On to Round 3

This past week I began the third of my six rotations. This is a twelve week rotation of Internal Medicine. It is split up into three parts of four weeks: the first involves rounding with the hospitalist. The second night calls (can't wait). The third is ICU and outpatient. The first part, to date has been very interesting. Some days have more patients than others.
I am paired with the same person for the entire twelve weeks, and thus far I think we have gelled quite well. She is very knowledgeable and thorough, and has done a few more rotations than I have. This is good because she has so far pushed me a fair bit. I need that. I like that, and I appreciate that. We actually live a block apart so that's nice in the sense that it is easy to share transportation and study, as well as coordinate social activities as well. No complaints there. The hospitalist we are rotating with is terrific. She gives us a great deal of information and wants us to learn. I think that's great!

Adventures in CTAing...

Saturday morning I was on a bus that travels down The MAGNIFICENT MILE, which means on Saturday morning tourists, and their crap. And hilarious antics, that went like this:

"HO MY GAWD!!!!! MICHAEL JORDAN STEAKHOUSE!!!!!"

"LOOK HONEY!!! IF YOU PUSH THE STOP BUTTON A BELL DINGS!!!" Good job ding-a-ling. Please stop pushing the damn button because the driver is stopping just for your ass.


Or my personal favorite..."Oh look Wacker and Wabash. We can get off there to go to the Art Institute!" Well...I guess you could, and walk about seven blocks. Or you could follow the directions in that giant book you smacked some poor lady's head with and wait two more stops and walk two blocks...but whatever.

Bath...water...

Heard the song "Bathwater" by No Doubt for the first time in years...I'm just as creeped out by it as I was the first time around...I'm also significantly more grossed out than the last time...I mean really...who thinks about such things!

Syringomylia

Last week on the pediatrics floor we had a patient with a syrinx. After checking the MRI it was plain as day, and looked REALLY cool. I so much better understand the disease now having seen the MRI. Lesson learned: check the blasted imaging studies!!

The mercury hit 97 degrees F today here in Chicago. Native Chicaaagans lost their minds. And when the wind kicked up to 30mph sustained with gusts substantially faster, blowing HOT AS A BLOODY SAHARAN SANDSTORM...this Atlanta native got a bit grumpy.

Adventures in CTAing

A: "Oh damn it's my anniversary tomorrow. I forgot!"
B:"It's fathers day this weekend too. You gotta do a little more."
A: "No I don't he ain't my daddy."


...my day suddenly became much more amusing.

Doctorese Babble -- Fluids and Electrolytes

Fluids and Electrolytes

1.     Heat loss – insensible water loss – 50%

2.     Solute loss – urine (Na, K, Cl) – 50%

100kcal --> 100mL fluid

Neonates have highest BMR – require more fluids

1.     Weight – Holiday Seey

Weight	Day	Hour
First 10kg	100mL/kg	4mL/kg/hr
Next 10kg	50mL/kg	2mL/kg/hr
Every subsequent kg	20mL/kg	1mL/kg/hr

2.     Body Surface area – more accurate but takes much longer to calculate

3.     Calculations

a.     Maintenance

                                               i.     100kcal -- 100mL H20, 3-4 meq Na, 2 meq K

                                             ii.     <3 months -- D5% + ¼ NS + 20meq K

                                            iii.     > 3 months -- D5% + ½ NS + 20meq K

                                            iv.     Bolus fluids

1.     Normal Saline

2.     Ringer’s Lactate

3.     Blood

4.     Albumin

5.     **Gatorade or Pedialite are closest to NS

6.     Do not withhold feeding

7.     20mL/kg – then reassess and repeat if needed up to 3-4 times unless edema increases (adults are 0.5-1.0L)

                                             v.     blah

b.     Deficit

	Mild 5% in neonates 3% in toddler and adults	Moderate 10% in neonates 6%	Severe 15% in neonates 9%
Tears/eyes	Sunken eyes	Sunken eyes	Sunken eyes
Membrane perf.
Skin turgor		Decreased turgor with tenting	Decreased turgoor with tenting
Fontanelle
Cap refill	<2s	<3s	> 3 s
Oral Mucosa
Urine output and spec gravity (1.010)		Decreased output and increased gravity	No output
HR	+	+	+
BP		Decreased	Decreased

c.     Ongoing losses – 10mL/kg extra fliud per loose stool

4.     I’s/O’s

a.     Urine (2:1) or specific gravity

b.     Blood à Hb, creatinine, BUN

c.     Urine osmolarity – 280-320

5.     Hypernatremic dehydration – give more fluids

I might be a hypocrite...

