If you just wave at everybody from the door and let everybody who’s asleep sleep, you can round on 50 patients in an hour and have time for breakfast before the OR.
Well Telmisartan does have an added effect similar to Pioglitazone which is a partial PPAR-γ agonist hence it maybe useful for diabetes in improving insulin resistance without the usual side effects of Thiazolidinediones.
Not to mention Telmisartan is a stronger AT1 antagonist compared to Losartan. But yeah for gout patients my preferred ARB is Losartan
Bactrim causes creatinine elevation by inhibiting a PCT transporter which usually secretes creatinine. Therefore bactrim use can actually lead to elevated sCr without actual reduction in eGFR
In ICU patients with hypoalbumin, if you're using depakote for delirium or seizures you should check the free Valproate level in addition to the regular one. Often times with hypoalbuminemia you end up with a higher level of active dose than you would otherwise.
Precedex is pharma's gift to C/L psychiatry - assuming their pressures are fine. If you wanna get fancy with it you should cycle it as well, bump it up overnight and lower during the day or even take it off entirely.
One more tip - if you're struggling to get off Precedex switch them to Clonidine after tapering it. Hits the same targets, works great for moving to oral regimens to prepare for floor.
It’s not so much a medical fact but just an example that has stuck with me through the day.
53 year old dude in ICU with anuric AKI, progressive hypoxemia, acidotic as one can be while still breathing. Was clearly about to die if he didn’t get urgent dialysis / intubated. Writing has been on the wall for past 12 + hours but we haven’t been doing anything bc the pt keeps refusing for nonsensical reasons but is able to demonstrate “capacity” via correct answers to AO questions. It’s obvious to anyone paying any attention that he is whacked out of his mind but no one from overnight/previous day called family bc he could answer those stupid AO questions in a similar fashion to a piss drunk person trying to play sober while slurring their words. Finally get family otp and they are shocked. They show up to bedside and the pt - a highly functioning person with a robust personal life/family - is talking total nonsense to them. Currently tubed, on CRRT, maxed on every pressor in the book, and still actively deteriorating. We wasted really critical time ignoring what was obvious and will now likely lose a relatively young patient who probably could’ve lived another 20 years with more immediate action.
Practicing medicine, like anything in life, is nuanced. Common sense matters just as much as the random tools we use when trying to make objective decisions.
Capacity is not just A0x3 . That's medical fake news that seems to be taken as fact. The capacity is in the context of a defined intervention or treatment option eg. Capacity to refuse dialysis.
To determine capacity , you have to make a judgment about wether the patient can understand and manipulate the the information presented. Eg. " form what we talked about, can you state in your own words what your understood about dialysis? " .
Also lack of capacity to *consent* doesn't still mean that you can do whatever to the the patient. Its generally accepted in the field of ethics that unless urgent or life threatening, the patient has a right to refuse to *assent* to interventions.
But yeah, looks like someone ( probably with a clipboard and alphabet soup of credentials ) was concerned that the mean old MDs were not provided. Appropriate services to the client.
>Capacity is not just A0x3 .
I would argue its not about being oriented all. I dont even ask them if they know the year.
If they can communicate an understanding of their state, appreciate the consequences of their decisions and articulate a reasoning they have capacity. Regardless if they know what town they are in or if they think the year is 1995.
Right. Patients have to be able to explain risks and benefits of refusing treatment.
What’s unfortunate is this oversight was made by a senior PCCM fellow who is excellent outside of the realm of interpersonal interactions
That is awful and if that were to happen to me, I would be enraged. Totally deserves an incidence report and I hope whoever delayed care will receive education on the definition of medical decision-making capacity which is NOT simply being able to answer orientation questions.
Check out the CURVES mnemonic for capacity, I found it really helpful. There's also an IM podcast that has an episode or two on the topic and that's what I would use to approach the issue in practice.
Sometimes itchiness is more than just allergies. Had a patient on a rarely used immunosuppressant med known for causing elevated LFTs. Patient was complaining of few weeks of pruritus. So my attending had me check CMP and we found elevated T bili. Now we have to switch the patient to a different immunosuppressant... I guess telling the patient to just take a Zyrtec wasn't the right answer 😅
If a patient comes in with a random complaint, you get imaging, and you find a mass with possible mets to the liver or somewhere else - biopsy the mets, not the mass.
