Saturday, December 21, 2013

December Snow Week!

Ol' Blue 

It's all melted now, but it was fun while it lasted.
One morning, Sarah's Subaru got stuck on the berm that the plow made between street and driveway but Ol'Blue made it and got her to work despite its two wheel drive. Think it was a combination of pure snow tires and a bit more clearance.
View image
© 2013 Dropbox

Monday, November 4, 2013

UTI's in the Elderly

Treatment of asymptomatic bacteriuria is not appropriate for the following populations: women (premenopausal, nonpregnant), diabetics, the elderly, nursing home residents, or patients with spinal cord injury or indwelling urethral catheters.
 
"Bacteriuria in a population sample of women: 24-year follow-up study. Results from the prospective population-based study of women in Gothenburg, Sweden"
Bengtsson C, Bengtsson U, Björkelund C, Lincoln K, Sigurdsson JA
Scand J Urol Nephrol. 1998;32(4):284.
 
So don't screen these women in the first place, and if you find bacteria, don't treat because it doesn't reduce recurrence, perhaps recurrence with a symptomatic strain. It may also lead to antibiotic resistance.

Haldol for delirium

Delirium is an altered mental status that is transient by nature, acute in onset, and can be caused by etiologies in 12 different categories.
drug intoxication , drug withdrawal, metabolic/endocrine disturbance, TBI, seizures, intracranial infection, systemic infection, intracranial neoplasm, systemic neoplasm, cerebrovascular disease, organ insufficiency, other CNS disorders, other systemic diseases.
 
Because I had a patient with delirium, I read two articles about the pharmacological treatment of it.
 
 
"Efficacy and safety of haloperidol versus atypical antipsychotic medications in the treatment of delirium"
Yoon et all
Found that haldol, risperidone, olanzapine, and quetiapine were equally effictive in improving the symptoms of delirium.
Patients over 75 did not respond as well to olanzapine.
Weaknesses of the study include that there was no placebo, no randomization, high dropout rate.
 
 
"Pharmacovigilance in Hospice/Palliative Care: Net Effect of Haloperidol for Delirium"
Crawford et all
119 participants, all on hospice with significant age or poor physical functional status.
Mean dose of 2.1mg/day
1 in 3 patients experienced benefit at 48hrs after starting haldol.
 
 
 
 

Prevention of Contrast-Induced Nephropathy: An Overview by Ellis and Cohan

Be especially careful in patient with GFR less than 60.
AKI
CKD
 
 
1. reduce dose
2. no clear evidence for low osmolality agents yet, maybe soon
Also consider carbon dioxide for vascular studies
3. pre-hydrate with IV fluids
4. weak evidence for N-acetylcysteine 600mg BID for two days before
5. hemodialsis vs hemofiltration, may work, but only in exceptional circumstances
 
 

Sunday, October 27, 2013

The Early Diagnosis of the Acute Abdomen by Sir Zachary Cope

A classic I've heard. Will summarize each chapter here to help me remember the key points.

1. The Principles of Diagnosis
Need to make a diagnosis because an "acute abdomen" = "surgical abdomen" and often requires surgery. Making the diagnosis early is often advantageous. 
Localization of inflammatory lesions is aided by knowledge of anatomy (think referred pain, innervations, rigidity in proportion to somatic innervation, etc)
Localization of obstructive lesions is aided by knowledge of physiology. Distension causes pain. Pain is mid-line until peritoneal nerves are directly irritated.
Exogenous steroids can diminish inflammation and thus mask early signs of peritonitis.

2. Method of Diagnosis: the history
Have a routine
I. chronology (time and mode of onset(acute vs. insidious))
II. pain (onset, distribution, and the seven characteristics)
III. anorexia is usually very significant
IV. nausea
V. vomiting is due to irritation of peritoneum or mesentary OR obstruction of an involuntary muscular tube. In obstructions, the onset of vomiting relative to pain can help localize proximity of the blockage. Is there bile in the vomit? Feculent vomit is pathognomonic of distal jejunal obstruction.
VI. bowels can be constipated, diarrhea common sign of appendicitis in children. Watery diarrhea with partial small bowel obstruction.. Blood or mucus in the rectum is suspicious for intussusception.
VII. menstruation history to rule out ectopic pregnancy
VIII. previous illness

