MTG

I am Blue/White
Take The Magic Dual Colour Test - Beta today!
Created with Rum and Monkey's Personality Test Generator.

I'm both orderly and rational. I value control, information, and order. I love structure and hierarchy, and will actively use whatever power or knowledge I have to maintain it. At best, I am lawful and insightful; at worst, I am bureaucratic and tyrannical.

Here is something just for fun. Imagine a doctor playing MTG with you;-p

My Third Year First Rotation -- Pediatrics

http://www.radiologyassistant.nl/en/43c63c41ef792

Am going to start with my first rotation after approximately a year of inactivity. Pediatrics. (Of all the world) Shelf exam is well known to be hard and lots of things need to learn. Wish me luck!

Retinopathy, Purtscher & Still's disease

http://emedicine.medscape.com/article/1225431-overview
Purtscher retinopathy is a hemorrhagic and vasoocclusive vasculopathy, which, in 1912, was first described as a syndrome of sudden blindness associated with severe head trauma. These patients had findings of multiple white retinal patches and retinal hemorrhages that were associated with severe vision loss. Since its original description, Purtscher retinopathy has been associated with traumatic injury, primarily blunt thoracic trauma and head trauma, and numerous nontraumatic diseases. Characteristic fundus findings of Purtscher retinopathy. Multiple cotton-wool spots surround the optic nerve after blunt thoracic trauma. Purtscher-like retinopathy is seen in diverse conditions, including acute pancreatitis; fat embolization; amniotic fluid embolization; preeclampsia; hemolysis, elevated liver enzymes, and low platelets (HELLP) syndrome; and vasculitic diseases, such as lupus.

The original findings of white lesions in the retina associated with intraretinal and preretinal hemorrhages and papillitis were believed to be caused by lymphatic extravasation from trauma. These lesions are known as Purtscher flecken (larger infarcts of the retinal capillary bed) and cotton-wool spots (small retinal microinfarcts at the level of the nerve fiber layer). Fluorescein leakage in Purtscher retinopathy suggests that an acute endothelial cell injury is caused by trauma, possibly predisposing the retinal vessels to occlusion.

The exact pathophysiology remains somewhat controversial, and different mechanisms have been proposed. The most accepted mechanism is leukoembolization that causes arterial occlusion and infarction of the microvascular bed. Leukocyte aggregation, which is induced by complement C5a, is believed to be the most likely mechanism of embolization because of its known association with trauma, acute pancreatitis, and vasculitic diseases.

Other possible sources of emboli include fat emboli in cases of long bone fractures and perhaps pancreatitis from enzymatic digestion of omental fat, amniotic fluid embolization during childbirth and postpartum, air emboli from traumatic chest compression, and granulocyte aggregation resulting from complement activation.

Other proposed mechanisms of vascular occlusion include angiospasm resulting from an acute rise in venous pressure from compressive chest injuries or possibly acute head injuries and endothelial cell damage resulting from acutely increased intraluminal pressure.

Presentation:
1. Patients with traumatic Purtscher retinopathy present with a recent history of blunt chest trauma or head trauma. The severity of chest trauma is not correlated directly with the incidence or severity of retinopathy, which is observed in these patients.
2. Patients may present with unilateral or bilateral vision loss (possibly severe) generally within 2 days.
M3. acular cotton-wool spots and intraretinal hemorrhages in patients with this history of trauma are diagnostic of the condition. Larger capillary bed infarcts (Purtscher flecken) are also seen in the macula and region surrounding the optic nerve. Typically, there is sparing of the retina whitening immediately adjacent to the larger retinal vessels.
4. Patients also may present with a Purtscher-like retinopathy in the absence of trauma. Various systemic conditions have been associated with developing the following characteristic retinal findings:
- Patients with acute pancreatitis are at risk for developing Purtscher-like retinopathy.
- Patients with long bone fractures are at risk for developing fat embolization and Purtscher-like retinopathy.
-Childbirth
i. Purtscher-like retinopathy may be seen in the postpartum period.
ii. Purtscher-like retinopathy may be due to amniotic fluid embolization with a catastrophic presentation, including shock and disseminated intravascular coagulopathy (DIC).
iii. Retinal arterial occlusions with microvascular infarcts and labor-associated hemorrhage have been reported in patients with preeclampsia and Purtscher-like retinopathy.
iv. Protein C and protein S deficiency have been reported.
-Purtscher-like retinopathy has been observed in patients with certain types of systemic vasculitides.
i. The most likely etiology is microvascular infarction due to complement C5a-induced leukocyte aggregation.
ii. Unexplained vision loss in patients with these conditions (eg, systemic lupus erythematosus, dermatomyositis, scleroderma) should raise the possibility of Purtscher-like retinopathy.

Regarding relationship of Purtscher retinopathy and Still's disease
Adult-onset Still’s disease (AOSD) is a rare systemic inflammatory disorder of unknown etiology. It is characterized by daily high spiking fevers associated with an evanescent rash, arthritis, and multiorgan involvement. Here we report a patient with AOSD-associated thrombotic microangiopathy (TMA) combining central nervous system and renal involvement, associated with 2 severe and unusual complications: Purtscher-like retinopathy and extremity gangrene. Interestingly, renal biopsy showed decreased expression of glomerular vascular endothelial growth factor (VEGF), which could have triggered the TMA and may represent a new pathophysiologic mechanism in human TMA
http://onlinelibrary.wiley.com/doi/10.1002/art.24826/pdf

Things to learn

1. Management of acute exacerbations of chronic obstructive pulmonary disease
Global Initiative for Chronic Obstructive Lung Disease (GOLD) defines an exacerbation of chronic obstructive pulmonary disease (COPD) as an acute increase in symptoms beyond normal day-to-day variation and includes one or more of following cardinal symptoms: cough increases in frequency and severity, sputum production increases in volume and/or changes character and dyspnea increases. Constitutional symptoms, an unchanged chest radiography, a variable decrease in pulmonary function and tachypnea are typical in acute exacerbations. Est that 70-80% of COPD exacerbations are due to respiratory infections. Viral and bacterial infections cause most exacerbations. Others are due to environmental pollutants or unknown etiology.

