Chronicles of an Inner City Hospital Resident Doctor #13

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:

• Subdural hematoma --> elderly, after fall with head injury, contralateral FNDs, crescent-shaped hemorrhage (between dura mater and arachnoid mater), shearing of cerebral bridging veins, cross suture lines but not midline
• Epidural hematoma --> lens-shaped hemorrhage (between skull and dura mater), meningeal artery, don't cross suture lines
• Subarachnoid hemorrhage --> "worst headache of my life," intracranial aneurysm (risk factors = smoking, family history, hypertension), rupture + stiff neck, starburst pattern around basilar cisterns on CT Head
• Diffuse axonal stretch injury --> acceleration-deceleration
• Insulinoma --> pancreatic beta islet cell tumor --> high 72-hour fasting insulin, hypoglycemia with high insulin + high C-peptide levels; Whipple triad = hypoglycemia, symptoms of hypoglycemia, improvement of symptoms when given glucose; treatment = surgery
• With hypoglycemia, rule out: exogenous insulin usage (C peptide would be low, as C peptide is produced when insulin is made by the body), oral hypoglycemic ingestion (i.e. sulfonylurea), autoimmune antibodies against insulin or insulin receptors
• Insulin-like growth factor (childhood growth, anabolic metabolism) seen in growth hormone excess (acromegaly, gigantism), made by liver in response to growth hormone from anterior pituitary
• Multiple endocrine neoplasia (MEN) Type 1 --> pituitary adenomas, pancreatic tumors (gastrinomas, insulinomas), parathyroid hyperplasia
• 
  Source: https://vayp-por.blogspot.com/2020/12/v-fib-vs-v-tach-strips.html
• Ventricular tachycardia: bizarre wide QRS complexes without P waves, rate >100 (wide QRS = being made by ventricles and not passing through AV node); symptomatic/unstable = sedation + DC cardioversion; stable = amiodarone / procainamide / sotalol
• Ventricular fibrillation: disorganized QRST complexes, rate 300-400; must be defibrillated with shock
• Atrial flutter: 250-300 BPM, sawtooth with narrow QRS in leads II, III, AVF (2-3 sawteeth between QRS)
• Paroxysmal supraventricular tachycardia: palpitations, aberrant atrial conduction pathway, regular narrow QRS tachycardia; if stable, start with vagal maneuvers --> adenosine 6 mg IV
• Zollinger-Ellison Syndrome (pancreatic gastrinoma) --> recurrent/refractory peptic ulcer disease with GERD symptoms, ulcer usually duodenal; pale, sticky, foul-smelling stools (steatorrhea), weight loss; excess gastrin, insufficient pancreatic enzymes; paradoxical gastrin rise when secretin is administered; MEN Type 1 association, lymph node or liver metastasis
• Functional dyspepsia --> chronic abdominal pain, nausea/vomiting, fullness, early satiety without alarm symptoms (no EGD needed); alarm symptoms = 55+ yrs old with iron deficiency anemia, upper abdominal mass, or significant weight loss, history of NSAID usage, history of gastric cancer
• Stress gastritis due to severe illness (ICU-level, i.e. respiratory failure, septic shock)
• USA: 30 day notice of withdrawal of care is required before withdrawing care (state dependent)
• Choledocholithiasis (bile duct stones made of bilirubin or cholesterol, usually traveling from the gallstone) risk factors = female, forty, fat, fertile; RUQ pain (can go to R scapula or shoulder), vomiting; worse with: high carb diet, prolonged fast, rapid weight loss, dehydration, low fiber; diagnosis with US (more specific = HIDA scan)
• Traumatic urethral injury (pelvic fracture; look for blood from urethral meatus, inability to urinate, high-riding prostate, scrotal/perineal ecchymosis) --> retrograde urethrogram --> if tear detected, suprapubic catheter (Foley is contraindicated); if negative, IV pyelogram (to assess for kidney injury) + CT Abdomen/Pelvis (to evaluate for upper genitourinary injury)
• Acute appendicitis --> confirmed on CT A/P with IV contrast (US > MRI in pregnant women + children); abdominal pain, nausea/vomiting, anorexia; McBurney (2 inches from ASIS towards umbilicus) / Rovsing (RLQ pain when palpating LLQ)
• USA: medical standard of care = what a prudent physician in similar or identical circumstances would do based on objective measures and guidelines (published by expert panels)
• Parathyroid adenoma (history of radiation therapy) --> primary hyperparathyroidism (hypercalcemia, high parathyroid hormone, low phosphate); bone pain, abdominal pain / nausea / vomiting, altered mental status, kidney stones; treat with IV fluids then Lasix, fix electrolytes, surgery
• Secondary hyperparathyroidism --> caused by chronic renal insufficiency ---> low Vit D --> low calcium --> high PTH
• Tertiary hyperparathyroidism --> caused by longstanding secondary hyperparathyroidism --> leads to hypercalcemia
• Pseudohypoparathyroidism --> kidney doesn't respond to PTH due to GNAS1 mutation --> high PTH and phosphate; associated with skeletal abnormalities (short 4th + 5th fingers), Albright hereditary osteodystrophy (intellectual), round face, obesity

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:

1. https://lakesidemedicalcare.com/history-osteopathic-medicine/
2. COMQUESTMED (my question bank for learning information)
3. https://vayp-por.blogspot.com/2020/12/v-fib-vs-v-tach-strips.html
4. 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.

Here are the previous editions of this blog:
Chronicles of an Inner City Hospital Resident Doctor #12Chronicles of an Inner City Hospital Resident Doctor #11
Chronicles of an Inner City Hospital Resident Doctor #10
Chronicles of an Inner City Hospital Resident Doctor #9
Chronicles of an Inner City Hospital Resident Doctor #8
Chronicles of an Inner City Hospital Resident Doctor #7
Chronicles of an Inner City Hospital Resident Doctor #6
Chronicles of an Inner City Hospital Resident Doctor #5
Chronicles of an Inner City Hospital Resident Doctor #4
Chronicles of an Inner City Hospital Resident Doctor #3
Chronicles of an Inner City Hospital Resident Doctor #2
Chronicles of an Inner City Hospital Resident Doctor #1

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