Judging from yesterday's post, many friends are interested in how to get the most out of these books 👇 and ace the exams, so a few more tips are on their way:
1. Tylenol use can lead to high anion gap metabolic acidosis. Don’t ask me about the mechanism! 2. Every patient who manages to fly eastbound with Southwest Airlines & subsequently develops pneumonia not responding to common antibiotics has actually blastomycosis
3. Every oncology patient who receives chemo is destined to develop tumor lysis syndrome. Please learn about hydration/allopurinol/rasburicase 4. Along these lines, every oncology patient on immunotherapy will develop pneumonitis. Remember the steroids from yesterday’s post?
5. Burn patients don’t die of SIRS, fluid losses or multidrug resistant organisms; in these books (and the boards), they die of undiagnosed CO poisoning 6. Thrombotic thrombocytopenic purpura is 20 times more frequent than iron-deficiency anemia and anemia of chronic disease
7. I know we cannot tell the flow-time from the pressure-time scalar but reverse triggering should be recognized from a mile away 8. If the patient in the clinical vignette is breathing 34/min w O2 Sat 90%, SBP 92 mmHg, HR 138/min and you are given the option to “extubate”,
this 👆 is the correct answer. Remember, this is a test not real life! 9. Every poor person living in a camper and presenting w diffuse weakness is suffering from botulism
10. Every patient who has his throat sprayed with benzocaine needs to have his iv flushed with methylene blue!
Thanks for reading! You just got another 10+ questions right...
These books from @accpchest & @SCCM represent my study goal for this month. Before starting any (re-)certification exam & especially f you want to ace the tests, there are a few recent trends (& old habits/tricks) that you need to be aware of:
1. If there is an option of "doing nothing", this is most likely the correct answer. 2. There is always a mixed metabolic disorder. Memorize Winter's formula. 3. Prepare for several COVID-19-related questions. No surprise here...
4. TEG is very popular. Even of you are a dinosaur, you have to learn the basics about visco-elastic tests. 5. I know you have no CAR T-cell therapies in your hospital (& no one can really spell them correctly), but be prepared for managing cytokine release syndrome.
ICU stories: 65 yo pt, fairly healthy besides HTN & an episode of diverticulitis 3 y ago, is brought to the ED due to 2 wks' hx of abd pain & 1 d hx of N/V ("coffee-ground"). Looked "bad". SBP in 60s - improved to 80s w ivf. Intubated. Had CT A/P 👇:
While you review the CT images, you get the lab results: Lactate 10, WBC 3K, INR 2.0, BUN/Creat 100/3.0, CRP 500 mg/l, Procalcitonin 300. The ED is calling you for the admission. What consult(s) do you ask?
The CT A/P showed a large amount of free intra-peritoneal air; stomach & SB were mildly distended & partially fluid-filled. There was colonic diverticulosis without diverticulitis & mild wall thickening involving the descending colon & the sigmoid colon
ICU stories: 70 yo pt without medical hx but tobacco use (2 ppd x 40 y) was admitted w shortness of breath a wk ago. CXR/chest CT without PE/infiltrate. Was in afib/RVR on admission; placed on heparin & dilt/b-blocker (w some hypotension). Remained dyspneic, at times restless,
“requiring” multiple sedatives, & eventually was brought to the ICU. Intubated for "resp distress" & mental status changes. "Formal" echo, the day of ICU transfer, showed “LVEF 20% w global LV dysfunction”. On the vent 50% - peep 10. BP 110-130/60-70. Lactate < 2.0
Cards follow for "well compensated heart failure". A look w POCUS upon ICU admission:
How do you examine the lower extremity venous system when you look for deep vein thrombosis? What points do you check with the probe? Do you use Doppler? What are the recommended protocols? The Society of Radiologists in Ultrasound recommends a complete duplex ultrasound:
👆 The black rectangles represent the extent of the compression US. The gray rectangles are the sites of Doppler.
2-CUS (2-points compression US) includes compression of the femoral veins 1-2 cm above & below the saphenofemoral junction & the popliteal veins
up to the calf veins
ECUS (extended compression US), includes compression US from the common femoral vein through the popliteal vein up to the calf veins confluence
CCUS (complete compression US), includes compression US from the common femoral vein to the ankle
Following up on a discussion during ICU rounds this am: Like most laboratory values in medicine, pH and lactate levels should be evaluated in their context. In this 👇 old study of 6 male oarsmen who participated in a maximal effort on a rowing ergometer,
the two lowest pH values were 6.74 and 6.76 (corresponding to [H+] of > 180 nmol/L); the HCO3 levels were undetectable. The lowest lactate level was 32 mmol/l. The oarsmen remained conscious and did not require medical help
The conclusion of the study was that "in healthy humans, pronounced, but transient,acidosis is well-tolerated". Finding a pH of 7.05 or a lactate of 10 is usually not a big deal in a patient with DKA or (post-)seizures
ICU stories (a boring one…): If you work in a general ICU of a community hospital in United States, one of the common admissions you will get is the unfortunate resident of a nursing home or rehabilitation center that lives there for several decades & at some point becomes
febrile/“altered” & is sent to the ED for “evaluation”. The course is so predictable that we usually consider these admissions “boring”. This is the case of a middle-aged pt w cerebral palsy/mental retardation/seizures (on valproic)/PEG-chronic Foley in place who was sent to
the ED for fever+hypotension+tachycadia. Labs: WBC 15k, lactate 4.0. UA -as usually- suggestive of UTI (WBC>50, +bacteria, +nitrite, +esterase). CXR “clear” & pt w sat 99% on room air. Received ivf, Abx (pip/tazo + vanco) but due to persistent ⬇️BP, norepinephrine gtt was ordered