Shoulder Exam

Last week I did a presentation at the HOME project on the shoulder exam with a few clinical cases I saw in clinic. It was a smashing success -- everyone seemed to appreciate an introduction/review of some of the maneuvers!

One of the toughest parts of the physical exam is remembering all of the routine shoulder maneuvers.

Here's a few mnemonics I shared that I use to help myself remember things:

Arm Movements

• Flexion of the arm = Forward to the Face
• Internal Rotation of the arm = In handcuffs
• (alternatively, External Rotation = Execution of Ex-Convict)
• ADduction of the arm = ADDing to the midline
• Scarf sign = toss a scarf around opposite shoulder

Forearm Movements

• Supination = Holding a Bowl of "Soup"
• Pronation = Putting away Palm

Special Maneuvers

• Range of Motion (and Impingement Signs)
• Neer = arm "Near" to the ear
• Hawkins = flap like a "Hawk"
• Apley scratch test = Applying Suntan lotion to back
• Rotator Cuff Tears
• Supraspinatus
• Jobe's Empty Can (duh!)
• Hornblower's (ditto!)
• Biceps
• Speed's = speedin' down the highway
• Labral Tear
• O'Brian = *Irish accent*
  What, so O'Brien gets the thumbs down, but Leno gets a thumbs awp?  I'm cryin' heah!!
• Subscapularis
• Gerber's lift off = wiping baby food off the back (okay, its a stretch, but you can't win 'em all!)

 

That's not my second opinion! :)

Pre-op "clearance"

Physicians often receive requests from surgeons for a pre-op physical to "clear the patient for surgery."

What this "clearance" entails is not entirely clear.

Surgeons are worried that an unknown medical problem will rear its ugly head during the surgery and bite them in the butt... or the anesthesiologist will call off the surgery because of blood pressure concerns.

 

Consults are often made to a cardiologist with the intent of doing a pre-op EKG/Echo + stress test to determine if the patient is fit for surgery at the surgeon's behest.  What is important to understand is that another physician is often the one responsible for keeping the patient alive during the surgery and it is this person, who is most interested in the pre-operative assessment.

Unfortunately, the anesthesiologist often just turns out to be the doctor who happens to be in the OR on that particular day and has not established any sort of relationship with the patient beyond their initial bedside assessment in the waiting room.

In the Cleveland Clinic Journal of Medicine, two anasthesiologists tackle this issue and give some general advice for pre-op consults.

Consults that provide pertinent quantitative data about the patient are helpful—eg, the heart rate at which ischemia was exhibited during stress testing and the degree of ischemia.

Anesthesiologists do not need assistance with managing intravenous drugs (with the exception of unusual agents), but they can use specific guidance on managing oral medications pre- and postoperatively to best achieve optimization and steady-state concentrations.

Pertinent recent information (< 5 years old) from the nonanesthesiology literature should be provided.

Medical consultants should arrange for follow-up care for patients with active conditions not addressed by the surgery.

Absolute recommendations should be avoided in a consult: the surgical team may have good reason not to follow them, and legal repercussions could ensue. The words “consider” or “strongly consider” usually suffice, except where there is an absolute standard of care.

Specific questions to answer include such things like assessment of cardiac function (hx of angina, last echo results, exercise tolerance,) successful blood pressure and diabetic regimens, etc.

 

References

Giving Anaesthesiologists What They Want: How to Write a Useful Preoperative Consult.  CCJM 11/2009

Rheum Case 1

A 55 year old Caucasian male presented to a neighbor island ED with lower extremity skin rash, swelling and severe arthritis following a sore throat.

History of Present Illness:  Pt had an itchy and sore throat for which he was treated with azithromycin.  He sought out new antibiotics after 5 days without relief.  Approximately ten days after the onset of the sore throat, he went to bed complaining of a "sore wrist."  Upon awakening the following morning, he felt severe pain in both wrists with progressive immobility of the left wrist.  His skin broke out with a rash later on in the day on his hands, wrists and ankles.  His legs started swelling and he had difficulty walking.

Denied red eyes or pain with urination.

Past medical history: significant for migratory arthritis, Crohn's disease, HLA-B27(+).  Patient has a long history of severe anaphylactic/eczemal allergic reactions as well.

 

Pertinent physical exam:

Skin exam revealed multiple, progressive, round tender "palpable purpuric" lesions on the hands and ankles.

4+ pitting edema was present in the lower extremities.