I realized today I never keep track or even remember whether my friends ever owe me money. If one is not my friend, however, I am likely to keep a mental record of how many days it took to pay me back.

Doctorese Babble: Acyanotic Heart Lesions

Acynanotic Heart Disease

- ASD most common in adults

o mostly asymptomatic due to minimal pressure difference

o Normal vitals

o Fixed split S2

o Ejection systolic murmur

o X-ray usually unremarkable

o Septum primum – sidenote

 Endocardial cushion defect

 Down’s syndrome – 30%

 30% of Trisomy 21 patients have ECD, 30% of ECD patients have Trisomy 21

 Cyanotic lesion

- VSD most common in children

o Becomes volume overload in lungs

o Full and red and wet

o Pressure difference isn’t large at birth

o As PVR decreases, L-R gradient increases

o Symptoms

 Increased respiratory rate

 Poor feeding *** -- only energy babies expend

• Will sweat around the forehead

• Poor weight gain

 Tachycardia

 Normal sats – unless severe pulmonary edema

 Biventricular hypertrophy

 Murmur

 Edema – sacral

 Crackles

o X-ray

 Cardiomegaly – cardiothoracic occupation is normally 60% in babies

 Edema

 White lungs

o Echo

 Size of lesion

 Location of lesion

• Muscular

• Membranous – will not close

 Many will close on their own – consider surgical repair if not resolved by 1-1.5 years

o Treatment

 Diuretics

 ACE inhibitors

 Surgical repair

 **Swiss cheese heart disease

- Bicuspid aortic MC congenital heart defect

- Coractation of the Aorta

o Critical if preductal – when PDA closes shock ensues

o Normal 10-20 point difference between upper and lower extremity BP – gap widens with coarct

I paid attention during anatomy lectures!!!

During an attempt to assist a resident insert a catheter on a ten month old, I thought that she was inserting the catheter in a little low...as in the vagina and not the urethra (look it up if you're not familiar with the difference...it's astonishing how many women aren't). At first I didn't say anything because 1) she's the resident and 2) I can't say I make a habit out of looking at underaged private parts--yes, I think (hope) that most balanced individuals are a bit wary and cautious of children and their parts. So I waited until attempt two went the way of attempt one--the catheter curled its way back out. I then asked if that was the vagina or the urethra. And it turns out this time I was correct.
Yay me...I can identify a ten month-old's urethra...Awkward.

Just woke up from my last night on call in pediatrics. Three overnight calls...zero sleep interruptions. I lucked out. Last night's attending, with whom I have called twice, called me her good luck charm.

...an Undercover Agent for the Blues...

The Chicago Blues Festival was this past weekend. I went for a little while, and it was enjoyable. The pre-main event was much more enjoyable, I thought, than the main event due to the fact that they actually played blues, which is fun. I mean, what doesn't lift your spirits better than hearing about how much more miserable someone else is?!? The main-event, meanwhile, was more what I call "Baby Making Music." Since I'm not really in the mood to make a baby, I left...

Thoughts

During my family and pediatric rotations I've noticed that adults, in our infinite wisdom, frequently underestimate the raw intelligence of babies. Frequently, babies will look at you like you're a complete baffoon if you make stupid noises and faces at them. The minds of babies and children are simpler, but they aren't stupid. Engage them on their level and they will respond. A simpler level does not a mean stupid level.

I love kids, and more often than not really enjoy working with them -- even the screamy ones. Having said that, in order to effectively work with a child who is less than about eight years of age, it is essential that one just comes to terms with the facts that 1) children will scream, kick, cry, and carry on and it's not really your fault and 2) one isn't going to break them--and this gets a lot of students. This is especially true of babies. Babies bounce, folks. I don't know this from personal experience, but their skeletons are, in the medical sense, rubberized. Shaken baby syndrome is a different story, but that's also a different cause. It is very hard to cause physical trauma to a baby in the doctor's office or hospital doing a routine exam. Older children--the ones strong and aware enough to kick and fight--are still almost impossible to hurt.