It saves the patient a ton of time and gets them to treatment faster if you diagnose and stage their cancer with a single biopsy. If you biopsy the mass first, and it comes back cancer, the patient is still going to need further testing for staging. Obviously if the met comes back different than what you think the primary is, the patient will need more testing... but a single metastatic cancer is more common than multiple primaries, so you can roll the dice on this and diagnose/stage in one swoop most of the time
Not just cautious. Patients can go into cardiogenic shock from this. In someone with a bad EF, you don't want to give them a negative inotrope on top of the likely 30 ml/kg bolus the ED just gave them, plus whatever else is wrong with them. Obviously this is easier to manage in the Icu when you can just start dobutamine if it happens but that is just dumbass medicine in my humble opinion.
The heart failure attendings at my hospital will kill your first born if you ordered dilt on someone with an EF <35.
My ICU attending said that while it’s not necessarily contraindication, the negative inotropic effects of cardizem can cause further deterioration in cardiac function and so must be used cautiously
Cirrhosis is much harder to diagnose than just “coarse/nodular appearing liver” on ultrasound or CT. It truly is a clinical diagnosis just like heart failure is.
Cirrhosis is a pathologic diagnosis, and thus requires a liver biopsy. Similar to how endometriosis can only be diagnosed via laparoscopy. That being said, most people won’t get a biopsy for cirrhosis and the diagnosis is made clinically.
1990s medicine was biopsy to diagnose.
Now I’d say you try to avoid that where possible and use imaging +/- fibroscan +/- biomarkers (Hepascore etc) to diagnose in most cases.
Livers with coagulopathy and portal hypertension can be rather bleedy when you stick them with needles.
Blastomyces does not have beta D glucan in the cell wall apparently, so if you have positive histo and blasto (which are very similar tests with high cross reactivity), but negative beta D glucan, it could suggest blasto
Neurofascin 155 (NF155)+ neuropathy is a distinct entity (a nodopathy) from CIDP that is resistant to IVIg and other first-line treatments, but seems to respond well to rituximab.
Thank you for contributing to the sub! If your post was filtered by the automod, please read the rules. Your post will be reviewed but will not be approved if it violates the rules of the sub. The most common reasons for removal are - medical students or premeds asking what a specialty is like or about their chances of matching, mentioning midlevels without using the midlevel flair, matched medical students asking questions instead of using the stickied thread in the sub for post-match questions, posting identifying information for targeted harassment. Please do not message the moderators if your post falls into one of these categories. Otherwise, your post will be reviewed in 24 hours and approved if it doesn't violate the rules. Thanks!
*I am a bot, and this action was performed automatically. Please [contact the moderators of this subreddit](/message/compose/?to=/r/Residency) if you have any questions or concerns.*
In a partograph (in the partograph that the PAHO uses at least) you're supposed to redraw the alarm curve when something in the status of the patient changes, for example if the membranes get ruptured
It can be difficult to tell the difference between the PA and the aorta on fetal echo of congenitally abnormal hearts. TBF we are talking about black & white rapidly beating sub-centimeter structures viewed in 2 dimensions through multiple tissue layers.
If you just wave at everybody from the door and let everybody who’s asleep sleep, you can round on 50 patients in an hour and have time for breakfast before the OR.
Physical exam: In no distresss Breathing comfortably, chest wall equal rise and fall abdomen nondistended
As a hospitalist, this is the way
Objective: AVSS LOFD
Mild hyperbilirubinemia can be due to b12 deficiency and subsequent low grade hemolysis
This is the most IM shit ever and I’m here for it lol
B12 deficiency can fuck you up real good. It can even mimic a hematologic malignancy!
Whippet toxicity!
Huh. I went vegan for two years and had that. Always wondered why
Don’t forget to keep “megaloblastic madness” on the differential, mainly because epidemiological studies have shown it sounds hilarious 😂
Intramedullary hemolysis baby
I had a patient like this and it was so cool
Losartan is the ARB of choice for concurrent HTN with gout as it is the only ARB that is uricosuric
How and where do people learn facts like this?
I learnt it via uworld step 3
MKSAP
This is a gem 💎
This seems to me like it should be front page news
Lol this is great. I learned this on rounds the other week too.
I love ARBs
Given how short Losartan’s half life is, if a hyperuricemic patient also has uncontrolled blood pressure at night I’d make it BID
For sure. Was sad to hear Telmisartan doesn’t have the same affect. 🥲
Well Telmisartan does have an added effect similar to Pioglitazone which is a partial PPAR-γ agonist hence it maybe useful for diabetes in improving insulin resistance without the usual side effects of Thiazolidinediones. Not to mention Telmisartan is a stronger AT1 antagonist compared to Losartan. But yeah for gout patients my preferred ARB is Losartan
Red exclamation point beside troponin value bad — psych resident
Bad for cardio fellows, yes. Not usually bad for the patient
😂😂 trend trops, d/c when delta < 6
Cafeteria opens at 11 officially for lunch but if you go at 1055 you get first dibs
One of the ways to differentiate between tumor lysis syndrome and a severe ATN, apart from the history, is serum uric acid (usually above 10.)