2. Serum creatinine
Serum creatinine = ARF - 1) Pre-renal 2) Vascular 3) Renal 4) Post-renal

3. http://medresidents.stanford.edu/TeachingMaterials/Shock%20and%20Sepsis/Sepsis%20and%20SIRS%20Examples%20-%20Key.doc
Sepsis: In patient with sever sepsis/septic shock, in fact in Jefferson hospital, the antibiotic being used is Vanc + Zosyn (Piperacillin and Tazobactam Injection). Vanc to cover Gram-positive while either a beta-lactam/beta-lactamase inhibitor (Piperacillin and Tazobactam), a third or fourth-generation cephalosporin (ceftriaxone) or a carbapenem such as imipenem for Gram-negative coverage.

4. Still disease
aka Systemic-onset juvenile arthritis
Early pattern of prominent systemic complaints and extra-articular involvement. Boys more common.

BIG - Bone Injection Gun

http://www.actnt.com/BIG/Bone_Injection_Gun.htm

Bone Injection Gun - The B.I.G.
National Distributor for EMS & Healthcare


National distributor for EMS and Healthcare



"The BIG provides an effective alternative IV access for critical patients in whom a peripheral IV line
cannot be readily obtained in the pre-hospital setting."
Journal of Trauma-Injury Infection & Critical Care. 64(3):650-655, March 2008.
Schwartz, Dagan MD; Amir, Lisa MD; Dichter, Reuven MA; Figenberg, Zvi MD

Medical studies have proven that survival rates for serious injuries or illnesses are significantly improved by prompt treatment. Rapid administration of fluids to stabilize shock and quick access for life-saving medications are key factors for survival. And when every second counts, delays in placing an IV line can be fatal. When you cannot find a vein, use the B.I.G. (Bone Injection Gun) -- a novel, automatic intraosseous infusion device.
B.I.G. Advantages
For administering fluids and medications in time critical conditions, B.I.G. provides the perfect solution.
Infusion established in less than 20 seconds
No parts to assemble or replace (100% disposable)
No batteries to fail or replace
Very reliable - 96% success rate
Pre-set needle depth (Adult), depth by age (Pediatrics)
Five (5) year shelf life
Extra safe - no direct contact with patient's blood
Can be used by Physicians, Nurses & Paramedics
Over 10 years of use in over 40 countries
FDA (adult & pediatric) and CE approvals
Completely mechanical, no need for any energy source (e.g. batteries)
B.I.G. Indications For Use
The BIG (Bone Injection Gun) is used by thousands of militaries, paramedics, nurses and physicians in countries around the world. In hospitals, in many cases, it is eliminating the need to place Central Venous Catheter (CVC), while in pre-hospital and military, the BIG (Bone Injection Gun) provides a safe, quick and easy solution when patient’s condition makes IV placement difficult or impossible.
BIG- Bone Injection Gun, is a novel, automatic intraosseous infusion device that provides rapid, safe and easy intravascular access through the bone marrow. The BIG is an effective answer to unsuccessful intravenous access during adult Trauma and Emergencies, which dramatically increases the caregiver's ability to save lives.
The BIG (Bone Injection Gun) Intraosseous Injection device completely eliminates delays in IV access. For administering fluids and medications under field conditions in the Military scene, BIG (Bone Injection Gun) provides the perfect solution.
In addition to the pre-hospital application, the BIG offers a good solution for in hospital emergencies.

Serratiopeptidase

http://serratiopeptidase.weebly.com/
http://www.ehow.com/about_5130452_serratiopeptidase-side-effect.html

If you suffer from pain to any extent – occasionally, chronically or somewhere in between – an enzyme known as serratiopeptidase may just be the answer for you. This is especially true if you have an aversion to, or are experiencing any side effects of, the medication you currently use for pain management. Whether you take prescription or over-the-counter “painkillers,” serratiopeptidase is a safe, natural alternative with no known side effects.

Serratiopeptidase, also known as serrapeptase, is a proteolytic (that is, having the ability to break down proteins into simpler compounds) enzyme which is naturally present in the silkworm intestine. Now, before you go running for cover, screaming, “I’m not swallowing anything that came from a worm’s innards!” – let me just emphasize: The type that is available to consumers today is processed through fermentation of plant-grown enzymes, and is generally of such purity that it is suitable even for consumption by vegetarians.

Serrapeptase has been widely used for over 30 years in many Asian and European countries. In Austria and Germany for instance, it is available by prescription only. Fortunately, in the U.S. – and elsewhere – this is not the case. It is so safe, in fact, that it can be taken by children, pregnant women, and has even been successfully used on pets.

Chronic inflammation lies at the heart of a myriad of ailments, including headaches, muscle and joint pain (from exercise, or in conditions such as arthritis or fibromyalgia) – and ultimately, even more serious diseases such as cancer and heart disease. Unlike conventional pain med’s, which are designed to only relieve the inflammation, serratiopeptidase actually breaks down the protein deposits (known as fibrin) which often remain – and continue to cause pain and discomfort – even after your body has healed from an injury or other irritation.

And, as stated, serrapeptase has no known side effects – unlike aspirin, ibuprofen, naproxen, and other over-the-counter NSAIDs – as well as acetaminophen (which is not classified as an NSAID.) These non-prescription drugs have been proven in clinical studies to cause stomach, kidney, liver, and even heart problems, especially when used regularly, and for prolonged periods. What’s worse, certain prescription med’s – especially in the NSAIDs category – have had even more serious side effects, which have been well-documented in the media in recent years.

