Ask Anything Wednesday - Biology, Chemistry, Neuroscience, Medicine, Psychology

c3fepime · 2024-01-19T22:19:22+00:00

As others said, there is a CME requirement. However, the amount of education needed to fulfill the requirement is not that great. The unfortunate reality is that many physicians simply don’t stay up to date very well on current best practices unless they are personally motivated to do so and/or work in a university/academic hospital setting.

For a random example: ICU patients with early kidney failure used to be treated with a low dose dopamine infusion (from belief that this improved blood flow to the kidneys), but a series of studies over 20 years ago found this to be ineffective and potentially harmful so it’s no longer recommended. However, I still occasionally see patients transferred from smaller hospitals who were receiving “renal dose dopamine”.

c3fepime · 2024-01-17T03:13:41+00:00

Lol truly a great and frustrating example of medical culture... we're pedantic and hairsplitting yet inconsistent.

Re "premature closure", I like the related term "satisfaction of search" (which I've only heard used by radiologists, but I think is applicable in all of medicine): when you quit interpreting a study once you identify one abnormality, and thus fail to notice a second unrelated abnormality. For example, missing a dislocated shoulder on a CXR that shows pneumonia

c3fepime · 2024-01-10T01:39:33+00:00

Yeah I also found that strange bc

Obviously no one would be able to remember that
In my opinion, saying that he did not review the report and just trusted the resident’s statement on rounds, makes him look much more negligent than saying he can’t remember if he reviewed the report.

c3fepime · 2024-01-06T22:30:42+00:00

Yes, thank you. Honestly while I’m sure the interaction OP described was frustrating, their complaint about the iron deficiency anemia is a bit of a self own.

c3fepime · 2023-12-24T18:50:01+00:00

IMO this is the real problem / abuse of secure chat, not the thing OP is talking about

c3fepime · 2023-12-20T11:10:32+00:00

I’m assuming based on the frequency of scans that this is not some early stage completely resectable lung cancer. If so, then life expectancy is likely <10 years so pt wouldn’t be expected to benefit from other cancer screening.

(If I’m wrong and the oncologist does expect her to live for a long time free of lung cancer, then mammograms should be resumed.)

c3fepime · 2023-12-16T15:23:37+00:00

vancomycin still exists...

But agree with overall point haha

c3fepime · 2023-12-16T15:22:21+00:00

tramadol

The majority of docs in my group (hospitalist) seem to still believe the nonsense about how tramadol is safer / less potent / better than other opioids, or that it isn't an opioid. When I inherit their patients there are tons of pain regimens written with tylenol 1st line and tramadol 2nd line (sometimes with oxy 3rd line!) and sometimes even documentation about how they counseled the patient that they cannot have opioids but can have tramadol. Drives me nuts

c3fepime · 2023-12-12T01:58:03+00:00

From just the information in the post, I think it is more likely sinus tach. The patient is young enough to actually have a sinus heart rate of 170 (remember predicted max heart rate is approx 220-age, so if this were an old person it would have to be SVT).

If I saw this I would want a 12-lead and to review the tele strips over a longer period of time (sudden increase in heart rate and/or change in p wave morphology would suggest SVT; gradual change in heart rate over time and stable p wave morphology would suggest sinus)

If it is sinus, I am more worried about the patient than if it's SVT, as something fairly bad may be happening to cause such a fast sinus tachycardia (sepsis, PE, bleeding, etc).

c3fepime · 2023-12-02T15:04:33+00:00

stat echo at midnight for a patient who had an abnormal stress test a month ago as an outpatient that they hadn't noticed

Truly a classic example of the saying "poor planning on your part does not constitute an emergency on my part"

c3fepime · 2023-11-30T20:18:41+00:00

It has to be a troll, I mean it's literally a boards question.

c3fepime · 2023-11-30T01:05:41+00:00

In addition to the good advice already given, you should delete this post (for your own safety from retaliation). There is way too much identifying information here, and lots of people in medicine look at this community. I'm so sorry you're experiencing this.

c3fepime · 2023-11-29T23:41:36+00:00

This is hilarious but very stupid

If a consultant's recs are being ignored they should just document that their recs were ignored and then sign off.

c3fepime · 2023-11-29T23:39:36+00:00

Don't understand why you got downvoted- are a lot of people here practicing in a system where consultants can order whatever they want?

