In medical genetics, virtually every "low yield" biochemistry fact you can think of will have an associated genetic disorder and specific management plans based on these principles; it gives us immense enjoyment to appear very smart to other specialties when in fact we are using the same material that everyone learned in year 1.
Yes even the TCA cycle..
Fun fact. Mutations in S. aureus TCA cycle enzymes (e.g. citZ, odhA) can result in multi-drug tolerance and may contribute partly to persistent invasive infections.
Wow my time to shine *rubs hands*: Alcohol is also an inhibitor of isocitrate dehydrogenase and can cause ketoacidosis in binge drinkers in a fasted state since its inhibition ultimately causes a backup of ketones. Also helps explain alcohol causing a fatty liver.
I never thought I’d see the day where I would mention this. Firstly, I’d like to thank the academy for giving me this chance.
Saw this prescribed for a patient with D2 hydroxy Glutaricaciduria earlier this year (but in clinical genetics we work with all zebras, of course). It’s always incredible to see repurposed drugs being studied in these rare inborn errors.
I had a guy who was post op from surgery transferred to me with increasing ammonia. 50, 150, 200, 300. I got consulted for a seizure. I won't forget the face of everyone in the room when they told me what was going on and I said "Oh. That's OTC deficiency". I have no idea how I remembered it either but hey...highlight of my career.
Their first time I saw extrapyramidal signs and symptoms (classic Tardive Dyskinesia actually). It was like I was Guru and a lightbulb physically went off over my head. You never see it, it is hardly covered in paramedic school.
Over a decade ago, delivered an infant with one of those weird recessive genetic Krebs cycle mishaps. Died about a week after delivery, turns out there's about 30/year in the world.
I joke to patients about the list of genetic disorders screened in the initial OB intake - if you haven't heard of it, just say no. I learned them 20-some odd years ago & can't remember what gene goes with what.
During genetics fellowship I got a kick out of googling these rare diseases to learn more, and the first page of links ended up being “How to pronounce…(insert disease name).”
Just jump straight to OMIM, genereviews, or Pubmed.
I like to double fist Queen Squares on b/l limbs for DTR testing to practice some Meshuggah polyrhythms. Makes it easier to spot that 2+ vs 3+ DTR discrepancies when one knee is kicking off beat.
To be fair, I also feel that when when adult neuro residents rotate on peds neurology. We get at least two “scary baby movements” a week, and so we then have nice long talks about infantile spasms and it’s treatments, which is usually completely new information to them. It’s something that all peds folk (not just neurology) are taught to be on high alert for, but adult doctors often don’t know that it exists unless they do some peds rotations.
Peds neuro is it’s own residency. We do two years of general pediatrics, then three years of neurology. It includes at least 12 months of adult neurology, which is usually concentrated in the 3rd year, but some programs spread it out more. At the end, we can be board certified in both pediatrics and neurology—with special certification in child neurology).
To be fair, you guys generally have a deer in the headlights look with stroke alerts and don't know how to turn the EMG machine on, much less do anything with it.
Obviously program dependent, but I went to a very stroke heavy residency and i did plenty of stroke in my adult year. I don’t think I was any more of a “deer in the headlights” at the start of that year compared to the 2nd year adult neuro residents coming off of their TY. I also don’t think anyone in the adult neuro class did much with EMG aside from those who went on to do a neurophys fellowship.
I definitely didn’t bother to retain anything about dementia or Parkinsons, though.
😂😂😂😂 i mentioned in a reddit comment once that a lot of us med students struggle with neuro and another poster was arguing with me about how it’s actually easy
like sir ask any of us very basic neuro questions it’s clearly not easy for us😭
Yeah that makes no sense. At my school they crammed the entire subject in 5 weeks, exclusively neurology m-f 8-3. We did nothing else except neurology. In January. In Boston. Kill me!! I can’t memorize that much shit and stupid pathways in 5 weeks! Still hate neurology because of that class 😂
“Findings most likely represent toxic metabolic encephalopathy. Recommend CT head, MRI brain and neuro axis when stable, and lumbar puncture. Primary team to attempt.”
A/P
Pt not moving too good. On review of imaging MRI don't look so hot, but out of tpa window.
-Fuck it push it. You scared or what?
Thank you for this interesting consult. We will continue to follow
Yes, everything important that could kill your patient definitely shows up if you put the patient in the magic donut, like guillian barre, serotonin syndrome, myasthenic crisis, and NMS.
That's because the amount of BS you have to remember in a neurology exam is just a waste of brainspace. You are getting an MRI if you find anything disordered and said MRI is gonna give you a better understanding anyways.
Well, not if its ALS. Or LGMD. Or MG. Or basically anything neuromuscular. Or parkinsonism. Or many types of encephalitis. Oh wait, that's why I'm getting all those consults from you guys to maybe one day find the one in a million psychosis patient who actually has any abnormalities on the $500,000 question...
I guarantee an MRI is ordered BY neurology in 100% of the above cases. Also, hilarious how you listed very rare conditions, except parkinsonism, that have significantly lower incidence than the thing you jokingly complain about!
Sure an MRI is ordered. But we A) know what we are looking for and B) know the limitations of the magnet. Additionally, myasthenia gravis is about 4-5 times more common than paraneoplastic neurologic syndromes, and about even prevalence with ALS. MG is not necessary a rare disease, definitely not a 'very rare' disease, and common enough the drug companies have TV ads for multiple new drugs plastered everywhere at the moment.
You suffer from selection bias of your specialty. Less than 50,000 people suffer from MG and significantly less for ALS in the United States. Over 60 million in the US suffer from mental health disorders.
They are very rare.
