Prepping intern notes
I received a wonderful tweet based on my nouns need adjectives post.
I’m prepping materials for incoming interns inspired in part by this. Focus is on notes for our inpatient service. Got anything to add?
The idea is to list common chronic problems and specify information that an admission note should include. Here are my thoughts including his suggestions and my modifications
COPD – PFTs if done, current meds, home oxygen?, possibly Gold Stage
Heart failure – systolic function, define type of heart failure, any valvular disease, current meds, if EF < 35% does patient have AICD, EKG – does t...
Source: DB's Medical Rants - March 23, 2018 Category: Internal Medicine Authors: rcentor Tags: Medical Rants Source Type: blogs
Uncontrollable itching – the denouement
The emergency department ordered a CT scan that showed a dilated common bile duct, no pancreatic masses, a mass in the duct – stone versus other.
Twelve hours after admission, he developed a temperature of 101 and a repeat CBC showed an elevated WBC with left shift.
Therefore, GI did an ERCP the next day – revealing a large gallstone – not easily removable. The placed a stent and drained pus.
So this man had painless jaundice from a common duct stone.
As an intern in 1976 I had a patient with ascending cholangitis. His internist told me that he had pancreatic cancer, but had declined surgery. In 197...
Source: DB's Medical Rants - March 21, 2018 Category: Internal Medicine Authors: rcentor Tags: Medical Rants Source Type: blogs
Uncontrollable itching – part II
As we heard the history we stopped, prior to hearing the exam and labs, and developed a differential diagnosis. With the combination of itching, probable jaundice and pale stools we assume either intrahepatic or extrahepatic obstruction. Our differential diagnosis with commentary:
Primary biliary cirrhosis – much more common in women then men – but does often present at this age with uncontrollable itching
Primary sclerosing cholangitis – no history of ulcerative colitis or diarrhea symptoms, but still possible
Gallstone – not all common duct stones cause pain
Cholangiocarcinoma – ...
Source: DB's Medical Rants - March 20, 2018 Category: Internal Medicine Authors: rcentor Tags: Medical Rants Source Type: blogs
This man had uncontrollable itching – a case presentation in 3 parts – Part 1
The man, in his 60s, had enjoyed good health until 6 weeks ago. His symptoms started with modest itching, but over the past 2 weeks it had become unbearable. During this time, he had lost 20 pounds because he had both nausea and some post-prandial vomiting. A physician had tried hydroxyzine, without any symptom relief. He denied abdominal pain. He had never had similar symptoms. He was taking no new medications.
Over the past week relatives and friends told him that he was starting to look yellow.
On further questioning he told us that he had dark urine but chalky colored stools.
Part 1 – develop a...
Source: DB's Medical Rants - March 19, 2018 Category: Internal Medicine Authors: rcentor Tags: Medical Rants Source Type: blogs
The importance of exercise
Exercise helps keep us healthy. Numerous studies document these benefits. Yesterday I tweeted another link –
For Heart Disease Patients, Think Exercise, Not Weight Loss
These studies do not expect vigorous exercise, but they do measure movement. Both movement and some resistance training help keep us healthy.
Here is another link – this one on 10 benefits of exercise
Readers know that I have become totally obsessed with exercise. I recently celebrated 2.5 years of Orange Theory Fitness. I go 4-5 times each week.
But one does not need to be as obsessed as I am. Moderate exercise works and works wel...
Source: DB's Medical Rants - March 8, 2018 Category: Internal Medicine Authors: rcentor Tags: Medical Rants Source Type: blogs
Many medical nouns need adjectives
Last week on twitter I wrote a series of tweets about necessary qualifiers. Here are the tweets which represent an incomplete sample of the problem:
1st tweet on importance of qualifiers w/ “diagnoses”
Do not label the patient as COPD exacerbation without saying why: Differential includes acute bronchitis, pneumonia, pneumothorax, left side heart failure, anemia, opiates, PE etc.
2nd qualifier tweet – Never tell me the patient has CKD without giving me the stage and the cause. Corollary – do not give me the eGFR for patients with AKI – the estimates do not work with increasing creatinine levels...
Source: DB's Medical Rants - March 5, 2018 Category: Internal Medicine Authors: rcentor Tags: Medical Rants Source Type: blogs
Mystery fiction and being a better internist
As a child, mystery fiction captivated me. Probably the Bobbsey Twins, then the Hardy Boys and Nancy Drew started the passion. I remember the TV show Perry Mason, which led me to reading books from the Earl Stanley Gardner series. Lt. Columbo captivated me. Discovering Sherlock Holmes was an epiphany. And throughout my life, I love finding great new mystery authors.
I suspect that my love of mystery fiction made my choice of internal medicine inevitable. While our field has many dimensions, the core of being a good internist is accurate diagnosis. While sometimes diagnosis is straightforward, often the patien...
Source: DB's Medical Rants - February 25, 2018 Category: Internal Medicine Authors: rcentor Tags: Medical Rants Source Type: blogs
The Fusobacterium story as of 2018 – a very long post
Conclusion:Fusobacterium necrophorum–positive pharyngitis occurs more frequently than group A ?-hemolytic streptococcal–positive pharyngitis in a student population, and F. necrophorum–positive pharyngitis clinically resembles streptococcal pharyngitis.
