Reflection on learning on ambulatory internal medicidine

March 6, 2020

Reflecting on my experiences on ambulatory internal medicine, I found it to be quite different from my clerkship experiences on the Clinical Teaching Unit (CTU). On CTU, I found that there was much more time to look up information to manage your patient compared to ambulatory clinics where the pace is much faster. I found that I had to accommodate for this by looking up patients ahead of time to prepare in order to feel comfortable in clinic. 

On CTU, there is also a sense of hierarchy as there are many different levels of learners and because of the larger team, I found it harder to be able to get one on one time with staff. I appreciated being able to work directly with my preceptors and felt that I had more supervision during my ambulatory clinics. This experience really allowed me to refine my skills in being able to take a history, physical, and coming up with my own management plans as I had could be directly observed and had time to discuss my thoughts on a case. 

I also found that I had more time to focus on the clinical aspects of patient care in ambulatory clinics compared to CTU where there are more administrative tasks to manage (e.g. consulting multiple specialties, arranging investigations, and liaising with allied health). It also allowed me to reflect on things like what happens when I discharge a patient from CTU or which patients should be sent to hypertension clinic. 

Another aspect that I enjoyed about my rotation was that my preceptors gave me opportunities to see my patients longitudinally. I had several patients that I worked up (e.g. palpitations, hypertension) and was able to see them in follow-up. This allowed me to see the impact of my management plans. I think this helps reinforce my clinical judgement and gives me the chance to recalibrate my plans for the future. 

Overall, the variety of ambulatory internal medicine and its subspecialty really gave me exposure to the breadth of internal medicine, which I think came at an appropriate time in my training to help me transition from being a medical student to a resident in the next few months. I am looking forward to continuing my training in Internal Medicine!

-JT-

Ambulatory Learning

March 6 2020

Before this selective, I had mostly experienced Internal Medicine through the Clinical Teaching Unit environment. Although the CTU setting offers a rich environment for learning and teaching, I knew the ambulatory setting had many unique opportunities for learning and wanted to experience this. After a month, this selective has not only shown me the valuable learning experiences that lie within ambulatory medicine, but has also allowed me to explore medical education research and practice my teaching skills. During these past weeks in clinic, I have been involved in cases I had never seen before, I have sharpened my ability to develop differentials, and also feel more confident in proposing management plans (even if I am wrong)!

The learning in the ambulatory setting is quite different compared to the inpatient service. On the wards, you often care for the same patients, get to know their medical history in depth, and often manage the same issues until they are safely discharged. In the clinic, you are seeing several patients in a day, who you may have never met before, often working up new issues, and following chronic issues. You need to be able to review their chart quickly and determine the reason they are being seen in clinic. In a short amount of time, you must decide if their clinical state is improved, worsened, or stable, and what your management plan will be. These assessments and decisions need to happen fairly rapidly to ensure all patients are seen in a timely manner.

This faster pace of patient care and learning was initially challenging for me. I often took a long time with patients, had difficulty expanding my differentials, and was unsure of my management plan. My preceptors allowed me to take my time and reassured me that ambulatory medicine is difficult even for Internal Medicine residents. Despite the challenges, this experience allowed me to become more comfortable in the ambulatory setting and showed me which areas I could improve on. I learned to focus on the most important issues for each patient and gained strategies to see patients more efficiently. For example, after reviewing the chart for a new patient, I would take a few minutes outside the room to think of my differential based on their referral and past medical history, and brainstorm which questions I would want to ask to help narrow my differential. Taking the time to do this allowed me to take more concise histories, focus my physical exam, and figure out which investigations I wanted.

All of my preceptors also fostered a positive learning environment and helped me get the most out of each patient encounter. They would push me to explain my reasoning, encourage me to formulate my differential in a systematic way, and help me review the most recent guidelines for my treatment plans. They would also provide their own clinical pearls and insight from their years of experience. This helped consolidate my knowledge and made me feel that my learning experience was valued.

This selective has further validated my decision to pursue my training in Internal Medicine. During clerkship, I had loved my experience on CTU, taking care of sick patients and building strong relationships with them. However, I had also really enjoyed seeing patients longitudinally in my Family Medicine rotation. This selective made me realize that a career in Internal Medicine can provide me with both aspects. I am grateful I was able to experience the ambulatory side of Internal Medicine and gain more exposure to medical education. I am eager to begin my residency in Internal Medicine and will definitely continue to seek involvement in medical education moving forward!