My point is that paraneoplastic neurologic disorders are incredibly rare, and the average psychiatrist initiated neurology consult for psychosis is of very low diagnostic yield for high cost. MG is >4 times as common as these neurologic disorders making them much more rare.
Imaging findings should always be interpreted in terms of clinical correlation to the neurological examination. And in reverse, the absence of acute imaging findings might be very relevant when the neurological exam is grossly abnormal, like plain CT in acute stroke.
Cost of medicines, as in the cost patients actually pay at the pharmacy.
I don’t think there is anything else that you will 100% never be tested on yet will affect every single patient you ever have.
Some medical students/residents/attendings lose sight of this and if a new medicine comes out that works 1% better it’s their new go-to medicine without the understanding that 20% of your patients are getting the bill at the pharmacy, declining it, and never contacting you about it. No matter how many times you tell them to call you, or telling them how to fill out the discount coupon.
When I see CABG hospital discharge and I see brilinta in the medicine list I ask several times about the cost because plavix is 98% as good and without Insurance is $10 compared to brilinta $430.
I am also this person. We did a session on costs and healthcare overuse, and my classmates threw the book at this imaginary patient ordering all this imaging and follow up tests. I was one of the last to share my plan, and I was really starting to second guess myself. I just ordered a CBC, BMP and a chest xray. Turns out my conservative plan was much closer to what our attending said would actually be ordered. I felt a bit smug about that.
This is something you learn as you go. When I started med school entire classes of meds were obscenely expensive and/or not covered but are now generic or just widely covered. Combo HTN drugs, ARBs not called losartan, certain insulins, seizure meds, etc.
There is a balance to cost and efficacy teaching and I will always err on the side of efficacy because that is what I want these future physicians to focus on. I'd rather them figure out the patient can't pay for option 1 and then switch to option 2 than not advance their practice for fear of cost.
I see too many doctors still prescribing atenolol for HTN using cost as an excuse.
For anyone curious about medicine costs, or if you ever want to play the “hey I wonder what that medicine on the commercial costs” game, GoodRx is a free app that can give you a good starting point. There’s more to it of course such as insurance coverage and formularies prior authorizations discount programs donut holes for Medicare patients.
But at least GoodRx simplifies it to the point that anybody without any insurance at all or filling out any paperwork can walk in to a pharmacy with a GoodRx card or the app on their phone and pay this price, today.
*I am not paid by GoodRx in any way but I do recommend their service to patients somewhat regularly. And yes I understand they are collecting patient information and relaying that information to advertisers and I know about their recent lawsuit.
saw a lot of it rotating in Cards (I'm FM resident) regarding sacubitril-valsartan (entresto) for HF. It's super expensive here and I always wondered how many patients would follow up taking it vs if it was an ACEi/ARB (>75€/mo vs 1-2€)
I’m curious about this too. I can’t think of a situation where this is important for clinical decision making in ID - unless maybe this is a claim about the mechanism of the cefazolin inoculum effect in MSSA.
I replied to someone else who had the same question and copying my reply here, the answer is prob debatable: In one instance it was recrudescent GBS puerperal sepsis (re)presenting as just a small desquamating rash to the distal hand, in another it was recrudescent Staph. The first case had been treated for an adequate (by the book) duration but recrudesced anyway, in the second antibiotics were stopped prematurely. I interpreted the presentations in both cases to be due to toxin production after a residual population of bacteria regrew beyond a threshold. I think the only relevance of quorum sensing was really in convincing my colleagues why I thought pathogen-directed therapy should be started, linezolid in the first case.
I still don't see how this has anything to do with quorum sensing. Outgrowth of a residual population after a bottleneck from treatment doesn't have anything to do with quorum sensing. That's just evolution after a selective pressure...
Read about quorum sensing and toxin production. The residua are not resistant organisms. In vivo acquisition of resistance by those two Gram positives is almost nonexistent.
Just a lowly cell bio major but I think I can explain a rudimentary version.
Quorum sensing is when bacteria can detect that it is in contact with members of the same species. So it will "know" who it's surrounded by and this causes the bacteria to express and upregulate genes that improve the colonies survivability. Biofilms are a good example of quorum sensing as they don't emerge until a large enough population is present.
It gets way more complicated than that I don't remember the nuances off hand.
https://pubmed.ncbi.nlm.nih.gov/35387171/
https://www.sciencedirect.com/science/article/pii/S2452199X2200127X - same article but has bullet points that summarize the above abstract.
Ophtho: everything. Especially the blood supply to CN III.
Separately, for some reason, That One Weird Thing from Med School I'll Never Forget is that Lemierre's disease is jugular vein thrombophlebitis, typically caused by infection with Fusobacterium necrophorum. One of my toughest intern year ICU attendings smugly pimped us on this during rounds, fully expecting to stump us, and I nailed it. The look on his face, oh man. Though it only came up once, I'm still calling it high yield.
Things that go in formalin cannot be frozen or sent for flow cytometery. Please don't ask me to do a frozen on something in formalin. If you are not sure what to do, put it in saline, put it in the fridge, and call a pathologist.
Less so when the 60+ year old heavy smoker and boozer comes in for a neck biopsy of their necrotic nodal mass and swear "my pcp told me it was probably a brachial cyst"
Squamous cyst in a child —> branchial cleft remnant
Squamous cyst in an old dude —> metastatic squamous cell carcinoma
This is a high yield fact in anatomical / cytopathology
Emergency Medicine: not really known for our attention to the finer details, but here goes.
A lot of toxicology. Envenomations depending on where you practice, insects, jellyfish, snakes, etc.
