Back in St. Andrews...

So I made it back to St. Andrews last night, and am currently involved in orienting Freshers (first years) to our Hall of Residence. Posts will probably resume once Fresher's Week is over.

Funny Quote from a Neurosurgeon a friend was working with over the summer:

Neurosurgeon: "And what should the patients [lab value] be?"
Intern: "Umm...I'm not sure"
NS: "Well f'ing guess then!"
Intern: "Umm...50??"
Neurosurgeon: "NO! There is no guessing in Neurosurgery!!"

-AMiB

Leaving, on a jet plane...

Cliche title, I know. Anyway, tomorrow I start the ridiculously long journey (like 23hrs total travel or something) back to St. Andrews. I should arrive at my hall at around 6ishpm GMT time (and have a meeting at 7pm. Great..)

I will continue my "What I Learned" series when I get back. For now, I must pack, get ready for Fresher's Week, etc.

-AMiB

What I Learned This Summer, Part 2

• When treating DKA, you cannot stop treatment before the bicarbonate has been corrected (~22-24)
• When a joint is inflamed, always feel the temperature - Warmth could be significiant of a septic joint
• When doing arthrocentesis of the knee, find the bottom of the patella, and go medial OR lateral (Dr. A thinks lateral is better)
• 7 Causes of Monoarticular Arthropathy
1. Septic Joints
2. Gonococcal Infection
3. Gout
4. Pseudogout
5. Bechet's
6. Trauma
7. Reactive Arthropathy
• Gout
• no need to tap if suspected in 1st metatarsal
• uric acid crystals found on microscopy
• 90% due to under-excretion of uric acid
• 10% due to over-production
• either way, Rx is NSAIDs + steroids
• in over-production, add allopurinol
• Pseudogout
• Calcium oxalate crystals
• Tx is NSAIDs and steroids
• Septic Joint will have >50,000 WBCs on microscopy
• True Iron deficiency shows low iron AND low iron saturation
• For the first 2 weeks s/p Acute CVA, allow for autoregulation of BP, except in hemorrhagic stroke
• AIDS
• CD4+ < 200 =" AIDS
• CMV Retinitis
• Toxoplasmosis
• Esophageal Cadidia
• TB
• MAI Reccurent
• Kaposi's Sarcoma
• Cryptosporidium
• Lymphoma
• General wasting, CD4+ count
• AIDS --> treat
• CD4+ < 350 =" treat
• CD4+ 350-500 = treat if >60,000 viral load
• CD4 >500 = don't treat
• If HAART works after 8 weeks, viral load should be gone
• If viral load is still present, they are resistant to part/all of the regime
• Geno/phenotyping to help determine what anti-virals to use
• Most common cause of Pulmonary HTN that is not easily explained is a chronic pulmonary embolus
• DVT's below the knee = no treatming
• DVT's above knee = Coumadin (warfarin)
• Recurrent DVT's = indication for continuous anticoagulation
• Best place to look on 12-lead EKG for A-Fib are in the inferior leads - II, III, aVF

What I Learned This Summer, Part 1

So, since I spent most of this summer prancing around the hospital in my shirt&tie or scrubs, pretending to be important, I decided I should have something to write down all the little tidbits that I pick up. Many of them are clinical "pearls", some are things that I just wrote down off of UpToDate (I mean uhh...my Attending stated it to me word for word, cuz stealing would be a Copyright Violation:-/), and some are just random things that a normal medical student would know that I didn't (aka the answers to pimping questions). So I decided it would be fun if I shared them with you. I've got 1 and a quarter (guesstimate) little shirt-pocket notebooks filled with info, so it make take more than 1 post. So without further ado, here we go:

• After every 6 units of blood, Calcium must be administered to help the clotting cascade.
• Consequences of Erythropoietin
• High BP (HTN)
• Seizures
• In Endocarditis,
• Janeway lesions --> no pain
• Osler nodes --> pain
• CLUBBING Acronym for causes of Clubbing
• C - cyanotic heart diseasse/Cystic Fibrosis
• L - lymphoma
• U - ulcerative colitis
• B - bronchiectasis
• B - bronchogenic malignancy
  