-MB-

Proposal to improve wellness

March 5, 2020

           
          After reviewing the literature on physician burnout, I spent some time trying to figure out what type of intervention I could implement to improve wellness in the internal medicine residency training program. One of the ideas that I thought of was to turn one of the weekly academic half day into monthly wellness and resiliency sessions. During my CaRMS tour, I remember some of the residents talking about how much they enjoyed having weekly "Ice Cream Rounds" during their academic half days because they were able to debrief with their peers about some of the stresses they have been experiencing. This gave them an opportunity to really connect with their fellow colleagues. I can see how this would greatly contribute to a feeling of wellness because these dedicated sessions normalizes the process of sharing concerns and allows for peer support. I do understand that it will be challenging to dedicate academic half days to wellness and resiliency due to limited curriculum time but I would argue that being able to take of one self in order to care for others is also part the Professionalism role of CanMEDS. Furthermore, I think we should be allowed to have self-compassion and follow our own recommendations that we give our patients because we are all human beings at the end of the day.


-JT-

Cutaneous tuberculosis

March 5 2020

I spent the day in the Dermatology Clinic today and saw a wide variety of common and interesting dermatologic cases! In the morning, we saw a patient that had been referred by the Tuberculosis Clinic for possibility of cutaneous manifestations of TB. Cutaneous lesions are a relatively uncommon manifestation of TB, occurring in only 1-2 % of infected patients. Therefore our staff spent some time discussing the various dermatologic presentations seen in TB.

The clinical variants of cutaneous TB are divided into: infectious acquired through exogenous inoculation, infectious that result from contiguous spread from nearby structures, infectious related to hematogenous dissemination, and the tuberculids, which are thought to be hypersensitivity reactions to M. tuberculosis.

Exogenous inoculation:

• Primary inoculation TB (tuberculous chancre): results from direct entry of organism into the skin or mucosa of someone previously not sensitized to M. tuberculosis. Lesions appear as red-brown papules or nodules that evolve into painless, shallow ulcers. The face and extremities are most commonly affected.
• Tuberculosis verrucosa cutis: occurs after direct inoculation of mycobacteria into the skin of previously  sensitized host. Lesions are usually painless, violaceous, indurated plaques, appearing on the fingers and dorsum of hands.

Contiguous spread:

• Scrofuloderma (tuberculosis colliquativa cutis): results from extension of the infection from a deep structure (eg lymph node) into the skin. Lesions appear as firm, painless, subcutaneous, red-brown nodules. The neck, axillae and groin are often involved.
• Tuberculosis cutis orificialis: develops in individuals with advanced TB of the GI tract, lungs, GU tract and impaired cell-medicated immunity. Lesions occur in the nasal mucosa, oral mucosa or anogenital skin/mucosa and appear as red-yellow nodules that break down to form painful, punched-out, friable ulcers.
• Lupus vulgaris (tuberculosis lupus): represents reactivation of TB infection and is a chronic and progressive form of cutaneous TB. It can result from either direct extension from an underlying focus or via lymphatic or hematogenous spread. It appears as collection of discrete, red-brown papules that coalesce to form an indolent plaque.

Hematogenous spread:

• Metastatic tuberculous abscesses (tuberculous gummas): occurs from the spread of mycobacteria to subcutaneous tissues. Patients present with a single or multiple, nontender, fluctuant, subcutaneous nodules, which eventually penetrate the skin and form ulcers.
• Acute miliary tuberculosis: results from the hematogenous dissemination of mycobacteria from a focus of infection. Cutaneous manifestations are rare but can present as pinpoint red-blue or purpuric papules with overlying tiny vesicles that then become umbilicated and crusted.
• Lupus vulgaris

Tuberculids:

• Papulonecrotic tuberculid: presents as firm, dark red or purple papules that are symmetric and often recurring. They subsequently become pustular and necrotic. Lesions occur on the face, ears, extensor surfaces and buttocks.
• Lichen scrofulosorum: collection of firm, yellow-red to red-brown papules that are follicular and often found on the trunk.
• Erythema induratum of Bazin (nodular vasculitis): presents as mildly tender, dull red, subcutaneous nodules on the lower legs. Nodules can break down and form deep, draining ulcers.

In our case, the patient did not end up having any cutaneous manifestations of tuberculosis. However, this case allowed me to learn about the various dermatologic presentations that can be seen in TB patients. Overall, the day was a fantastic opportunity to gain more exposure to dermatologic presentations and to review the many cutaneous manifestations seen in systemic diseases!