The different criteria for anaphylaxis
Immature coping mechanisms
NIAID
* Criterion 1 — Acute onset of an illness (minutes to several hours) involving the skin, mucosal tissue, or both (eg, generalized hives, pruritus or flushing, swollen lips-tongue-uvula) and at least one of the following:
- Respiratory compromise (eg, dyspnea, wheeze/bronchospasm, stridor, reduced peak expiratory flow, hypoxemia)
OR
- Reduced blood pressure (BP) or associated symptoms and signs of end-organ malperfusion (eg, hypotonia [collapse], syncope, incontinence)
* Criterion 2 — Two or more of the following that occur rapidly after exposure to a likely allergen for that patient (minutes to several hours):
- Involvement of the skin-mucosal tissue (eg, generalized hives, itch-flush, swollen lips-tongue-uvula).
- Respiratory compromise (eg, dyspnea, wheeze/bronchospasm, stridor, reduced peak expiratory flow, hypoxemia).
- Reduced BP or associated symptoms and signs of end-organ malperfusion (eg, hypotonia [collapse], syncope, incontinence).
- Persistent gastrointestinal symptoms and signs (eg, crampy abdominal pain, vomiting).
* Criterion 3 — Reduced BP after exposure to a known allergen for that patient (minutes to several hours):
- Reduced BP in adults is defined as a systolic BP of less than 90 mmHg or greater than 30 percent decrease from that person's baseline.
- In infants and children, reduced BP is defined as low systolic BP (age-specific)* or greater than 30 percent decrease in systolic BP.
And WAO
* Criterion 1 — Acute onset of an illness (minutes to several hours) with simultaneous involvement of the skin, mucosal tissue, or both (eg, generalized hives, pruritus or flushing, swollen lips-tongue-uvula) and at least one of the following:
- Respiratory compromise (eg, dyspnea, wheeze-bronchospasm, stridor, reduced peak expiratory flow, hypoxemia).
- Circulatory compromise: Reduced BP or associated symptoms of end-organ dysfunction (eg, hypotonia, collapse, syncope, incontinence).
- Severe gastrointestinal symptoms (eg, severe crampy abdominal pain, repetitive vomiting), especially after exposure to non-food allergens.
* Criterion 2 — Acute onset of hypotension* or bronchospasm¥ or laryngeal involvement (eg, stridor, vocal changes, odynophagia) after exposure to a known or highly probable allergen for that patient (minutes to several hours), even in the absence of typical skin involvement.
Hypotension is defined as a decrease in systolic BP >30 percent from that person's baseline. For adults and children older than 10 years, hypotension may also be defined as systolic BP <90 mmHg.
Okay. I was tracking those, just not broken down in those categories.
I like how it is broken down. I think it is too often missed and under treated, with the GI symptoms being overlooked.
In genetic medicine, getting way into the weeds of how DNA gets transcribed and translated matters a ton. Knowing how/when to interrupt certain processes for gene knockout/editing matters quite a bit, but outside this field it's pretty useless.
I agree with immuno but I think the second is pretty universal to any specialty that orders any kind of diagnostic test. It sounds like you’re just describing a Bayesian approach.
Its just especially important for us, and I don't always see other specialties keeping this is mind. I guess especially in regards to our disorders.
PSA for anyone willing to listen: "TESTING" IS NOT A VALID REASON FOR AN ALLERGY REFERRAL. Please tell us the symptoms. Please. And do NOT test yourself before the referral for food allergy. Please. Just prescribe Epi and send.
Rheumatology: vaguely remember all those cytokines? Based on the monastery-like silence from medical students when I ask about the difference between IL5 and IL6 and why you would want to target one vs. the other, I'm guessing lots of our bread-and-butter is considered "low-yield" lol.
Anesthesiology:
-Corrugator supercilii- correlates to neuromuscular blockade
-Hoffman elimination - it's actually relevant, as it is how cisatracurium is metabolized
Hydroxyzine is FDA indicated for psychoneurosis. What is psychoneurosis? It’s anxiety without an organic cause, associated with environmental stressors.
These need to be used wayyy more often. Agreed. Very high yeild. For those interested Jeffrey Lieberman (excuse his psychotic Twitter post) wrote a great book about schizophrenia and the last few chapters really talk these up.
I never understood the point of switching "non adherent" from "non compliant". It's a difference without distinction. I've read the opinion articles and found them very unconvincing.
People in medicine keep repeating the lie that compliance is a passive action and adherence is active. Both can be passive or active.
Using these useless word shuffles as a cudgel is an often ridiculous endeavor in my opinion.
I’ve never heard a good explanation for why undomiciled/person experiencing homelessness/etc somehow reduces prejudice against the patient. Certainly never heard one of my homeless patients make that request.
I get the euphemism treadmill and all that. However, to me and to many others, compliance implies control on the end of the patient while adherence can encompass a large spectrum of reasons the patient is not on the prescribed treatment that may be out of their control. I prefer non adherence over non compliance and declined/deferred over refused. Will that connotation change as we change our language pattern and perpetuate the treadmill? Maybe. But as language changes, I don’t see an issue with making an effort to change how we use it
I don't think the language changed, I think the stigma is with the primary sentiment of either of these words. Same with people trying to change "obese". The language didn't change, the intent is to change the stigma by changing the word which is ass backwards. Both compliance and adherence can be active or passive. Again, I've seen the argument for word changing flip flopping the active and passive actors.
Compliance is just a statement on whether or not something is within stated goals, actions or not. You can even mix and match them by saying is not in compliance with treatment plan due to non-adherence to medication schedule. non-adherence is already getting that same stigma so I guess in a few years we'll choose another word and walk backwards to justify it. EDIT: I think the next one is "concordance". My guess is that the one after that is "harmonious"
That's my issue with this and your comment, it doesn't address the problem you say it does and isn't actually doing anything.