3. Method of Diagnosis: the examination of the patient
I. general appearance: watch the patient quietly, observe the attitude in bed (restlessness from colic vs. immobility in peritonitis)
II. pulse: changes only in late disease
IIa. BP: drops late in shock
III. respiration rate: goes up late in abdominal disease, early if thoracic disease.
IIIa. chest: 
IV. temperature: high fever is unusual during early stages of abdominal disease except for severe pancreatitis.
V. abdomen: inspect, movement on respiration, palpation, percussion. Rigidity can be absent in the elderly. Hyperesthesia is not a useful diagnostic sign.
VI. Iliopsoas test
VII. liver: percussion can expose free peritoneal air if dullness is missing
VIII. rectal exam: test for tenderness against pelvic peritoneum. Don't forget to use stoma if patient has one.
IX. thigh rotation test
X. spine: 

4. Method of Diagnosis: the grouping of symptoms and signs
I. Abdominal pain by itself
II. Central abdominal pain: examine the patient again in 2-3 hours (don't forget about glaucoma)
III. Severe central pain with shock: acute pancreatitis, ruptured aortic aneurysm, dissecting aneurysm, mesenteric thrombosis, splenic rupture, ectopic pregnancy rupture.
IV. Pain with vomiting and increasing distention but no rigidity: intestinal obstruction
V. Abdominal pain with constipation, increasing distention, and little or know vomiting: large bowel obstruction, uremia, lead poisoning. In infants remember pneumococcal peritonitis, intussusception (barium enema).
VI. Severe abdominal pain with collapse and general rigidity of the abdominal wall: visceral perforation, 
- RUQ pain and rigidity: acute cholecystitis, leaking duodenal ulcer, amebic hepatitis
- LUQ pain and rigidity: acute pancreatitis, perforated gastric ulcer, inflamed jejunal diverticulum, splenic artery aneurysm, splenic rupture, and leukemia?
- RLQ pain, tenderness, and rigidity: acute appendicitis, pancreatitis, gallbladder, duodenum, kidney, ileocecal lymph nodes, meckels diverticulum, lileitis, retained testis, fallopian tube, ovary (chapter 7).
- LLQ pain, tenderness, and sometimes rigidity: diverticulitis of the left colon, crohns, acute pyelitis, left pleurisy.
- Hypogastric pain and rigidity: perforated inflamed appendix, perforated sigmoid diverticulum, uterus, fallopian tubes, ovaries

5. Laboratory and Radiological Tests
CT is the imaging of choice for
  1. appendicitis
  2. perforation
  3. pancreatitis
  4. diverticulitis
  5. abscess
  6. aortic aneurysm and rupture
  7. renal colic
HIDA for cholecystitis after ultrasound

Ultrasound for
  1. aortic aneurysm
  2. fuptured ovarian follicle
  3. ectopic pregnancy
  4. tubo-ovarian abscess
Plain X-ray or X-ray with contrast for
  1. perforation
  2. intestinal obstruction
  3. intestinal inflammation
6. Appendicitis
Often significant inflammation before symptoms are noticed.
Appendix can be in different locations leading to different presentations.
  • ascending
  • iliac (appendix above the brim of the true pelvis)
  • pelvic (appendix below the brim of the true pelvis) has less rigidity if any upon perforation and the pain stays epigastric for longer.
  • retrocecal is when pain is felt later and often starts localized
History
Indigestion, gastritis, flatulence.
Irregular bowel movement.

Signs and Symptoms
  1. Pain often referred at first to epigastric or umbilical region, sometimes more like tenesmus.
  2. Anorexia, nausea, and vomiting a few hours after initial pain. If patient is hungry, doubt the diagnosis of acute appendicitis.
  3. Local tenderness comes late, try percussion and DRE.
  4. Hyperesthesia is inconstant
  5. Rigidity of abdominal muscles over inflamed area. Watch to see if moves with respiration. Pelvic appendix will not cause rigidity.
  6. Fever develops before 24 hrs have passed. 
  7. Constipation and/or diarrhea.
  8. Pulse acceleration corresponds to peritonitis or 
  9. Distention of the cecum can be present due to adynamic ileus. 
  10. Testicular symptoms 
Order of Occurrence of the Symptoms
  1. Pain
  2. anorexia, nausea, or vomiting
  3. tenderness
  4. fever
  5. leukocytosis
Diagnosis after perforation is due to accentuated pain and renewed vomiting. 