 

Diagnosis: enteropathic arthritis and erythema nodosum most likely secondary to a streptococcal infection of the throat with subsequent reaction *HLA-B27(+)

Differential:
Reiter's/Reactive arthritis triad: conjunctivitis, arthritis, urethritis (Can't see, can't pee, can't climb a tree)

Course: Dermatology, ID, and rheumatology consultations were made.  Pt was reluctant to start a course of steroids in the ED, given a past history of steroid-associated insomnia and psychosis.  After 5 days of worsening edema and tender arthritis, he agreed to a steroid burst of 40mg daily and tapering regimen with rheumatology to follow.

 

References

eMedicine: Erythema Nodosum

eMedicine: Enteropathy arthritides

Learning Radiology: An Approach to Arthritis

I love my Kindle!

I always wanted some "electronic paper" device that I could take notes on and hold all of the files I wanted at my fingertips ...

My parents gave me the Kindle DX as a birthday gift!  It has "whispernet" dedicated wireless for simple bookdownloading/wikipedia browsing (battery life 2 days) and a solid read time of 2 weeks with the internet disabled.  Since it doesn't have a backlight and it only draws power when the pages turn, it's a great device for travel.

It feels almost blasphemous to admit how I am fond of my iPhone, especially now that the iPad has come out as the sexy attractive alternative to this eReader.  Amazon will hopefully step up its game and work harder with the Kindle.  In any case, I think that the Kindle was/IS still a good buy.

For my MD preparations, I bought a series of clinical books:

• DeGowin's Diagnostic Exam
• Good reference, a bit thorough but a fun read nonetheless with great quotables!
  
• The Rational Clinical Examination by JAMA
• Great analysis for an evidence-based H&P!
  
• ECG Diagnosis Made Easy
• Image quality can be an issue on a grayscale e-Ink pad.  Keep that in mind when purchasing eBooks.
  
• First Aid for the Family Medicine Boards
• Hopefully this will pay off in spades over the next 3-4 years during my residency!

Then, I uploaded the AFP pdf series on assorted Family Medicine topics (we received a CD with copies of some important articles published in the past 10 years in our third year rotation.)

Additionally, I have been tossing in pdfs along the way, for ICU topics mainly.

There are tons of free e-books to read as well.  I've read half of the Sherlock Holmes books and I'm attempting to read the Autobiography of Benjamin Franklin and Physics for Entertainment now.

I put it in a clipboard I bought at Office Depot -- one of those storage clipboard cases -- for protection from damage/theft.  I am working on making a USB drive with the PortableApps to create my perfect portable experience now, to use while rounding in the hospital.

I do enjoy the multiple formats that I can use to read my Kindle books -- it is nice to curl up in bed with my Kindle app on the iPhone when I don't want to read with the lights on.

 

The only thing I dislike about the Kindle is the bookmarking -- there's no way to label the bookmarks so it is a lot of page number memorization!  Very frustrating when you're trying to navigate to something specific as a quick reference.

------------

Picture by ivyfield via flickr

What does PPD/BCG/TB mean?

Clinical scenario:
In the Hawaii HOME project, we had a series of patients who were being screened for TB with PPDs.  Three of them had a history of (+)PPDs.  Two of them claimed to have a history of (+) chest x-ray without follow-up of medications.  One of them came in with fever and cough.

Definitions:

• TB: Tuberculosis
  • Caused by Mycobacterium tuberculosis
  • Tubercles are warty, cheesy lesions
  • Respiratory infection characterized by:
    • Cough
    • Hemoptysis (bloody sputum)
    • Fever/Chills/Night sweats
    • Weight loss
  • DIFFICULT: to catch, to culture, to get rid of
• BCG: Bacillus Calmette-Guerin
  • Calmette (French bacteriologist) and Guerin (assistant) cultured a cow-version of the TB bacteria and created a TB vaccine
  • Similar theory to the smallpox vaccine
    • Jenner made a vaccine from cowpox
  • Causes a false-positive PPD skin test
• PPD: purified protein derivative aka Mantoux test
  • Sterilized tuberculin glycerol extract from the tubercle bacillus
  • Injected subcutaneously (right under skin)
  • Read 2-3 days later (delayed type IV hypersensitivity reaction)
    • (+) if induration (hardness) forms >5/10/15mm depending on situation
    • (-) if no reaction is present
• Chest x-ray
  • Test of choice in non-active TB for determining clinical status
  • (+) indicates that lesions suspicious for TB are observable
  • (-) indicates that the patient is at risk for secondary TB activation in the future, but currently does not have active TB assuming the patient is asymptomatic

Why is this important?
Swaziland has the highest prevalence of TB in Africa (1,198:100,000), shortly followed by South Africa (948:100,000). In the Pacific Islands, Cambodia, Kiribati and the Philippines have high rates as well (495, 365 and 290:100,000 respectively.) In Southeast Asia, DPR Korea, Timor-Leste and Bhutan have high rates; also places of conflict.
Many immigrants pass through Hawaii to the mainland US and the immigrant homeless population has a significantly higher risk of exposure to TB and subsequent infection.