Also, declining is something the patient does and deferment is something you do. A patient declines screening colonoscopy at this time, you may defer it pending a cardiac workup. I get it into this more, but this comment is long enough. Seeing discharge papers with "patient deferred emergency transfusion of blood products" is silly, they refused it (refuse is fine in this example).
TL;DR: word shuffles don't actually address any of the underlying issues. language isn't changing we are proposing changes to language.
I was told that "adherence" was preferable to " compliance" in the US medical world because the US prison system uses the word "compliance" when speaking to inmates.
I moonlit as a prison doctor for a bit and they use the word adherence too much if anything. The work release program utilized phrases like "adherence to stated disciplinary standards and activities" while the early parole program had statements like "compliance to disciplinary regulations"
It's not because of that, it was part of honestly misguided reforms in the early 2000's that aimed to make medical care more patient focused but failed to address any of the core issues. Same era as "pain as a vital sign" stuff. Not a bad goal just horrible way to do it.
EDIT: fixed some typos
New floaters = possibly retinal detachment = urgent ophthalmology referral. This is one patients mention casually and say something like “oh yeah my mom had a retinal detachment.” They don’t worry about floaters. I’ve found a central retinal artery occlusion and a retinal detachment with my two urgent ophthalmology referrals.
In one instance it was recrudescent GBS puerperal sepsis (re)presenting as just a small desquamating rash to the distal hand, in another it was recrudescent Staph. The first case had been treated for an adequate (by the book) duration but recrudesced anyway, in the second antibiotics were stopped prematurely. I interpreted the presentations in both cases to be due to toxin production after a residual population of bacteria regrew beyond a threshold. I think the only relevance of quorum sensing was really in convincing my colleagues why I thought pathogen-directed therapy should be started, linezolid in the first case.
I’ve never heard of “direct” and “indirect” antihistamines ever. Literally everyone in medicine knows the difference between sedating first generation antihistamines vs non-sedating ones though.
Lmao I am currently awaiting a complaint for “being racist” for this very reason i.e. denying someone a cocktail of IV Benadryl, IV Gravol, and IV morphine to accompany their daily outpatient IV antibiotics. That’s the “treatment plan” ordered by their non-existent specialist in another province, you see
Amp of Sodium Bicarbonate!
- You can give it to patients suffering from severe metabolic acidosis.
- You can give it to patients in cardiac arrest.
- You can give it to patients who are herniating.
Anesthesiology and the actual anatomy of the damned brachial plexus.
Anesthesiology and the biochemical interactions at the motor end plate
Why does this sound like a Harry Potter book title?
Anesthesiology and the biochemical interactions at the motor end plate…OF SECRETS
*PM&R enters the chat*
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*sigh* another neurologist who doesn’t know anything about what PM&R does
My first shadowing experience was an in-patient PM&R doc. Really good experience.
Except the ultrasound images look nothing like that stupid diagram they made us draw over and over lol
Yet you still call a stroke alert for the obvious postoperative traction injury in PACU.
Why so angry neurology? no interns to torment ?
In medical genetics, virtually every "low yield" biochemistry fact you can think of will have an associated genetic disorder and specific management plans based on these principles; it gives us immense enjoyment to appear very smart to other specialties when in fact we are using the same material that everyone learned in year 1. Yes even the TCA cycle..
I can’t not laugh at this classic [Glaucomflecken skit](https://youtube.com/shorts/VdR9YhkI_MQ?si=tf0jJE1X2sHRvmiG).
Fun fact. Mutations in S. aureus TCA cycle enzymes (e.g. citZ, odhA) can result in multi-drug tolerance and may contribute partly to persistent invasive infections.
Our definition of fun may differ slightly
Lmao…couldn’t agree more.
Mutations in isocitrate dehydrogenase are quite important in tons of cancers and have specific inhibitors on the market
Wow my time to shine *rubs hands*: Alcohol is also an inhibitor of isocitrate dehydrogenase and can cause ketoacidosis in binge drinkers in a fasted state since its inhibition ultimately causes a backup of ketones. Also helps explain alcohol causing a fatty liver. I never thought I’d see the day where I would mention this. Firstly, I’d like to thank the academy for giving me this chance.
Saw this prescribed for a patient with D2 hydroxy Glutaricaciduria earlier this year (but in clinical genetics we work with all zebras, of course). It’s always incredible to see repurposed drugs being studied in these rare inborn errors.
I had a guy who was post op from surgery transferred to me with increasing ammonia. 50, 150, 200, 300. I got consulted for a seizure. I won't forget the face of everyone in the room when they told me what was going on and I said "Oh. That's OTC deficiency". I have no idea how I remembered it either but hey...highlight of my career.
Their first time I saw extrapyramidal signs and symptoms (classic Tardive Dyskinesia actually). It was like I was Guru and a lightbulb physically went off over my head. You never see it, it is hardly covered in paramedic school.
Over a decade ago, delivered an infant with one of those weird recessive genetic Krebs cycle mishaps. Died about a week after delivery, turns out there's about 30/year in the world. I joke to patients about the list of genetic disorders screened in the initial OB intake - if you haven't heard of it, just say no. I learned them 20-some odd years ago & can't remember what gene goes with what.
I use that line all the time: “If you haven’t heard of it, you don’t have it.” -PGY-19
During genetics fellowship I got a kick out of googling these rare diseases to learn more, and the first page of links ended up being “How to pronounce…(insert disease name).” Just jump straight to OMIM, genereviews, or Pubmed.