7. The Differential Diagnosis of Appendicitis

The pain part
  • Influenza
  • Diaphragmatic pleurisy
  • Spinal disease
  • Typhoid fever
  • Acute porphyria
  • Gastroenteritis
  • Infectious hepatitis
  • Diabetes with DKA
The peritonitis part
  • Intestinal obstruction
  • thrmbosis or embolism of mesenteric vessels
  • acute pancreatitis
  • pneumococcal peritonitis
  • Pyelitis
  • general peritonitis (from ruptured ulcers)
Things that mimic a perforating or perforated ascending appendix
  • cholecystitis
  • inflamed duodenal ulcer
  • pyelonephritis
  • hydronephrosis
  • pyonephrosis
  • kidney/ureter stone
  • perinephric disease
  • omental torsion
Differential of inflamed iliac appendix (this one should be easiest)
  • perforated duodenal ulcer (look for free air because free air is almost never present in acute appendicitis
  • Crohn disease
  • Carcinoma
  • Ureteral stone
  • Meckel diverticulum
  • Ruptured or bruised right rectus muscle
  • cecal ulcer

Differential diagnosis for pelvic appendix.

A) Male
  • large bowel obstruction
  • ileal obstruction
  • diverticulitis
  • typoid ulcer perforation
  • stone in ureter
  • gastroenteritis
  • pelvic abscess
B) Female
  • Dysmenorrhea
  • ectopic pregnancy
  • twisted pedicle, rupture of ovarian cyst, torsion of ovary
  • inflamed fibroid
  • hydrosalpinx
  • salpingitis or pyosalpinx
  • endometrioma rupture

8. Diverticulitis 
Pathogenesis
Fecolith obstructs lumen, usually in sigmoid

Symptoms
hypogastric pain
anorexia, nausea, vomiting
shift of pain and tenderness to left iliac fossa
diarrhea
fever and leukocytosis
mass in left iliac fossa

Secondary intestinal obstruction
can happen from acute diverticulitis
usually small bowel

9. Perforation of a gastric or duodenal ulcer
Early, intermediate, and late stages of symptoms
things get better around 12 hours into the pain, don't fall into the trap!

Differential diagnosis
  • severe colic (biliary or renal)
  • pneumonia or pulmonary infarction
  • gastric crises of tabes dorsalis
  • acute pancreatitis
  • acute perforative appendicitis
  • acute intestinal obstruction
  • ruptured ectopic pregnancy
  • dissecting thoracic or ruptured abdominal aortic aneurysm
  • general or diffuse peritonitis
  • postemetic rupture of esophagus
  • mesenteric embolus or thrombosis

10. Acute Pancreatitis
Etiology
EtOH
Gallstones
trauma
hyperlipidemia
hyperparathyroidism --> hypercalcemia
thiazide diuretics

Signs and symptoms
  • Pain
  • vomiting or retching
  • fever
  • Tenderness
  • rigidity is not constant
Signs from pancreatic edema
palpable
jaundice
obstructive vomiting


Signs from extravasation of blood
ecchymosis (Turner sign and Cullen sign)

Labs
hyperglycemia
glycosuria
amylase
hyperlipidemia
albuminuria


11. Cholecystitis and other causes of acute pain in the RUQ
Usually...
  • cholecystitis
steady pain, subsides over 4-6hrs, 
chronic hydrops of gallbladder may form after impaction of stone in duct
jaundice may be transient if stone passes
Signs and Symptoms
Pain often midline, unrelenting constant, 
Anorexia/nausea/vomiting
Jaundice
Fever, very high temps likely to be cholangitis
Palpable gallbladder
Tenderness and rigidity

Acalculous cholecystitis is most often observed when patient is one TPN

  • biliary "colic"

  • duodenal ulcer
Pain comes 2.5 hrs after meals
Retroperitoneal perforation mimics renal problems, because there can be increased micturition and even hematuria. Also CVA tenderness.
  • hepatitis
Tenderness all over the liver, including the lateral aspect.


but must rule out...
  • appendicitis
  • renal pain or colic
  • MI and angina pectoris
EKG
Tropins
  • pleurisy or pneumonia
high fever
initial rigor
pain on top of right shoulder
hemoptysis



12. Acute abdominal lesions in left hypochondrium
fundus of stomach
- rare to have perforated ulcer in the fundus

spleen
- rupture, think sickle cell, may be friction rub
- splenic artery aneurysm, watch for in pregnant women, 

pancreas tail
- acute pancreatitis

splenic flexure of colon
- carcinoma
- stricture
- diverticulitis

upper pole of left kidney
- perinephric abcess more dangerous on left side because inflammation can go up to diaphragm. Irregular fever, 

Aorta
- aneurysm

Jejunum
- jejunal diverticulitis, watch for flatulence, borborygmi, and diarrhea. 