-MB-

References:

1. Handog EB, Macarayo MJE, Rosen T (Ed.). Cutaneous manifestations of tuberculosis. UpToDate. Accessed on March 5 2020 from: https://www-uptodate-com/cutaneous-manifestations-of-tuberculosis.

Medical education research

March 4, 2020


          Part of the CEEP selective involves exploring an aspect of medical education research. This was something that I was also very excited about as I had relatively recently become interested in medical education after working on a project to improve our advocacy curriculum. Something that has crossed my mind in the past few years is the topic of physician burnout. During clerkship, burnout seemed to be prevalent no matter where I went. Sadly, it seems that there is no real intervention in place to help with this. The topic of resiliency came up a lot during these conversations, often accompanied by some measure of contempt. As a medical student who will be entering residency training soon, I became concerned about how I would personally manage burnout but also how could we improve the system to support wellness in the future.

          As I delved into the literature, there has been a huge number of studies studying physician burnout. Burnout is a widespread phenomenon that affects approximately 30-50% of physicians, and is particularly prevalent during residency training (1,2). Burnout is a response from exposure to chronic stress that results in a syndrome involving exhaustion, depersonalization, and a sense of low personal accomplishment (3). This has been linked to medical errors, unprofessional conduct, and decreased altruism, which can be detrimental to patient care as well as compromising the physicians’ own well-being and safety associated with substance use and suicide (4). Unfortunately, there continues to be stigma and normalization associated with burnout that makes burnout challenging to address (5). Given that professionalism is one of the core competencies of the CanMEDS Physician Competency Framework, which includes a “responsibility to self, including personal care, in order to serve others,” tackling burnout is important to ensuring both physician and patient safety (6).

There are many factors that contribute to burnout, including: long hours, heavy workloads, sleep deprivation, exposure to intense emotional experiences, poor control over scheduling, changing work environments, and a high burden of administrative tasks (7). Additionally, the culture of medicine itself has been found to be a barrier to physician wellness as there is a strong expectation to be a “superhuman” and to prioritize work over personal time and self-care (5).

            Many studies investigating ways to manage physician burnout focus on improving resiliency training (8). Resiliency can be described in many ways but essentially allows one to thrive in the face of adversity. In order to implement resiliency strategies, there needs to be self-awareness to recognize the need for self-care. Formalized resiliency curriculum involves skill-building workshops on topics such as meditation, mindfulness, and managing expectations (9).

            A randomized clinical trial of 74 practicing physicians found that participation in biweekly facilitated discussion groups incorporating elements of mindfulness, reflection, shared experience, and small-group learning during 1 hour of protected time resulted in significantly improved empowerment and engagement at work, decreased depersonalization, emotional exhaustion and overall burnout (10). Another study found that a resiliency curriculum with sessions on setting realistic goals, managing expectations, letting go of medical errors, and finding gratitude was considered very valuable to interns to mitigate stress (11).

The discourse around well-being focuses on training individuals to have the skills in resiliency to combat adversity. However, there has been criticism to this approach as it places a strong responsibility on individuals to manage their burnout as if this was a result of a personal deficiency in resiliency rather than external barriers to wellness such as systemic organizational issues. Although addressing systemic issues is a daunting task, it can be guided based on the six categories of work stress by Maslach and Leiter: 1) workload, 2) control, 3) balance between effort and reward, 4) community, 5) fairness, and 6) values (12,13).

-JT-

References:

1.        Rosen IM, Gimotty PA, Shea JA, Bellini LM. Evolution of sleep quantity, sleep deprivation, mood disturbances, empathy, and burnout among interns. Acad Med. 2006;81(1):82–5.

2.        Thomas NK. Resident burnout. Vol. 292, Journal of the American Medical Association. American Medical Association; 2004. p. 2880–9.

3.        Maslach C, Leiter MP. Understanding the burnout experience: Recent research and its implications for psychiatry. World Psychiatry. 2016 Jun 1;15(2):103–11.

4.        Dyrbye LN, Massie FS, Eacker A, Harper W, Power D, Durning SJ, et al. Relationship between burnout and professional conduct and attitudes among US medical students. JAMA - J Am Med Assoc. 2010 Sep 15;304(11):1173–80.

5.        Ironside K, Becker D, Chen I, Daniyan A, Kian A, Saheba N, et al. Resident and Faculty Perspectives on Prevention of Resident Burnout: A Focus Group Study. Perm J. 2019;23.