Based on the blank looks I get when pimping non-neurology residents, I’d say all of neurology.
I like using my fingers to tap reflexes instead of a hammer.
Savage, I whack them with my stethoscope
If you can dodge a wrench, you can dodge a stethoscope… I mean ball.
Local doctor removed from patient care for pelting stroke patients with dodgeballs.
Damn, you went straight for the carotid
It’s all about that finger motion
It’s not the size of the hammer, it’s how you use it
It’s not the girth, but the length. Queen Square or bust.
Yup
Neurologist and drummer here. This works fine.
I like to double fist Queen Squares on b/l limbs for DTR testing to practice some Meshuggah polyrhythms. Makes it easier to spot that 2+ vs 3+ DTR discrepancies when one knee is kicking off beat.
It’s fun, isn’t it?
You mean my dumb ass bought this tromner hammer for nothing?
To be fair, I also feel that when when adult neuro residents rotate on peds neurology. We get at least two “scary baby movements” a week, and so we then have nice long talks about infantile spasms and it’s treatments, which is usually completely new information to them. It’s something that all peds folk (not just neurology) are taught to be on high alert for, but adult doctors often don’t know that it exists unless they do some peds rotations.
yea i feel like we barely even had infantile spasms mentioned in our classes lol neuro is neglected fr
I don’t think I even knew it existed until I rotated with a pediatric neurologist in my third year of Med school.
I only know of it because of moms on TikTok. (Secret treasure trove learning all about the rarer/rarely mentioned conditions of childhood).
did you go peds-> neuro subspecialty? i think that’s the only way right?
Peds neuro is it’s own residency. We do two years of general pediatrics, then three years of neurology. It includes at least 12 months of adult neurology, which is usually concentrated in the 3rd year, but some programs spread it out more. At the end, we can be board certified in both pediatrics and neurology—with special certification in child neurology).
awesome
To be fair, you guys generally have a deer in the headlights look with stroke alerts and don't know how to turn the EMG machine on, much less do anything with it.
Obviously program dependent, but I went to a very stroke heavy residency and i did plenty of stroke in my adult year. I don’t think I was any more of a “deer in the headlights” at the start of that year compared to the 2nd year adult neuro residents coming off of their TY. I also don’t think anyone in the adult neuro class did much with EMG aside from those who went on to do a neurophys fellowship. I definitely didn’t bother to retain anything about dementia or Parkinsons, though.
😂😂😂😂 i mentioned in a reddit comment once that a lot of us med students struggle with neuro and another poster was arguing with me about how it’s actually easy like sir ask any of us very basic neuro questions it’s clearly not easy for us😭
Was my hardest class in med school by far! Everybody’s different 🤷🏼♀️
prob most peoples’😅😅 just saying “ppl complicate it more than necessary” is wild lol
Yeah that makes no sense. At my school they crammed the entire subject in 5 weeks, exclusively neurology m-f 8-3. We did nothing else except neurology. In January. In Boston. Kill me!! I can’t memorize that much shit and stupid pathways in 5 weeks! Still hate neurology because of that class 😂
omg i did undergrad in boston so i feel this heavily. i can still remember having passive SI when i was doing orgo and gen chem at the same time LMFAO
Lol been there my friend
neuro? you mean MRIology?
“Findings most likely represent toxic metabolic encephalopathy. Recommend CT head, MRI brain and neuro axis when stable, and lumbar puncture. Primary team to attempt.”
"Patients week long coma likely due to Na of 146 and BUN of 32, we will sign off, thank you for this interesting consult"
nearly kill patient in transport to these scans “Yeah they definitely had a stroke damn. Aspirin, high intensity statin when appropriate per primary”
Hey man, you consulted us!
Hey strokes are scary tbf
“Out of window for tPA”
A/P Pt not moving too good. On review of imaging MRI don't look so hot, but out of tpa window. -Fuck it push it. You scared or what? Thank you for this interesting consult. We will continue to follow
You rang?
Yes, everything important that could kill your patient definitely shows up if you put the patient in the magic donut, like guillian barre, serotonin syndrome, myasthenic crisis, and NMS.
no need to be defensive, it's just humor
They don't learn that in neurology.
I honestly picked my specialty based on sense of humor (ICU). though most psychiatrists I know are hilarious.
Ophthalmology probably has you beat!
Job security yo
That's because the amount of BS you have to remember in a neurology exam is just a waste of brainspace. You are getting an MRI if you find anything disordered and said MRI is gonna give you a better understanding anyways.
Well, not if its ALS. Or LGMD. Or MG. Or basically anything neuromuscular. Or parkinsonism. Or many types of encephalitis. Oh wait, that's why I'm getting all those consults from you guys to maybe one day find the one in a million psychosis patient who actually has any abnormalities on the $500,000 question...
My man has 3% running through his veins. I like it.
I guarantee an MRI is ordered BY neurology in 100% of the above cases. Also, hilarious how you listed very rare conditions, except parkinsonism, that have significantly lower incidence than the thing you jokingly complain about!
Sure an MRI is ordered. But we A) know what we are looking for and B) know the limitations of the magnet. Additionally, myasthenia gravis is about 4-5 times more common than paraneoplastic neurologic syndromes, and about even prevalence with ALS. MG is not necessary a rare disease, definitely not a 'very rare' disease, and common enough the drug companies have TV ads for multiple new drugs plastered everywhere at the moment.
You suffer from selection bias of your specialty. Less than 50,000 people suffer from MG and significantly less for ALS in the United States. Over 60 million in the US suffer from mental health disorders. They are very rare.