13. The Colics
Tubes that we have to consider contracting against resistance are:
- Stomach
- Small bowel from entereitis or obstruction OR lead poisoning. Epigastric region, vomiting
- Cystic, hepatic, and common bile ducts (rule out acute porphyria)
- Gallbladder
- Pancreatic duct (duct of Wirsung)
- Colon refers to hypogastrium, constipation, colitis, sysentery, stricture
- Ureters, pain can refer to testicle/vulva, check for phyeresthesia, vomiting frequent, 
- Uterus, dysmenorrhea
- Fallopian tubes

They all have spasmodic pain, associated with sympathetic NS symptoms (pallor, weak pulse, vomiting, low temp). Restless patients don't want to remain still. 


14. Acute Intestinal Obstruction
a) strangulated hernia
b) adhesions
c) intussusceptions
     C1) ileocecal inussusception in kids
d) cancer
e) volvulus
     e1) volvulus of stomach is rare, elderly people, vomiting and then continued retching, no bile comes out, steady pain, associated with paraesophageal hiatal dephragmatic hernia.
f) pyloric stenosis (kids)
g) atresias and annular pancreas (kids)

Symptoms
Pain
Vomiting occurs sooner the higher up the obstruction, colonic obstruction may only result in nausea and anorexia
Constipation not always evident at first. Diarrhea is very common in partial obstruction. Flatulence is rare in both.
Distention occurs very late, more distal = more distended.
Tenderness after distention.
Rigidity is unusual.
Peristalsis visible in skinny patients.
Borborygmi can rule in, but its absence cannot rule out.
Shock late, you missed the diagnosis.


Differential includes:
- (distention absent) renal colic, biliary colic, gastric crisis.
- (distention present) uremia, mesenteric thrombosis/embolism, peritonitis.

Diagnose with:
- plain films vertical and decubitus


Colonic obstruction presents differently depending on competence of ileocecal valve. If incompetent, then looks similar to SBO on radiography.
70% colon cancer. Early symptoms include diarrhea, blood, mucus.
Then later constipation that gradually increases.
10% volvulus possible at ileocecal region and sigmoid region.
5% diverticulitis
?% fecal impaction

Differential includes:
- colitis with distention (toxic megacolon)
- uremia
- peritonitis
- reflex paralysis of colon vs adynamic ileus (opioids) vs colonic ileus


15. Intussusception and other causes of obstruction

16. The early diagnosis of stragulated and obstructed hernias
17. Acute abdominal symptoms due to vascular pathology
18. Acute abdominal symptoms in women
19. Early ectopic gestation
20. Acute abdominal disease with genitourinary symptoms
21. The diagnosis of acute peritonitis
22. The early diagnosis of abdominal injuries
23. The postoperative abdomen
24. The acute abdomen in the tropics
25. Diseases that may simulate the acute abdomen
26. Acute abdominal pain in the immunocompromised patient
27. Abdominal catastrophes when sensation is impaired


Didn't have time to take notes on these last chapters as medicine starts tomorrow morning and it's time to go to bed. Was a bit rushed because this book is due back at the library tomorrow.





Friday, October 11, 2013

Nephrology Elective

Again, a sample of some articles I read, and some commentary on some things I learned.

Venous and Arterial Thrombosis in Dialysis Patients by Ocak et all, 2011
Dialysis patients have clearly elevated risks of venous thrombosis AND arterial thrombosis.

Prevalence of thrombophilic mutations in patients with unprovoked thrmboembolic disease. A comparative analysis regarding arterial and venous disease by Mandal E et all, Hippokratia 2012, 16, 3: 250-255.
Concluded that primary thrombophilic states (mutations) lead to not only venous thrombotic events but also arterial thrombotic events.