Treatment
Active TB Standard recommended regimen:
2 months of RIPE: rifampicin, isoniazid, pyrazinamide, ethambutol
4 months of RI: rifampicin, isoniazid
Latent TB infection:
6 months of isoniazid, or 3 months of RI
-Advise patients about side effects of isoniazid:
GI upset (loss of appetite, nausea, vomiting, stomach pains)
Weakness, peripheral neuropathy (prevented by vitamin B6 intake)
Liver damage
-Do Cr and LFTs monthly for monitoring

Resolution of clinical scenario:
The two patients with (+)PPDs and (+)chest x-rays were questioned further.
The one with fever and cough was confused and through a translator, thought that the word "positive" meant "good."  In the context of the tests, both were negative.
The other patient had a card with a record locator number.  The main office for TB screening was contacted for confirmation: the chest x-ray was reportedly normal.  This patient had unintentional weight loss of 35 lb over the past year (since becoming homeless.)
The patient was warned about the possibility of "reactivation TB" and was advised to start isoniazid.  The patient agreed to prophylactic treatment and routine testing.

Take home lesson:
Always question your patients about what they mean!  Positive in terms of disease is may not mean the same thing to a patient as it does to a clinician.

References:
WHO estimates of TB incidence by country, 2007
NICE 2006 guidelines: Clinical diagnosis and management of TB and measures for its prevention and control by the UK's National Institute for Health and Clinical Excellence

Traumatic rhabdomyolysis

In recent news, a survivor of the 7.0 earthquake in Haiti have been found after 10 days -- including a 22 year old, Jean-Pierre.  In the rubble of the collapsed hotel he fed on cola, beer and cookies to stave off dehydration and malnutrition until his timely rescue.

He was lucky enough to dive underneath a desk as the earthquake hit, avoiding major trauma.  What if his legs were pinned under tons of rock and timber?  What if he were held immobile for the better part of a week?

Jean-Pierre was spared the fate of acute renal failure/acute tubular necrosis by traumatic rhabdomyolysis.  It would start as dark red urine, that eventually lessens until there is no urine being produced at all.

 

--------------------------------

Myoglobin is a heme-binding molecule present in skeletal and cardiac muscle. It makes our muscles red, especially the slow-twitch (Type I) muscles. It is similar to hemoglobin but greedier -- it's affinity for oxygen is much stronger.  Underwater mammals like seals and whales are able to hold their breath much longer than us due to their higher concentration of myoglobin in muscle.

For reasons that are not entirely clear to us, when muscle tissue breaks down from trauma and immobility, myoglobin is released into the bloodstream and subsequently filtered by the kidneys where it can cause major damage -- nephrotoxicity by iron-dependent and -independent mechanisms.
1) Ferrous oxide (Fe2+) is oxidized into Ferric oxide (Fe3+) and leads to free radical damage in the kidneys.
2) Tubule obstruction and direct toxic effects are thought to occur as well.

Aggressive saline infusions with possible addition of sodium bicarbonate to alkalinize the urine (and prevent conversion of myoglobin into its more toxic metabolites) are the sole treatment of this kidney condition.  This makes sense, since you're clogging up the filtration system with this muscular gunk, you vigorously flush the whole system out!

We're talking about boluses of 20cc/kg (or ~1.5 L of NS for the typical person) initially, with maintenance IVF of 200-300cc/hr thereafter!

This is expected to go on until the urine output hits 2-3cc/kg/hr (or 150-200cc/hr for the typical person) and the urine clears up.

 

Hopefully you find this topical and interesting as well.

 

References

Photo by simminch via flickr

BurnDoc ICU Rounds:
-Traumatic rhabdomyolysis/Crush Syndrome
-Acute Renal Failure

Myoglobinuria - Medscape

"Nonreassuring" Vocabulary

The word "nonreassuring" is a curious phenomenon of OB/GYN.  Nowhere else is this particular word used in a professional context... which is embarrassing that the word is cited in literature when it doesn't exist.

