Chronicles of an Inner City Hospital Resident Doctor #12

9 months ago (Edited)

Howdy, StemSocial friends! I'm a 3rd year resident doctor in an inner city hospital. This is a blog to document some of the experiences I encounter as a training doctor, and some of the things that I learn in the process. After all, being a physician means that I'll be learning some fascinating topics for the rest of my career, and seeing how I can use those to help patients.

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The next multiple entries in this series will be notes that I take from my question bank; I am using these posts as a way to bolster my attention the questions and to consolidate the information I learn. They are my own summaries of key points within the questions that I am practicing, so do not take them as medical gospel – rather, as learning points from which to further build knowledge. If the topics appear scattered, it is because the questions are randomized. Once I complete my board examination I will resume these chronicles with a more story-like approach, as with my prior entries. Let's get started with today's key points:

Atypical depression --> mood improves with pleasurable activities, weight gain / increased appetite, hypersomnia, leaden paralysis (limbs feel heavy), rejection sensitivity
Adjustment disorder resolves within 6 months, dysthymia is 2+ years (symptom free 2+ months maximum at a time), MDD with melancholic features = anhedonia with no mood improvement with pleasurable activities, interrupted sleep, decreased appetite
Coronary Artery Bypass Graft (CABG) for L main coronary artery stenosis >70%, 3 vessel disease not treatable with PCI (percutaneous coronary intervention)
For unstable angina, give morphine, B blockers, ASA, nitrates, O2; if EKG/troponins abnormal, evaluate with coronary angiography +/- PCI
Subarachnoid hemorrhage --> worst headache of life, sudden onset, mild nuchal rigidity, due to ruptured aneurysm; CT Head = blood in cisterns ("center" of brain), lumbar puncture = yellow/pink, increased pressure, slightly high white count + red count, high protein, normal glucose
Bacterial meningitis = headache, photophobia, petechial rash, nuchal rigidity; LP = neutrophil predominant, low glucose, high protein, white color
Viral meningitis / encephalitis = slightly milder than bacterial; LP = lymphocyte predominant, normal glucose, high protein + opening pressure, high RBCs, clear; HSV encephalitis most common
Fungal meningitis = similar symptoms; LP = lymphocyte predominant, normal glucose, high protein, cloudy
Autoimmune CNS disease (multiple sclerosis, Guillain=Barre, autoimmune encephalitis) LP = clear fluid, normal opening pressure, normal WBCs, slightly elevated proteins (from oligoclonal bands), slightly elevated RBCs; with Guillain-Barre there is albuminocytologic dissociation (high protein, normal white count)
Peripheral arterial disease → claudication (leg pain when walking) + weakness + shiny hairless skin → ankle-brachial index (compares blood pressure in upper extremity vs. lower extremity)
Spinal stenosis → improves with bending over / sitting, worse when straight / walking downhill; NSAIDs → steroids → surgery
Asymptomtic bacteriuria in pregnancy (bacteria in urine >100,000 Units, no symptoms) @ 1st prenatal visit → treat (i.e. E coli with nitrofurantoin/ampicllin/cephalexin, avoid trimethoprim-sulfamethoxazole (TMP-SMX) = teratogenic
Osteopathy: avoid muscle energy treatments in crtically ill patients, those with recent surgery, MI, hemorrhagic stroke, hypertensive emergency; HVLA contraindications → pregnancy (ligament laxity), osteoporosis
Acute renal failure → most commonly due to prerenal acute renal failure (BUN:Cr >20:1, urine Na <20, FENa <1% = fractional excretion of sodiu, urine osmolality >500, hyaline casts in urine) caused by volume depletion, liver failure/cirrhosis, congestive heart failure, sepsis, antihypertensives, renal artery stenosis
Acute tubular necrosis = granular / brown muddy casts, renal tubular casts, FENa >2%
IgA nephropathy → nephritic; few days after upper respiratory or GI infection, RBC casts, proteinuria, hematuria
Poststreptococcal glomerulonephritis → 2 weeks after upper respiratory infection, RBC casts, proteinuria, hematuria
Renal tubular acidosis → non-anion gap hyperchloremic metabolic acidosis
Osteopathy: muscle energy (active, direct or indirect) mechanisms = respiratory assistance (on ribs), reciprocal inhibition (contracting antagonist muscle makes target muscle relax), post isometric relaxation, joint mobilization using muscle force (muscle contraction used to reposition a joint), oculocephalogyric reflex (extraocular movements to relax cervical and trunk muscles), crossed extensor reflex (contract contralateral muscle to relax target muscle)
Osteopathy: muscle energy on ribs → inhalation dysfunction (ribs stuck up) = patient exhales + lifts head up (for ribs 1-5, pump handle motion) or exhales + reaches for isolateral knee (for ribs 6-10, bucket handle motion)
Antiphospholipid antibody syndrome with history of thrombosis → lifelong anticoagulation with warfarin; if pregnant, low molecular weight heparin until week 36-37 then start heparin bridging (except if mechanical heart valve is present, then use low-dose warfarin + ASA or restart warfarin in 2nd trimester) or directly to heparin if pulmonary embolus is present, severe renal insufficiency, or labor is imminent
Clopidogrel (Plavix) → drug-eluting coronary + peripheral artery stents, recent strokes
Secondary amenorrhea (absent menstrual cycle 3+ months due to secondary cause, i..e pregnancy, deficiency of GnRH = gonadotropin-releasing hormone from the hypothalamus → low FSH, low estrogen, low gonadotropins → ovarian follicles don’t develop → no LH surge → no ovulation); GnRH deficiency causes = low body weight, anorexia, excess exercise, stress
Primary ovarian insufficiency → early menopause, low estrogen → high GnRH → high FSH + LH from anterior pituitary gland
PCOS → high androgens, oligomenorrhea, facial hair, weight gain, insulin resistance, acne
Pituitary adenoma → high prolactin (also due to pregnancy, antipsychotics, hypothyroidism)

I hope you've enjoyed these little notes of topics I learned as a resident in an inner city hospital. I'll have many more stories and learning experiences coming in the future, so stay tuned.

Sources:

https://lakesidemedicalcare.com/history-osteopathic-medicine/
COMQUESTMED (my question bank for learning information)
Me 😊

Disclaimer: this blog is for entertainment (and possibly educational) purposes only. This is not medical advice. If you have any questions or concerns about your own health, please contact a healthcare provider.

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