6.        The Royal College of Physicians and Surgeons of Canada :: CanMEDS Role: Professional [Internet]. [cited 2020 Mar 1]. Available from: http://www.royalcollege.ca/rcsite/canmeds/framework/canmeds-role-professional-e

7.        Edmondson EK, Kumar AA, Smith SM. Creating a Culture of Wellness in Residency. Acad Med [Internet]. 2018 Jul 1 [cited 2020 Mar 1];93(7):966–8. Available from: http://insights.ovid.com/crossref?an=00001888-201807000-00010

8.        West CP, Dyrbye LN, Erwin PJ, Shanafelt TD. Interventions to prevent and reduce physician burnout: a systematic review and meta-analysis. Lancet. 2016 Nov 5;388(10057):2272–81.

9.        Bird A, Pincavage A. A Curriculum to Foster Resident Resilience. MedEdPORTAL Publ. 2016;12(12).

10.      West CP, Dyrbye LN, Rabatin JT, Call TG, Davidson JH, Multari A, et al. Intervention to promote physician well-being, job satisfaction, and professionalism a randomized clinical trial. JAMA Intern Med. 2014 Apr 1;174(4):527–33.

11.      Bird A-N, Martinchek M, Pincavage AT. A Curriculum to Enhance Resilience in Internal Medicine Interns. [cited 2020 Mar 1]; Available from: http://dx.doi.org/10.4300/JGME-D-16-00554.1

12.      Jennings ML, Slavin SJ. Resident Wellness Matters. Acad Med [Internet]. 2015 Sep 1 [cited 2020 Mar 1];90(9):1246–50. Available from: http://content.wkhealth.com/linkback/openurl?sid=WKPTLP:landingpage&an=00001888-201509000-00024

13.      The Truth About Burnout: How Organizations Cause Personal Stress and What to ... - Christina Maslach, Michael P. Leiter - Google Books [Internet]. [cited 2020 Mar 1].

Too low for comfort

March 2 2020

We saw a patient today who had been initially followed for management of his hypertension, but had subsequently developed severe orthostatic hypotension. Despite treatment, his hypotension was ongoing and significantly affecting his life. In medicine, we often manage patients with difficult-to-treat hypertension, however we less often encounter persistent orthostatic hypotension. I took this opportunity to learn more about the management strategies for orthostatic hypotension in the ambulatory setting.

Orthostatic hypotension is defined as a decrease in systolic blood pressure of 20 mmHg or a decrease in diastolic blood pressure of 10 mmHg within 3 minutes of standing when compared with the blood pressure in the sitting or supine position. It can be asymptomatic or symptomatic, causing light-headedness, dizziness, fatigue, palpitations or syncope. Goals of treatment involve improving hypotension without excessive supine hypertension and symptomatic relief for the patient. There are many non-pharmacologic and pharmacologic options available.

Non-pharmacologic options: These are an important first-line for neurogenic orthostatic hypotension (ie caused by autonomic dysfunction).

• Discontinue offending medications: this commonly includes diuretics, antihypertensive agents (primarily sympathetic blockers), nitrates, alpha-adrenergic antagonists,  antidepressants.
• Modification of daily activities and patient education: this includes strategies such as getting up slowly, avoiding straining or violent coughing, ensuring adequate hydration and avoiding overheating, raising the head of the bed, and exercise in some cases.
• Compression stockings and abdominal binders: may be helpful in patients who are able to tolerate them.
• Certain physical maneuvers: tensing the legs by crossing them while actively standing on both legs was found to increase blood pressure by 13%.
• Increased salt and water intake: target daily water ingestion of 1.5 - 3 L per day and encourage high sodium foods or prescribe salt tabs.

Pharmacotherapy options: Non-pharmacologic measures should always be maximized prior to starting pharmacotherapy and must be continued after initiating medications. A stepwise approach should always be used with pharmacotherapy, with frequent monitoring.