So for the millions of pain sufferers who turn to these medications on a regular basis, the emergence of serratiopeptidase as a viable alternative is most welcome, to put it mildly. In upcoming articles, we will be keeping you informed of exciting news and developments on this incredible enzyme – as well as the best source for obtaining it – so bookmark this site, and check back often.

This is a drug that I found out in my clinic. Before this, I never get to know this drug. Never have I know that this drug exist and it's so "natural". I really thought this is something artificial or some sort of complex channel blockers. [Most of the clinical studies conducted do not document any side effects. In the few that do document side effects, there is not enough data to determine if they are caused by the serratiopeptidase or if they were just a coincidence. With the positive results of the preliminary data, there is sure to be more studies to document the benefits and side effects.]

Conditions I Learnt Today

After looking at so many articles, the condition is actually named Chronic Fatigue Syndrome to replace other names like I mentioned below. I guess it's the difference between how the Americans and British call them? PVS seems to be written by UK people...
Post-Viral Syndrome: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1710789/pdf/jroyalcgprac00029-0021.pdf

I am going to share some conditions I witnessed today. First, post-viral syndrome. There is one patient who complains of whole body-ache after a viral infection.
Quote: "The syndrome typically follows an upper respiratory tract infection from which the sufferer fails to make a full recovery, complaining of a multitude of symptoms which may persist for months or even years. The cardinal symptom is profound
muscular fatigue and this is often accompanied by muscle pain, headache, paraesthesiae, dizziness, urinary frequency, cold extremities, bouts of sweating and fainting attacks. Other symptoms are poor memory, lack of concentration, sleep disturbance, mild expressive and receptive dysphasia, hyperacusis and emotional lability. Clinical examination usually shows no abnormalities, nor do routine laboratory investigations. The diagnosis is therefore one of exclusion. The illness follows one of three courses: many patients recover completely, in others there is a relapsing and remitting course and in some there is chronic illness. Relapses are precipitated by undue physical or mental stress: patients who rest adequately in the early stages are said to have the best chance of an early, complete recovery without relapse."

There is another term which I want to bring up: Neurasthenia. 'Neurasthenia is a condition of nervous exhaustion, characterised by undue fatigue on slightest exertion, both physical and mental, with which are associated symptoms of abnormalfunctioning, mainly referable to disorders of the vegetative nervous system. The chief symptoms are headache, gastrointestinal disturbances, and subjective sensations of all kinds'. (The term has remained in use in some European countries including France and Russia, but has become virtually obsolete in the United States.)

The doctor told me that there are people who suffer from this condition and landed up in their most downs in their life. It took one year for that person to finally decided to find the meaning of his life and strife to rid of this syndrome and become a normal person again. That was how debilitating this condition can do to a person.

Diet and Lifestyle

I am going to make a summary in regards of patient education for diet and lifestyle.

1. Exercise
CDC recommends 30-60 minutes of moderate (brisk walking, bicycling, vacuuming, gardening, or anything that causes small increases in breathing or heart rate) to vigorous (running, aerobics, heavy yard work, or anything else that causes large increases in breathing or heart rate) physical activity per day at least 5 days per week in all children.
Almost all patients should be able to incorporate recommended levels of physical activities in their lifestyle.

Barriers: Bad weather, lack of time and access to facilities or equipment etc. Attempts to further characterize and eliminate these barriers. PE classes are currently inadequate to meet physical activity recommendations.

2. Effect on Adolescents (all positive health-related behaviors)
- Decreased smoking
- Decreased drug use
- Increased fruit and vegetable consumption
- Decreased risk of pregnancy and STD
- Decreased anxiety, stress and depression
- Decreased illicit drug use
- Increased seat belt use
- Increased academic performance

3. Food
Plenty of fresh fruits and vegetables (5 servings) and less than 30% of total calories as fat
Fruit juice (can take only 10-12 ounces) is often an unrecognized culprit in childhood obesity and is not a substitute for fresh fruits.
Parents play a part as model since children will learn by example.

4. Others...
Avoid all diet fads and diet "revolutions"
Avoid anorexic drugs
Change composition of the diet
Attend multiple office visits to establish a baseline and to motivate continual weight loss
Decrease caloric intake to approx 500kcal/day less than energy expenditure --> loss 1 pound/week
Positive reinforcement from a support group etc.
Treat comorbid conditions

Hypercholesterolemia diet management:
Begin with Step 1 diet of AHA: no more than 300mg cholesterol, no more than 30% total fat and no more than 10% saturated fat.
Continue for at least 6 months. If cholesterol levels do not normalize, consider AHA step 2 diet: no more than 200mg cholesterol, no more than 30% total fat, and no more than 7% saturated fat.

Common Problems in Pediatrics

Fever of unknown origin (FUO) implies fever of prolonged duration (>=14 days), documented temeperature greater than 101 degrees on multiple occasions and uncertain etiology, for ex. infection, connective tissue disease, malignancy, etc.

History: Fever (Spiking? Intermittent? Describe the quality and duration), Toxicity (How severe is it?), Weight Loss, Anorexia
Exposure: Any ill contacts, residence (zoonotic infections), travel, food, drugs
Discriminative: Rashes, Pallor, Jaundice, Vasculitis, Tonsils, BCG flare, lymphadenopathy, hepatosplenomegaly, joint swelling.