 

Reassuring is defined thusly:

tr.v. re·as·sured, re·as·sur·ing, re·as·sures

1. To restore confidence to.

2. To assure again.

3. To reinsure.

The implication is that "nonreassuring" means the opposite -- worrisome, vexing.  Of course, to a pregnant mother about to deliver, that's some of the scariest news to hear about her unborn child!

 

In an effort to further obscure the assessment in Fetal Heart Tone monitoring, in April of 2008 the "National Institute of Child Health and Human Development Workshop Report on Electronic Fetal Monitoring" issued a new statement to categorize it in a "Three-Tier Fetal Heart Rate System:

Category I
Category I fetal heart rate (FHR) tracings include all of the following:
• Baseline rate: 110–160 beats per minute (bpm)
• Baseline FHR variability: moderate
• Late or variable decelerations: absent
• Early decelerations: present or absent
• Accelerations: present or absent

Category II
Category II FHR tracings include all FHR tracings not categorized as Category I or Category III. Category II
tracings may represent an appreciable fraction of those encountered in clinical care. Examples of Category II
FHR tracings include any of the following:
Baseline rate
• Bradycardia not accompanied by absent baseline variability
• Tachycardia
Baseline FHR variability
• Minimal baseline variability
• Absent baseline variability not accompanied by recurrent decelerations
• Marked baseline variability
Accelerations
• Absence of induced accelerations after fetal stimulation
Periodic or episodic decelerations
• Recurrent variable decelerations accompanied by minimal or moderate baseline variability
• Prolonged deceleration 2 minutes but 10 minutes
• Recurrent late decelerations with moderate baseline variability
• Variable decelerations with other characteristics, such as slow return to baseline, “overshoots,”
or “shoulders”

Category III
Category III FHR tracings include either:
• Absent baseline FHR variability and any of the following:
- Recurrent late decelerations
- Recurrent variable decelerations
- Bradycardia
• Sinusoidal pattern

Basically, Category I is "reassuring", Category III is "Nonreassuring" (ugh) and Category II is somewhere in between.

 

Personally, I don't like it when the assessment of a patient needs to be translated for the patient's benefit -- why is there a deliberate effort to make something difficult to understand even harder to explain to patients?!?  We don't need to tell someone what they already know, but in a completely different language.

 

It's doubtful, but in the future it could be categorized as "good," "hmm" and "uh oh."

 

DR C BRaVADO: mnemonic for Fetal Heart Monitoring

Define Risk (low/high)
Contractions (freq)
Baseline Rate (110-160)
Variability (10-15bpm)
Accelerations (2, >20 over 20s)
Decelerations (early/variable/late)
Overall assessment (reassuring vs "nonreassuring" ugh!)

 

References:

Advanced Life Support in Obstetrics (ALSO)

AAFP website

AAFP Mnemonics brochure

National Institute of Child Health and Human Development Workshop Report on Electronic Fetal Monitoring

The Match.

I submitted my Rank-Order List for Family Medicine programs on Friday. I updated it again today to double-check that my top program numbers were inputted appropriately. Whew!

There's a lot of factors that go into the decision-making process for residency program selection -- geography, work-hours, resident/faculty support, curriculum, monetary factors, etc.

When I looked at Family Medicine programs on the Mainland, I must say, I had NO idea what to look for -- being a medical student from Hawaii, almost all of the faculty in our Family Medicine department trained in the Family Med program here as well! So, I took a shortcut of investigating the P4 programs because I figured that they were excellent programs already, looking for fresh new ideas to integrate into their curriculum. My other choices were based on good things I heard from people, as well as my discussions with them at the Kansas City AAFP National Conference (if you're looking for the perfect family medicine program for YOU, I'd highly recommend visiting in your first month as a fourth year!)

Despite the "4", in the name, not all P4 programs are four year programs, although I found some of the ones that were to be of particular interest. Innovations are a great topic to discuss, but I want to share something else on my mind.


-----------------

Now that the rank-order list is out of my hands, I have nothing to do but wait and see what the final outcome will be, come March 18th. The National Resident Matching Program "matches" me with my #1 choice, putting me in the queue of their program according to their ranking for me -- if I happen to be in their top 10 (or so,) then I get matched there. If someone higher on their list ranks the program highly as well, then I would get bumped down (and possibly off) their list and when all the slots are filled, I would move on to my #2 choice or my #3, until I get placed.

Naturally, I feel a sense of relief.
I've gone through the grueling process of medical school (for the most part.) The countless hours of mind-numbing study in the first two years, culminating in the Step 1 exam. The thrill and terror of third year, suddenly exposed to the organic, living, breathing patient that we've heard so much about. The uncertainty and anxiety of the interviews and the ever-expanding hole of debt traveling across the country far and wide for the perfect place to spend the next three+ years of my life. Now it is time to relax and breathe. It is out of my hands.