Then two great articles on preeclampsia of all things. I did a presentation on this during my first week and actually found it to be quite interesting. 

I've decided to keep the articles that I read for professional learning in refworks folders, and use this blog just to keep track of the books that I read. Refworks is a bit more searchable and links directly to my university library that subscribes to the medical journals so that I can get PDF texts when I need them. 

Next up, basic science, then I start medicine at Highland.

Saturday, October 5, 2013

GI Consult Elective

I'll summarize some of the things I read for this elective below. 
Otherwise, I spent my days doing new consults and following up on my old consults. I learned a whole bunch and became clearer in my head that I'm not really drawn toward the procedural side of medicine. GI specialists know a lot of medicine but they are also technically adept at using endoscopes and all the tools that you can put on those scopes these days.


"Long-Term Colorectal-Cancer Incidence and Mortality after Lower Endoscopy" by Reiko Nishihara et all, NEJM 9/19/13

Colonoscopy and sigmoidoscopy are associated with a reduced incidence in left sided distal colon cancer. Right sided or proximal colon cancer is not reduced as much by colonoscopy, a fact that we learned last year. The polyps and other precancerous lesions are much more difficult to see in the right colon due to a different genetic mutation pathway. Cancers that pop up between colonoscopies are likely to have the "serrated pathway" mutations.


"American College of Gastroenterology Guideline: Management of Acute Pancreatitis" by Scott Tenner et all, 7/30/13

- Mild Acute Pancreatitis is self-limiting, does not have organ failure and/or pancreatic necrosis. Patients start eating again within 48hrs.
- Moderately Severe Acute Pancreatitis has local complications (fluid/necrosis) and/or transient organ failure (<48hrs).
- Severe Acute Pancreatitis has two phases:
  1. early (first week) has SIRS and/or organ failure.
  2. late (after the first week) characterized by local complications (peripancreatic fluid/necrosis/pseudocysts)
Diagnosis
1. Two of three criteria
     i) abdominal pain (epigastric or LUQ, constant, radiates to back, chest, or flanks)
     ii) serum amylase (rises in hours, falls in days) and/or lipase (more specific, stays elevated longer)greater than 3X the upper limit of normal
     iii) characteristic findings from abdominal imaging
2. CT and MRI should be reserved for patients who fail to improve clinically within the first 48-72hrs after hospital admission.

Etiology
1. Ultrasound on everybody to rule out gallstones.
2. History of EtOH (need 5 years of heavy drinking? If no, check serum triglycerides.
3. In patients older than 40yo, tumor should be considered.

Initial Assessment and Risk Stratification
1. Assess hemodynamic status.
2. Assess risk (age, obesity, mental status, comorbidities, SIRS, Labs, imaging)
3. If signs of organ failure, admit to ICU

Initial Management
1. Aggressive hydration (250-500mL/hr) is most beneficial during the first 12-24hrs. LR might have some advantages because prevents the hyperchloremic non-anion gap metabolic acidosis that is possible with large volumes of normal saline.

ERCP
do it within 24hrs of admission if cholangitis is sure.
don't do it if there is no evidence of obstruction
MRCP if no jaundice or cholangitis
use stents and NSAID suppositories after ERCP

Antibiotics
Give for extrapancreatic infection.
No role for prophylactic antibiotics
Carbapenems, punolones, and metronidazole penetrate pancreatic necrosis.

Nutrition
Start oral feeding asap when nausea and vomiting resove
Enteral nutrition better than parenteral if PO route not available.

Surgery
cholecystectomy before discharge unless necrotizing in whic case wait until inflammation subsides.




Persistence of Nondysplastic Barrett's Esophagus Identifies Patients at Lower Risk for Esophageal Adenocarcinoma: Results from a Large Multicenter Cohort by Srinivas Gaddam et all





Cyclic Vomiting Syndrome and Abdominal Migraine in Adults and Children by Randolph W. Evans and Chad Whyte
CVS is 5 separate attacks, episodic, stereotypical, vomiting, symptom free between attacks, not attributable to another disorder.
Epidemiology
2% of children
headache/migraine history
slight male predominance

Clinical Features
Four phases to each episode:
  1. well phase without symptoms
  2. prodrome with pallor, sweating, and nausea
  3. intense vomiting
  4. recovery phase
Pathophysiology
similar to migraines, periaquaductal grey matter, autonomic dysfunction.
"brain-gut" disorder mediated by the neuroendocrine system as evidenced by ACTH, ADH, cortisol, and other endocrine substances that rise in serum. CRF is stimulated by stress in the hypothalamus and it leads to delayed gastric emptying due to inhibiting the dorsal motor nucleus of the vagus nerve. TCAs inhibit the promoter activity of the CRF gene, and thus efficacious in treating CVS.