Regardless, there is a reason pediatrics is a specialty. Children have different needs and in many cases different anatomy and physiology than adults. I am definitely considering pediatrics in my future. Now if only it weren't for the psycho parents...

Doctorese Babble -- Cyanotic Heart Lesions

I. Tetralogy of Fallot


A. Facts

        1. MC congenital cardiac abnormality

        2. Cyanotic lesion

        3. 1% prevalence of CDH – 1% total worldwide will receive care

        4. R-> L shunt

        5. Typically no observed immediately at birth – some decreased sats don’t always present with obviously blue appearance



B. Features

       1. RVOT – pulmonic stenosis is supra or infravalvular – clinically most important component

       2. VSD

       3. RVH

       4. Overiding aorta

C. Tet spell

       1. Infundibular spasm -- less blood circulates to the lungs  hypoxia and increased deoxygenated blood through VSD

       2. Present as grey babies with difficulty breathing – increased anaerobic respiration  lactic acid, which affects contractility and leads to cardiogenic shock

D. Treatment

      1. Sedate

      2. Fluid bolus to increase blood volume going to heart – getting the IV can be difficult

      3. Increase SVR – can reduce shunting

             a. Knee-chest positioning – compresses femoral artery and vein increasing SVR and venous return
             b. Alpha-1 receptor agonists – phenylephrine



       4. CxR shows boot-shaped heart (RVH) – decreased pulmonary blood flow  very black lungs  oligemia

       5. Echo

       6. Corrective surgery

             a. Transanular patch – pulmonic stenosis

             b. Don’t completely close VSD

                    (1) Must incise RV

                   (2) Slight VSD serves as pressure release valve, otherwise heart can fail – “blue blood is better  than no blood”

                   (3) If baby is too small, an ASD can improve saturation

           c. BTT shunt if baby is very tiny – often performed in developing countries, and can result in pulmonary hypertension if more comprehensive treatment not pursued later



II. Transposition of the Great Vessels

A. PDA can close late

B. Patients arrive cyanotic and in shock

C. Can make ASD or VSD

         1. ASD is easier

         2. PFO balloon atrial septostomy

D. “Switch procedure” ultimately curative

III. Tricuspid Atresia

IV. Truncus Arteriosus

A. Present with overcirculated lungs – edema and RSD

B. VSD murmur

C. Truncus becomes new aorta

D. RV to PA conduit


V. TAPVR

A. Peripheral veins don’t return to left atrium

B. Those that cross diaphragm frequently obstructed – pulmonary edema and RSD

          1. Bilateral edema

          2. RSD

          3. GSB pneumonia

C. Treatment – return aberrant vein to LA

VI. Hypoplastic Left Heart

Overnight Call

As part of my pediatrics rotation we are scheduled for an overnight call once a week. To date I have done two. And they have been very uneventful. Normally we are scheduled to leave at 4pm. Whoever is on call, however, stays and is literally "on call" that night. Chicago Hope Hospital provides on call rooms for each department, and we, the students, are permitted the use of one of the rooms. The rooms are very basic, but have a bed and satellite TV (which is great for me because it allows me to catch up with Roland Garros) so they are perfectly adequate. So, in essence, when the night MD trots off to the call room, the student does as well. I usually lag behind the MD a few minutes just in case something happens the minute the doctor leaves. Then I head over to the call room where I promptly change out of the clothes I've been wearing all day, and into a pair of scrubs. It is much more comfortable to sleep in scrubs (which is the point of the call room) and your clothes also don't get wrinkled--essential because you will be wearing them the next day during your rounds and commute home. My fellow students have apparently had more night action than I have, because during both of my calls the phone did not ring between the hours of 8pm and 6am, and as such I slept. Not being a night owl I am perfectly fine with being allowed to sleep all night. The next day, however, I feel grimy and gross and just want to take a thirty minute shower. Perhaps next week I will get up a few minutes early and take a quick shower before morning rounds resume. Usually "post-call" students leave around 11 the next morning.

Would I like my arse grilled or fried today?