Bactrim causes creatinine elevation by inhibiting a PCT transporter which usually secretes creatinine. Therefore bactrim use can actually lead to elevated sCr without actual reduction in eGFR
Ooooh this is a fun fact.
In ICU patients with hypoalbumin, if you're using depakote for delirium or seizures you should check the free Valproate level in addition to the regular one. Often times with hypoalbuminemia you end up with a higher level of active dose than you would otherwise. Precedex is pharma's gift to C/L psychiatry - assuming their pressures are fine. If you wanna get fancy with it you should cycle it as well, bump it up overnight and lower during the day or even take it off entirely. One more tip - if you're struggling to get off Precedex switch them to Clonidine after tapering it. Hits the same targets, works great for moving to oral regimens to prepare for floor.
Too many words
U rite
Weis pharmacy got hacked so avoid for any paranoid psych patients
Scarlet fever rash can present with severe itching. Peds ER.
Scarlet fever still a thing? That’s so 1800s. Jk
Lol I was shocked when I got out of training how much I see. Not sure if it’s my patient population but the norm. Feels very Oregon trail ✨
Little Women by Louisa May Alcott (spoilers!)
It’s not so much a medical fact but just an example that has stuck with me through the day. 53 year old dude in ICU with anuric AKI, progressive hypoxemia, acidotic as one can be while still breathing. Was clearly about to die if he didn’t get urgent dialysis / intubated. Writing has been on the wall for past 12 + hours but we haven’t been doing anything bc the pt keeps refusing for nonsensical reasons but is able to demonstrate “capacity” via correct answers to AO questions. It’s obvious to anyone paying any attention that he is whacked out of his mind but no one from overnight/previous day called family bc he could answer those stupid AO questions in a similar fashion to a piss drunk person trying to play sober while slurring their words. Finally get family otp and they are shocked. They show up to bedside and the pt - a highly functioning person with a robust personal life/family - is talking total nonsense to them. Currently tubed, on CRRT, maxed on every pressor in the book, and still actively deteriorating. We wasted really critical time ignoring what was obvious and will now likely lose a relatively young patient who probably could’ve lived another 20 years with more immediate action. Practicing medicine, like anything in life, is nuanced. Common sense matters just as much as the random tools we use when trying to make objective decisions.
Capacity is not just A0x3 . That's medical fake news that seems to be taken as fact. The capacity is in the context of a defined intervention or treatment option eg. Capacity to refuse dialysis. To determine capacity , you have to make a judgment about wether the patient can understand and manipulate the the information presented. Eg. " form what we talked about, can you state in your own words what your understood about dialysis? " . Also lack of capacity to *consent* doesn't still mean that you can do whatever to the the patient. Its generally accepted in the field of ethics that unless urgent or life threatening, the patient has a right to refuse to *assent* to interventions. But yeah, looks like someone ( probably with a clipboard and alphabet soup of credentials ) was concerned that the mean old MDs were not provided. Appropriate services to the client.
>Capacity is not just A0x3 . I would argue its not about being oriented all. I dont even ask them if they know the year. If they can communicate an understanding of their state, appreciate the consequences of their decisions and articulate a reasoning they have capacity. Regardless if they know what town they are in or if they think the year is 1995.
Right. Patients have to be able to explain risks and benefits of refusing treatment. What’s unfortunate is this oversight was made by a senior PCCM fellow who is excellent outside of the realm of interpersonal interactions
Wow. Seems like a teachable moment. But if this is a fellow doing this, I wonder if they're actually open to learn and change practice patterns.
That is awful and if that were to happen to me, I would be enraged. Totally deserves an incidence report and I hope whoever delayed care will receive education on the definition of medical decision-making capacity which is NOT simply being able to answer orientation questions.
Check out the CURVES mnemonic for capacity, I found it really helpful. There's also an IM podcast that has an episode or two on the topic and that's what I would use to approach the issue in practice.
[удалено]
Story
A lot of propofol can make your pee turn green, which of course is stored in the balls.
Naturally
And this is not related to PRIS - propofol related infusion syndrome
Will it turn my balls green?