• I - idiopathic pulmonary fibrosis
  
• N - neoplasms
  
• G - granulomatous diseases
• Part of DDx of BRB in Stools:
• Diverticular bleed
• Aterio-venous malformations
• not too common
• usually in lower GI
• MMSE (Mini-Mental Status Exam)
• out of 30 points
• 28-30 = probably not demented
• 25-27 = borderline
• <25>
• ~13% of >75yo's have a MMSE <25
• Absolute Indications of Dialysis
• Pericarditis
• Fluid overload
• HTN
• Uremia
• N/V
• Creatinine >12 or BUN>100
• 2 Major Abx that cause Antabuse-like reactions when taken w/ alcohol
• Metronidazole (Flagyl)
• Isoniazid
• When UTI culture shows Proteus Mirabilis, a urea-splitting organism, investigations for staghorn calculi (e.g. Renal US) must be performed
• NEVER use Levaquin (levofloxacin) when pt is on Coumadin (warfarin) - raises INR dramatically (=bad!)
• Bicipital tendonitis - hold arm to chest wall; with flexed elbow, rotate humerus laterally while palpating the bicipital tendon (where bicep originates in shoulder) - if inflamed, will cause intense pain
• Pancreatitis (elevated Lipase) + Elevated ALT = Gallstone Pancreatitis
• 3 Leading causes of cough:
• Post-nasal drip
• Asthma
• Acid reflux (GERD)
• Pneumonia (PNA)
• crackles/rales
• CXR lags 3/4 weeks behind clinical (fever, O2 Sat, etc), even after pt feels better
• BUN more specific on CMP for PNA
• Put on abx: macrolide, 3rd generation cephalosporin, and broad spectrum flouroquinolone
• Septic Joint/Nongonoccocal arthritis is sometimes the presenting complaint in Infectious Endocarditis
• Causes of Macrocytic Anemia
• Reticulocytois (reticulocytes are macrocytes)
• Alcoholism
• Liver disease
• Interference with DNA synthesis
• Folate or Cobalamin (B12) deficiency
• Drugs e.g. hydroxyurea, methotrexate, etc
• Myelodysplastic syndromes
• Hypothyroidism
• Hyperlipidemia
• When Increased Creatinine or ARD is due to drug rxn, urine may contain eosinophils - test for them
• When alcoholic patients develop constipation, they develop hepatic encephalopathy - treat with lactulose to move bowels, and thiamine/multivitamins (e.g. banana bag - though these aren't used too much anymore)
• Pts with chest tubes/drains must be outputting 100mls or less over 24hrs before clamping off tube
• 6 Cardioprotective Agents
1. Statins
   
2. ACE-I/ARBs
3. Heparin/Lovenox (enoxaparin - an LMWH)
4. ASA (aspirin)
5. B-Blockers
6. Thrombolytics/TPA
• When dialysis patients get very itchy, its usually due to uremia
• Hypercalcemia can be secondary to malignancy - both solid tumours and leukemia
• 10-20% of cases are due to this, especially Breast & Lung, and multiple myeloma
• Occurs through:
• osteolytic metastases w/ local cytokine release
• tumor secretion of PTH-related protein
• tumor production of calcitrol
• Procrit (Epoietin) contraindicated in sickle-cell patients - does not differentiate between sickle cells and normal cells, so more of both are made (=bad!)
• In new-onset Type II Diabetes Mellitus, when trying to determine whether to start insulin or oral agents, use a fasting blood glucse of ~400 (mg/dL NOT mmol/L) as a barrier
• Below, use oral
• above, use insulin - but remember, insulin has side-effects!
• In pregnant DM patients, DO NOT use oral medications - insulin only!!
• When I/O is negative (down), you expect H&H to go up (less blood, more cells). If it goes down, check for active bleeding
• Esophageal Spasm, which can cause CP & mimics AMI symptoms can also be relieved by NTG
• AST + ALT in 1000's = Toxic (eg Tylenol OD)
• Normal AST/ALT with Increased Bili = obstruction
• Nitrofurantoin (Macrobid)'s major side effect = Irreversible Pulmonary Fibrosis
• Intracranial HYPOtension Triad:
• MRI showing sagging of the brainstem
• Bilateral subdural hygromas
• Diffuse dural enhancement
• Bronchiectasis (chronic infection of bronchi and bronchioles leading to permanent dilatation)
• Causes:
• Cystic fibrosis
• reccurent PNA
• immunocompromise
• Major bacteria:
• Staph Aureus
• Pseudomonas Aeruginosa
• Antibiotic most likely to cause C. diff infection - Clindamycin
• Can Flagyl (metronidazole - Rx for C. diff) cause C. diff? Yes.
• DVT's below the knee don't need treatment
• Pts on Metformin who are undergoing contrast studies need to hold Metformin for 48-72hrs after contrast administration, while monitoring BUN/Creatinine
• Do not enema/colonoscopy a pt with diverticulitis - you will perforate their bowels.