• Midodrine: is a peripheral selective alpha-1-adrenergic agonist causing both arterial and venous constriction. The dose should be titrated from 2.5 to 10 mg three times a day, with a maximum dose of 40 mg a day. It should not be used in patients with severe heart disease, uncontrolled hypertension or urinary retention. Side effects include: supine hypertension, pilomotor reactions, GI complaints, pruritus and urinary retention.
• Droxidopa: is a norepinephrine (NE) precursor which is converted to NE after ingestion. Dosing starts at 100 mg and can be titrated up to 600 mg three times a day. It is approved for treatment of symptomatic neurogenic orthostatic hypotension associated with Parkinson's, multiple system atrophy, and autonomic neuropathy. Again supine hypertension is a side effect.
• Fludrocortisone: is a synthetic mineralocorticoid which acts by increasing blood volume. Treatment is initiated at a dose of 0.1 mg per day (in the morning) which can be increased to 0.3 mg/day. Side effects include: development of edema, worsening seated or supine hypertension, and hypokalemia (potassium supplementation is usually required).
• Other agents (such as caffeine, erythropoietin, pyridostigmine) have been used in small trials but there is limited evidence to support their use. 

This case allowed me to learn more about the different management options for patients with orthostatic hypotension. Although I was previously familiar with a few of the non-pharmacologic methods, I did not know much about the various pharmacologic options. Through this case, I was able to learn more about the medications available, their mechanism of action, indication for their use, dosing protocol, and their side effects! 

-MB-

References:

1. Kaufmann H, Aminoff MJ (Ed.), Kowey P (Ed.). Treatment of orthostatic and postprandial hypotension. UpToDate. Accessed on March 2 2020 from: https://www-uptodate-com/treatment-of-orthostatic-and-postprandial-hypotension.
2. Lanier JB, Mote MB, Clay EC. Evaluation and Management of Orthostatic Hypotension. Am Fam Physician. 2011 Sep 1; 84(5):527-536.

Sweet Misery

Feb 28 2020

Today we presented our teaching activity to our fellow clerks on selectives. The topic I chose for my teaching session was Hyperglycemic Crises, reviewing the presentations, laboratory findings, and management of DKA and HSS. For the session, I wanted to use some of the strategies I had learned while doing the Student as Teachers program in second year medical school, as well as incorporate some new strategies I had learned from preceptors.

• Case-based: I have always enjoyed lectures and seminars with cases and thus wanted to make my teaching session case-based.  I find that case-based learning not only allows you to think critically through a case and build your knowledge, but also really engages the learners.
• Probing rationale: In a training session for an upcoming teaching activity I am involved in, we learned about probing the rationale of learners. When a learner gives an answer, it is useful to ask why they gave that answer., probing them further. This can help deepen their understanding and lead to further discussions.
• What if questions: In discussing my teaching project with Dr. C, he also suggested using "what if" questions to present variations on a case, encourage students to think differently, and enhance learning.

Overall, I think the teaching session today went well. The learners said that they enjoyed the interactive nature of the session, and the variations on the case helped solidify their learning. From the feedback of the learners and staff observing us, I also learned many strategies on how to improve my teaching for the future.

• I want to limit the amount of information I have on a slide. Learners can sometimes focus on reading the text on the slide, rather than listen to you talk. Instead, I will focus on just the key information on the slide, expanding more when I talk.
• In general, I will avoid covering too much material in a teaching session. I have the tendency to want to cover as many learning points, however this can lead to information overload for the learner.
• I also want to work on even further engaging learners during a talk. In small group sessions, if the learners are talking more than the teacher, that is often a good sign. I learned about other strategies that can be used to engage learners, such as online polling/answering tools.

I also saw the value that clinical experience adds to being an effective teacher. When building my teaching session, I referenced guidelines and resources such as UptoDate for information regarding presentation and management plans. However, in discussing with the staff, we learned how the guidelines sometimes differ from clinical practice. For example, although guidelines state to treat hypokalemia in DKA once the potassium level is less than 3.3 mmol/L, the staff explained that they would often start oral and IV potassium supplementation along with insulin once the potassium is below 4.0 mmol/L. Being able to have the perspective of experienced staff helped to enhance my understanding, and highlighted the differences between guidelines and practice.

I really enjoyed this teaching experience! It allowed me to try out some new teaching strategies, as well as learn ways to improve in the future. I want to be involved in teaching and medical education in my future career and look forward to improving my teaching skills as I move along in my training.

-MB-

Teaching Dermatology in Internal Medicine

February 28, 2020

After spending the past few weeks planning for my teaching exercise, the day had finally arrived where I would have the opportunity to lead a 30-minute session on dermatology in internal medicine to our fellow clerks. I decided on this topic because I felt that this is an area that we spend very little formalized curriculum time on (~ 1 week) and an area that people often feel uncomfortable with due to our limited experiences. The goal of my teaching exercise was to raise awareness about dermatological manifestations related to internal medicine conditions as there can be many cutaneous clues if one were to look for it on inspection. 

