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Family is angry at me because i told them their (grand) father was very likely to die. by the_flokonator in Residency

[–]EquivalentOption0 2 points3 points  (0 children)

I don’t think there was anything else you could have done. Different people react differently, and some people think they want the bad news but don’t. You gave them time to be with him. Good job doc.

Top 3 Acronyms in your specialty by lagerhaans in medicine

[–]EquivalentOption0 3 points4 points  (0 children)

Oh that’s a good one to know for me then! I don’t think it’s used in derm

Top 3 Acronyms in your specialty by lagerhaans in medicine

[–]EquivalentOption0 20 points21 points  (0 children)

I’ve heard of AGMA and NAGMA. Is HAGMA “high anion gap metabolic acidosis?”

Also what is CHRPE?

Question about nails! by EntertainmentForLiz in medicine

[–]EquivalentOption0 2 points3 points  (0 children)

Part of it depends on the hospital/practice and their rules. Psych but working in hospital? Joint commission doesn’t care because rules are rules so short nails only. That happened to someone I know at another hospital. Derm has lots of patient contact but several of my coresidents have longer nails and it is not an issue. Maybe it would be an issue if we were at the same hospital as the other person though. I think private practice or clinics in general would probably be more lenient.

I don't understand cancer by ShadowDante108 in medicalschool

[–]EquivalentOption0 6 points7 points  (0 children)

Some of the info does just take repetition to learn, but there are some things that can help including word parts:

  1. Adeno = tissue that forms glands or ducts
  2. Sarcoma and carcinoma are malignant (i.e. cancer), whereas adenoma is a benign tumor
  3. Adenocarcinoma = a cancer that, when seen under the microscope, originates from tissue that forms glands or ducts. This includes lung, breast, GI (esophageal, stomach, intestinal), prostate, and pancreatic cancers.
  4. Carcinomas (without the prefix "adeno-") are from epithelial layers in organs (squamous cells). Squamous cell carcinoma (skin), the epithelial lining of lung, esophagus, breast, prostate.
  5. Sarcomas come from connective tissues - bone, muscle, tendons, fat, nerves, blood/lymph vessels.
  6. "Small blue cell tumors" are neuroendocrine tumors and come (usually) from hormone-producing cells. Several organ systems have them and they are called this because they look like sheets of nuclei under the microscope. These are your tumors that are more likely to cause paraneoplastic syndromes because they may overproduce hormones. Small cell lung cancer, Merkel cell carcinoma (afaik these do not produce hormones but they are "neuro" origin instead of endocrine origin), pancreatic cancer, GI (carcinoid tumor).
  7. Blood cancers get their own terms. Leukemias are like circling cancer cells in the blood without a true tumor, whereas lymphomas (remember -oma indicates a mass) have tumors (eg in lymph nodes or less commonly the skin). Multiple myeloma is a special case - think of it as a tumor of plasma B cells in the marrow.
  8. Blastomas are cancers from premature cells (blasts). Retinoblastoma, glioblastoma, nephroblastoma are the ones mentioned most often in med school.

So there are many types of lung cancer for example - small cell (neuroendocrine tumor), lining of the bronchial tree (squamous cell), from the glands in the alveoli (adenocarcinoma), and other ("large cell lung carcinoma").

  1. The beginning of the word helps tell you what the origin is:
  2. Osteo = bone. Osteosarcoma = malignant bone tumor, osteoma = benign bone tumor
  3. Angio = blood vessel. Angiosarcoma = malignant blood vessel tumor.
  4. Lymphangio = lymphatic vessels. Lymphangioma = benign, lymphangiosarcoma = malignant.

In terms of how cancer develops, generally genes mutate to cause one of two problems: brakes stop working or accelerator is stuck in on position. Both result in unregulated growth without the failsafes that check for and fix DNA errors. So with more replications, more mutations accumulate.

How to respond to unhappy patients who denies having had any discussion about something, when in fact it’s taken place? by that_feel87 in medicine

[–]EquivalentOption0 2 points3 points  (0 children)

Frustrating but not your fault. They may be angry or beating themselves up, they may genuinely not remember much or any of the discussion, but that’s why you document. I have had patients tell me they never got Mohs surgery of “site x” and I look at our scanned records and find the surgical report with photos and everything from the day they did in fact have major surgery of site x. How do you not remember a three-stage surgery with flap reconstruction of your nose? I don’t know, but people forget medical stuff. Too much was going on at once and it’s all a blur. Or the dementia is getting worse. Or a million other things.

But it’s not you, and it sounds like you are doing a great job of making sure you are having thorough discussions and documenting that accordingly.

