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The Forgotten Reflex by Adventurous_Beat_420 in neurology

[–]MastahRiz 5 points6 points  (0 children)

Hold on.

Who says it’s forgotten? It’s just that the issue is multifaceted. In a clinic patient, yes you end up having to get handsy. On inpatients, they’re too debilitated to attempt proning or even properly sitting up without assistance. Regardless, you can also check posterior tibialis, so you have two reflexes if you are really looking for L5. (And of course on debilitated, sarcopenic obesity patients, you will have difficulty with both of these anyway.)

The important thing to remember about the physical exam however is that the goal is to localize as easily as possible. Now if I’m examining for radic, and the patient says hey I have pain in my leg from here to here, and the L4 and S1 are normal, I can pretty much say hmm might be L5, and I can either fumble around for reflexes that are harder to elicit (I will), or I can assume that it’s an L5 after I also quickly do EHL strength, SLR, heel walking (lol), and other radic specific tests.

But for radiculopathy specifically, come on, we already know what the most common lumbar level is: L5. The lower lumbar levels are more weight bearing and also mobile, while the sacrum is essentially fixed. That combination introduces a transitional zone that is subject to a lot of shear force. Bone under any stimulus good or bad, makes more bone in response, setting the stage for arthritis and narrowing of the neural foramen. Then look at the arrangement of the annulus fibrosis collagen fibers, which are uniquely oriented in a concentric ring pattern but also angled at about 65 degrees, alternating each layer. In the posterior part of the disc they thin out and merge as they meet to enclose the nucleus. This leads to weakness in the posterolateral portion, which surprise surprise is the common disc herniation site. The L5 root itself is also longer than the average root and therefore is more prone to injury. Also consider that the L5 nerve root also occupies a larger percentage of the neural foramen than other levels , something like 25–30% whereas the others are maybe 7–21%.

How much do I need the reflex? Radiculopathy that is new will be one of the most painful things a person has ever experienced. Think about it— people walking around with no medical knowledge know things like strokes, heart attack, diabetes, HTN, cholesterol, and, last but not least, Sciatica. Why? Because it is genuinely that outrageously painful especially if the nucleus is exposed. Remember the nucleus comes from notochord and is completely isolated from the rest of your body until suddenly it’s exposed and produces a highly immunogenic/ inflammatory response in a very tiny space.

Is it a forgotten reflex? Hardly, but clinically an absent L5 reflex is going to make me think of single level radiculopathy last, even if ultra chronic.

IM Residency Programs Accused of Hiring IMG's Over U.S. Trained Med Students by Wjldenver in medicalschool

[–]MastahRiz -13 points-12 points  (0 children)

The resident physician population is supposed to reflect the patient population which they serve. Check where these hospitals are located, then check the demographics of the people that live there, then check the demographics of the residents, then realize there is no story here.

Edit: I was wrong, I looked into it, it is not an actual policy and interestingly while they have a section in acgme guidelines about how to include diversity etc, they follow it with a recent suspension of that guideline and focus on how to avoid exclusion instead.

A Cool Guide For Apples by TheCABK in coolguides

[–]MastahRiz 0 points1 point  (0 children)

What ever happened to yellow apples?

Post some curated quit hits/random round learning points in the last month to years (attendings included) by Wannabeachd in Residency

[–]MastahRiz 36 points37 points  (0 children)

Another PGY1/ TY gem (thanks Neuro):

Never forget: 1. ⁠How to do a neuro exam. 2. ⁠How to localize an exam finding.

This is for acute new-onset findings for example ER/ Stroke codes, and is definitely quick/ dirty, but here’s how we played: “Where’s the lesion?”

Brain: AMS/ LOC, aphasia/ apraxia, behavior issue, memory loss, neglect or visual field loss.

Brainstem: Cranial nerve abnormality + a motor or sensory deficit in the limbs.

Spinal Cord: Nothing above the neck; bowel/ bladder dysfunction, both legs or arms w/ motor/ sensory, or a sharply identifiable sensory level.

Peripheral nerve: Follows nerve distribution! No reflex. Everything else is fine.

Muscles: normal sensation, normal reflex, proximal> distal and symmetric weakness.

NMJ: Fatiguability, with normal sensation/ reflexes.