I approached this teaching session using a mixed approach involving didactic teaching and case-based learning with interactive components. 

I began the presentation with an overview of basic morphology to describe cutaneous lesions:

Then we went through a mini-quiz to describe various lesions. (However, I should have made sure to include dimensions for each lesion because it is challenging to tell on screen). 

Next, I went through 2 cases involving erythema nodosum. The first case was about sarcoidosis. This gave me an opportunity to have a discussion about sarcoidosis, Lofgren syndrome, and lupus pernio. The second case was about IBD. There are a lot of extra-intestinal manifestations of IBD but the two cutaneous ones that I covered were erythema nodosum and pyoderma gangrenosum. I brought up pyoderma gangrenosum because it can be easily mistaken to be infectious in etiology but it is actually inflammatory.  I then reviewed erythema nodosum, including its differential diagnoses, work-up, and management.

Reflecting on this experience, I realized that I tried to condense too much information into such a short-time period. If I were to do this again, I would have made just focused on erythema nodosum and the work-up for it, including the sensitivities and specificities for certain tests. I would have eliminated dermatological manifestations of internal malignancy all together. I would also summarized the information with a jeopardy format or have a pre- and post- mini-quiz to reflect on their learning. 

-JT-

Reference(s):
1. https://dermnetnz.org/
2. https://aad.org
3. Diagnosis and management of sarcoidosis. https://www.aafp.org/afp/2016/0515/p840.html
4. Erythema nodosum. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4918049/
5. Erythema nodosum as a presentation of inflammatory bowel disease.        https://www.ncbi.nlm.nih.gov/pmc/articles/PMC1174850/

Short of breath

February 27, 2020

I spent this week following an elderly man who was recently discharged from the GIM ward for an upper gastrointestinal bleed due to an duodenal ulcer. He was referred to us for management of his shortness of breath.

Given that his shortness of breath only recently began within the past month, I attributed this to secondary to his anemia from his UGIB. However, we had to rule out other causes including CHF exacerbation and potentially COPD due to his smoking history. As such, we had ordered a chest x-ray and BNP which were negative. We also arranged for him to have a PFT. I also spent some time thinking about how I would best manage his symptomatic anemia. His most recent Hb was 86. Looking at the guidelines, a transfusion would be warranted to achieve a target Hb of >70, but a target Hb > 80 can be aimed for if he has coronary artery disease. At this time, it does not seem like he qualifies for a transfusion. There were also logistical things that would need to be arranged if he needed an outpatient transfusion. In order to get a transfusion, we would have to put in a referral to Women's College Hospital for this to be done as an outpatient. Fortunately, it seems this his SOB appears to be improving as his Hb is recovering.

This was a memorable case for me because I had the opportunity to follow him longitudinally over the past 2 weeks. I think longitudinal exposure to a patient's course of illness really allows the learning to settle in as you have can have the time to reflect on your medical decision making and see how it directly impacts your patient's outcomes.

This encounter also made me reflect on what it is like to care for patients with limited English proficiency. Although my patient did not speak English, I was fortunate to be able to communicate with him in my native language. Dr. Rawal recently had a talk during rounds about this topic as their is significant health disparities between patients who can speak English and those who cannot. Someone shared the experience of how a non-English speaking patient was diagnosed with COPD exacerbation and unfortunately the patient actually was having a NSTEMI but nobody had taken the time to communicate with this patient because of the "language barrier."

-JT-

Reference(s):

Barkun, A. N., Bardou, M., Kuipers, E. J., Sung, J., Hunt, R. H., Martel, M., & Sinclair, P. (2010). International consensus recommendations on the management of patients with nonvariceal upper gastrointestinal bleeding. Annals of internal medicine, 152(2), 101-113.

Villanueva, C., Colomo, A., Bosch, A., Concepción, M., Hernandez-Gea, V., Aracil, C., ... & Guarner-Argente, C. (2013). Transfusion strategies for acute upper gastrointestinal bleeding. New England Journal of Medicine, 368(1), 11-21.

Harvey and murmurs

February 27, 2020

We had two Harvey teaching sessions this week, which I found to be incredibly valuable to my learning. Harvey functions as a high-fidelity simulator, which can be applied to teaching the cardiac physical exam. Learning in a small group with a facilitator to walk us through the different murmurs and then applying it to difference case scenarios really allowed me conceptualize murmurs.