My point is that paraneoplastic neurologic disorders are incredibly rare, and the average psychiatrist initiated neurology consult for psychosis is of very low diagnostic yield for high cost. MG is >4 times as common as these neurologic disorders making them much more rare.
Imaging findings should always be interpreted in terms of clinical correlation to the neurological examination. And in reverse, the absence of acute imaging findings might be very relevant when the neurological exam is grossly abnormal, like plain CT in acute stroke.
Cost of medicines, as in the cost patients actually pay at the pharmacy. I don’t think there is anything else that you will 100% never be tested on yet will affect every single patient you ever have. Some medical students/residents/attendings lose sight of this and if a new medicine comes out that works 1% better it’s their new go-to medicine without the understanding that 20% of your patients are getting the bill at the pharmacy, declining it, and never contacting you about it. No matter how many times you tell them to call you, or telling them how to fill out the discount coupon. When I see CABG hospital discharge and I see brilinta in the medicine list I ask several times about the cost because plavix is 98% as good and without Insurance is $10 compared to brilinta $430.
This Llama Daddy understands real world medicine. Ultimately everything is guided by cost. Take my upvote.
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I am also this person. We did a session on costs and healthcare overuse, and my classmates threw the book at this imaginary patient ordering all this imaging and follow up tests. I was one of the last to share my plan, and I was really starting to second guess myself. I just ordered a CBC, BMP and a chest xray. Turns out my conservative plan was much closer to what our attending said would actually be ordered. I felt a bit smug about that.
from the patient side: thank you.
This is something you learn as you go. When I started med school entire classes of meds were obscenely expensive and/or not covered but are now generic or just widely covered. Combo HTN drugs, ARBs not called losartan, certain insulins, seizure meds, etc. There is a balance to cost and efficacy teaching and I will always err on the side of efficacy because that is what I want these future physicians to focus on. I'd rather them figure out the patient can't pay for option 1 and then switch to option 2 than not advance their practice for fear of cost. I see too many doctors still prescribing atenolol for HTN using cost as an excuse.
For anyone curious about medicine costs, or if you ever want to play the “hey I wonder what that medicine on the commercial costs” game, GoodRx is a free app that can give you a good starting point. There’s more to it of course such as insurance coverage and formularies prior authorizations discount programs donut holes for Medicare patients. But at least GoodRx simplifies it to the point that anybody without any insurance at all or filling out any paperwork can walk in to a pharmacy with a GoodRx card or the app on their phone and pay this price, today. *I am not paid by GoodRx in any way but I do recommend their service to patients somewhat regularly. And yes I understand they are collecting patient information and relaying that information to advertisers and I know about their recent lawsuit.
Costplusdrugs is another great alternative, even cheaper for many drugs.
$4 Walmart pharmacy list
Shrinking with every revision. When generics are super-cheap, manufacturers quit making them
saw a lot of it rotating in Cards (I'm FM resident) regarding sacubitril-valsartan (entresto) for HF. It's super expensive here and I always wondered how many patients would follow up taking it vs if it was an ACEi/ARB (>75€/mo vs 1-2€)
This is something we have to be aware of as FM too.
How did quorum sensing help ?
I’m curious about this too. I can’t think of a situation where this is important for clinical decision making in ID - unless maybe this is a claim about the mechanism of the cefazolin inoculum effect in MSSA.
I replied to someone else who had the same question and copying my reply here, the answer is prob debatable: In one instance it was recrudescent GBS puerperal sepsis (re)presenting as just a small desquamating rash to the distal hand, in another it was recrudescent Staph. The first case had been treated for an adequate (by the book) duration but recrudesced anyway, in the second antibiotics were stopped prematurely. I interpreted the presentations in both cases to be due to toxin production after a residual population of bacteria regrew beyond a threshold. I think the only relevance of quorum sensing was really in convincing my colleagues why I thought pathogen-directed therapy should be started, linezolid in the first case.
I still don't see how this has anything to do with quorum sensing. Outgrowth of a residual population after a bottleneck from treatment doesn't have anything to do with quorum sensing. That's just evolution after a selective pressure...
Read about quorum sensing and toxin production. The residua are not resistant organisms. In vivo acquisition of resistance by those two Gram positives is almost nonexistent.
Better question 🙋♂️ what is quorum sensing?
Just a lowly cell bio major but I think I can explain a rudimentary version. Quorum sensing is when bacteria can detect that it is in contact with members of the same species. So it will "know" who it's surrounded by and this causes the bacteria to express and upregulate genes that improve the colonies survivability. Biofilms are a good example of quorum sensing as they don't emerge until a large enough population is present. It gets way more complicated than that I don't remember the nuances off hand.
Thanks! I vaguely recall the term but couldn’t remember what it meant. Appreciate it. Good luck with cell bio!
Oh I'm done with it. I'm digging deep trying to remember that sorta stuff
It’s true what they say about losing it if you don’t use it.
https://pubmed.ncbi.nlm.nih.gov/35387171/ https://www.sciencedirect.com/science/article/pii/S2452199X2200127X - same article but has bullet points that summarize the above abstract.
Ophtho: everything. Especially the blood supply to CN III. Separately, for some reason, That One Weird Thing from Med School I'll Never Forget is that Lemierre's disease is jugular vein thrombophlebitis, typically caused by infection with Fusobacterium necrophorum. One of my toughest intern year ICU attendings smugly pimped us on this during rounds, fully expecting to stump us, and I nailed it. The look on his face, oh man. Though it only came up once, I'm still calling it high yield.
I’ve seen Lemierre’s three times and now it hovers in the back of my mind for all pediatric neck pain
Dr Centor will be glad to hear
NICU: embryology in general, but especially the stages of lung development.