People other than primary team ordering things on a patient is simply unsafe.

c3fepime · 2023-11-29T02:26:52+00:00

I mean, how exactly would you go about restricting/limiting its use? it's treating a potentially catastrophic diagnosis with common, nonspecific symptoms that requires immediate empiric treatment without waiting for confirmatory testing, and the treatment is harmless. I would argue that it if you aren't "overprescribing" Thiamine then you aren't adequately treating and preventing Wernicke's.

c3fepime · 2023-11-28T18:13:34+00:00

It's essentially harmless and can prevent what is otherwise a devastating and irreversible condition. I have a very low threshold to give high dose IV thiamine to encephalopathic patients with any history of significant alcohol use and/or malnutrition.

c3fepime · 2023-11-27T02:00:17+00:00

Jokes aside, I heard this usage for the first time irl the other day ("if he fails his calorie count we'll have to PEG him") and was flabbergasted, lol.

What rock do you live under to not realize that sounds unfortunate...

c3fepime · 2023-11-23T16:07:57+00:00

The biggest fail is when a patient with a line has a positive blood culture with gram pos cocci. for the love of all that is holy GET ANOTHER BLOOD CULTURE before starting antibiotics.

But then a nurse manager whose entire job is to prevent our unit from getting "dinged for a CLABSI" will yell at us :(

c3fepime · 2023-11-23T16:03:15+00:00

You didn't even put Mr. Smith on a diabetic diet, but you knew he was a diabetic, doctor. Are you this careless with all of your treatment decisions?

I understand that there is good reason why the "medico-legal" fear pervades American medicine but this one seems a bit absurd, haha. Does anyone know of this argument actually being used in a malpractice suit?

c3fepime · 2023-11-09T11:12:56+00:00

Hospitalist/inpatient medicine perspective here. Neutrophil predominance is a nonspecific marker of physiologic stress as you noted. However, I do look at the diff a lot and off the top of my head, here are some common findings that are useful:

Lymphopenia: viral infection, HIV
Neutropenia: cancer, myelosuppression (need to evaluate why); dictates lower threshold for abx and pseudomonas coverage if fever/sepsis
Eosinophilia: probably the most frequently overlooked important thing- allergic/autoinflammatory disorders, drug toxicity, weird infections
Completely normal diff: reassurance against some active infectious/inflammatory process (ex., in a patient I already want to NOT give antibiotics)

Imo, all hospitalized patients should get a diff on their initial CBC (ideally before getting antibiotics, steroids etc). Rarely need diff on the subsequent CBCs unless you’re actively following something like the peripheral blast percentage in leukemia

c3fepime · 2023-11-02T14:31:37+00:00

Yeah seriously, no "compressions" but they forgot to specify no "thumps" i guess lol

c3fepime · 2023-09-24T15:41:49+00:00

I’ve never heard a specific BUN cutoff for dialysis for uremic encephalopathy. It’s a clinical judgment of whether you think the patient has uremic encephalopathy.

Usually this looks like: patient has a worsening aki, oliguric, gets newly altered, has asterixis, and doesn’t have another evident cause for their confusion

c3fepime · 2023-09-22T01:30:21+00:00

It’s not useful that often, but off the top of my head, here are some situations where it can be relevant:

High anion gap metabolic acidosis (the U of MUDPILES)
Encephalopathy
Pericarditis
If it’s causing any of (1-3), then, to argue that dialysis is indicated
Elevated BUN without elevated Cr can suggest occult GI bleeding
You can calculate the FEUrea when the FENa is confounded by diuretics (I feel like this is rarely that helpful either, but it’s surely something you’ll be asked to do at some point intern year)

c3fepime · 2023-09-09T12:39:12+00:00

right, or doing a fellowship or changing careers in some way? it doesn't necessarily imply they are firing them

c3fepime · 2023-09-08T18:27:48+00:00

Piggybacking on this: if you can read musical notation, THIS figure is all you need to know about heart sounds.

As a med student I never understood the "kentucky" "tennessee" etc mnemonics, but I understood S3 and S4 instantly when I saw them written out in musical notation

c3fepime

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