I was really surprised by how much I retained from these Harvey sessions. During my cardiology clinic, I was able to appreciate a few murmurs including physiological S2 and severe regurgitation. I was also able to apply my knowledge in differentiating the different types of murmurs.

I would say that the 2 main ones that I focused on were:
1) aortic stenosis: systolic murmur, aortic area, crescendo-decrescendo, radiates to clavicles
2) mitral regurgitation: systolic murmur, holosystolic, radiates to axilla


I spent some time reading the literature around Harvey as a teaching tool. Interestingly, the article by Humphrey-Murto (2019) suggests that there are no differences between using Harvey and a standardized patient (SP) in teaching medical students physical examination skills but that the SP group had an improved ability at coming to a unifying diagnosis. Personally, I think that using both SP and Harvey would be of great value to medical students. I think it would be challenging to be able to get SPs for all the different types of murmurs that Harvey is able to reproduce. There are limitations to Harvey however that one must acknowledge and that it does not replace real life experiences.

-JT-

Reference(s):
Gauthier, N., Johnson, C., Stadnick, E., Keenan, M., Wood, T., Sostok, M., & Humphrey-Murto, S. (2019). Does Cardiac Physical Exam Teaching Using a Cardiac Simulator Improve Medical Students’ Diagnostic Skills?. Cureus, 11(5).

Feeling the Pressure

Feb 26 2020

In the GIM clinic today, I saw a patient who was been followed for findings of elevated RVSP on echocardiogram. He had symptoms of dyspnea with exertion, but was otherwise asymptomatic. We questioned the presence of pulmonary hypertension, however had no clear cause based on his current presentation and investigations. I always have difficulty remembering the classification for pulmonary hypertension, and so this was a great opportunity for me to review this topic.

Pulmonary hypertension (PH) is defined as a mean pulmonary artery pressure ≥ 25 mmHg. Clinically, PH is a pathophysiological disorder that may involve multiple clinical conditions. The WHO classification describes 5 groups of pulmonary hypertension:

• Group 1: Pulmonary artery hypertension (PAH). This develops due to an occlusive vasculopathy of the pulmonary arterioles, which may be idiopathic or associated with several disease states. Commonly associated conditions include: connective tissue diseases (scleroderma, lupus), congenital heart disease, portal hypertension, HIV or schistosomiasis infections, and drugs.
• Group 2: PH due to left heart disease. This develops due to chronically elevated left atrial pressure, which causes PH by a passive retrograde transmission of pressure. Causes include left ventricular systolic/diastolic dysfunction, and aortic or mitral valve disease.
• Group 3: PH due to lung diseases and/or hypoxia. This develops in patients with lung disease (COPD, interstitial lung disease), sleep disordered breathing, or other abnormalities of blood gases (hypoventilation, high altitude). Hypoxic pulmonary vasoconstriction (a normal physiologic response), loss of pulmonary capillary cross-sectional area, and pulmonary vascular remodeling can all be contributing factors.
• Group 4: Chronic thromboembolic PH. Approximately 3% of patients with acute pulmonary embolism go on to develop obstructive pulmonary arterial remodeling resulting in PH. These patients are often found to have an underlying thrombophilic disorder.
• Group 5: PH with unclear and/or multifactorial mechanisms. This is a diverse group of PH etiologies. Hematologic disorders (such as chronic hemolytic anemia), systemic disorders (such as sarcoidosis), metabolic disorders (such as glycogen storage diseases), and others may cause PH by unclear and/or multifactorial mechanisms.

For our patient, there was no obvious explanation for his elevated RVSP. He had no history of conditions associated with Group 1 PH, such as connective tissue disease, congenital heart disease or past infections, however could still have idiopathic PAH. His exam and echocardiogram showed no evidence of left ventricular or valvular disease, ruling out Group 2. There was no history of PE or thromboembolic disease, and no evidence of any systemic diseases, excluding Groups 4 and 5. We decided to send him for pulmonary function testing to assess for any underlying lung disease for Group 3 PH. His PFT will also determine his DLCO which will help in the diagnosis (DLCO is reduced in PH and an isolated reduction in DLCO is a typical finding in Group 1 PH). This case allowed me to gain a better understanding of pulmonary hypertension, the various classifications, and how to approach a patient with PH in the future.