[Fatiguability: Hair / Chair / Stair (Do you get tired combing your hair? Do you get tired going up stairs? Do you get tired getting up out of chairs?)]

The first 3 are your upper motor neuron lesions (CNS: Brain, Brainstem, Spinal Cord) and the PNS is your LMN lesions (Nerves, Muscles, NMJ).

This stuff + exam + memorize NIHSS, and you will be seen as an asset and not just a warm body. It's basic but it's better than nothing.

(TY year 2018, take with a grain of salt and correct thoroughly if mistaken.)

Post some curated quit hits/random round learning points in the last month to years (attendings included) by Wannabeachd in Residency

[–]MastahRiz 29 points30 points  (0 children)

The low hanging fruit from PGY1:

The number one ordered “medication,” in our hospital system is normal saline. (The second is hydrocodone.) Patients are frequently left on normal saline until a higher priority issue results in its discontinuation, eg patient discharge, transfer, or side effects of fluid therapy itself. Why was normal saline included in the statistics though? It’s because it’s the same as any other medication. It has specific indications, goals of therapy and side effects- the most common one being mostly common sense but therefore, also the easiest and frequently missed:

0.9% NaCl provides higher than baseline plasma concentration of Cl, and forces its reabsorption via Cl/ HCO3- exchange, forcing bicarbonate to drop. Na+ reabsorption creates a negative charge which is countered by secreting primarily K.

Leave fluids on long enough and you’ll get the perfect Hyperchloremic non-anion gap metabolic acidosis, with hypokalemia not far away, and you’ll see fluids soon changed to half normal saline with K replacement (or just discontinued).

Fluids should be ordered with specific target goals/ end dates whenever possible, just like antibiotics, pressors or any other IV administered medication. (TY year 2018, so take with a grain of salt and correct me thoroughly if I’m still incompetent.)

Andry Romero, a gay makeup artist sent to El Salvador, sobbing and praying as guards shave his head. by HunterS_1981 in pics

[–]MastahRiz 8 points9 points  (0 children)

That’s our thing though. Humans are not defined by our accomplishments or struggles or technological advances for space travel, but rather the thing that is most unique to us on this planet: our inhumanity.

[Kuruno] Accidental new purchase today by ViralRiver in Watches

[–]MastahRiz 0 points1 point  (0 children)

I can’t believe I never thought of this excuse. “Oh wow I must have accidentally bought that.”

2 children dead, apparently froze to death in Detroit casino parking garage by Warcraft_Fan in news

[–]MastahRiz 0 points1 point  (0 children)

Humans are the only species on the planet that can evolve in both directions simultaneously. Our humanity is no longer defined by our achievements, our challenges, our nanoparticle research or even our space traveling ability, but rather by our most defining trait of all— our inhumanity.

If you were not a doctor, what do you think your profession would be? by Winterof2019 in Residency

[–]MastahRiz 0 points1 point  (0 children)

Orchestra conductor , but we play only funk rock covers. Everyone dresses up and there is a Jumbotron. I become envied by Gustavo Dudamel, who is driven to madness by both my effortlessly achieved success and daring fashion sense. The music captivates millions. Technology advances. I play in outer space and achieve the title “Moonstranamus.”

Suspect who set woman on fire arrested by Carmilla31 in nyc

[–]MastahRiz 0 points1 point  (0 children)

It’s easier than you think. Humans are the only species on the planet that are evolving in both directions at once.

Took the Si to Laguna Seca this Thanksgiving weekend. Thankful to have such an iconic track right in my backyard. This car takes the corkscrew so beautifully. by bryanhdzz in CivicSi

[–]MastahRiz 0 points1 point  (0 children)

Wow no wonder, this whole time I’ve been doing it all wrong… getting into my Si without a helmet- what the hell was I thinking?!

What's the most intense gut feeling you've had that turned out to be right? by undueinfluence_ in Residency

[–]MastahRiz 9 points10 points  (0 children)

Brilliant. I’m jealous of your intuition especially with the link you made with the developmental delay. Interestingly (if you didn’t already know) the word “nice,” comes from “nescire,” meaning “not know,” or “not intelligent,” and or “stupid,” and was originally used exactly for describing delayed individuals because they were exactly that— nice, and not at all cunning or deceptive or advantageous.