Kawasaki Disease (aka mucocutaneous lymph node syndrome)
Three phases of the disease as listed here, some authors put "four":
Acute febrile phase - 1-2 weeks
1 The temperature is elevated (>104°F).
2 The child is irritable.
3 Bilateral conjunctivitis and rash are present.
4 The hands and feet develop the erythema and edema that cause the child to refuse to walk. Note that this finding may be the last to develop. Lack of extremity findings may cause consideration of incomplete Kawasaki disease.
5 The tongue and oral mucosa become red and cracked.
6 Hepatic dysfunction may develop.
7 Cardiac complications noted in the first stage include myocarditis and pericarditis.
Subacute phase - Begins when fever and other signs have abated. This phase should end by the 4th week.
1 This is characterized by persistent irritability, anorexia, and conjunctival injection.
2 Fever resolution begins this stage. However, persistent fever beyond 2-3 weeks may be an indication of recrudescent Kawasaki disease. (See Recrudescent Kawasaki disease below).
3 If fever persists, the outcome is less favorable because of a greater risk of cardiac complications.
4 Thrombocytosis develops, and the platelet count may exceed 1 million/mm3.
5 Desquamation of the fingertips and toes begins at this time.
6 Aneurysm formation may occur during this stage.
7 Children are at greatest risk of sudden death during this phase.
Convalescent phase - Approximately 4-6 weeks
1 This phase begins when all signs of illness have disappeared and continues until acute-phase reactants (ESR, CRP level) have returned to normal.
2 The most significant clinical finding that persists through this phase is the presence of coronary artery aneurysms.
(Taken from http://emedicine.medscape.com/article/804960-overview)

Lab test to do: Platelet count, ESR, echocardiogram (to look for coronary artery aneurysm. Big thing, can cause death)
Symptoms to look out for in your clinic: Fever, Rash, Conjunctival injection, Oropharyngeal changes, Peripheral extremity changes and cervical lymphadenopathy. Of course there are tons of other symptoms you may associate with this condition but these are the few things that you can pick up. One thing to note about this condition is that you need to have vigilant to be able to pick this condition up.
Treatment: IVIG and aspirin.

Inguinal Hernia
Patent processus vaginalis. Need to show patient how to reduce it. Do not attempt to massage it as it will cause adhesion and complications. Complication of this indirect inguinal hernia that you should pick up: distressed, irreducible, vomit or abdominal distention.

Hydrocele
Tend to get bigger during the evenings. Wait till 2years old for operation unless testis is big and tense. If there is any recent onset of tense testis, you need to exclude tumor.

Wheezing ==> High pitched musical sound heard during expiration and is caused by turbulence of air in the airway. Need to differentiate: broncholitis (viral, 3-6mths); bronchitis (viral, bacteria, atypical, affect older children); Pneumonia (viral, bacteria, atypical, any age group).
Wheezing = Mucosal edema + secretion (bronchospasm is not characteristic)
Recurrent Wheezing
1. Age -- > Congenital vs Non-congenital
2. Sudden wheezing -- > Foreign body
3. Pattern -- > Episodic vs Persistent
4. Assoc c cough -- > GERD, asthma, allergy
5. Assoc c feeding -- > GERD
6. Better/wose c positional changes -- > tracheomalacia, anomalies of great vessel
7. FH of wheezing -- > asthma, allergy
Fact about GER (affect 65% healthy infants, this is reflux, not a disease) whilst GERD affects 1:300 infants and associated with FTT, feeding/oral aversion, esophagitis
Types of childhood wheezing
Is divided into: 1) Transient Wheezing (typically occurs around 0-3 y/o during viral infection); 2) Non-atopic Wheezing; 3) IgE-associated wheezing/asthma

Intussusception
Re current jelly stool
3months to 1 year
Irritability and colicky pain
Laparotomy Reduction +/- resection

Newborn vomit
- Malrotation volvulus ==> green vomit (bilous vomit)
- Pyloric stenosis ==> 2-8wks (nonbilous projectile vomit)

Glue ear
http://www.ehealthmd.com/library/glueear/ge_whatis.html
Also known as otitis media with effusion, middle ear effusion, secreting otitis with effusion, serous otitis with effusion. (just put the effusion in it) Children comes with deafness. Frequently associated with Eustachian tube obstruction or dysfunction, e.g. adenoitis/nasopharyngitis; rhinosinusitis; cleft palate (the soft palate plays a role in closing or opening the Eustachian tube, therefore it makes sense when you don't have a soft palate, there is trouble for you to maintain the pressure in your middle ear)
Management:
1. Wait and see
2. Antibiotics (symptoms persist for more than 48 hrs), nasal steroid, decongestant
3. Surgery: ventilation tube (grommets) +/- adenoidectomy

Clinical Pearls

These are 100 clinical pearls I come through from a forum. Why not read them and check it out?