-MB-

References:

1. Simonneau G, Gatzoulis MA, Adatia I, et al. Updated Clinical Classification of Pulmonary Hypertension. Journal of the American College of Cardiology 2013; 62(25): 35-41.

Pulsus Paradoxus

Feb 25 2020

Today in Cardiology clinic, I was preparing to see a patient who had a history of pericardial thickening, among other cardiac issues. Before going in for my assessment, my preceptor reminded me to screen for any symptoms of constrictive pericarditis and to examine for the presence of pulsus paradoxus. I took a moment to review the significance of pulsus paradoxus and how to perform this measurement.

Pulsus paradoxus refers to an exaggerated fall in a patient's blood pressure during inspiration by greater than 10 mmHg. It is caused by changes in the mechanical forces imposed on the chambers of the heart and pulmonary vasculature. The exact pathophysiology is quite complex and varies depending on the etiology, with several mechanisms involved. Pulsus paradoxus is often associated with pericardial disease, often cardiac tamponade and to a lesser extent constrictive pericarditis. However this finding can also been seen in non-pericardial diseases (such as right ventricular MI, restrictive cardiomyopathy), as well as non-cardiac diseases (severe COPD, asthma, tension pneumothorax).

Pulsus paradoxus is measured using a manual sphygmomanometer and stethoscope. Assessment is made by inflating the cuff until the Korotkoff sounds are absent. The cuff is than deflated very slowly. The first sounds auscultated will be heard only during expiration, and this pressure should be noted. As the cuff pressure is dropped further, the pressure when Korotkoff sounds are heard during both inspiration and expiration should be noted. The variation between these 2 systolic pressures is what quantifies pulsus paradoxus. Pulsus paradoxus can also be quantified by an invasive arterial measurement.

An important tip when assessing for pulsus paradoxus is to ensure the patient is breathing normally. Do not instruct them to change their breathing pattern as the depth of respiration influences the magnitude of pulsus paradoxus!

In the end, there was no finding of pulsus paradoxus in our patient and she had no clinical symptoms of pericardial disease. This was a great opportunity to review the significance of this physical exam finding and practice performing it in a real-life setting!

-MB-

References:

1. Van Dam MN, Fitzgerald BM. Pulsus Paradoxus. [Updated 2019 Jun 4]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing.

Thrombocytopenia

February 21, 2020

In the GIM clinic today, I had a middle-aged patient referred for assessment of his incidental thrombocytopenia. 

My takeaway for an approach to thrombocytopenia is as follows:

• Etiology
• Decreased production of platelets
• Bone marrow suppression - e.g. methotrexate, alcohol, MDS, aplastic anemia
• Increased consumption/destruction of platelets
• Hematological - DIC, TTP, HUS
• These are particularly important to rule out
• Autoimmune - ITP (idiopathic thrombocytopenic purpura), Evan's syndrome
• Drug-induced - e.g. heparin (HIT), anti-convulsants
• Infectious - hepatitis C, HIV
• Sequestration in spleen
• Splenomegaly due to increased portal hypertension (e.g. cirrhosis)
• History
• Symptoms
• Bleeding
• Mucosal - epistaxis, gum bleeding, GU bleeding
• GI bleeding - hematemesis, BRBPR, and melena
• Bruising
• Rashes - particularly purpura and petechiae
• Risk factors
• Drug-related - e.g. heparin, anticonvulsants, antibiotics
• Malignancy, sepsis, cirrhosis
• Physical
• General
• Mucosal bleeding
• Bruising and rashes - petechiae, purpura
• Stigmata of liver disease
• Neuro: 
• Mental status 
• HEENT:
• lymphadenopathy
• Abdominal
• Assess for hepatosplenomegaly
• Investigations:
• CBC to monitor platelets but also assess for anemia
• Peripheral blood smear
• Consider 
• DAT to rule out hemolytic anemia
• hepatitis C and HIV serologies
• Management 
• Transfusion if platelets <10 or <50 for certain surgeries (in general)
• Immune suppression: IVIG +/- steroids, rituximab
• Consider splenectomy
• Treat underlying cause - e.g. discontinue heparin

My patient likely has a transient mild thrombocytopenia secondary to a viral infection or secondary to his use of anti-convulsants or PPI. I also recently found out about the importance of using a PPI for prophylaxis when using high-dose steroids. 

-JT-

Reference(s):

https://ashpublications.org/bloodadvances/article/3/23/3829/429213/American-Society-of-Hematology-2019-guidelines-for