I also feel a sense of dread and underlying anxiety.
Questions of self-doubt and second-guessing arise.
Should I have applied to X program?
What if the people at Y didn't like me?
Would I really be happy at Z program?
Can I handle the responsibilities to come?
Will medical school be enough preparation for the next harrowing experience known as INTERN YEAR?

This lack of control is both comforting and anxiety-provoking.
I have no choice but to have faith that my interviews went as well as I felt they did and just keep my brain active in the mean-time. I am tutoring a small group of incredibly fun second year med students and I'm touching on all sorts of issues that I know will be important in the future. More to come on this. :)

*Picture by 96dpi, courtesy of flickr.

Anathem Review

On my interview trail, I purchased this book for my Kindle DX -- and boy, am I glad that I got it electronically, since it clocks in at 960 pages and nearly 3 pounds in the hardcover edition!

It is a work of Science Fiction in the classic sense, inventing a whole world of "compossibility." A world where concents (monasteries) outlive surrounding civilizations by millenia, watching them rise and fall. The Avout (monks) revere Science, Reason, Logic and Physics instead of religion. Indeed, orders of the avout are called "maths." They strive to preserve the world's knowledge and seek out new discoveries, even though a Saunt (Saint) Lora of the 16th century proposed that all possible ideas had already been thought of, which includes Saunt Lora's own Proposition as well.

Stephenson dreamed up this world after participating in the 10,000 Year Clock of the Long Now project, where he thought of the idea of a church that had a clock with a set of individual gates, each programmed to open only at a set time: everyday, every year, every decade, every century and every millenia. A group of monks tended to the clock and were cloistered until such time that their specific gates opened.

The story follows a young "Tenner" who was collected at age 9 and finds himself released back out into the Saecular world shortly after completing his ten-year term. World-altering events call upon young Fraa Erasmus and his fellow clock-winders to solve a great mystery and save Arbre.


Stephenson definitely does not cut you any slack in the novel as you are introduced to the "Orth" language of the people Arbre on the first page and he never lets up. Slowly, the definitions for all of these words unfold in the novel. The payoff is rich in the form of contemplative prose in classic Plato and Socrates style dialoging that encompasses the physics of geometric coordinate phase space, the philosophy of consciousness, the existence/non-existence of time, the power of observation, and the exciting possibilities of science fiction (yes, there are parts of the book that include classic sci-fi space-opera elements to make geeks and nerds glomph and squeal and huggle and hurr.)

If you enjoy xkcd comics, Snow Crash, His Dark Materials, or anything along this vein where education itself is a form of entertainment for you, then this book is a definite buy.

It is quite a struggle for me to describe how this book has affected me, save to say that I have some upsight into the possible tracings of my own Narrative along multiple Worldtracks as they progress along a Directed Acyclic Graph in a Wick fashion, leaking in from the Hylean Theoric World. Complete nonsense to most, but I could put it best in no other way.

And that's Not My Second Opinion.

Further Blogging Musings

I started off one of my Family Medicine interviews in a very interesting way.

"I noticed you were a blogger and I must say, I was disappointed." He paused to drink in my reaction and his eyebrows furrowed as he continued in a very somber tone. "You haven't blogged in a few months!"

"Well, I have been busy interviewing," I confessed. "Plus, I would not want to blog about a specific program only to have it come back to me in a bad way."

"Exactly. I thought that I could comment on your thoughts about interviews in the hopes of bringing up a point of awkwardness."

I thought to congratulate him on doing just that, but we moved forward from that point... but he did make me think more about the frequency of my posts as well as the content itself.

One of the things that has made blogging difficult for me has been the way I have spent my free time.
My blogging dropped off precipitously when I started a relationship with a special someone (with a p-value of <0.0001! I like to joke) and when I decided to blog, it quite often turned out to be "catching up on blogs" rather than "writing cool and fun content for my own blog." Sadly, my comments on other blogs dropped off with the exclusive use of Google Reader for my blogging needs. It does a splendid job of offering me text content, but a terrible job in helping me reach out and become a part of a virtual community. I put myself in the position of observer alone, having all of these amazing bloggers teach me about fascinating clinical cases.

I have been afraid to post things of personal interest.
My posts of late have adopted more of a neutral tone and lacked personality. Tossing back the curtain of "pseudoanonymity" by attaching my Real Name to this blog and revealing its presence to ALL of my potential residency programs made me meek. I have been afraid to say anything that may offend, provoke or be of any real interest, to be quite frank. This has made me think of the Happy Hospitalist and his "crap or not, here it comes" attitude to posting. Despite the fact that I often disagree with his philosophy and politics, he does occasionally have an excellent pearl or two to share... the rest are just his opinions.