1. If a patient has a fever, give acetaminophen (unless it is contraindicated)
2. If a patient is on a statin or you order a statin, get baseline LFTs and check frequently
3. If a patient is found to have abnormal LFTs, get a TSH
4. If a patient is going to surgery (including cardiac catheterization), make them NPO
5. All NPO patients must also have their urine output measured (type "urine output")
6. If a woman is between 12 and 52 years old and there is no mention of a very recent menses (that is, < 2 weeks ago), order a beta-hCG
7. Don't forget to discontinue anything that is no longer required (especially if you are sending the patient home)
8. When a patient is stable, decide whether or not you should change locations (if you anticipate that the patient could crash in the very near future, send the patient to the ICU; if the patient just needs overnight monitoring, send to the ward; if the patient is back to baseline, send home with follow-up)
9. In any diabetic (new or long-standing), order an HbA1c as well as continuous Accuchecks.
10. If this is a long-standing diabetic, also order an ophthalmology consult (to evaluate for diabetic retinopathy)
11. In any patient with respiratory distress (especially with low oxygen saturations), order an ABG
12. In any overdose, do a gastric lavage and activated charcoal (no harm in doing so, unless the patient is unconscious or has risk for aspiration)
13. In any suicidal patient, admit to ward and get "suicide contract" and "suicide precautions"
14. Patients who cannot tolerate Aspirin get Clopidogrel or Ticlopidine
15. Post-PTCA patients get Abciximab
16. In any bleeding patient, order PT, PTT, and Blood Type and Crossmatch (just in case they have to go to the O.R.)
17. In any pregnant patient, get "Blood Type and Rh" as well as "Atypical Antibody Screen"
18. In any patient with excess bleeding (especially GI bleeding), type "no aspirin" upon D/C of patient
19. If the patient is having any upper GI distress or is at risk for aspiration, order "head elevation" and "aspiration precautions"
20. In any asthmatic, order bedside FEV1 and PEFR (and use this to follow treatment progress)
21. Before you D/C a patient, change all IV meds to PO and all nebulizers to MDI
22. In any patient who has GI distress, make them NPO
23. All diabetic in-patients get Accuchecks, D/C oral hypoglycemic agents, start insulin, HbA1c, advise strict glycemic control, recommend diabetic foot care
24. All patients with altered mental status of unknown etiology get a "fingerstick glucose" check (for hypoglycemia), IV thiamine, IV dextrose, IV naloxone, urine toxicology, blood alcohol level, NPO
25. If hemolysis is in the differential, order a reticulocyte count
26. If you administer heparin, check platelets on Day 3 and Day 5 (for heparin-induced thrombocytopenia), as well as frequent H&H
27. If you administer coumadin, check daily PT/INR until it is within therapeutic range for two consecutive days
28. Before giving a woman coumadin, isotretinoin, doxycycline, OCPs or other teratogens, get a beta-hCG
29. If you give furosemide (Lasix), also give KCl (it depletes K+)
30. All children who are given gentamycin, should have a hearing test (audiometry) and check BUN/Cr before and after treatment
-
31. Don't forget about patient comfort! Treat pain with IV morphine, nausea with IV phenergan, constipation with PO docusate, diarrhea with PO loperamide, insomnia with PO temazepam
32. ALL ICU patients get stress ulcer prophylaxis with IV omeprazole or ranitidine
33. If you put a patient on complete bedrest (such as those who are pre-op), get "pneumatic compression stockings"
34. If fluid status is vital to a patient's prognosis (such as those with dehydration, hypovolemia, or fluid overload), place a Foley catheter and order "urine output"
35. If a CXR shows an effusion, get a decubitus CXR next
36. If you intubate a patient you ALSO have to order "mechanical ventilation" (otherwise the patient will just sit there with a tube in his mouth!)
37. With any major procedure (including surgery, biopsy, centesis), you MUST type "consent for procedure" (typing consent will not reveal any results)
38. With any fluid aspiration (such as paracentesis or pericardiocentesis), get fluid analysis separately (it is not automatic). If you don't order anything on the fluid, it will just be discarded.
39. With high-dose steroids (such as in temporal arteritis), give IV ranitidine, calcium, vitamin D, alendronate, and get a baseline DEXA scan.
40. In all suspected DKA or HHNC, check osmolality and ketone levels in the serum.
41. In ALCOHOLIC ketoacidosis, just give dextrose (no need for insulin), in addition to IV normal saline and thiamine
42. All patients over 50 with no history of FOBT or colonoscopy should get a rectal exam, a FOBT, and have a sigmoidoscopy or colonoscopy scheduled.
43. All women > 40 years old should get a yearly clinical breast exam and mammogram (if risk factors are present, start at 35)
44. All men > 50 years old should get a prostate exam and a PSA (if risk factors are present, start at 45)
45. If a patient has a terminal disease, advise "advanced directives"
46. In any patient with a chronic disease that can cause future altered mental status, type "medical alert bracelet" upon D/C
47. Any patient with diarrhea should have their stool checked for "ova and parasites", "white cells", "culture", and C.diff antigen (if warranted)
48. Any patient on lithium or theophylline should have their levels checked
49. All patients with suspected MI should be given a statin (and check baseline LFTs)
50. All suspected hemolysis patients should get a direct Coombs test
51. Schedule all women older than 18 for a Pap smear (unless she has had a normal Pap within one year)
52. Pre-op patients should have the following done: “NPO”, “IV access”, “IV normal saline”, “blood type and crossmatch”, “analgesia”, “PT”, “PTT”, “pneumatic compression stockings”, “Foley”, “urine output”, “CBC”, and any appropriate antibiotics
53. If a patient requires epinephrine (such as in anaphylaxis), and he/she is on a beta-blocker, give glucagon first
54. If lipid profile is abnormal, order a TSH
55. All dementia and alcoholic patients should be advised “no driving”
