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CHIEF RESIDENT BLOG

This blog is created and edited by your 8Mates chief residents! Our goal is to make the lives of our outstanding residents a little bit easier by highlighting key points from conferences, providing easy access to our latest wellness resources, and keeping all the pages on Medres up to date.

 

 

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Conference Pearls: Reagan Fresh Case on October 31st, 2018

Thanks Beth for presenting a "fresh case” last week! The patient presented with fevers and was found to have a large empyema. At the time of conference, we did not know the etiology of the empyema.


Following up on the clinical course…


The pleural fluid was found to grow Strep Anginosus! The patient was taken for a VATS procedure.


So… What is Strep Anginosus?


Strep Anginosus is part of the Strep Viridans group, and is often an odontogenic infection. This patient likely aspirated, causing a pneumonia and empyema.


Strep Anginosus tends to cause abscess formation, in a variety of locations. If you have bacteremia or localized infection with this species, make sure to look elsewhere (CNS, head and neck, lung, abdomen, etc) for abscess formation.


The preferred antibiotic of choice is ceftriaxone. However, mixed infections with anaerobes are common, so consider adding anaerobic coverage like metronidazole.

 

Conference Pearls: VA Morning Report on October 19th, 2018

Thanks to Adrian for bringing a case from Malawi and for the opportunity to learn about PCP and Kaposi Sarcoma.


Key points about PCP  

  • PCP classically presents with an indolent course of exertional dyspnea, mild fever, and non-productive cough. You may have a normal lung exam or hear basilar dry crackles. The CXR can be normal in 5-10% of cases (especially with a low CD4).
  • Treat PCP with Bactrim 15-20 mg/kg. It may take 5-10 days to see a response.
  • High mortality! 35-50% in HIV infected individuals.

Conference Pearls: Resident Reports on September 13th and October 18th, 2018

We had two really interesting cases on Adrenal Insufficiency this past month. Thanks to Monica and Liz for these cool cases and great learning.


A few key points from the cases:

  • Think of adrenal insufficiency with non-specific symptoms like nausea, abdominal pain, and fatigue, especially when paired with electrolyte abnormalities or orthostasis.
  • Differentiate primary from secondary adrenal insufficiency. In primary AI, hypoaldosteronism is present, while in secondary AI, aldosterone production is spared because of presence of the RAAS system.
  • In chronic AI, patients should be counseled on the 3 x 3 rule. Take 3 times the steroid dose for 3 days!

Conference Pearls: Reagan Resident Reports on September 6th, 2018

Thanks Azra for presenting a case of PE and going through a review of the management.

 

A few key points!

  • Use the PESI score to calculate 30 day mortality. The PESI score can help risk stratify patients into risk categories and guide management
  • The PEITHO trial studied patients with intermediate risk PE with regards to fibrinolytics. In this trial, fibrinolytics decreased hemodynamic decompensation but was associated with an increased risk of major hemorrhage and stroke.
  • Utilize our PERT Team! Page 87378 for patients with PE.
Conference Pearls: Reagan Resident Report on August 30th, 2018
Thanks Sam for an awesome resident report case on Nocardia Endocarditis, a rare diagnosis!
Here are some pearls to take with you:
  • Think of Nocardia in our immunocompromised patients!
  • Nocardia likes the lung (1), brain (2), and skin and lymph nodes
  • The mainstay of treatment is Bactrim
Conference Pearls: VA Morning Report on August 17th, 2018
Thanks Eric for a cool morning report case on Spinal Epidural Abscess! 
Some takeaways!
  • Get blood cultures AND more definitive needle aspiration before using antibiotics in lower risk patients (see algorithm below)
  • This is an often missed diagnosis: Common red flags missed are unexplained fever, focal deficits, and active infection


     

     

    Hospitalist Lecture: Reagan Noon Conference August 3rd, 2018

     

    Thanks for an awesome lecture by one of our core hospitalists (and former chiefs!) Dr. Faysal Saab on Inpatient Hypertension.

     

    Remember, there is new terminology for inpatient hypertension: Hypertensive emergency, Hypertensive Urgency, and Severe Uncontrolled Hypertension. Think hard about the risks and benefits before you treat Severe Uncontrolled Hypertension, it's probably not necessary!

     

    (AAFP)

     



     

     

    Chief Special: Santa Monica Noon Conference July 23rd and Reagan Noon Conference on July 24th, 2018

    Congrats to our winners of the Chief Specials, Team "Mystery Faculty" and "Casey n the Boyz"

     

     

    Top 5 Pearls from the Cases:

    • Post-Streptococcal GN has low C3, normal C4 due to preferential use of the alternative complement pathway
    • The shoulder-fat-pad sign is pathognomonic for amyloidosis
    • Think of Dengue with retro-orbital pain and the tourniquet sign
    • Hyperkalemia is a poor prognostic sign in Acute Digoxin Toxicity. Don't rely on Dig levels!
    • Alcohol induced bone pain and lymph node swelling could be a sign of Hodgkin's Lymphoma


     

    Conference Pearls: VA Morning Report on July 19th, 2018

    Thanks Rani for a very interesting case (and complete Zebra) presentation on a patient with pancreatitis due to ectopic pancreatic tissue in the stomach! During the case we had the opportunity to review pancreatitis, infectious diseases from Southeast Asia and Latin America, and gastric masses.

     

    Pancreatic Rest

    A “pancreatic rest” is ectopic pancreatic tissue, found in 2% of patients on autopsy. These have a tendency to become inflamed causing pancreatitis, and have a high likelihood of secondary infection. They are diagnosed on EGD.

     

    Gastric Mass Differential

    Benign

    • GrowthPeptic Ulcer Disease
      • Gastric epithelial polyp
      • Adenomatous polyp
      • Benign stromal tumor (leiomyoma)
      • Pancreatic rest
    • Menetrier’s Disease (Hypertrophic gastropathy)
    • Hematoma
    • Perforation/Abscess

     

    Malignant

    • Gastric adenocarcinoma
    • Gastric lymphoma (MALToma)
    • Gastric carcinoid
    • Leiomyosarcoma
    • Kaposi Sarcoma


     

    Conference Pearls: Reagan Resident Report on July 16th, 2018

    Thanks Michelle for an awesome resident report on a patient presenting with syncope. In a heart stopping (no pun intended) turn of events, the patient had AV block and was later found to have cardiac sarcoid!

    • In patients with syncope, think of your three broad categories: Reflex-mediated (most common), Cardiac (including arrhythmia and structural), Orthostasis
    • High value workup for syncope: A careful history and exam, orthostatics (immediate and delayed 3-5 minutes), and EKG. Only obtain a TTE if you have suspicion for structural heart defects.
    • Diagnose cardiac sarcoid with a cardiac-PET and by ruling out other diseases (sarcoidosis is a diagnosis of exclusion)
    • AV block has a very interesting differential.

    Slide courtesy of Michelle Chong


 

 

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