The new issue of AFP is out but my back is too beat up to sit and write :( But I will try out this iPhone app while I am on the pt bed..... I've been listening to the medscape family medicine podcasts but they are real short. They mentioned that in urinalysis, pay attention to albumin (AKA micro-albumin) because it is a good index of cardiovascular health. If a pt has hypertension and glomerular disease, you can consider using verapamil and diltiazam because it causes dilation of the pre and intra glomerular vessels, similar to and ACEI or ARB.
In peripheral vessel disease, classic claudication is only seen in 10% of patients with claudication so be aware of atypical symptoms. ABI is a very good test to do if you are suspicious. You can give them a statin even if their lipid levels aren't that high. There is also some other medication that starts with an "S" and ends with an "L" that you can use. It is also effective to give them an exercise regiment where they walk till they have pain, continue a little more, then take a break and continue when the pain subsides. They should do about 30-45 minutes 4-5 times a day.
Hmm what else... Oh yeah, ticks can also spread a parasite called nabezia(?) which can be seen on a blood smear. In a lipid panel, non-HDL cholesterol is a more important (and cheaper) index than apoE and ... I forgot the other index. Whooping cough is on the rise in Colorado...
Friday, November 30, 2012
Wednesday, November 28, 2012
Gimme the Keys, Grandpa! - The Older Driver
Its a well known fact that old people drive like crap. I know you probably think its because they are too busy checking Facebook and texting and tweeting, but you would be wrong. Old people have things like arthritis, dementia, hearing and vision problems. Actually, most older drivers do drive fine and most older drivers are able and responsible enough on their own to stop driving. The purpose of this article is to figure out how to tweeze out all the crabby old bastards who refuse to accept the fact that its time to get a bus pass.
Fist thing that you want to do is to find out their driving history. Have they gotten into more accidents recently, more tickets, or more "close calls"? What do passengers say about how the older person drivers? Do they feel safe? It also a good idea to review the medications that the driver is on. Changing medications with ones that have fewer unwanted side affects may be beneficial.
It is also important to consider chronic diseases, especially diabetes. It has been shown that hypoglycemic episodes and improper insulin doses are often seen in automobile injuries[2]. Other diseases, such as epilepsy, heart disease, musculo-skeletal, Parkinson's etc. can contribute to problems driving.
It is important to check the hearing, vision, cognition (with a Mini Mental Status Exam or Clinical Dementia Rating,CDR), alcoholism (CAGE questions) attention (reciting numbers backwards), and visual spatial skills (clock-drawing test and the Trails B test[3]). Patients with a Clinical Dementia Rating (CDR) of 1 or more should not drive [3,5]. Referral to an occupational therapist who specializes in driving may be a consideration. A road test to assess the patients competence may also be valuable. Depending on the state, this can be a slippery slope, so it is helpful if the family supports your decision and is willing to help in this transition. Offering to give rides and helping with public transportation can really make a big difference in the quality of an old bastards life.
Fist thing that you want to do is to find out their driving history. Have they gotten into more accidents recently, more tickets, or more "close calls"? What do passengers say about how the older person drivers? Do they feel safe? It also a good idea to review the medications that the driver is on. Changing medications with ones that have fewer unwanted side affects may be beneficial.
It is also important to consider chronic diseases, especially diabetes. It has been shown that hypoglycemic episodes and improper insulin doses are often seen in automobile injuries[2]. Other diseases, such as epilepsy, heart disease, musculo-skeletal, Parkinson's etc. can contribute to problems driving.
It is important to check the hearing, vision, cognition (with a Mini Mental Status Exam or Clinical Dementia Rating,CDR), alcoholism (CAGE questions) attention (reciting numbers backwards), and visual spatial skills (clock-drawing test and the Trails B test[3]). Patients with a Clinical Dementia Rating (CDR) of 1 or more should not drive [3,5]. Referral to an occupational therapist who specializes in driving may be a consideration. A road test to assess the patients competence may also be valuable. Depending on the state, this can be a slippery slope, so it is helpful if the family supports your decision and is willing to help in this transition. Offering to give rides and helping with public transportation can really make a big difference in the quality of an old bastards life.
1. Marottoli, RA,The Physician's Role in the Assessment of Older Drivers, Am Fam Physician. 2000 Jan 1;61(1):39-42.
2. Carr, DB. The Older Adult Driver, Am Fam Physician. 2000 Jan 1;61(1):141-146.
3. Carr DB, Duchek, JM, Meuser, TM, Morris Oldr Adult Driver with Cognitive Impairment.Am Fam Physician. 2006 Mar 15;73(6):1029-1034.