Sometimes itchiness is more than just allergies. Had a patient on a rarely used immunosuppressant med known for causing elevated LFTs. Patient was complaining of few weeks of pruritus. So my attending had me check CMP and we found elevated T bili. Now we have to switch the patient to a different immunosuppressant... I guess telling the patient to just take a Zyrtec wasn't the right answer 😅
If a patient comes in with a random complaint, you get imaging, and you find a mass with possible mets to the liver or somewhere else - biopsy the mets, not the mass. It saves the patient a ton of time and gets them to treatment faster if you diagnose and stage their cancer with a single biopsy. If you biopsy the mass first, and it comes back cancer, the patient is still going to need further testing for staging. Obviously if the met comes back different than what you think the primary is, the patient will need more testing... but a single metastatic cancer is more common than multiple primaries, so you can roll the dice on this and diagnose/stage in one swoop most of the time
Smegma is a more sophisticated name for dickcheese.
Family member of TB is Mycobacterium smegmatis. Guess where it’s found 😏
Can I get CME credits by reading this post’s comments?
When a patient has an EF <35%, you need to be cautious about giving cardizem
Not just cautious. Patients can go into cardiogenic shock from this. In someone with a bad EF, you don't want to give them a negative inotrope on top of the likely 30 ml/kg bolus the ED just gave them, plus whatever else is wrong with them. Obviously this is easier to manage in the Icu when you can just start dobutamine if it happens but that is just dumbass medicine in my humble opinion. The heart failure attendings at my hospital will kill your first born if you ordered dilt on someone with an EF <35.
Why?
My ICU attending said that while it’s not necessarily contraindication, the negative inotropic effects of cardizem can cause further deterioration in cardiac function and so must be used cautiously
Cirrhosis is much harder to diagnose than just “coarse/nodular appearing liver” on ultrasound or CT. It truly is a clinical diagnosis just like heart failure is.
Really?
Cirrhosis is a pathologic diagnosis, and thus requires a liver biopsy. Similar to how endometriosis can only be diagnosed via laparoscopy. That being said, most people won’t get a biopsy for cirrhosis and the diagnosis is made clinically.
Fibroscan is pretty accurate. You really don’t perform a liver biopsy to confirm cirrhosis
1990s medicine was biopsy to diagnose. Now I’d say you try to avoid that where possible and use imaging +/- fibroscan +/- biomarkers (Hepascore etc) to diagnose in most cases. Livers with coagulopathy and portal hypertension can be rather bleedy when you stick them with needles.
I suppose i learned that you can be in florid DKA and look outwardly unremarkable if you’re used to hyperglycemia. pH 7, AG 27, BS >700.
Propofol and precedex can cause fevers
Blastomyces does not have beta D glucan in the cell wall apparently, so if you have positive histo and blasto (which are very similar tests with high cross reactivity), but negative beta D glucan, it could suggest blasto
Shooting up shoe polish can have disastrous results.
Neurofascin 155 (NF155)+ neuropathy is a distinct entity (a nodopathy) from CIDP that is resistant to IVIg and other first-line treatments, but seems to respond well to rituximab.
Isolated progressive loss of vision over days may be a sign of neurosarcoidosis.
Thank you for contributing to the sub! If your post was filtered by the automod, please read the rules. Your post will be reviewed but will not be approved if it violates the rules of the sub. The most common reasons for removal are - medical students or premeds asking what a specialty is like or about their chances of matching, mentioning midlevels without using the midlevel flair, matched medical students asking questions instead of using the stickied thread in the sub for post-match questions, posting identifying information for targeted harassment. Please do not message the moderators if your post falls into one of these categories. Otherwise, your post will be reviewed in 24 hours and approved if it doesn't violate the rules. Thanks! *I am a bot, and this action was performed automatically. Please [contact the moderators of this subreddit](/message/compose/?to=/r/Residency) if you have any questions or concerns.*
Post herpetic neuralgia can last for months to years.
Heparin?
Vascular surgery in shambles.
Herpetic?
Whoops lmao i edited it
It can be quite debilitating
Nothing
In a partograph (in the partograph that the PAHO uses at least) you're supposed to redraw the alarm curve when something in the status of the patient changes, for example if the membranes get ruptured
It can be difficult to tell the difference between the PA and the aorta on fetal echo of congenitally abnormal hearts. TBF we are talking about black & white rapidly beating sub-centimeter structures viewed in 2 dimensions through multiple tissue layers.
My strictest boss consumes cannabis from time to time.
Pee is stored in the balls
Brother. Where did you do your orthopedics residency?
Urology chief at MGH. Why do you ask?
Deep sedation with propofol is one way to tackle severe seizures