Tis the question I always ask myself prior to rounds. No matter how hard you try, you are at the mercy and whim of an attending. If you attempt to organize it the way he just instructed a previous student to, he will change his mind. Fact. And there's nothing you can do about it. Lather, rinse, repeat tomorrow. If rounds with an attending were to be served in a restaurant the menu would look something like this: "A generous portion of your arse, your choice of grilled or fried. Served with a side helping of no-matter-what-you-say-it's-wrong. Special daily with each different attending. Degree of doneness will vary."

Adventures in CTAing

Yesterday, taking the el to the hospital, I had the pleasure of sitting behind a gentleman on the phone. I have no idea who he was talking to, or really what he was talking about, because the entire conversation went something like this:

Him: "yeah....uhhuhuhuhuhuhuh" in a slow belly-bouncing chuckle. This goes on for at least ten minutes before I get off the train. I thought my sides were going to split.

Adventures in bike riding...

While riding my bike in the park (yes, I have become that crunchy), I rode past several joggers. Most, like me, had their headphones in. One, was seemingly just jogging along when out of nowhere he screams ''WHOMP THERE IT IS!!!"
...and that's a true story, folks.

Doctorese babble -- Acid/Base

Acid/Base

pH: 7.35-7.45
HCO3: 24-26
CO2: 35-40

ABG: pH/pCO2/pO2/HCO3/SaO2


Anion gap = 12-16. Na – (Cl+HCO3)
Increased in anion gap metabolic acidosis



Urinary anion gap

     1. Na -(Cl + K)
     2. Normal = < 0
     3. > 0, RTA

Serum osmolarity

     1. 2Na +glucose/18 +BUN/2.8

     2. Normal = 280-300

Serum Osmolar gap
     1. Elevated gap – Ethylene glycol and MeOH
     2. Elevated = > 25

Respiratory acidosis
     1. pH < 7.35
     2. PCO2 > 45
     3. Compensation is metabolic retention of bicarb

Respiratory Alkalosis – hyperventilation
     1. pH > 7.45
     2. CO2 < 35

Metabolic Acidosis -- Diarrhea
     1. pH < 7.35
     2. HCO3 decreased
     3. Nonanion gap (<12)
          a. Diarrhea – 3rd space
          b. RTA
          c. Then measure urine AG
                 i. <0 – diarrhea
                 ii. >0 – RTA
     4. Anion gap Metabolic acidosis (>12 AG)
          a. Aspirin overdose
                i. Respiratory alkalosis first, then MA
                ii. Measure LFT
                iii. tinnitus
          b. Lactic acidosis
                i. Exercise
                ii. Hypovolemia
          c. Uremia
          d. Ethylene glycol
                i. Increased osmolar gap
                ii. Calcium oxylate stones
          e. Methanol – affects retina à color blindness à blindness
          f. DKA – hyperkalemia
Serum Anion Gap


∆∆ = Serum AG – 12 + HCO3
     1. Only calculate in AG met. Acidosis
     2. If ∆∆ < 23 – non-AG met acidosis + AG metabolic acidosis
     3. If ∆∆ > 30 – metabolic alkalosis + AG met acidosis


Metabolic Alkalosis

   *Hypochloremic state
    pH Increased
    HCO3 increased

    CO2 increased – compensatory mechanism
     1. Saline responsive
            a. Contraction alkalosis
            b. HCO3 moves to ECF due to dehydration, usually from emesis
            c. Pyloric stenosis ****
                    i. Hypochloremia
                    ii. Hyponatremia
                    iii. Metabolic alkalosis
     2. Non-saline responsive
            a. Hyperaldosteronism
                    i. Primary
                    ii. Secondary
            b. Bartter’s Syndrome
                    i. Inherited thick ascending limb defect
                    ii. Low K
                    iii. Alkalosis
                    iv. Normal to low BP
                    v. Seen 24-30 weeks gestation with polyhydramnios
                    vi. Polyuria and polydipsia postnatal
                    vii. Hypercalciuria and nephrocalcinosis
                    viii. Presentation
                           1. Chronic vomiting
                           2. Diuretic abuse
                           3. Mg deficiency
                           4. Often have elevated rennin and aldosterone
            c. Gitelman syndrome
                    i. AR kidney disorder
                    ii. Metabolic alkalosis
                    iii. Hypocalciuria
                    iv. Hypomagnesemia
                    v. LoF of thiazide-sensitive Na-Cl symporter in distal convoluted tubule
            d. ***Hypokalemia