4. Finestone, AJ, Rauch CJ. The older driver: When is it time to take away the keys?,Consultant. 2012. 52;11:753-760.
5. http://alzheimer.wustl.edu/cdrtraining
Why is My Urine Purple? A Review of the "Hospital Medicine Podcast" 8/30/12, by Dr Gill Porat, MD
This is a review of "The Hospital Medicine Podcast- Uninalysis Pearls for Managing Adult Patients" added on 8/30/2012 which can be found at https://itunes.apple.com/us/podcast/hospital-medicine-podcast/id541752791 along with many other of his podcasts
So I listened to this quick podcast on the way to work this morning and it was prety decent. It was a brief discussion on urinalysis. First, Dr. Porat spoke about nitrates. Common urinary bugs convert nitrate into nitrite in the urine, but there are circumstances when this does not happen. There are some bugs, like yeast and E. faecalis, that do not make nitrates. Also, which is particularly interesting, is that if the patient has urinary frequency, and is emptying their bladder often, then the bacteria may not have TIME to make the nitrites. Thus don't assume that a negative nitrate means that the patient doesn't have a UTI.
Leukocyte esterase is another test that commonly comes back positive on a UA. But where does it come from. Well ,WBC's make it , and it is also released when WBC's get killed, such as when battling an infection. If they all get killed, there will be a positive LE, but you may not see them in the UA... AH HAH! Kind of like in all those action movies where the good guys come to the enemies camp and the bad guys aren't there. The water may even be boiling on the stove and the bacon may still me sizzling... Bear in mind that contamination may give a false positive and lack of pyuria my make it false negative.
The big "blow my mind" teaser was this idea of purple urine. And no, its not from diluted hematuria. Its from gram negative bacteria. According to Dr. Porat, the GI tract breaks down tryptophan into indole. The bacteria then converts indole into indigo. This will then "stain the polyvinyl chloride foley bag purple". So the point being is that you have to send the urine for cultures. While looking for other resources about this reaction, I came across a reference that said that purple urine can also be found in porphyria.
He also mentions that brown urine can be seen in "diffuse melanosis" and that green urine can be from pseudomonas (or medications). For completeness, red urine is bloody (or myoglobin), milky or cloudy urine is pusy, orange urine can be from medications or your diet.
The last important point that Dr. Porat is about urine pH. I'll let you check the podcast if you want to know what he says (TEASER!)
1.MacFaddin, Jean F. "Biochemical Tests for Identification of Medical Bacteria." Williams & Wilkins, 1980, pp 173 - 183
2. http://www.mayoclinic.com/health/urine-color/DS01026
So I listened to this quick podcast on the way to work this morning and it was prety decent. It was a brief discussion on urinalysis. First, Dr. Porat spoke about nitrates. Common urinary bugs convert nitrate into nitrite in the urine, but there are circumstances when this does not happen. There are some bugs, like yeast and E. faecalis, that do not make nitrates. Also, which is particularly interesting, is that if the patient has urinary frequency, and is emptying their bladder often, then the bacteria may not have TIME to make the nitrites. Thus don't assume that a negative nitrate means that the patient doesn't have a UTI.
Leukocyte esterase is another test that commonly comes back positive on a UA. But where does it come from. Well ,WBC's make it , and it is also released when WBC's get killed, such as when battling an infection. If they all get killed, there will be a positive LE, but you may not see them in the UA... AH HAH! Kind of like in all those action movies where the good guys come to the enemies camp and the bad guys aren't there. The water may even be boiling on the stove and the bacon may still me sizzling... Bear in mind that contamination may give a false positive and lack of pyuria my make it false negative.
The big "blow my mind" teaser was this idea of purple urine. And no, its not from diluted hematuria. Its from gram negative bacteria. According to Dr. Porat, the GI tract breaks down tryptophan into indole. The bacteria then converts indole into indigo. This will then "stain the polyvinyl chloride foley bag purple". So the point being is that you have to send the urine for cultures. While looking for other resources about this reaction, I came across a reference that said that purple urine can also be found in porphyria.
He also mentions that brown urine can be seen in "diffuse melanosis" and that green urine can be from pseudomonas (or medications). For completeness, red urine is bloody (or myoglobin), milky or cloudy urine is pusy, orange urine can be from medications or your diet.