Differential Diagnosis
acute illness causes of nausea and vomiting.

Treatment
Supportive measures (hydration, electrolytes, quiet, dark, ondansetron, benzodiazepines, diphenhydramine.
Sumatriptin can be taken upon onset of episode.
Abortive agents include NSAIDS (ketorolac) and opioids.
Treatment with amitriptyline, venlafaxine

Prognosis
CVS resolves in many children by teenage years. 86% of adults are cured with TCAs.


abdominal migraines 
Epidemiology
slight femal predominance
5-15 years old

Clinical Features
Recurrent , episodic attacks of abdominal pain with associated nausea, vomiting, and or lethargy lasting as long as migraines.
Periumbilical pain.
Often premonition.

Pathophysiology
unknown

Differential Diagnosis
other causes of abdominal pain

Treatment
treated with prochlorperazine and eletriptan
avoid triggers, dietary management
IV valproate
Pizotifen, flunarizine
Propanolol, cyproheptadine.




I also read a whole bunch of textbook chapters from MD Consult, and learned a lot about diarrhea. I am starting to realize that information technology has changed medicine more quickly than the training can keep up with. As a medical student, I am able to become an expert on tiny pieces of medicine relatively quickly in a way that would not have been possible 10 years ago. It makes me think that the fragmentation of care is not really necessary. Why can't a family doctor refer a complicated patient to herself and spend the 3 or 4 hours that are required to access the detailed information about the complex management necessary. That same 3-4 hours will be spent by a slew of specialists who will use the very same resources (or likely have memorized them) to come up with the same answer. It seems to me that family doctors should have yearly exams, rotating through all of the traditional specialties each year, open book, to ensure that they are on top of their game, because they must recognize and diagnose diseases of every organ system. Better yet, patients should start out at specialists (knee pain, go to an orthopedic specialist) and then get referred to family doctors for management of complex, multiorgan/biopsychosocial challenges. Pay scales should be revered accordingly because specialists will actually need much less training than generalists. Training for specialties can be substantially shortened by skipping all the generalized stuff at the beginning. Technical wizardry would be mastered much more quickly just out of high school so why not get those same folks before they "waste their time" learning how to talk about feelings with their patients.


Sunday, September 15, 2013

Primer of Palliative Care, 5th edition, by Timothy E. Quill et all

Read this book during my Palliative Care elective

1. Introduction

"The goal of palliative care is to prevent and relieve suffering, and to support the best possible quality of life for patients and their families, regardless of the stage of the disease or the need for other therapies". 

Hospice can be added on top of palliative care if the end of life is near, and focuses exclusively on caring, not curing.

2. Pain Management
Define what is causing the pain as precisely as possible.
Identify other limitations such as
  • Renal insufficiency: (use methadone or fentanyl). Avoid morphine and codeine.
  • Hepatic insufficiency: requires more caution with fentanyl, hydromorphone, oxycodone, and methadone. Avoid morphine.
  • Cost: methadone is the most efficient.

Add a prn that is about 10% of daily dose for breakthrough pain.

Opioid Caveats:
  1. Respiratory depression is almost always preceded by sedation.
  2. Constipation should be anticipated and treated prophylactically.
  3. Nausea normally resolves after a few days.
  4. Sedation is common in the beginning just like nausea.
  5. Myoclonus means time to try another opioid or add a benzo.
  6. Delirium must be analyzed carefully as the cause is usually multifactorial.
  7. Urinary retention
  8. Addiction
  9. Pseudoaddiction is iatrogenic syndrome that mimics addiction behaviors due to inadequately treated pain.
  10. Physical dependence is a physiologic withdrawal syndrome.
  11. Tolerance is a state of adaptation.
3. Dyspnea
Treated most effectively with opioids. Second line is anxiolytics such as benzodiazepines. Corticosteroids can also be used to reduce airway inflammation and edema.
Respiratory secretions can be treated with atropine eye drops, scopalamine patch, glycopyrrolate IV or SC.