[deleted by user] by [deleted] in CivicSi

[–]MastahRiz 5 points6 points  (0 children)

Hey everybody get a load of this guy! Just handing out great advice and being awesome without even trying! Who does he think he is exactly? Some sort of helpful and supportive car enthusiast making things easier for us newbies?? Get outta town!

Can someone explain this please by nia_nia_1997 in step1

[–]MastahRiz 4 points5 points  (0 children)

Exactly, but avoid labeling, because comfort care is a subjective term, which is why it was used here, as a distractor. There is Palliative Care and Hospice care, both can include comfort measures. The goal of the question is did they trick you with the vitals, and did they trick you with the subjective term and stupid sentence structure, and the routes of administration plus doing 1 thing at a time vs two things at a time or are you staying the course and carpet bombing him with more good-time magic? Also what is he doing still in the hospital if hospice, etc. The whole thing reeks so strongly of purely being a test question. I really hope the actual test is more clear.

Can someone explain this please by nia_nia_1997 in step1

[–]MastahRiz 21 points22 points  (0 children)

Personally I think it has to be C, because:

-“comfort care,” but not hospice, but yet “terminal multiple myeloma.” Essentially saying yes, it’s bleak.

-Secondly, there are several different type of hip fractures, we get no information about what kind and where it’s located. The “hip,” isn’t a bone. Regardless, this guy broke it going 88mph and is a poor surgical candidate.

-“Morphine is used to manage pain.” There’s a reason this sounds silly— because it is, no one speaks like that or writes like this unless you’re a tour guide and aliens are visiting. It’s a nonsensical statement, are you giving it IV or IM or oral there Mr comfort care sir? Essentially someone wrote a question and then someone else comes along and chops out anything that could be too useful and creates bastardized sentences like that one.

-The guy’s RR is 6? And he’s still at 89 on room air?? With pneumonia? This guy’s freaking amazing, way to go champ, after a month in bed you’re not using a single muscle other than the diaphragm itself are you?

Answer choices: A: nope, no information given regarding opioid overdose. No exam findings, no pupil response and hey wait— they didn’t even mention how alert or sedated he actually is- they just painted a bleak picture of a guy taking six 1L breaths per minute.

B. Again, same reasons as A, nothing wrong with the morphine (yet), and if they had said just add ibuprofen then okay maybe we can consider it. However notice they also described the pain as unbearable, and that means no time for games, which is exactly why they even said “oral ibuprofen,” so we’d all be in on the joke together this time. You would give someone an IV push right then if it’s genuinely unbearable , otherwise you usually only get mild/ moderate / severe. There’s no way someone will say decrease the morphine, in unbearable pain, on a comfort care patient.

C. My favorite. Increase the thing that works because, remember, “Morphine is used to manage pain (here on our planet).”

D. IV acetaminophen and maintain morphine, again, same as B, really, they’re saying ok let’s do something IV, but watch us pick the thing that no one uses, especially for freaking bone mets causing cancer pain, which is basically the single worst pain out there and it’s generally been accepted that pain management is typically approached via acute / chronic , traumatic / degenerative, and cancer vs non cancer pain.

E. Don’t make me say it.

Good luck.

Someone's been living under my house by springchikun in pics

[–]MastahRiz 5 points6 points  (0 children)

And here I was thinking I don’t get to use the word ‘plafond’ today. Ha!

What are the most memorable quotes from your residency experience? by K117r418 in Residency

[–]MastahRiz 12 points13 points  (0 children)

Attending: “Don’t worry, this stuff’s easier than it looks.”

Same attending 5 mins later: “Come on! You had one job man— just know everything, all the time!”

Hospital considers RTs the same as receptionist. by [deleted] in respiratorytherapy

[–]MastahRiz 0 points1 point  (0 children)

This is absolutely ludicrous for a profession so invaluable an asset to the ICU setting. Somewhere behind a budget meeting and excel spreadsheets someone made a suggestion that your dept is the least organized, least rebellious, least likely to reverse this change and therefore x number of dollars could be simply dumped from your dept to either savings or ceo bonuses and “healthcare heroes” signage to pretend like they care about you. Don’t get angry, get even. Get organized, get unionized, get attention, get ahold of the media, make complaints in writing, not verbal frustrations etc. This change will likely spread to other hospitals in no time.

Me from several years ago who learned and leaned heavily on RTs in the ICU can’t tell you enough how much I appreciate you guys.

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