwork that blossomed during this creative session! Residents collaborated, offering tips and tricks for perfect tail feathers or lending a helping hand when the glue refused to cooperate. It was a refreshing reminder that we’re not just colleagues; we’re a supportive community navigating residency together!

Here’s to more unconventional learning experiences and laughter-filled conference rooms!

11/13/23: Noon Teaching Conference

Today, for Hillcrest noon teaching conference, our incredible 2nd year resident Dr. Jenny Franke presented the case of a 55-year-old male who presented with 2 weeks of progressively worsening pain in the 3rd and 4th digits of his left foot with associated dark purple discoloration.

His history was notable for an LV thrombus diagnosed 3 years prior, and a recent admission for splenic artery thrombosis and renal infarction, presumed embolic in etiology.

With the help of expert hematologist, Dr. Gopal, we talked through his CBC which revealed erythrocytosis, thrombocytosis, and leukocytosis. She pointed out that his differential was also notable for granulocytosis with a left shift.

We reviewed his prior records and determined that his elevated blood counts were longstanding!

Next, Dr. Gopal walked us through the definition and workup of Erythrocytosis. We learned to use EPO level to differentiate primary erythrocytosis (bone marrow problem) or secondary erythrocytosis (bone marrow responding appropriately to stimulus to produce more RBCs).

Our patient’s EPO came back low and JAK2 mutation was detected, establishing a diagnosis of Polycythemia Vera!

Our patient’s CT chest demonstrated increased focal eccentric, hypoattenuating filling defects along the walls of the aortic arch and descending thoracic aorta with associated thin components extending into the aortic lumen, appearing to represent embolized thrombus (likely the etiology of his toe pain). Broad hypercoagulability workup was otherwise negative, favoring PV as most likely etiology for his hypercoagulable state!

Dr. Gopal taught us about Polycythemia Vera including its presentation and her approach to management. We learned that the goals of therapy are to prevent thrombosis, alleviate symptoms if present, and monitor for evidence of progression (post-PV MF/AML/MDS). To determine appropriate treatment, patient’s are stratified according to their risk of thrombosis as either low risk (Age ≤60 AND no history of thrombosis) or high risk (everyone else).

Our patient was considered high risk because of his history of thrombosis and was therefore started on hydroxyurea in addition to resumption of his aspirin and warfarin on discharge. He is scheduled for outpatient phlebotomy and bone marrow biopsy (as the presence of fibrosis may influence prognosis and treatment, even though not necessary for diagnosis in our patient)!

Thanks for a great case, Hillcrest!

11/9/23 VA Noon Teaching Conference – Cavitary Lung Lesions

For our NTC at the VA today, one of our star senior residents and rising chiefs Dr. Zoya Qureshy presented an interesting of a patient who she took care of on the BMT service. Patient has a history of MDS and underwent allogeneic stem cell transplant a little bit more than a year ago, presented with a month of intermittent fever, cough, and fatigue. After going through the initial data, our astute residents quickly asked for a chest CT given concerns of lung infection in our patient who may be immunocompromised. With the help of our awesome PCCM attending Dr. Lauren Sullivan, we went through our patient’s chest CT and saw multifocal cavitary lesions. Our residents split into small groups and came up with the DDx of cavitary lung lesions. Our patient underwent a broad infectious workup and a bronchoscopy with BAL sampling. One of his BAL galactomannan came back positive and our patient was treated for presumptive pulmonary aspergillosis. With Dr. Sullivan, we reviewed how to appropriately utilize BAL galactomannan as well as a basic approach to invasive aspergillosis.