And I certainly do not live up to my pseudonym if I am afraid to offer up opinions of my own, as ill-informed, naive, idealistic, fluffy bulshytt as they may be.

Writings and Ramblings

January 1st is a time of reflection on the past year as well as a time to resolve to make changes.

There's a few things that I want to do differently in the year 2010 and beyond.

I want to complete the 100 pushups workout. This is something that I think will be achievable by March.

I want to Blog more. Technically, this is something that I have accomplished with the simple exercise of writing this post! More specifically, I want to blog daily. There are a lot of things that go unwritten that I might find of relevance at a later date.

Recently, during a resident dinner, I found myself making two quite random non-sequitors on the subjects of urushiol and polydactyly -- subjects I fancied enough to blog about in the past. I found it quite striking that these topics bubbled up from my subconscious and became somewhat relevant!

One of my favorite interviews (at my favorite residency program) included a discussion on blogging. Indeed, said interviewer encouraged resident blogging as a way of reflecting on issues that came up!
There was a suggestion to ask yourself three questions:

What?
So what?
Now what?

What: Subject of discussion
So What: WHY is this of importance to you (the writer) and me (the reader?)
Now What: Conclude with something of significance.

So there. I've come up with a new method for generating blogging content that hopefully will me more entertaining and engaging than recent posts (that have been so dry that I bored myself writing them) and hopefully I can find a way to blog more often.

Cheers!

No Such Thing as "Healthy Obese"

I've been doing a lot of thinking about Science Writing.

Here is an example of great Scientific Journalism from Forbes.com (via Dr. Ves)
Study Debunks Notion of 'Healthy Obese' Man

The report concisely analyzes a new study in the journal Circulation, including the patient size and population (1800 Swedish men) and most importantly, context: ("starting at age 50 for an unusually long time, 30 years, recording those who have died of a heart attack or stroke.") Problems with previous studies did not track patients over an adequate period of time (in which patients were only followed for 15 years or less.)

The results:

the study found that over the 30-year period, the risk of cardiovascular disease was 63 percent higher in men of normal weight who had metabolic syndrome, compared to normal-weight men who did not have metabolic syndrome. It was 52 percent higher in overweight men without metabolic syndrome, 74 percent higher in overweight men with metabolic syndrome, 95 percent higher in obese men without metabolic syndrome and 155 percent higher in obese men with metabolic syndrome.

The only thing that this report fails to do is cite the original article, which I will do (along with an older one that is readily available on PubMed.)

Circulation. 2008 Jun 17;117(24):3057-9.
Healthy lifestyle: even if you are doing everything right, extra weight carries an excess risk of acute coronary events.
Johan Ärnlöv, Erik Ingelsson, Johan Sundström, and Lars Lind
Impact of Body Mass Index and the Metabolic Syndrome on the Risk of Cardiovascular Disease and Death in Middle-Aged Men
Circulation, Dec 2009
Poirier P.

-----------------


It's topical and relevant, especially in this holiday season :)

So what will I tell my patients?
If you are a middle-aged Swedish male with a pot-belly, high cholesterol, elevated blood sugars, and high blood pressure, you are doubling your risk for a cardiovascular event (1.74x for overweight, 2.55x for obese.) If you only have a pot-belly you ALSO increase your risk (1.52x for overweight, 1.95x for obese.)

This is likely even higher for other more at-risk populations.

Podcasts

This part was a real struggle for me, since I have never used podcasts before. I didn't even use iTunes before. After a lot of searching, I came across some fun podcasts.

My new podcast stream:






<

iDistraction

My blogging has dropped off, due to some new distractions.
I thought I'd share one of them, since it bears medical/educational relevance, in the same vein as Joshua Schwimmer of Efficient MD.com:

Other apps recommended: "8 Medical iPhone Apps You Should Prescribe to your Health-Care Professional."

Medscape loads faster than Epocrates, but Epocrates is the go-to for medicine info.
Medcalc is a classic that I used a lot on my PDA, just like Eponyms.
Heme Calc also has formulas for nephrology, cardiology, gastroenterology and obstetrics -- I couldn't tell the difference between the other apps offered (so I went with the one with the prettiest color.)
Reach MD radio has streaming radio for medical professionals. Really good for a smattering of general medical topics.
PubMed on Tap: Joel Topf found this very helpful when he needed a citation to back up the statement he made that "the data doesn't support the common sense notion that contrast accelerates the loss of residual renal function."
Shots online and NEJM Image Challenge are two weblinks that I found worthwhile storing on my homepage.