The last important point that Dr. Porat is about urine pH. I'll let you check the podcast if you want to know what he says (TEASER!)
1.MacFaddin, Jean F. "Biochemical Tests for Identification of Medical Bacteria." Williams & Wilkins, 1980, pp 173 - 183
2. http://www.mayoclinic.com/health/urine-color/DS01026
Tuesday, November 27, 2012
REVIEW-Diagnosis of Deep Venous Thrombosis and Pulmonary Embolism JASON WILBUR, MD, and BRIAN SHIAN, MD
Diagnosis of Deep Venous Thrombosis and Pulmonary Embolism
Venous thromboembolism is basically a blood clot that can go to the legs, causing a DVT, or the lungs, causing a PE. DVT's occur twice as often, but if you have one, there is a greater chance that you may actually have both. The etiology is described commonly as "vichow's triad", which is hypercoagulability, alterations in blood flow, and endothelial injury. The WELLS criteria is commonly used to determine pretest probability. It categorizes patients into low, medium, and high probability. It is used to determine if you want to order a D-dimer. This is a very sensitive test, so you only use it if you think the patient does NOT have a VTE and you want to rule it out. (You may come across an overzealous ER doc who orders this on every patient with a cough, thus you are stuck admitting the patient if the results come back indeterminate). So basically if you have a suspicion, and the WELLS criteria comes back intermediate or high, you are gonna order a compression ultrasound for a DVT. If it comes back negative, THEN you can do the D-dimer. Consider repeating the ultrasound in one week if the d-dimer is positive do confirm the patient is DVT free.
PE is a little trickier because first you decide if the patient is hemodynamically stable. If they are unstable and critically ill, and they have a high pretest probability (WELLS), you can send them for an echocardiogram of your choice (transthoracic or transesophageal). If they are not critically ill, you have to option to send them for a multidetector CT if it is available, otherwise you cand send for an echo. If the patient cant do a CT, you can consider a V/Q scan. If the CT is positive or if the echo shows right ventricular disfunction, its a PE. If the CT comes back negative, but you know in your heart it a PE, you can continue to evaluate. You can also consider a pulmonary angiogram if you want more testing, although it will expose the patient to a good amount of radiation.
One other thing I wanted to mention is that a patient with a PE may have "S1Q3T3 syndrome" on EKG. Its worth googling if you forgot what it means.
This article has some nice algorithms and charts, so check it out!
REVIEW- Lactic acidosis podcasts from "ICU rounds-Dr. Jeffrey Guy" Nov 11, 19 2011
So, I often listen to podcasts and i'd like to incorporate them into my blog. I was listening to a great one by Dr. Jeffrey Guy (at http://www.burndoc.net) about lactic acidosis, which was recorded nov 11,19 2001. Now since I listened while driving, I didnt take notes, so lets see.. (this is more an exercise of my own personal retention rather than a complete synopsis)
The first thing is that elevated lactic acidosis most commonly is a reflection of decreased oxygen delivery. Lactic acidosis is a biomarker, thus the lactate itself is not the causative agent. Glucose is converted to pyruvate through glycolysis. The pyruvate is then broken down in the kreb cycle, the first enzyme being pyruvate deydrogenase ( I think). BUT if there is no oxygen to support the kreb cycle, then the pyruvate is converted to lactate. It also leads to a build up of lactate. It also produces much less ATP.
Lactate is removed from the body by the liver and kidneys (and a small part by heart and skeletal muscle) The liver uses the cori cycle to convert the lactate back to glucose (by gluconeogenesis). The kidneys also metabolize the lactate, specifically in the renal cortex[1] -(my first official footnote!). It can also be excreted if there is a whole lot of lactate.
Dr. Guy also mentions that you should not automatically avoid Ringer's Lactate for fluid replacement. There is not to much lactate in it to make a difference, and the solution is actually at a basic pH (6.6). If you hang Normal saline, although there is no lactate, the large amount of chloride that is in it can cause a hyperchloremic acidosis.
There are two basic types of lactic acidosis, type A and type B. A is through the decreased oxygen delivery/ increased oxygen demand. Type B is do to other diseases, medications, or inborn metabolic error. There is also a D-lactic acidosis, which is an increase in one of the lactate isomers.
Basically if you have a patient with lactic acidosis, concentrate more on the cuasative agent rather than getting the lactate level down.
There was a whole lot more Dr. Guy talked about, so you can check it out on Itunes (ICU rounds) or the website above.