Since Fusobacterium necrophorum recovery increased as the Centor score increased we argued that we had sufficient circumstantial evidence that this organism explained many of the 3s and 4s and that the score really reflected bacterial pharyngitis. Our subsequent recently published paper on the pharyngitis microbiome strongly supports our contentions.
So where ...
Source: DB's Medical Rants - February 11, 2018 Category: Internal Medicine Authors: rcentor Tags: Medical Rants Source Type: blogs
Why I love inpatient IM ward attending
38 years and I still get excited making rounds. 45 years ago I discovered that I was meant to be an internist – it was my first week on the IM rotation. Prior to that week I had no idea!
Internal medicine combines understanding medical science and people. Internal medicine requires detective work and compassion. Internal medicine typifies what I thought of as I thought of being physician.
Practicing internal medicine is honorable. One need not do more than that to contribute to patients. But from my student years the teaching of internal medicine attracted me.
I remember being an intern and wanting to hel...
Source: DB's Medical Rants - January 28, 2018 Category: Internal Medicine Authors: rcentor Tags: Medical Rants Source Type: blogs
Tips for IM attendings – Chapter 21 – make rounds a conversation
Recently I observed rounds someone else’s rounds. During those rounds, interns or students reported to the attending physician who took notes. Interaction was minimal, and other members of the team totally ignored the interactions.
This week I realized that our rounds were conversations. We take cues from each other, and use these cues to improve understanding. We involved the entire team in decision making and learning. I teach some things, but the resident and intern also do some teaching. Everyone on the team understands what our plan is for each patient.
The secret is an ongoing conversation. Studen...
Source: DB's Medical Rants - January 20, 2018 Category: Internal Medicine Authors: rcentor Tags: Medical Rants Source Type: blogs
The #5goodminutes project
As readers and twitter followers know, I have embarked on a yearlong project – tweet a relatively short internal medicine topic each day. This project came from advice I have been giving learners for several years – each day after rounds pick 2 topics to read about for 5-10 minutes. This educational theory comes from the neuroscience recommendation that learning something in more than one way improves learning. So if we discuss something, and then the learner reads about it and writes down a salient point, prolonged learning is more likely to occur.
So I decided that if this really works, why should I not...
Source: DB's Medical Rants - January 18, 2018 Category: Internal Medicine Authors: rcentor Tags: Medical Rants Source Type: blogs
Try to avoid vancomycin/pip-tazo
This study used a retrospective matched cohort technique – not a randomized controlled trial, but a reasonable methodology.
Patients in both VC and VPT groups had similar baseline characteristics in terms of age, length of ICU stay, Charlson comorbidity index score, baseline creatinine, and use of concomitant nephrotoxins.
The groups had great similarity.
The rate of AKI was higher among patients receiving VPT compared to those receiving VC combination therapy. Based on RIFLE criteria, 81 patients in the VPT group developed AKI compared to 31 patients in the VC group (29.0% vs 11.1%; hazard ratio [HR] = 4.0; 95% conf...
Source: DB's Medical Rants - January 8, 2018 Category: Internal Medicine Authors: rcentor Tags: Medical Rants Source Type: blogs
#5goodminutes Type IV RTA
For a number of years I have advised students and residents to keep a notebook of topics that arise on rounds. Pick 2 topics that we discussed, then read about them for 5 minutes. Everyone has 5 minutes to read about a topic.
The idea here is that cognitive science has shown that we remember better if we both hear about a topic and read about the same topic.
Since I have embarked on this project of one medical tweet each day, I have embraced the 5 good minutes philosophy. So I will use the hashtag #5goodminutes each day, along with other tags.
Today I want to increase understanding of Type IV RTA as many students, re...
Source: DB's Medical Rants - January 3, 2018 Category: Internal Medicine Authors: rcentor Tags: Medical Rants Source Type: blogs
The daily clinical post #KashlakChief
In honor of becoming the Chief of Medicine at Kashlak Memorial (for those who are not aware, this the imaginary hospital that hosts the Curbsiders podcast. This position comes with great responsibility (insert your Spiderman quote here).
Each day I plan to tweet a clinical thought based upon either my reading or a recent patient. I would love suggestions of what should go into the daily tweet. Please hold me accountable.
(Source: DB's Medical Rants)
Source: DB's Medical Rants - January 1, 2018 Category: Internal Medicine Authors: rcentor Tags: Medical Rants Source Type: blogs
My suggested New Year ’ s resolution for physicians and patients
Exercise!
This should come as no surprise to regular readers. I admit to an exercise obsession. Each day I make plans to do something.
As I read the research, exercise is the best preventive tool we have. While exercise alone cannot create weight loss, it does make it easier. Most committed exercisers start to modify their diets towards more healthy eating (I will let you define healthy as there are varied implications of the phrase healthy eating). Exercise clearly helps with weight maintenance.
You should move significantly each day. For some walking is the key; some love running; others do biking or the elli...
Source: DB's Medical Rants - December 31, 2017 Category: Internal Medicine Authors: rcentor Tags: Medical Rants Source Type: blogs