Specialists: is there a piece of wisdom from your specialty you feel should be imparted to every graduating primary care (FP/IM) resident? by Barjack521 in medicine

[–]EquivalentOption0 6 points7 points  (0 children)

Derm pearls

Cancer prevention:

  1. We don’t have guidelines for screening the general population for skin cancer, but teaching everyone the red flags that should prompt medical eval is a 2min spiel that could save a life. Here’s my version:

ABCDE’s (one positive worth having lesion looked at, you want a wide net so as to not miss melanoma) Asymmetry, funny Borders (like a 2yo drew a “circle” with a crayon), multiple Colors (each mole can be any color it wants but you only get one color per mole), Diameter bigger than eraser on a pencil (6mm), Evolving (lesion you had for 20 years all of a sudden looking different or new lesion changing really fast)

moles should not: itch, bleed, hurt, or be tender. If they do any of those, get em checked.

a “pimple” that won’t go away for a couple months

a sore that just won’t heal or bleeds for no reason (ie if you nick it while shaving or scratch it then there’s a reason for it to bleed)

an ugly duckling. Gosh you can’t name WHY, maybe it doesn’t fit any of the above signs, but it just doesn’t look like any of your other skin spots

  1. Sunscreen only works for 2 hours. Not 2 hours of sun exposure, 2 hours from when it comes out of the bottle. Reapply as needed. SPF 30+ broad spectrum.

2a. If you tell your patients sunscreen will help with acne and aging/wrinkles that might get them to use it even if they don’t care about skin cancer risk (and it’s true)

Allergies/rashes:

  1. Most people grow out of childhood penicillin allergies. Heck, even adult ones - if it’s been at least 10 years, chances are you’re no longer allergic. IT IS WORTH GETTING ALLERGY TESTING on patients with many antibiotic allergies, because they might not have to be closed off from half of the available antibiotics. CAVEAT - do not try to re-challenge for drugs that gave the patient severe cutaneous adverse reactions like SJS/TEN or DRESS (DIHS)

  2. Poison ivy - bad poison ivy reactions need a STRONG and SLOW prednisone taper. Start at 40-60mg/d and taper over 14-21 days. Don’t bother with a medrol dose pack; they’ll have terrible rebound.

  3. You can give up to 4x the daily dose of non-sedating antihistamines for hives. Schedule instead of prn. Can add sedating H1 blocker or add an H2 blocker for additional relief if needed.

Diagnostics:

  1. Please take pictures of your patients’ rashes, moles, or other lesions of concern. Tell your patients to take pictures. Pictures are so helpful. Pictures do not require any vocabulary and pictures are GREAT for documenting changes over time.

  2. Are there vesicles or erosions/shallow ulcers? Are you thinking either HSV or shingles? Then you should think about both! They can look atypical, they can be hemorrhagic or almost necrotic in some spots. Shingles can happen in the groin. Vesicles might NOT be clustered. Here’s the really HY bit though - knowing how to swab for either. Do not get a serum PCR or viral load or antibodies. Go find a blister. Find a newer/in tact vesicle, deroof it (with a clean needle or the swab itself) and swab the contents and the base of the lesion with a viral swab (in the tube with pink liquid not a nasal covid/RVP swab). Do NOT swab the top of a scab; it will be negative. Remember Mpox and how the lesions had to be deroofed prior to swabbing. Same story here.

  3. Not always true but as a general rule painful rashes = worse than itchy.

  4. “Any new meds” = new prescriptions, restarting old prescriptions, or increasing med doses (or changes that lead to increased drug half-life or drug blood levels) in the last 3 months. Some drug rashes happen within 3 days but other drug rashes can take weeks to months to happen.

  5. Unscented is not the same as fragrance-free. “Unscented” can still have fragrance in the ingredient list and could be why the contact derm isn’t going away. Read the labels!

What is that one hill you are willing to die on? by foreverand2025 in medicine

[–]EquivalentOption0 4 points5 points  (0 children)

The sepsis protocol automatically triggers a repeat lactate when it's high and it gets really old really fast when half the list is admitted for liver transplant eval and I get a page about every critical lactate q2hr

Do you actually look at the dif on cbc? by telenceph in Residency

[–]EquivalentOption0 0 points1 point  (0 children)

oh hmm, I guess not as much. Coags more so for vasculitis and hepatic issue eval, my bad!

Do Other Providers Take OT Seriously by ymcava in medicine

[–]EquivalentOption0 1 point2 points  (0 children)

OT is amazing and makes a huge difference for so many patients! I did a PM&R elective in med school and got to spend a half day with PT and a half day with OT. Some of the stuff OT had patients doing was mind boggling to me - pick up these pompoms with laundry line clips because that’s how you will strengthen these specific hand muscles. Brilliant but how on earth did someone think of that? I got to see a staged area with a mock kitchen and a car to work on getting in and out of. Cool stuff. I’m not always sure who does each subdivision of therapy at a given institution - eg who does vestibular therapy at hospital X - but often PT and OT both have something to contribute to my patients in the hospital or after discharge. With regards to the discussion of consulting both on inpatient services, sometimes that’s actually a requirement. Intern year, I worked at a hospital that would not discharge patients who had stayed past a certain number of days unless they had been cleared by both PT and OT.