Evernote is ever AWESOME. Especially when I found out that I could *Favorite* my handout on Acid-Base and EKG reading for quick access (local file, no repeat downloading necessary)
Google Reader and Twitter provide me with round-the-clock streaming data on the latest and greatest, by subscribing to some of the best, web-savvy, provocative and brilliant physicians!

Family Medicine?

A question I get asked a lot is "Family Medicine, huh? Is that like a GP?"

It is strange but a lot of people do not know what a Internist does, much less a Family doc.

I was pleased when I came across this article in the Annals of Family Medicine: FAMILY MEDICINE: WHAT ARE WE GRADUATING?
From the Association of Family Medicine Residency Directors

The original guidelines from family medicine covered a mere 3 pages laying out the length of training, and general content, as well as proposed categories of programs that reflected and embraced the wide variation of locations where family medicine physicians lived and worked. Our founding document also defined the family medicine physician in 4 domains

First, the family medicine physician was to serve as the physician of first contact with the patient who provided an entry for the patient into the health care system.

Second, the family physician was tasked to evaluate the patient’s total health care needs and to provide personal medical care and referral management.

Third, our graduates were to provide continuous and comprehensive care as well as the coordination of care.

Lastly, the vision asserted that family medicine physicians were to provide care for the patient within the context of the patient’s family and social milieu.

Primary care. Primary as in First contact. Total care as in from beginning to end. Family medicine -- with a focus on the context of interrelationships, family, and society. I love it! It's all in the name but the IDEA is somehow so foreign to the sort of fragmented, disjointed care that we have now that we've lost sight of these sorts of basic principles.

----------------
The Residency Directors ask this question:

Do we need to expand the definition of the family physician to include alternate types of practice? And, lastly are our values antiquated, are our visions of ourselves valid, or should we change?

I answer with an emphatic No.
I will strive to have a committed relationship with each and every one of my patients. One of the most frustrating thing about being a medical student is the time and effort required to get to know a patient in a 30-45 minute time span only to see them vanish into the Healthcare system never to be seen again. So I look forward to a time when a patient is scheduled for a follow-up appointment in 6 months and I actually get the chance to follow-through.

Adventures in Brain Tumors (Prolactinoma!)

notmy2ndopinion: Adventures in Brain Tumors, (by @mathowie) http://bit.ly/37DMa4 (via @JoshuaSchwimmer)

My favorite part comes in the conclusion and it is very revealing about how AWFUL the patient experience can be. All too often, health care professionals feel pressured by their own time schedule and do not take the time to move at the pace more comfortable for the patient. Even small, simple things can make a big impact, like pulling up a chair to sit while talking, tuck the blanket in after pulling it down to examine their abdomen, etc...

The days in the hospital didn't go by so much as a blur as they did a smear. I was either asleep, passed out and seizing, lethargic, and very briefly completely awake each day as an army of medical professionals grilled me with a couple dozen identical questions and eventually life altering decisions were presented to me when I had been awake for all of 30 seconds.

I came away from this experience feeling the OHSU hospital in Portland continues to impress me with its amazing staff, but that the process of dealing with patients could be done in a more efficient manner. I know they all sort of kept an internal log of my story but to constantly be asked the same things by different groups of people and then not know who is your main decision maker was a challenge. Given my state of sickness and exhaustion, I felt like what an elderly man might feel like in the medical system. I had trouble understanding what people were saying as they woke me from sleep, I was constantly poked and prodded without descriptions of what results entailed, I literally wanted to "phone a friend" when those surgeons asked me in the early morning hours what I wanted to do.

"Time Lost is Brain Lost"

I woke up at 0430 and I couldn't get out of bed. Oh, that's weird, I thought. My right arm was completely numb from the shoulder all the way down to the fingertips. After about two minutes I jumped out of bed but I fell straight down onto the floor with a crash. My legs were weak -- it was like the right side of my body didn't exist!

My wife awoke in the commotion and asked me what was wrong.

I opened my mouth to talk to her, but nothing came out! I could understand her but my words weren't there.

After about three minutes, I got up and I said "oh, I'm okay now." I took a shower (there was still some numbness in the arm) and went to work. I figured something was probably going wrong so I called the doctor and he told me to go to the ER.