56. To diagnose Alzheimer’s, first rule out other causes. Order a CT head, vitamin B12 levels, folate levels, TSH, and routine labs like CBC, BMP, LFT, UA. Also, if the history suggests it, order a VDRL and HIV ELISA as well
57. Also rule out depression in suspected dementia patients
58. For all women who are sexually active and of reproductive age, give folate. In fact, you should give ALL your patients a multivitamin upon D/C home
59. All pancreatitis patients should be made NPO and have NG suction so that no food can stimulate the pancreas
60. Send patients home on a disease-specific diet: diabetics get a “diabetic diet”, hypertensives get a “low salt diet”, irritable bowel patients get a “high fiber diet”, hepatic failure patients get “low protein diet”, etc
61. Do not give a thrombolytic (tPA or streptokinase) in a patient with unstable angina patient
62. Patients who are having a large amount of secretions, order “pulmonary toilet” to reduce the risk of aspiration
63. Every patient should be advised to wear a “seatbelt”, to “exercise”, and advised about “compliance”
64. In any patient who presents with an unprotected airway (as in overdoses, comatoses), get a CXR to rule out aspiration
65. In any patient with one sexually transmitted disease (such as Trichomonas), check for other STDs as well (Gonorrhea, Chlamydia, HIV, syphilis, etc.) and do a Pap smear in all women with an STD
66. Remember to treat children with croup with a “mist tent” and racemic epinephrine
67. Any acute abdomen patient with a suspected or proven perforation, give a TRIPLE antibiotic: Gentamycin, Ampicillin, Metronidazole
68. Get iron studies in patients with microcytic anemia if the cause is unknown. Order “iron”, “ferritin”, “TIBC”
69. Women with vaginal discharge should get a KOH prep, saline (wet) prep, vaginal pH, cervical gonococcal, chlamydia culture
70. If a woman is found to have vaginal candida, check her fasting glucose
71. When the 5 minute warning screen is displayed, go through the following mnemonic (RATED SEX). I know it probably is not the best mnemonic, but it is difficult to forget!:
Recreational drugs / Reassurance
Alcohol
Tobacco
Exercise
Diet (eg. high protein, no lactose, low fat, etc.)
Seat belt / Safety plan / Suicide precautions
Education (“patient education”)
X (stands for safe seX)
72. All suspected child abuse patients should be admitted and you should order THREE consults: consult “child protection services”, consult “ophthalmology” (to look for retinal hemorrhages), consult “psychiatrist” (to examine the family dynamics)
73. When a woman reaches menopause, she should have a “fasting lipid profile” checked (because without estrogen, the LDL will rise and the HDL will drop), a DEXA scan (for baseline bone density), and of course, FOBT and colonoscopy (if she is over 50)
74. If colon cancer is suspected, order a CEA; if pancreatic cancer, order CA 19-9; if ovarian cancer, order CA 125.
75. Remember to give “phototherapy” to a newborn with pathologic unconjugated bilirubinemia (it is not helpful if it is predominantly conjugated). Also, with phototherapy, keep the neonate on IV fluids (the heat can dehydrate them), and give erythromycin ointment in their eyes
76. Before giving a child prednisone, get a PPD
77. If a patient is found to have high triglycerides, check “amylase” and “lipase” (high triglycerides can cause pancreatitis)
78. Remember that any newborn under 3 weeks of age who develops a fever is SEPSIS until proven otherwise. Admit to the ward and culture EVERYTHING: “blood culture”, “urine culture”, “sputum culture”, and even “CSF culture”. And give antibiotics to cover EVERYTHING.
79. If you get a high lead level in a child, you have to check a “venous blood lead level” to confirm. If the value is > 70, admit immediately and begin IV “dimercaprol” and “EDTA”. Order “lead abatement agency” and “lead pain assay” upon discharge.
80. If you perform arthrocentesis, send the synovial fluid for “gram stain” and the 3 Cs: “crystals”, “culture”, and “cell count”
81. If a patient has exophthalmos with hyperthyroidism, it is not enough to just treat the hyperthyroidism (as the eye findings may worsen). You should give prednisone.
82. If any patient has cancer, get an “oncology consult”.
83. In a patient with rapid atrial fibrillation, decrease the heart rate first (then worry about converting to sinus rhythm). Use a CCB (diltiazem) or a beta-blocker (metoprolol) for rate control.
84. In any patient with new-onset atrial fibrillation, make sure you check a TSH
85. In any patient with suspected fluid volume depletion, order “postural vitals” to detect orthostasis
86. Before a colonoscopy or a sigmoidoscopy, you should prepare the bowel: make the patient NPO, give IV fluids (if necessary) and order “polyethylene glycol”.
87. Any patient with Mobitz II or complete heart block gets an immediate “transcutaneous pacemaker”. Then order a cardiology consult to implant a “transvenous pacemaker”
88. If calcium level is abnormal, order a “serum magnesium”, “serum phosphorus”, and “PTH”
89. Treat both malignant hyperthermia and neuroleptic malignant syndrome with “dantrolene”
90. All splenectomy patients get a “pneumovax”, an “influenza” vaccine, and a “hemophilus” vaccine if not previously given.
91. If you give INH (for Tb), also give “pyridoxine” (this is vitamin B6)
92. If you give pyrazinamide, get baseline “serum uric acid” levels
93. If you give ethambutol, order an ophthalmology consult (to follow possible optic neuritis)
94. If you perform a thoracocentesis (lung aspirate), send the EFFUSION as well as a peripheral blood sample for: LDH and protein (to help differentiate a transudate versus an exudates) and pH of the effusion
95. Give sickle cell disease children prophylactic penicillin continuously until they turn 5 years old
96. Any patient with a recent anaphylactic reaction (for any reason), should get “skin test” for allergens (to help prevent future disasters) and consult an allergist
97. Do not give cephalosporins to any patient with anaphylactic penicillin allergies (there is a 5% cross-reactivity)
98. Order Holter monitor on patients who have had symptomatic palpitations.
99. Any patient with a first-time panic attack gets a “urine toxicology” screen, a TSH, and “finger stick glucose”
100. All renal failure patients get: “nephrology consult”, “calcium acetate” (to decrease the phosphorus levels), “calcium” supplement, and erythropoeitin"