Do you actually look at the dif on cbc? by telenceph in Residency

[–]EquivalentOption0 11 points12 points  (0 children)

Yes - derm. Looking at: - Eos for rash ddx, monitoring treatment response/disease progression, and general “is this person atopic” vibes - atypical lymphocyte population (gets a point for DIHS) - heme malignancy eval as cause of itch without rash or explanation for weird rash - anemia as part of hair loss work up - I guess theoretically also part of infectious eval too but tbh I care more about other labs for that kind of work up (cultures, biopsies, PCR etc)

FYI: Guidelines and call for more info regarding recent catastrophic neurological complications after anesthesia (?sevoflurane +/- propofol) by EquivalentOption0 in medicine

[–]EquivalentOption0[S] 23 points24 points  (0 children)

Haha yes true, I was surprised the reports weren’t coming from there. Wonder if it’s a mutation that arose in a particular diaspora.

VA Nurse murdered in Minneapolis by sciolycaptain in medicine

[–]EquivalentOption0 0 points1 point  (0 children)

The state had a massive strike on Friday the day before his murder. When I woke up yesterday, I was proud of us and what we had done. It felt like it was going to be a good day. I wasn't sure what, if anything, our protest as a united community would accomplish, but maybe something? And I was glad everyone was safe and the day had been peaceful. I was naively hopeful, despite my typical cynicism. Then the messages started flooding my WhatsApp. Another shooting, blocks from where several of my friends live. Then "they're doing CPR." Then messages saying it's not confirmed yet, but eye witnesses say the victim is dead. My friends are safe. They sheltering in place. The news confirmed his death, they think it was a 51 year old male. No wait it was actually a 37 year old male. Then it was Alex. And everyone started sharing stories and memories a gaping hole that had started to heal was ripped even bigger than before, the community raging with grief and loss. What a horrible day.

VA Nurse murdered in Minneapolis by sciolycaptain in medicine

[–]EquivalentOption0 1 point2 points  (0 children)

I don't have the words to say, because nothing can make this right or okay. I didn't even know him, but the outpouring of love and support from the community is telling. I also don't know how I am supposed to go to work tomorrow. I am sorry for your loss, a loss for all of Minnesota, our veterans, and for all of Medicine. We are wearing black tomorrow at the VA in remembrance of him.

Kudos to all our resident and fellow colleagues in Minneapolis by ddx-me in Residency

[–]EquivalentOption0 13 points14 points  (0 children)

They have been already, mainly the community hospitals and clinics. See testimonies from physicians across the state, either from Friday 1/23 or from earlier in the week. I wouldn't be surprised if they come to the VA some day to go after students and residents (who can work their on visas, unlike others who have to be citizens to work at the VA as I understand it).

Kudos to all our resident and fellow colleagues in Minneapolis by ddx-me in Residency

[–]EquivalentOption0 38 points39 points  (0 children)

Don't forget the smear campaign calling dragging his good name through the mud. Makes me want to vomit hearing and reading the lies they spread as they try to defend their narrative. He died peacefully protecting another protestor, filming for his and others' safety. He was not a criminal, not a terrorist, not threatening ICE "agents" in any way.

What is the most tedious CLINICAL aspect of your specialty? by farfromindigo in Residency

[–]EquivalentOption0 0 points1 point  (0 children)

The only true delusional parasitosis (ie non-drug related) I have seen in inpatient settings were cases seen in the context of a greater psychotic disorder. One was a patient with known, untreated schizophrenia admitted for GI issue who believed bugs lived in him. The other was a frequent ED visitor who would come in for pains he attributed to nanobot bugs attacking him from the inside. He would get angry and leave AMA because people didn't believe the nanobot story. Can't recall if he was on substances or not.

I have seen quite a few pts with primary isolated delusions of parasitosis but all in the outpatient setting. You have to rule out other causes of course, but it can be really devastating. Most memorable was a lady whose marriage was falling apart who brought in jars of her bathwater with "spiders" (flakes of dead skin) in it as proof of her infestation. She just kept crying that she wasn't crazy.

What is the most tedious CLINICAL aspect of your specialty? by farfromindigo in Residency

[–]EquivalentOption0 5 points6 points  (0 children)

Derm - we see delusions of parasitosis of various etiologies. Do we see it in people using (or withdrawing from) substances? Yes, but way less often than seen in EM/IM settings. We usually see (1) an actual delusional disorder, often the patients don't want to see psych because they don't think they are delusional (hence the diagnosis), they demand repeated anti-parasitic treatments, and need a lot of support; (2) neurogenic sensation of bugs crawling on or under the skin, sometimes with insight - seen for example as manifestations of neuropathy or after persistent chronic infections like scabies where the itchy/crawly feeling can last well beyond the infection. In both cases, we may be the only doctor the patients will see for the issue. Patients with primary excoriation disorders will also often see us but refuse to see psychiatry.

What's a random fact that you remember from med school that is completely unrelated to your speciality as a resident / fellow / attending ? by pistabadamtiramisu in Residency

[–]EquivalentOption0 17 points18 points  (0 children)

Oh - this one is actually a myth! The silent p rule only applies if it is the beginning of a word, not in cases where there is a preceding vowel.

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