4. GI symptoms
The most important thing I learned from this chapter is that feeding tubes do not reduce aspiration events. That seems to go against what most doctors assume.
Also learned that IV fluids rarely reverse the circulatory shutdown at the end stages of illness and can potentially cause fluid overload, particularly as renal function worsens.

The anti-nausea drugs used in palliative care are quite effective.
Haloperidol for nausea caused by metabolites (liver failure, renal failure, tumor products)
Dexamethasone for raised ICP.
Meclizine for vestibular disease (H1 blocker, acts at CTZ?)
Octreotide especially if co-exists with bowel obstruction.


4D. Bowel obstruction causes pain, nausea, and vomiting. In palliative care we go straight for the symptoms.
Pain treated with Glycopyrrolate is antimuscarinic, Hyoscyamine is another antimuscarinic. Celiac plexus block is last resort.

4E Constipation.
Increase fluid and fiber (psyllium, methylcellulose) intake.
Stool softeners = detergent laxitives = docusate sodium
Stimulants = Senna and Bisacodyl
Osmotic agents (8) = glycerin, sorbitol, lactulose, polyethylene glycol, milk of magnesia, magnesium citrate, sodium phosphate.
Enemas (5) = warm water, saline, mineral oil, milk and molasses, soap suds.
Prune juice, 
Metoclopramide
Methylnaltrexone is mu opioid receptor antagonist
Lubiprostone is chloride channel activator


5. Delirium, Depression and Anxiety, Fatigue, and Spirituality

Delirium = Encephalopathy = an acquired syndrome of disordered consciousness and cognition that develops over a short period of time and fluctuates during the course of the day. Can have different levels of psychomotor activity. Polypharmacy in up to 60% of hospitalized patients. Second most common cause is metabolite build up. Third is infection. Then a bunch of other less common causes. 
First treat the underlying cause if possible. Treat symptoms with haldol or other antipsychotic. Benzos can cause paradoxical agitation. Ritalin can be used for hypoactive delirium.

It seems important to differentiate 
loss of hope, 
loss of meaning, 
loss of value, 
loss of relationship. 
For each of these feelings, acknowledge, explore, legitimize, empathize.

How to take a spiritual history: SPIRIT
- Spiritual belief system
- Personal spirituality
- Integration in a spiritual community
- Ritualized practices and restrictions
- Implications for medical care
- Terminal events planning

Dignity Therapy is "a therapeutic intervention aimed at alleviating suffering and depression and helping patients find and reshape meaning and dignity".
  • Most important accomplishments and what do you feel most proud of?
  • Words or instruction for your family to help them prepare for the future?
  • Any particular things you still need to say to your loved ones?
6. Goal setting, prognosticating, and Self-Care

Six steps to establishing patient centered goals
  1. Prepare and plan by identifying stakeholders and have pre-meeting huddle to align agenda with those concerned.
  2. Find out what the patient and family know and how much they want to know.
  3. Review what the medical teams know and fire a warning shot. Discuss prognosis and benefits and burdens of treatment options. Pause frequently to check for understanding.
  4. Respond empathetically after you have delivered the news. Listen more than talk. 
  5. Identify and resolve conflicts. Use "I wish" statements.
  6. Elicit values and preferences in order to establish patient-centered goals. Be prepared to make a recommendation. Summarize the meeting, establish plan, follow-up.

7. Last-Resort Options 

Proportionate Palliative Sedation
"If rapid sedation to unconsciousness is felt to be the best approach because of the patient's unique clinical circumstances, then it is critical to have experts in palliative care and ethics involved before initiation to ensure all other approaches have been fully considered and the circumstances warrant the intervention.

Ventilator Withdrawl

Requests for "hastened death"

8. Care during the last hours of life








Pediatrics flash lessons learned

"Does This Child Have Acute Otitis Media?" R Rothman et all
Otitis media costs about $5billion a year. 
Happens most in kids 6-18months old.
Breast feeding is protective.
S. pneumoniae, H. influenza (often co-existing conjunctivitis), C. moraxella.
Look at position, color, landmarks, degree of translucency, and mobility.
Ear pain is the only useful symptom, but only has a likelihood ratio of only 3.0. 
Signs are more useful:
Distinctly impaired mobility has LR of 31.
Cloudy opaque eardrums also have LR of 34.
Bulging has LR of 51.
In conclusion, "a tympanic membrane that is cloudy, bulging, or distinctly immobile is highly suggestive of acute otitis media".