Source taken from: http://cafemedico.net/forums/clinical-subjects-discussion-forum/11024-best-clincal-mcq-pearls.html

Sick Building Syndrome

http://www.epa.gov/iaq/pubs/sbs.html

The term "sick building syndrome" (SBS) is used to describe situations in which building occupants experience acute health and comfort effects that appear to be linked to time spent in a building, but no specific illness or cause can be identified.

Symptoms of Sick Building Syndrome

Sick building syndrome involves a variety of seemingly unrelated symptoms, much like other unexplained conditions such as chronic fatigue syndrome (CFS), and Gulf War syndrome (GWS) do. Some authorities have attempted to separate the symptoms into distinct categories such as 'allergic' and 'non-allergic', or 'chemical related' and 'microbe related'. Since there is yet no concensus on these distinctions, the common symptoms of SBS are listed here together:

Headache
Eye, nose, and throat irritation
Dry cough
Dry, itchy skin, rashes
Dizziness and nausea
Difficulty in concentrating
Fatigue
Sensitivity to odors

Distinction between sick building syndrome and building related illness has to be identified. One reason is that they have different etiologies and that treatment method is different too.

Cutaneous Manifestation of Hepatitis C

Resource: http://emedicine.medscape.com/article/1134161-overview
http://www.medscape.com/viewarticle/548006_4

I have seen a patient today with a history of Hepatitis C. The lesion is located inferior to the right medial malleolus. Itchiness and clear discharge due to scretching of lesion was mentioned by patient. No obvious erythema noted except for some purpura over the skin.

Differential Diagnosis:
1) Prurigo nodularis
2) Acral necrolytic erythema
3) Cryoglobulinemia (Leukocytoclastic vasculitis)
4) Erythema nodosum
5) Erythema multiforme
6) Porphyria Cutanea Tarda (Least likely due to the fact that it required sunlight to cause symptom)

Family Medicine

https://www.med-ed.virginia.edu/CourseSites/quiz/quizsheet.cfm?keywordID=1999&CourseID=19&num=1&start=1&noindex=1
http://www.gpnotebook.co.uk/homepage.cfm
http://fmclerkship.mc.duke.edu/student/commprob.html
http://www.hmc.psu.edu/ume/fcmonline/
http://www.sh.lsuhsc.edu/fammed/OutpatientManual.htm
http://www.nlhep.org/books/pul_Pre/intro-plpr.html

I come across 2 women the other day and domestic violence was brought up between conversation before they broke out into tears. Helpless as I can say and I think I can do more for them. SAFE questionnaire and Abuse Assessment Screen (AAS) can be used to access the situation.

Common stuffs in FM:
1) Post-nasal drip
Post-nasal drip is mucus accumulation in the back of the nose and throat leading to, or giving the sensation of, mucus dripping downward from the back of the nose. One of the most common characteristics of chronic rhinitis is post-nasal drip. Post-nasal drip may lead to chronic sore throat or chronic cough. Post-nasal drip can be caused by excessive or thick secretions, or impairment in the normal clearance of mucus from the nose and throat.
2) Skin Problems
Scabies and tinea. http://www.medicinenet.com/ringworm_pictures_slideshow/article.htm A good website with slideshow showing you a list of tinea problems. One thing good to know is that it is NOT a problem with WORM, but it's a fungus problem. The word that comes after tinea dictates which part of the body it is occuring. I think you know it already. Scabies, big thing. 5% permethrin preparation should do it.
http://dermatlas.med.jhmi.edu/derm/
3) Osteoporosis
http://www.medpagetoday.com/Endocrinology/Osteoporosis/4247http://www.webmd.com/osteoporosis/features/soda-osteoporosis Interestingly, scientists are trying to link osteoporosis with consumption of soft drink. Theory-wise, it's linked but there are still a long way down the road to proof the connection.
4) http://www.mhhe.com/socscience/hhp/fit_well/web15/

Cancer Screening

http://www.cancer.org/Healthy/FindCancerEarly/CancerScreeningGuidelines/american-cancer-society-guidelines-for-the-early-detection-of-cancer

I guess this link will provide you a knowledge on cancer screening:
American Cancer Society Guidelines for the Early Detection of Cancer
The American Cancer Society recommends these screening guidelines for most adults. Good to know so that you can get up-to-date information.

Enjoy reading'em.

My Ob Gyn

www.permanente.net/homepage/kaiser/pdf/6289.pdf
https://secure1.csmc.edu/nicu/cbg/ (Cord gas)

This is a good article talking the difference of level 1 ultrasound and level 2 ultrasound. Still have a lot of readings to do and assignments to complete. Got to hasten my pace.

http://www.gentlebirth.org/archives/dic.html

This is an article about DIC in pregnancy. I witnessed a patient with this condition. Was transferred to ICU and was well taken care of. Let's not forget that there is a possibility that a mother will get into this condition during pregnancy.

Golden phrase from Jefferson

Below listed are the phrases I got from today's orientation:

1. Don't ever ask questions that you can look up the answers.
2. Never pimp another student in front of team.
3. Never answer question directly specific to another student. Wait for your turn.
4. If you are asked a question, even if you do not the answer, make sure you reason them "out loud"
5. Always be within or easy contact with residents. Observe also what the residents are doing.
6. Check patient often!
7. Appear interested all times!
8. Think "How can I make my resident's job easier?" e.g. discharge summaries, scripts, pre/post-ops checks
9. Do not get caught in race for information with fellow students

Journals:
1. Periodically bring respected journals e.g. NEJM, JAMA
2. Read whole article and make an intelligent sentence or 2 summing them up
3. Do not overdo a.k.a. overkill (one to two times per week will be good)
4. Do not print and distribute to whole team

Presentation:
1. Handouts for all
2. Appropriate presentation
3. Practice before you give presentation
4. If information is split among teammates, NEVER present information someone was assigned to

Handheld/Smartphones:
Do not use them in rounds unless looking for drugs. Resident will think you are playing games. You are warned!

If you are absent in rotation, call the clerkship coordinator or resident on team.
Nurses are your biggest ally. DO NOT SLEEP IN ROTATION!

Hidradenitis suppurativa

http://www.aocd.org/skin/dermatologic_diseases/hidradenitis_suppu.html
http://www.mayoclinic.com/health/hidradenitis-suppurativa/ds00818

Hidradenitis Suppurativa

Hidradenitis suppurativa, also known as acne inversa, is a chronic, often debilitating disease primarily affecting the axillae, perineum, and inframammary regions. Prevalence rates of up to 4% have been estimated. Our understanding of the disease has changed over time. It is now considered a disease of follicular occlusion rather than an inflammatory or infectious process of the apocrine glands. Clinically, the disease often presents with tender subcutaneous nodules beginning around puberty. The nodules may spontaneously rupture or coalesce, forming painful, deep dermal abscesses. Eventually, fibrosis and the formation of extensive sinus tracts may result. The location of the lesions may lead to social embarrassment and the failure to seek medical treatment. Therapies in the past have consisted of long-term antibiotics, antiandrogens, and surgery. New treatments like tumor necrosis factor-alfa inhibitors have given clinicians more options against this difficult disease.

