db's Medical Rants

Over the past several weeks I have emphasized in-hospital pain control.  Regularly I find patients with "legitimate" pain who complain about their pain control.  The resident's default order for many years is (pick your opioid) q 3 or 4 hours p.r.n.
My palliative care colleagues have stressed that we should schedule pain control rather than provide [...]

The answers were great.  I knew that GERD rarely caused severe odynophagia.  Therefore I guessed that should would have Candida esophagitis – just playing the odds.
Her upper endoscopy the following day confirmed my hunch.

Took care of a young woman (with a 15 year h/o DM I) recently who presented with DKA.  We suspected that cocaine use had precipitated her DKA, but her Hgb A1c >10 also. 
On day 3 we were ready to d/c the patient.  She protested because her reflux was causing too much pain.  She told [...]

This week I am rounding for 3 days.   Because at least one of my colleagues wanted to read how I used set pieces on rounds, I am planning to highlight some set pieces that I used for each day this week.
1. Pt. with COPD, s/p CABG and sterniotomy infection – admitted with increased dyspnea
Set piece [...]

 
Running ward-attending rounds has more in common with jazz than symphony. Patients do not follow a script. Admissions do not follow a script. The ward attending has multiple responsibilities each day.  These responsibilities include directing patient care, teaching, evaluating, and coaching learners to grow. We believe that we should combine directing [...]

I have several "chalk talks" that I give repeatedly.  One favorite is secondary prevention for cirrhotic patients.  I missed this article when it was first published, but fortunately a Pharm D colleague sent it me.  Carvedilol  likely trump propranolol.  Fortunately, carvedilol is now generic and a "$4 drug".  Study shows carvedilol is effective in preventing [...]

KevinMD has a great piece today – The balancing act between science and art is what makes medicine so challenging

In a recent piece in The Atlantic, Dr. Verghese again writes not to let technology obstruct patient care. Indeed, he observes that “I still find the best way to understand a hospitalized patient whose care I [...]

This month I celebrate 30 years of ward attending.  I estimate that I have done over 100 months of ward attending during this time.  I find ward attending energizing, enjoyable and rewarding.  I hope my learners agree.
Here are some things I have learned:

Ward attending rounds should be enjoyable.  They can only be enjoyable if the [...]

I left a couple of questions hanging prior to starting a vacation.  Two days of football watching, golf playing, wine drinking and great camaraderie will continue today and tomorrow.   This morning I did awaken early and go to the workout facility, continuing my exercise pattern.
When last I blogged, I posed a question about the circumstances [...]

David understood the problem.  Our patient had had bilateral above the knee amputations, causing his creatinine to drop precipitously.
I am a big fan of eGFR, but I do know the times when it does not work.  So today's question to ponder – when should you not use the GFR estimation equations.
Like all laboratory tests, we [...]

Day 7 was a post call day – we had 6 new patients.  COPD exacerbations dominated our service.
We discussed 2 major issues

When to give antibiotics and which antibiotic to give
When to evaluate for pulmonary thromboembolism

For the first issue I recommend – Antibiotic Therapy in Elderly Patients with Acute Exacerbation of Chronic Bronchitis

Several potential triggers for [...]

Back at the VA, I inherited 3 patients.  We are on call today (day 2), but given 3 patients I stretched rounds out for 100 minutes.
Internists can do that.  I dissected each patient, made multiple teaching points, and just had a blast.
I have a dilemma that I uncovered.
 
The patient is in his early 50s, has [...]

Some time ago, I was making post call rounds.  The team presented a patient admitted from the oncology service.  He was in his 50s and had new chest pain.  He described the chest pain as substernal pressure with radiation down both arms.  He received relief from stretching against the wall.  The pains lasted around an [...]

Yesterday we focused on the oliguric patient.  I will provide the essence of that chalk talk.
For the purpose of this talk, we define oliguria as < 500 cc / day or 20 cc / hr

Always consider obstruction first.  Pass a urinary catheter.  If small amount of urine, remove it.  You still need to consider a [...]

I received this tweet:

Do you have any recommendations on how an MS3 should approach an attending to request something like your 2 hour commitment for ed

I actually do not have any recommendations.  Your have a classic problem that many students have.  Most attending physicians have a different conceptualization of their role than I have. 
I [...]

Day 2 was easy.  We had 2 patients, and despite coming in the afternoon, we had no admissions at that point.
After spending 15 minutes getting to know my team – 2 students, 2 interns, and 1 resident (all guys) – we saw the existing patients and then went to the conference room to teach.  Because [...]