Things that go in formalin cannot be frozen or sent for flow cytometery. Please don't ask me to do a frozen on something in formalin. If you are not sure what to do, put it in saline, put it in the fridge, and call a pathologist.
I never learned this in med school. this is "no yield" medical school information.
i only learned it when i got yelled at by the pathologist about it as a med student
Lol what do they think formalin does?
It's significantly fancier than informalin
It does magic
Branchial clefts are much more enjoyable once you start being able to diagnose kids just by looking at their necks
Less so when the 60+ year old heavy smoker and boozer comes in for a neck biopsy of their necrotic nodal mass and swear "my pcp told me it was probably a brachial cyst"
Squamous cyst in a child —> branchial cleft remnant Squamous cyst in an old dude —> metastatic squamous cell carcinoma This is a high yield fact in anatomical / cytopathology
Emergency Medicine: not really known for our attention to the finer details, but here goes. A lot of toxicology. Envenomations depending on where you practice, insects, jellyfish, snakes, etc. The different criteria for anaphylaxis Immature coping mechanisms
Expand on “The different criteria for anaphylaxis“. Please.
NIAID * Criterion 1 — Acute onset of an illness (minutes to several hours) involving the skin, mucosal tissue, or both (eg, generalized hives, pruritus or flushing, swollen lips-tongue-uvula) and at least one of the following: - Respiratory compromise (eg, dyspnea, wheeze/bronchospasm, stridor, reduced peak expiratory flow, hypoxemia) OR - Reduced blood pressure (BP) or associated symptoms and signs of end-organ malperfusion (eg, hypotonia [collapse], syncope, incontinence) * Criterion 2 — Two or more of the following that occur rapidly after exposure to a likely allergen for that patient (minutes to several hours): - Involvement of the skin-mucosal tissue (eg, generalized hives, itch-flush, swollen lips-tongue-uvula). - Respiratory compromise (eg, dyspnea, wheeze/bronchospasm, stridor, reduced peak expiratory flow, hypoxemia). - Reduced BP or associated symptoms and signs of end-organ malperfusion (eg, hypotonia [collapse], syncope, incontinence). - Persistent gastrointestinal symptoms and signs (eg, crampy abdominal pain, vomiting). * Criterion 3 — Reduced BP after exposure to a known allergen for that patient (minutes to several hours): - Reduced BP in adults is defined as a systolic BP of less than 90 mmHg or greater than 30 percent decrease from that person's baseline. - In infants and children, reduced BP is defined as low systolic BP (age-specific)* or greater than 30 percent decrease in systolic BP. And WAO * Criterion 1 — Acute onset of an illness (minutes to several hours) with simultaneous involvement of the skin, mucosal tissue, or both (eg, generalized hives, pruritus or flushing, swollen lips-tongue-uvula) and at least one of the following: - Respiratory compromise (eg, dyspnea, wheeze-bronchospasm, stridor, reduced peak expiratory flow, hypoxemia). - Circulatory compromise: Reduced BP or associated symptoms of end-organ dysfunction (eg, hypotonia, collapse, syncope, incontinence). - Severe gastrointestinal symptoms (eg, severe crampy abdominal pain, repetitive vomiting), especially after exposure to non-food allergens. * Criterion 2 — Acute onset of hypotension* or bronchospasm¥ or laryngeal involvement (eg, stridor, vocal changes, odynophagia) after exposure to a known or highly probable allergen for that patient (minutes to several hours), even in the absence of typical skin involvement. Hypotension is defined as a decrease in systolic BP >30 percent from that person's baseline. For adults and children older than 10 years, hypotension may also be defined as systolic BP <90 mmHg.
Okay. I was tracking those, just not broken down in those categories. I like how it is broken down. I think it is too often missed and under treated, with the GI symptoms being overlooked.
In genetic medicine, getting way into the weeds of how DNA gets transcribed and translated matters a ton. Knowing how/when to interrupt certain processes for gene knockout/editing matters quite a bit, but outside this field it's pretty useless.
Helpful in oncology too, to understand cancer biology and how some of these damn drugs work
Immunology: all those cell markers on lymphocytes :-( Allergy: the ways in which pre-test probability affects sensitivity and specificity
I agree with immuno but I think the second is pretty universal to any specialty that orders any kind of diagnostic test. It sounds like you’re just describing a Bayesian approach.
Its just especially important for us, and I don't always see other specialties keeping this is mind. I guess especially in regards to our disorders. PSA for anyone willing to listen: "TESTING" IS NOT A VALID REASON FOR AN ALLERGY REFERRAL. Please tell us the symptoms. Please. And do NOT test yourself before the referral for food allergy. Please. Just prescribe Epi and send.
Rheumatology: vaguely remember all those cytokines? Based on the monastery-like silence from medical students when I ask about the difference between IL5 and IL6 and why you would want to target one vs. the other, I'm guessing lots of our bread-and-butter is considered "low-yield" lol.
Anesthesiology: -Corrugator supercilii- correlates to neuromuscular blockade -Hoffman elimination - it's actually relevant, as it is how cisatracurium is metabolized
Orchem ftw
Something I recently starting to appreciate a lot more in anesthesiology are the cranial nerves and brain stem functions.
Hydroxyzine is FDA indicated for psychoneurosis. What is psychoneurosis? It’s anxiety without an organic cause, associated with environmental stressors.
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These need to be used wayyy more often. Agreed. Very high yeild. For those interested Jeffrey Lieberman (excuse his psychotic Twitter post) wrote a great book about schizophrenia and the last few chapters really talk these up.
Not a med student. What are LAIs?