From: http://www.ncbi.nlm.nih.gov/pubmed/19293006

Corn a.k.a. hyperkeratosis, clavus, heloma and tyloma

http://www.epodiatry.com/corns-callus.htm
http://footcare.ygoy.com/foot-corns-and-corn-treatment/

The above mentioned websites are some reference if you are interested in a condition called foot corn. Well, it's basically, as suggested from the name, a corn-like lesion over the foot. To be accurate, it's hyperkeratosis. The function is nothing but to protect your feet from the hardship they are exposed to. Differentiation from it with that of a callus is important. Here is the difference: A callus generally refers to a more diffuse thickening of the skin (more common on the toes, but can occur under the ball of the foot) whereas a corn is a thicker more focal area area (more common on the toes). A corn can occur under and be surrounded by callus. Complication worried is that infection can occur on the it, and eventually leading to the formation of an abscess.

ECG -- RBBB & LBBB

I am showing a case of ECG from this website. Actually if you just google it, you will get it. Nevertheless I put down the list of ECG interpretation here just in case I need to refer, or maybe you who would like to know more.

http://meds.queensu.ca/courses/assets/modules/ts-ecg/right_bundle_branch_block.html
http://library.med.utah.edu/kw/ecg/ecg_outline/Lesson6/index.html
http://www.americanheart.org/presenter.jhtml?identifier=563
http://cmbi.bjmu.edu.cn/uptodate/electrocardiography%20tutorial/ECG%20tutorial-Miscellaneous%20diagnoses.htm
http://ecgblog.com/?tag=rp-interval
http://www.amc.edu/amr/archives/200408/EKG2_ans.html

To date, I am still doubtful of the ECG interpretation, especially the RBBB and LBBB which kind of haunted me and that during the cardiovascular module back in IMU, these are the few ECGs which I could not fully understand. These are the questions I have in mind: what is an RP interval? In regards of ST segment shapes, there are not much literature reviewing the articles about them. Only one reference quote a significant observation to be noticed of, whether the ST segment shape is concave, straight or convex[1].

Loads of websites teaching you but how much can I absorb? Aiz...

Reference:
1. Karadede A., Aydinalp O., Temamogullari A.V., Toprak N. The relationship of ST segment elevation shape with preserved myocardium
and signal-averaged electrocardiography in acute anterior
myocardial infarction. Heart and Vessels [serial on the Internet]. 2002; 16(4): 146-153. Available from: http://www.springerlink.com/content/cqu8tkxdvc83q91j/fulltext.pdf

Lesson I Learnt from Jefferson -- Sexual & Interpersonal Relationship

Sometimes in your interview, you will come across people with gay or lesbian relationship. First and foremost, do not show any signs of surprise since it will make patient feels uncomfortable. Try to be neutral and more understanding.

Before I begin, quick mention on what kind of words to be used. Start of by asking permission. "I care about you. To do that, I need to ask something private"/ "As a physician, I need to know that. It will be kept confidential." Reassure the patient that you are asking in good will and that you will keep his/her private live in secret. (Homosexuality is still a big issue here despite efforts of making homosexual legal). Afterwards, ask about the sexual history. "Are you in a relationship? With men or women or both?" Same rule applies, do not beat around the bush. Ask straight, but don't do it too prominent, of course.

Ask about screening tests done in any couples. Tests like HIV testing and STDs. (People always think HIV test first then other tests, therefore I can't think of any other tests which you can do)

Ask about a possible abuse relationship. This is not a funny issue as domestic violence or sexual assault is pretty common. Approximately 25% of women in US will be abused by a current or former partner sometime during their lifetime and most of the time (85%), victims are women[1]. Kick start this by asking "How's your marriage?" or "How's things going on at home?". If you suspect possible abuse, initiate SAFE questionnaire. 1. Stress/Safety; 2. Afraid/Abuse; 3. Friends/Family; 4. Emergency plan. Then proceed to Abuse Assessment Screen (AAS) to access how severe the abuse can be. One point I want to mention is patient may indirectly hint you that they are in an abuse relationship. Remember that women tend to cover up this messy relationship and tend not to talk about them too much. Say for example, patient may say their relationship is good but they did argue. Argue but still in a good relationship? Ask more...

Depressed patient. They won't say anything (sometimes), even though they start speaking, it will be slow. It's pretty hard, actually, to get a full history done by a short period of time due to the slow nature of the interview. Nevertheless, you need to be patient and try not to hurry the patient too much. It's bad. Question patient intention of how to overcome them. Let's just start a scenario like this. Firstly, NO BEATING AROUND THE BUSH. Ask him/her "I think you are feeling depressed because ..." Explain to him/her and explore whether he/she has suicidal intention. Questions like "Do you feel you want to harm yourself/other people?" should be asked. Optional question like "Do you own a gun?" can be asked.

P/S: As long as you see a gown, please drape. Assure patient that you have the best quality of care and that you do your best to help. Scenario: Patient indecisive of admission to hospital for treatment as he/she is afraid that he/she will end up dying like of his/her parents who have the same disease as he/she. Assure her: "We have the equipments to make you feel better and that we need to put you early to hospital." (S.P. amazed but the bolded phrase. This is just an example I made up with the intention which I feel from the S.P.) Night sweats. Can be lymphoma, TB etc. In diarrhea, talk about quality of stool (watery? Color? Frequency?) When you want to do examination on female patients, due to modesty, you would need to ask "May I go under the gown?"

Reference:
1. Fortner K B, Szymanski L M, Fox H E, Wallach E E. The Johns Hopkins Manual of Gynecology and Obstetrics. Baltimore: LWW; 2007, p. 355