I also learned about magic mouth wash for the mouth lesions that cocksackie virus causes (BMX = lidocaine+malox,+diphenhydramine)

The difference between lactose intolerance and milk protein allergy.
Difference between allergy shiner and Dennie-Morgan Folds.
Amelogenesis Imperfecta vs. Enamel Hypoplasia
HEEADSSS survey for adolescents.
How ring worm can cause kerions.
The 5S's of comforting babies (Suck, Swing, Swaddle, Shhh, Side/stomach position).
Treat ring worm with clotrimazole unless under hair where you need griseofulvin.

I loved this brief 2-week window into pediatrics. I seem to get along with kids pretty well and can put their parents at ease by clearly explaining everything I'm doing and the reason I'm doing it (or asking for it).
The most frustrating thing about pediatrics for me was the lack of interest and pride in gynecologic care of their female patients and overall sexual health of both males and females. The reality is that many kids are having sex in their teens and it has a profound effect on their physical and mental health. I want to practice in a specialty that allows me to directly address sexual health in a proactive rather than reactive way.

Thursday, August 15, 2013

Surgery Rotation Complete

On the last day of surgery (a teaching day), we had a lecture about the culture of surgery and the skills required to accept feedback and criticism from those around you. 

It really struck a cord with me as my last three weeks of surgery were marred by my inability to respond appropriately on the second day when I had not completed the reading assigned to me. Besides the random facts of anatomy reviewed, the modest progress made on toward understanding more completely disease process and therapeutics, the largest and most important lesson I learned from surgery is that I must practice constant mindfulness in order to both give and accept evaluations in a constructive way.

This idea of a community where confrontation is acceptable and expected is quite possible, as I witnessed at Haverford. I have been working to make it more of a reality here in medical school through my work with the nascent honor board, but so far have not made much progress.

At the end of this morning's lecture, the presenter hit a brick wall in attempting to convince residents to be part of a culture change because they are afraid of retribution from their superiors. Ironically, any culture change in surgery will have to come from the top down. In the current culture, there is no way that a junior resident can call out a superior for making sexist jokes or practicing poor medicine and still expect to get a letter of recommendation upon which her future career depends.

The only part of surgery left to do is take the "shelf exam", a test which I am woefully unprepared for, mainly because it has so much medicine in it that I will experience much more through the rest of my rotations. But I had to have something first, so might as well get surgery out of the way.

Okay, back to doing practice questions...

Thursday, July 4, 2013

Anton Chekhov stories

I started reading this sometime early in the spring when it was still cold outside. I didn't finish them until I was on the flight back from my Utah backpacking trip yesterday. There were some nights before step 1 where I would only read a paragraph or two before passing out each night.

The Death of a Clerk
Small Fry
The Huntsman
The Malefactor
Panikhida
Anyuta
Easter Night
Vanka
Sleepy
A Boring Story
Gusev
Peasant Women
The Fidget
In Exile
Ward No. 6
The Black Monk
Rothschild's Fiddle
The Student
Anna on the Neck
The House with the Mezzanine
The Man in a Case
Gooseberries
A Medical Case
The Darling
On Official Business
The Lady with the Little Dog
At Christmastime
In the Ravine
The Bishop
The Fiance

So there really were a fair number of stories. Many of them gave me homesick feelings toward Ukraine. Chekhov portrays the sharp edges of poverty and second/third world survival simultaneously commenting on the bleakness wealth without goodness.

I am enchanted at the beginning of each story by how Chekhov sets the scene, from the sounds to the smells, I slip into the scene and can embrace the normalcy of the thoughts and dialog that takes place in each locale.

Thursday, April 25, 2013

How Doctors Think by Jerome Groopman

fascinating analysis of cognitive error
underlined how important it is to think about how you think

reminded me of taking some time to learn how I learn
so that I can then be a bit more efficient as I prepare for step 1

it's a bit of a weight on my shoulders
so far I haven't been able to work at quite the volume that I would like
but then again, we still have classes, outpatient office days, and some other random school work to do.
Soon enough, I'll be able to let go completely and study to my hearts content, 9+ hours each day

I guess medical school self selects for people who find this enjoyable...