(next time ill listen twice before blogging)
1-http://www.ncbi.nlm.nih.gov/pmc/articles/PMC137458/
The first thing is that elevated lactic acidosis most commonly is a reflection of decreased oxygen delivery. Lactic acidosis is a biomarker, thus the lactate itself is not the causative agent. Glucose is converted to pyruvate through glycolysis. The pyruvate is then broken down in the kreb cycle, the first enzyme being pyruvate deydrogenase ( I think). BUT if there is no oxygen to support the kreb cycle, then the pyruvate is converted to lactate. It also leads to a build up of lactate. It also produces much less ATP.
Lactate is removed from the body by the liver and kidneys (and a small part by heart and skeletal muscle) The liver uses the cori cycle to convert the lactate back to glucose (by gluconeogenesis). The kidneys also metabolize the lactate, specifically in the renal cortex[1] -(my first official footnote!). It can also be excreted if there is a whole lot of lactate.
Dr. Guy also mentions that you should not automatically avoid Ringer's Lactate for fluid replacement. There is not to much lactate in it to make a difference, and the solution is actually at a basic pH (6.6). If you hang Normal saline, although there is no lactate, the large amount of chloride that is in it can cause a hyperchloremic acidosis.
There are two basic types of lactic acidosis, type A and type B. A is through the decreased oxygen delivery/ increased oxygen demand. Type B is do to other diseases, medications, or inborn metabolic error. There is also a D-lactic acidosis, which is an increase in one of the lactate isomers.
Basically if you have a patient with lactic acidosis, concentrate more on the cuasative agent rather than getting the lactate level down.
There was a whole lot more Dr. Guy talked about, so you can check it out on Itunes (ICU rounds) or the website above.
(next time ill listen twice before blogging)
1-http://www.ncbi.nlm.nih.gov/pmc/articles/PMC137458/
Monday, November 26, 2012
REVIEW- "Revised AAP Guideline on UTI in Febrile Infants and Young Children" by KENNETH B. ROBERTS, MD
This is a quick review of the article found here
http://www.aafp.org/afp/2012/1115/p940.html
Am Fam Physician. 2012 Nov 15;86(10):940-946.
The American Academy of Pediatrics has updated its guidelines for treatment of urinary tract infections in children between two months and 2 years old. A positive culture is now defined as having at least 50,000 colony forming units per milliliter (instead of 100,000) Also, oral medication is as effective as parental treatment.
The other big changes from the 1999 guidelines is that now both urinalysis and culture should be performed. Also, performing a voiding cystourethrogram is no longer recommended after the first UTI. It is indicated, however, if the ultrasound shows hydronephrosis, scarring or obstruction. Otherwise it can be considered after recurrent infections.
According to the algorithm, if you have any belief that the patient has a UTI, (is between 2 months and 2 years old), and has a fever of at least 38C, you can go ahead and perform a urinalysis by catheterization or you can do a dipstick analysis. A urine collected by a bag is not reliable. If it's positive, you can start treatment, but send cultures first (or you are gonna hear it from everyone). If the culture and UA come back negative you can stop the treatment. You would also adjust the therapy according to the culture sensitivities. Once a UTI is confirmed you can do a renal bladder ultrasound. If it's the patient's second or more UTI, you can perform a voiding cystourethrograph.
In general it appears that there is a low threshold for checking urine in a patient with an infection of undetermined origin. Even if the child does not appear to be having a UTI, it should be assessed anyway.
The patient should be treated with antibiotics for 1 to 2 weeks.
As far as prophylaxis for current UTIs there has been shown to be no statistically significant benefit in this age group.
http://www.aafp.org/afp/2012/1115/p940.html
Am Fam Physician. 2012 Nov 15;86(10):940-946.
The American Academy of Pediatrics has updated its guidelines for treatment of urinary tract infections in children between two months and 2 years old. A positive culture is now defined as having at least 50,000 colony forming units per milliliter (instead of 100,000) Also, oral medication is as effective as parental treatment.
The other big changes from the 1999 guidelines is that now both urinalysis and culture should be performed. Also, performing a voiding cystourethrogram is no longer recommended after the first UTI. It is indicated, however, if the ultrasound shows hydronephrosis, scarring or obstruction. Otherwise it can be considered after recurrent infections.
