NTC 11/29/22 — Multifocal Atrial Tachycardia

At noon teaching conference today, we discussed the case of a middle-aged woman with a history of pulmonary arterial hypertension, HFpEF, and severe OSA, who presented to the ED with URI symptoms and developed a tachyarrhythmia after receiving Duoneb. Her tachyarrhythmia was initially attributed to atrial fibrillation with rapid ventricular response, but on closer review of her EKG, she was actually found to be in multifocal atrial tachycardia!

We discussed a four-step approach to narrow QRS complex tachyarrhythmia: 1) assess patient stability, 2) determine if the QRS complex is narrow or wide, 3) determine if the rhythm is regular or irregular, and 4) closely evaluate the P waves. We then used this framework to discuss the differential for narrow QRS complex tachyarrhythmia: sinus tachycardia, focal atrial tachycardia, AVRT, AVNRT, atrial flutter, atrial fibrillation, and multifocal atrial tachycardia.

MOASC Spotlight on Hematology 1/28/23 in Huntington Beach

For anyone who’s interested in heme/onc, here’s a great nearby conference opportunity!

MOASC, in partnership with the UCI Hematology/Oncology Fellowship Program and Faculty, have organized a LIVE learning symposium, entitled Spotlight On Hematology on Saturday, January 28, 2023 at the Hyatt Regency in Huntington Beach. This symposium will cover timely updates in clinical practice, research & development, technology and drug advancements in the field of hematology.
Experts will discuss innovations in the diagnosis and management of complex hematologic topics, including highlights from a recent national hematology meeting.

Hematology/oncology fellows and internal medicine residents are invited to submit their original research to present during the Breaks and Reception.
Those interested should submit a 300-word abstract describing their research (case report, original basic science, prospective and retrospective clinical research) directly to Nichole East (neast@moasc.org) by Friday, December 16, 2022.
Selections will be notified soon after submission. Research will be presented via a poster format during the breaks and reception.

Here are the links for a tentative agenda and registration information: Agenda, Registration Info

You can email Nicole East anytime if you have questions about the conference!

11/29 VA NTC: Mystery Case

Today chief resident Erin Roberts walked our VA wards teams thru a mystery case presented by chief resident Alex Tong involving a young female with breast cancer history s/p mastectomy and chemotherapy presenting with fever, myalgias and shortness of breath. Our teams pair-shared and considered many differentials including infectious, inflammatory/autoimmune, malignant (including leukemia) and iatrogenic causes. As the case evolved, teams prioritized labs and imaging based on new data. We reached a pivot point with the CBC with diff which disclosed leukocytosis yet also anemia and thrombocytopenia, with a follow up smear disclosing abnormal myelocytes concerning for AML blasts in addition to RPNA showing rhinovirus. Kudos to our teams for considering the final diagnoses early on!

VA NTC 11/28: Syphilitic Tonsillitis

Today, Dr. Amy Guzdar presented a case of a man with recurrent tonsillitis and tonsillar mass, initially concerning for malignancy. However, on biopsy, the lesion was syphilis! We were joined by Infectious Disease Specialist, Dr. Sanjay Mehta, to discuss causes of oropharyngeal infections as well how syphilis is the “Great Imitator” of other diseases.

NTC 11/28/22 — Ankylosing Spondylitis

At noon teaching conference today, we discussed the case of a 44-year-old man who presented to continuity clinic with a twenty-year history of low back pain and was found on lumbosacral XR to have evidence of bilateral sacroiliitis, concerning for ankylosing spondylitis!

We discussed the differential diagnosis of chronic back pain (mechanical vs non-mechanical vs visceral) and indications to obtain imaging (red flag signs; radiculopathy not improving with conservative management; chronic pain and signs/symptoms/risk factors for malignancy, compression fracture, or inflammatory arthritis).

We also discussed signs and symptoms of spondyloarthritis (inflammatory back pain, asymmetric oligoarthritis, enthesitis, dactylitis) and the four main forms (ankylosing spondylitis, psoriatic arthritis, IBD-associated arthritis, and reactive arthritis). We discussed how first-line treatment of ankylosing spondylitis is scheduled NSAIDs.

NTC 11/21/22 — Deep Neck Space Infections

At noon teaching conference today, UCSD Infectious Disease specialist Dr. Cowell led us through the case of a 37-year-old man who presented with one week of left neck pain and swelling (three weeks after an episode of tonsillitis) and was found to have left parapharyngeal space infection 2/2 Fusobacterium necrophorum with bacteremia. CT and US of neck/neck vasculature showed no evidence of septic thrombophlebitis of the left internal jugular vein, the feared complication of Fusobacterium parapharyngeal space infection. He was treated with IV Zosyn with significant improvement in his symptoms and was discharged on Augmentin to complete a three-week course of antibiotics.

We discussed how deep neck space infections can be divided based on the anatomic spaces — defined by cervical fascia — that they occupy. The major spaces are the peritonsillar space, submandibular space, pretracheal space, parapharyngeal space, retropharyngeal and danger spaces, and prevertebral space. Deep neck space infections can lead to life-threatening complications involving structures neighboring these spaces, including airway obstruction (peritonsillar, submandibular [Ludwig angina], pretracheal), carotid artery mycotic aneurysm/erosion (parapharyngeal), septic thrombophlebitis of the internal jugular vein c/b septic emboli (parapharyngeal [Lemierre syndrome]), mediastinitis (danger space), and cord compression (prevertebral).

CPRS Outage

For unplanned CPRS outages, there is a read only version of CPRS. You can find this under SDC Shortcuts call Downtime VistA Read Only. This has the most recent labs and imaging reports and all notes. Orders can be handwritten, notes can be written in Microsoft Word printed for the night team and put into CPRS later. If you admit patients during an outage, the night time team does not put in orders overnight. The handwritten orders stand and are entered into CPRS in the morning by the admitting team. This is to reduce the possibility of mistakes. There is no alternative to SOCS but the ED usually has a list of pagers for the most important consultants: Surgery, Cards, etc.

Remember! You can always contact the Chief on Call for help during these times if you aren’t sure what to do!

FRIDAY SCHOOL 11.18.22

It’s our favorite time of the week again! FRIDAY SCHOOL! Today our interns learned about GI Bleeds from Dr. Kyle Geary.

The seniors started out with our Excellence in Quality Improvement and Patient Safety conference. Next we kicked off the Rheumatology block with a bang with lessons in Crystal Arthropathy and Systemic Vasculitis.

Both seniors and interns re-convened for an AHEAD (Advancing Health Equity and Diversity) session which was a thought provoking discussion about Reproductive Health in collaboration with our OB/Gyn colleagues [see below for article].

Noon Teaching Conference 11.15.22: TB or not TB, that is the diagnosis

Picture above is from https://www.nejm.org/doi/pdf/10.1056/NEJMicm2001934. A representative picture similar to this patient’s presentation.

Today, we talked about a fascinating patient who has suspected military tuberculosis AND military histoplasmosis. We were joined by Dr. Morgan Birabaharan (ID fellow and former UCSD PSTP resident). We discussed that about 15-20% of patients with military findings on imaging have both a fungal infection and tuberculosis. While the medications to treat these infections are complicated with serious side effects, the risk of not treating is very high.

Key Takeaways:

  1. Military TB needs to be treated or is uniformly fatal
  2. Common microbiological tests in patients with advance HIV can be unreliable and the index of suspicion needs to remain high
  3. Our Owen service is amazing!