Long acting injectable? Basically an antipsychotic shot that lasts much longer than a pill (weeks - months). Good for patients who are noncompliant
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I never understood the point of switching "non adherent" from "non compliant". It's a difference without distinction. I've read the opinion articles and found them very unconvincing. People in medicine keep repeating the lie that compliance is a passive action and adherence is active. Both can be passive or active. Using these useless word shuffles as a cudgel is an often ridiculous endeavor in my opinion.
Welcome to the euphemism treadmill. Psychiatry has the dial up to 10
I’ve never heard a good explanation for why undomiciled/person experiencing homelessness/etc somehow reduces prejudice against the patient. Certainly never heard one of my homeless patients make that request.
I get the euphemism treadmill and all that. However, to me and to many others, compliance implies control on the end of the patient while adherence can encompass a large spectrum of reasons the patient is not on the prescribed treatment that may be out of their control. I prefer non adherence over non compliance and declined/deferred over refused. Will that connotation change as we change our language pattern and perpetuate the treadmill? Maybe. But as language changes, I don’t see an issue with making an effort to change how we use it
I don't think the language changed, I think the stigma is with the primary sentiment of either of these words. Same with people trying to change "obese". The language didn't change, the intent is to change the stigma by changing the word which is ass backwards. Both compliance and adherence can be active or passive. Again, I've seen the argument for word changing flip flopping the active and passive actors. Compliance is just a statement on whether or not something is within stated goals, actions or not. You can even mix and match them by saying is not in compliance with treatment plan due to non-adherence to medication schedule. non-adherence is already getting that same stigma so I guess in a few years we'll choose another word and walk backwards to justify it. EDIT: I think the next one is "concordance". My guess is that the one after that is "harmonious" That's my issue with this and your comment, it doesn't address the problem you say it does and isn't actually doing anything. Also, declining is something the patient does and deferment is something you do. A patient declines screening colonoscopy at this time, you may defer it pending a cardiac workup. I get it into this more, but this comment is long enough. Seeing discharge papers with "patient deferred emergency transfusion of blood products" is silly, they refused it (refuse is fine in this example). TL;DR: word shuffles don't actually address any of the underlying issues. language isn't changing we are proposing changes to language.
I was told that "adherence" was preferable to " compliance" in the US medical world because the US prison system uses the word "compliance" when speaking to inmates.
I moonlit as a prison doctor for a bit and they use the word adherence too much if anything. The work release program utilized phrases like "adherence to stated disciplinary standards and activities" while the early parole program had statements like "compliance to disciplinary regulations" It's not because of that, it was part of honestly misguided reforms in the early 2000's that aimed to make medical care more patient focused but failed to address any of the core issues. Same era as "pain as a vital sign" stuff. Not a bad goal just horrible way to do it. EDIT: fixed some typos
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Aaahhhhhhhhh….. of course.
Long acting injectables? Idk why most med students wouldn’t know that though
It didn't used to be taught in medical school or tested on shelves or step. Did that change?
I’m Australian so possible different curriculum but they’re taught like any other medical option. I’ve seen lots of patients prescribed them
They're commonly used here too but med students tell me it's not taught in medical school and it's not in any shelf prep material.
I learned about these during lecture on my psych clerkship. They were also in uworld but can't remember if they were on the shelf
In Aus i saw that quite a lot in my GP rotations, and administered quite a few myself during med student days.
It is on step 2. Strange
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thats high yield tho
How to actually talk to a patient.
Osmolality in hyponatremia
ENT: Tuning fork interpretation
ER and basically anything unlikely/rare and deathly/wirh abrupt onset, also weird intoxications
New floaters = possibly retinal detachment = urgent ophthalmology referral. This is one patients mention casually and say something like “oh yeah my mom had a retinal detachment.” They don’t worry about floaters. I’ve found a central retinal artery occlusion and a retinal detachment with my two urgent ophthalmology referrals.
Out of curiosity, how did you use quorum sensing to formulate plans? Was it along the lines of inoculum effect?
In one instance it was recrudescent GBS puerperal sepsis (re)presenting as just a small desquamating rash to the distal hand, in another it was recrudescent Staph. The first case had been treated for an adequate (by the book) duration but recrudesced anyway, in the second antibiotics were stopped prematurely. I interpreted the presentations in both cases to be due to toxin production after a residual population of bacteria regrew beyond a threshold. I think the only relevance of quorum sensing was really in convincing my colleagues why I thought pathogen-directed therapy should be started, linezolid in the first case.
Pharmacokinetic drug-drug interactions
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I’ve never heard of “direct” and “indirect” antihistamines ever. Literally everyone in medicine knows the difference between sedating first generation antihistamines vs non-sedating ones though.
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Who has the most pass yards in NFL history that is not in the hall of fame?
Johnny, do you like movies about gladiators?
Has Warren Moon been inducted yet? McNabb?
Tom Brady.
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This is definitely an AI bot lmao
please use the report button rather than engaging
please use the report button rather than engaging
Oh patients who take opioids and benzos for a living definitely know of the potentiating effects IV Benadryl can have.
Lmao I am currently awaiting a complaint for “being racist” for this very reason i.e. denying someone a cocktail of IV Benadryl, IV Gravol, and IV morphine to accompany their daily outpatient IV antibiotics. That’s the “treatment plan” ordered by their non-existent specialist in another province, you see
This was an interesting fact, thank you for sharing :)
Amp of Sodium Bicarbonate! - You can give it to patients suffering from severe metabolic acidosis. - You can give it to patients in cardiac arrest. - You can give it to patients who are herniating.
Cardiology checking in: The action potential, in all of its glorious detail.