Lucky thing too... it sounds like you had a mini-stroke or what we call a"transient ischemic attack," (TIA) -- a temporary event. The residual numbness suggests more long term damage though. Since you're right-handed, you are most likely left-brained -- and your language is controlled by that side of your brain too. When you had the brain ATTACK (as threatening as a heart attack!), you wiped out your left brain, paralyzing your right body and knocking out your ability to talk.

We call this right-sided Hemiparesis (weakness) or hemiplegia (no movement), right hemineglect (inability to register things on the right side of the world) and Broca's aphasia (inability to verbalize thoughts; staccato, halting speech.)

I went over the ABCD2 scale with him and calculated a moderate risk for stroke:

2-Day Stroke Risk: 4.1%.
7-Day Stroke Risk: 5.9%.
90-Day Stroke Risk: 9.8%.

We started him on clopidogrel (Plavix) and he is undergoing a cardiac workup to rule out an embolic cause for his TIA/stroke.

In stroke patients, further assessment is done with the NIH Stroke Scale.

An pdf of the NIH Stroke Scale is available at http://www.ninds.nih.gov/doctors/stroke_scale_training.htm

An online course for provider education is available on
http://www.strokeassociation.org/presenter.jhtml?identifier=3023009

Hoarseness

In my Neurology rotation, I saw a lot of patients with "spasmodic dysphonia," which makes people sound like they are choked up with emotion or they are sick. It is described as "breathy," or "halting, strangled" voice that trips up on diphthongs, two vowel sounds. It can be precipitated by a stressful event, leading many physicians to think that it is psychogenic.



Surprisingly, Botox (Botulinum toxin A) is a definitive treatment! With EMG guidance, a needle is advanced into the vocalis muscle and injected with a small amount of Botox to paralyze the spastic muscle for 3-4 months.



Other causes for hoarseness include:
Inflammation-> allergies, trauma, URI
GERD-> laryngopharyngeal reflux (treated with a PPI)
Vocal cord lesions (granuloma, papilloma, edema, squamous cell carcinoma,)
Recurrent Laryngeal Nerve injury or Vagus nerve injury (aortic aneurysm, mass effect)
Neurological problems like Parkinson disease, multiple sclerosis, myasthenia gravis
Systemic disease (acromegaly, amyloidosis, hypothyroidism, inflammatory arthritis, sarcoidosis)

The Mito Mystery

Brownout: The Mitochondria Detective work Gets a Little Easier

“The mitochondria are like engines,” he says. “When a car engine doesn’t work right, it smokes.” Similarly, malfunctioning mitochondria produce nasty gunk Enns refers to as “biochemical smoke.”

I love little pictorial metaphors that just make sense.

The article delves into the medical mystery of a young girl who is "anorexic" despite a healthy appetite who had two siblings who passes away with some sort of muscular dystrophy. They get referred to a mitochondrial specialist.

But sometimes, for a single patient, a glimmer of hope breaks through the fog. Veronica Segura recently learned what’s at the root of her disease: a mutation in the cellular instructions for building the enzyme thymidine kinase 2, which plays a key role in synthesizing new mitochondrial DNA. Most important for Segura, a child must receive a bad copy of the gene from each parent to manifest disease. Segura’s husband, Aurelio, doesn’t carry the disease gene, which means their little daughter will never suffer her mother’s mitochondrial illness.

The article ends on this happy note, but I am doubtful of its veracity.
It is my understanding that mitochondrial DNA are EXCLUSIVELY inherited by the mother, who provides ALL of the baby mitochondria as the egg donor -- the sperm mitochondria do not become a part of a zygote->baby...

"The Neuro Exam is not dead"

Bedside Eye Exam Outperforms MRI in Identifying Stroke

"We only misclassified 1 out of 25 patients who had a vestibular disease that was a benign condition of the inner ear,"

"This study demonstrates the critical importance of function-linked tests over purely time-static anatomic tests in discerning the localization of vestibular dysfunction early in its course," session cochair Nina Schor, MD, PhD, from the University of Rochester Medical Center, New York, told Medscape Neurology. "It's so much the better that the tests described by Dr. Newman-Toker can be performed at the bedside in these often critically ill patients."

There are three signs to look for:
Head Impulse test
Beating Nystagmus in lateral gaze
Test of Skew with the Cover/Alternating Cover

These signs showed a Sensitivity of 100% (n=69) and a specificity of 96%(n=25) which is remarkable... while it makes sense to "wait and see" if future tests show that these results are reproducible, it really does not hurt to spend a few extra minutes in a neuro exam to check for these things:

"I No (know) Strokes!" Impulse/Nystagmus/Skew.