According to the algorithm, if you have any belief that the patient has a UTI, (is between 2 months and 2 years old), and has a fever of at least 38C, you can go ahead and perform a urinalysis by catheterization or you can do a dipstick analysis. A urine collected by a bag is not reliable. If it's positive, you can start treatment, but send cultures first (or you are gonna hear it from everyone). If the culture and UA come back negative you can stop the treatment. You would also adjust the therapy according to the culture sensitivities. Once a UTI is confirmed you can do a renal bladder ultrasound. If it's the patient's second or more UTI, you can perform a voiding cystourethrograph.
In general it appears that there is a low threshold for checking urine in a patient with an infection of undetermined origin. Even if the child does not appear to be having a UTI, it should be assessed anyway.
The patient should be treated with antibiotics for 1 to 2 weeks.
As far as prophylaxis for current UTIs there has been shown to be no statistically significant benefit in this age group.
REVIEW- "Universal HIV Screening Recommended by USPSTF"
This is a brief review of the medscape article "Universal HIV Screening Recommended by USPSTF" by Laurie Barclay MD
http://www.medscape.com/viewarticle/774957?src=nldne
According to the US Preventive Services Task Force, physicians should screen all patients between the ages of 15 and 65 years for HIV, and patients of all ages of those who are at increased risk. This is due to better testing procedures and evidence that starting anti retroviral therapy early can lower AIDS-related events or death. The last recommendation for the USPSTF was in 2005. HIV infection occurs approximately 50,000 times each year. One quarter of those infected are aware. HIV is prevalent in approximately 1.2 million people. 1.1 million have been diagnosed with AIDS and over half a billion people have died from it.
http://www.medscape.com/viewarticle/774957?src=nldne
According to the US Preventive Services Task Force, physicians should screen all patients between the ages of 15 and 65 years for HIV, and patients of all ages of those who are at increased risk. This is due to better testing procedures and evidence that starting anti retroviral therapy early can lower AIDS-related events or death. The last recommendation for the USPSTF was in 2005. HIV infection occurs approximately 50,000 times each year. One quarter of those infected are aware. HIV is prevalent in approximately 1.2 million people. 1.1 million have been diagnosed with AIDS and over half a billion people have died from it.
REVIEW-"Diagnosis and management of gonococcal infections" by Mejebi T. Mayor , Michelle A. Roett, and Kelechi A. Uduhiri
Am Fam Physician. 2012 Nov 15;86(10):931-938
This is a quick review of the above article, this is also my first real post!
Gonorrhia can cause different types of symptoms and can also be asymptomatic. Common symptoms are pelvic pain and discharge. If left untreated it can lead to pelvic inflammatory disease, which can lead to infertility, or it can lead to disseminated disease such as Reiters arthritis. Diagnosis can be achieved by nucleic acid amplification or cervical swab which would show gram negative diplococci. Treatment is typically 250mg ceftriaxone intramuscular as well as azithromycin to cover for chlamydia. We no longer use fluoroquinolones due to its resistance. If a patient does have reactive arthritis we can use long term antibiotics (at least 3 months) , along with other comfort measures. We can give a prescription for the sexual partner (depending on the state you practice in). The patient should be retested in 6 months.
Gonorrhia should be tested for yearly in sexually active women. The same goes for all high risk men.
This is a quick review of the above article, this is also my first real post!
Gonorrhia can cause different types of symptoms and can also be asymptomatic. Common symptoms are pelvic pain and discharge. If left untreated it can lead to pelvic inflammatory disease, which can lead to infertility, or it can lead to disseminated disease such as Reiters arthritis. Diagnosis can be achieved by nucleic acid amplification or cervical swab which would show gram negative diplococci. Treatment is typically 250mg ceftriaxone intramuscular as well as azithromycin to cover for chlamydia. We no longer use fluoroquinolones due to its resistance. If a patient does have reactive arthritis we can use long term antibiotics (at least 3 months) , along with other comfort measures. We can give a prescription for the sexual partner (depending on the state you practice in). The patient should be retested in 6 months.
Gonorrhia should be tested for yearly in sexually active women. The same goes for all high risk men.
Ok my second post ( but still nothing medical)!
So I figured out how to blog on my iPhone! Feeling totally geeky but also feeling like I am taking full potential of what the Internet is. I'm still not sure how this blog is going to evolve but hopefully ill be able to post things that I have learned through patient cases... But for now it will just have to be what I pick up on independent study.
My very first blog ( and my very first original title)
My first order of business is to figure out how to change the name of my blog. Ultimately I would like to use this space to post reviews of medical podcasts, journals, etc., to chronicle what I have done each day to become a better doctor. So today I plan to figure out how this blogging shtuff works!
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