And with that, I will leave it till next time (it's late, whatever). If you have any questions/clarification, feel free to comment (I feel like I haven't been getting enough comments lately :-D)

-AMiB

Neonatal Opioid Withrdawal

3 day old AAM presents to the Emergency Room (at 2am) with agitation, excessive suckling, inability to sleep, etc. Upon further questioning of the Mother, we discover that during the last few weeks of the pregnancy, the mother was taking Percocet (and not small dose either, the 10/325 kind). Was discharged from the hospital today, fine.

After a little while, baby starts having seizures, etc. Scored an 8 on the Neonatal Abstinence Scale (although the NICU nurses determined he was a lot worse than that). Admitted to NICU (Neonatal ICU) for Neonatal Opioid Withdrawal. Treatment is Supportive care, except in cases of seizures, inability to sleep, and some other things (forgot to write it down off UpToDate).

Now, I'm not going to pass judgement on the mother or the condition of the baby...but, y'know, feel free to comment.

-AMiB

"Going to the ER"

Part 1:

http://www.youtube.com/watch?v=k9m2FLHlEwA

Part 2:

http://www.youtube.com/v/UM-HWkbnDfg


Thanks to ERnursey

So, it's been a while...

Well, I know it's been quite a while since my last post (which was featured in a Grand Rounds [only the second time I've submitted a post]). Things have been busy, I have been doing some steady 6-day weeks at the hospital and 5-6 day weeks at the gym. Am finishing up now, was in the ER today, have one more shift with the Hospitalists tomorrow as well as a night shift in the ER tomorrow and Saturday night. Then it's a few days of relaxation until my return to St. Andrews!

Couple interesting things I saw today:

86yo M on Coumadin bit his tongue 2 days ago, hasn't stopped bleeding since. Dr. M (female ER doc) puts a single 4-0 Vicryl (absorbable suture) in the hole, and applies some gauze. A little while later, patient has still not stopped bleeding, so we put some gel foam (little pieces soaked in thrombin/fibrin) to help the clotting...the bleeding slows, but the patient is poorly complaint (retired psychiatrist, Chinese - not much English) and it takes 3 things of gel foam and a small piece of surgicell to get it to stop. INR was only 2.0, btw.

64yo F originally from Northern Ireland on Vacation, forgot both her insulin refills and her glucometer. Felt horrible (very compliant in past, never forgot insulin shots ever); we thought it would be an easy script, but turns out her sugar is 501. We give her fluids and some insulin, but she doesn't understand what 501 is. Then I realize - in the UK we do blood sugars in mmol/L, while in the US its mg/dL. So, here is something for all you guys out there who encounter this problem: 1 mg/dL = 0.0555 mmol/L. So if you find her BS to be 501, tell her it's 27. If she tells you she's normally 5-8, that means she's normally 90-144. Hope that helps!

Today was also my last day shift in the ER...it always happens that I have to leave just when the nurses/techs/docs are getting used to me being around and are starting to feel more comfortable letting me talk to pt's, etc. Oh well, I've got years of that left.

-AMiB

Nail guns...

Man working with nail gun.
Man shoots nail gun (on accident) through great toe.
Man admitted to hospital for surgical removal of foreign body and debridement.

Always feels good to know that my profession is the one that fixes these people, not the one that it usually happens to.